suffers from wakefulness and restlessness at night, and it
occasionally happens that the wakefulness becomes a distressing
symptom. But in a great many cases, sooner or later in the course of
the disease, drowsiness supervenes. In mild cases this symptom is late
in making its appearance, and is generally slight and evanescent, but
in grave cases it may come on as early as the eighth day, and when
once present may gradually become more profound until it deepens at
last into unconsciousness. It usually persists until the occurrence of
death or of convalescence, but may alternate with periods of delirium,
the delirium being more frequent at night and the somnolence by day.
It is as frequent in children as in adults. Occasionally, the
wakefulness of the earlier stage may reappear at the beginning of the
third week, and coexist with muttering delirium, or occasionally with
delirium of a more violent character. It then constitutes a most
unfavorable symptom, the patient frequently passing several days and
nights in incessant agitation, and sinking finally from exhaustion due
to want of sleep.
Some degree of mental hebetude is rarely absent, even in the mildest
cases of typhoid fever, and is usually among its earliest symptoms. It
may, however, be absent occasionally in cases which run a severe
course. It exhibits itself in the beginning in an indisposition to be
disturbed, a slight inability to fix the thoughts, or a loss of
memory. Generally, the {278} patient will be able at first, by an
effort, to rouse himself from this apathy, but the moment he relaxes
this effort will lapse into his former condition. As the disease
progresses the hebetude becomes more profound and is overcome with
greater difficulty. In mild cases it may continue until the occurrence
of convalescence, but in grave cases it is soon lost in delirium. This
is one of the commonest symptoms of the disease. If I should rely
solely upon my own experience, I should say that it was rare for any
but the mildest cases to run their course without its occurring at
some time or other. Louis found, however, that it was absent in 32
cases, 8 of which were fatal, out of 134 cases, and Murchison in 33
cases, 3 of which ended in death, out of 100 cases. In 8 of these
fatal cases death was due to perforation--a fact which would seem to
show, as suggested by James C. Wilson, that this symptom is not
dependent upon the intensity of the local disease alone. The delirium
of course varies with the severity of the other symptoms, and
especially with the intensity of the fever. In its mildest form it
consists of a slight confusion of ideas, which is readily dissipated
by fixing the patient's attention, and is most apt to occur in the
night or when he first wakes up from sleep. In other cases it is much
more marked; occasionally it is violent and noisy; the patient may
talk wildly and incoherently, he may break out into a paroxysm of
screaming, or, possessed with a sudden terror, he may leave his bed
and attempt to rush from the room or to jump from the window. Later in
the course of the disease the active delirium subsides, and low
muttering delirium takes its place. The latter may go on until
convalescence occurs, or the patient may gradually fall into a
comatose condition, which very often ends in death.
The delusions from which the patient suffers are various. I have known
in two instances a perfectly pure young girl call loudly for her baby,
which she accused her mother and sister of keeping from her. Very
frequently patients insist that they are in a strange place, and beg
piteously to be taken to their home and friends; occasionally, in
grave cases, the patient declares that there is nothing the matter
with him. This Louis was accustomed to regard as a bad symptom, having
never known recovery to take place after it. Delirium generally first
makes its appearance some time in the course of the second week, but
occasionally the invasion of the disease is marked by maniacal
excitement. I have known delirium to occur on the second or third day.
Louis records two cases in which it was present during the first
night, and Bristowe[51] one in which it was noted on the fourth night.
It is sometimes so prominent a symptom in the beginning of an attack
that the patient has at first been supposed to be affected with acute
mania. M. Motet[52] indeed refers to a case in which a man was
actually admitted into an insane asylum before the true nature of his
disease became known. On the other hand, delirium may not occur until
much later in the disease--sometimes not before the close of the third
or even the fourth week, when it may suddenly make its appearance when
least expected. I have known it to be present in a marked degree
during a relapse when it had been wholly wanting in the primary
attack.
[Footnote 51: _Trans. Path. Soc. Lond._, vol. xiii.]
[Footnote 52: _Archiv. gén. de Méd._, 1868, quoted by Murchison.]
During convalescence, especially in cases in which there has been much
{279} mental disturbance during the febrile period, the intellect may
be weak, and continues so in some cases even after recovery in other
respects is complete; but it is rarely permanently impaired. Insanity
may also occur during the convalescence or after recovery, but it is
usually under these circumstances amenable to treatment. In some cases
the moral sense appears to be weakened after an attack, as in the case
reported by Nathan Smith, in which a young man of previously good
habits developed thieving propensities after his recovery.
Hyperæsthesia of the skin exists, according to Murchison, in about 5
per cent. of the cases, and may occur at any stage of the disease. It
is chiefly observed in the abdomen and lower extremities, and is more
frequently met with in women and children than in adult males. In a
case which was partially under my care during the past summer the
slightest touch made the patient, a boy of fifteen years, cry out with
pain, and the administration of an enema gave him excruciating agony.
Occasionally, the tenderness over the abdomen is so great that it is
sometimes difficult to distinguish it from that due to peritonitis,
except by the coexistence of hyperæsthesia in other parts of the body.
It is very often associated with spinal tenderness, and sometimes with
other spinal symptoms. Murchison does not regard it as a formidable
symptom.
Cutaneous anæsthesia may also occur, but it is certainly less common
in the earlier stages than hyperæsthesia. Rilliet and Barthez look
upon it as of grave diagnostic import when it occurs in children.
Muscular tremor is also a common symptom of typhoid fever. A little
tremulousness of the tongue when protruded may often be detected
before the close of the first week. A little later the hands will be
observed to tremble when held up, and still later twitching of the
tendons at the wrist may be appreciable while the pulse is being felt.
When muttering delirium supervenes this subsultus tendinum becomes
constant, and extends to other parts of the body. The hands of the
patient are frequently then in constant motion, either picking at the
bed-clothes--a very unfavorable symptom--or moving in an objectless
manner through the air. This condition presents many points of
resemblance to that often seen in delirium tremens, and is said to
come on earlier and to be more marked in those who are addicted to the
abuse of alcoholic liquors. Hiccough is occasionally observed toward
the close of grave cases, and is justly regarded as a bad symptom.
Spasmodic contraction of various groups of muscles is occasionally
observed in severe cases, but is less frequent than muscular tremor,
and in my experience is generally met with in the earliest period of
the disease. The muscles of the extremities, especially those of the
legs, are oftenest affected, but I have known the head as rigidly
retracted as in tubercular meningitis, and have seen cases in which
strabismus has been an early symptom. Murchison has had patients under
his care who have suffered from constriction of the pharynx to such an
extent that they could not swallow. He also reports cases in which
trismus and spasm of the glottis have been present. General
convulsions are not common, but occasionally do occur. Although a very
grave symptom, they are not invariably fatal. Recovery took place in
one of two cases which came under my own observation, and in four of
the six recorded by Murchison. They are not always associated with an
albuminous {280} condition of the urine. In neither of my cases was
there albuminuria, and in only one of the four of Murchison's cases in
which the urine was examined was it present. In one of my cases--the
fatal one--the convulsions seemed to have been induced by giving the
patient improper food; in the other no cause could be discovered.
Ringing or buzzing noises in the ears are present in the early stage
of the disease in a large proportion of the cases, and may sometimes
persist until the disease is well advanced. Usually, however, after a
few days they subside and give place to deafness. This is a very
common symptom, and may either affect both ears or be limited to one.
In the former case it is probably generally due to the blunted
perceptions of the patient, although in a few instances it may be
caused, as suggested by Trousseau, by inflammation of the Eustachian
tube. When only one ear is affected the deafness is of more serious
import, as it is then dependent upon the presence of local
inflammation, which may possibly extend to the meninges. It is, as a
rule, most marked in the severest cases. Unless there has been a local
inflammation it is not followed by permanent impairment of the
hearing. It has even been regarded by some observers as a favorable
symptom, but this opinion does not appear to rest upon a more
substantial basis than the observation of Louis, that the most
profound deafness adds nothing to the gravity of the prognosis.
Imperfect or perverted vision occasionally occurs in the course of
typhoid fever. In a case which was recently under my care, and which
has already been referred to in another connection, there was double
vision associated with strabismus. Sometimes haziness of vision, and
sometimes even visual illusions, are observed. Bartlett and Murchison
have often known intolerance of light present in cases characterized
by active febrile excitement. As a general rule, the pupils are widely
dilated and the conjunctiva pearly white--a condition which is in
marked contrast with what is seen in typhus fever. When, however,
stupor supervenes in bad cases, the pupils are frequently as much
contracted and the conjunctivæ as much injected as in the latter
disease. In a few cases unequal dilatation of the pupils has been
noticed. Trousseau was accustomed in his clinical lectures to call
attention to the frequency with which sloughing of the cornea occurred
in the condition known as coma vigil, in which the patient lies with
his eyes wide open. He attributed this accident to the fact that the
eye in this condition is not kept constantly moist by the occasional
closure of the eyelids, and hence, as its innervation is also
impaired, is especially prone to take on ulcerative inflammation. In
other cases there is a free secretion of viscid matter, which often
glues the eyelids together.
The sense of taste is often lost or perverted. This is partly due to
impaired innervation of the tongue and palate, and partly to the thick
deposits which usually cover the mucous membrane of these organs.
Frequent observations of the temperature in typhoid fever not merely
give most important information in a diagnostic and prognostic point
of view, but also often furnish valuable indications for treatment.
From a close study of a large number of cases, Wunderlich and other
physicians have discovered that the pyrexia has certain characters
which distinguish it from other fevers, and which, being present in a
case in which the other symptoms are obscure or ill defined, will
often enable us to recognize {281} its true nature. The pyrexia may be
divided into three periods, each having its own peculiarities. It is
usually said that each period lasts about a week, but in severe cases
the second and third periods extend over a longer time than this, and
the occurrence of a complication or of any other disturbing influence
will have its effect in producing either a prolongation of any one or
more of these periods, and especially of the last two, or an unwonted
elevation or fall of temperature. During the first period there is a
progressive rise of temperature, but the rise is never so abrupt as in
typhus or in many of the phlegmasiæ. As there are morning remissions,
ranging from a degree to two degrees in extent, corresponding to the
morning fall in the daily variations of temperature, the tracing upon
the temperature chart will be a zigzag line, each evening temperature
being from a degree and a half to two degrees higher than that of the
preceding evening, while the same difference will be observed in the
morning temperature. The temperature ought, therefore, never in an
uncomplicated case to be much over 100° on the first evening or 102°
on the second. A temperature of 104° at any time during the first or
second day will consequently exclude typhoid fever from the diagnosis.
From six to eight days are usually occupied before the maximum is
reached. I have seen it attained as early as the fourth day in mild
cases, and, on the other hand, not until much later in severe ones. It
is usually 104° or 105°, but will of course vary with the gravity of
the other symptoms. The temperature rarely rises higher than 106° at
this period. On the other hand, I have known cases in which it never
exceeded 103° during their whole course. It would therefore be wrong
to exclude typhoid fever from the diagnosis, as Wunderlich does, if
this temperature is not reached by the sixth, or at latest the eighth,
day.
[Illustration: FIG. 12. Chart of typical range of temperature in
typhoid fever, after Wunderlich.]
In the next period the temperature usually ceases to rise, but has a
tendency to oscillate about the maximum temperature of the previous
period as a fixed point, occasionally not quite reaching it, at other
times rising a little above it. The morning remissions, too, become
less decided. In other words, the fever now becomes continuous. This
period, although usually lasting about a week, may extend over more
than two weeks, even in the absence of complications, in cases which
run a severe course, and when it is prolonged from this cause the
temperature may again show a tendency to rise, and may even attain an
elevation considerably above that of the preceding period. The
prognosis in all such cases in which the temperature rises after the
middle of the second week is grave. Temperatures of 108°, and even of
110.3°, have been noted at this time. Death invariably follows such
high temperatures as these, but before death actually occurs a
considerable fall of temperature very often takes place. Wunderlich
has also called attention to the fact that it is not uncommon for a
sudden and temporary remission of temperature to take place at this
stage, varying from one degree to two degrees and a half, which may
last from ten to twelve hours, and which usually has occurred in his
experience from the sixteenth to the eighteenth day. Toward the close
of the second period the morning remissions will be observed to be
more decided, while the evening temperature remains about the same as
before. The beginning of the third period is indicated by a diminution
of the evening exacerbation, while the morning remissions become still
more marked. The diminution is progressive, but slow, the {282}
temperature each evening falling short by from half a degree to a
degree of the point it reached the preceding evening. The morning
remissions, on the other hand, each day become greater, a fall of
three and a half degrees being not uncommon. The lysis, therefore,
occupies usually a longer time than was required by the pyrexia in
reaching its maximum. Toward the close of this period the morning
temperatures may be normal, as even subnormal, while an elevation of
temperature may continue to take place in the evening. Occasionally,
however, an abrupt defervescence takes place. The duration of this
period will be very much prolonged if complications are present or if
the intestinal ulcers are slow in healing. I have known it to last for
more than three weeks. During convalescence the temperature is
frequently subnormal even in the evening, but the slightest cause is
often sufficient to produce a considerable though temporary elevation
of temperature. I have known the temperature in one case to rise from
99° F. to 105.6° in a few hours in consequence of an indiscretion in
diet, and in another from 100° to 104° from the suffering and
excitement caused by a severe attack of toothache. Indiscretions in
diet are a fruitful source of these recrudescences of fever. The fever
of the third period has all the characters of an irritative fever, and
is probably kept up by the irritation arising from the intestinal
ulcers. On the other hand, that of the first two periods is due to the
action of the specific poison upon the nervous system and the other
tissues of the body, and corresponds exactly with the primary fever of
the eruptive diseases.
{283} [Illustration: FIG. 13. Chart showing recrudescence of fever
from indiscretion of diet.]
The febrile movement, however, rarely follows a perfectly typical
course, and I consequently find, in looking over the temperature
sheets of a large number of cases, very few which bear, except during
the first period, anything more than a general resemblance to the
chart which {284} Wunderlich has prepared as typical. A very slight
cause will exercise, as has already been said, a disturbing influence
upon the course of the fever, and serious complications or accidents
will of course produce a still more marked effect. An intestinal
hemorrhage, for example, will cause a rapid and decided fall of
temperature. I have often known it to fall from 104° to the normal
temperature, or even below it. This depression, unless the bleeding
continues and the case ends fatally in the course of a few hours, is
only temporary, the temperature rising within twenty-four hours to its
former height, and sometimes even beyond it. A free epistaxis or a
copious diarrhoea will in the same way cause a fall of the
temperature, but it is rarely so marked as in the preceding case. The
same effect is produced by the administration of large doses of quinia
or by the application of cold water either in the form of the bath,
the douche, or any other form, to the surface of the body. On the
other hand, the occurrence of a complication will cause a rise of
temperature, often considerably above the maximum of the first period.
[Illustration: FIG. 14. Chart showing fall from intestinal
hemorrhage.]
The thermometer should be used at least twice daily. In this country
it is generally introduced into the axilla, and less frequently into
the mouth, for the purpose of making an observation. In other
countries it is not infrequently inserted into the rectum, and even
into the vagina. The best hours for making the thermometric
observations are eight in the morning and eight in the evening, since
it has been ascertained from {285} frequent observations that the
daily remissions are more marked between the hours of 6 and 8 A.M.,
and that the temperature usually reaches its maximum some time between
those of 7 and 12 P.M.
Loss of appetite is, except in mild cases, one of the earliest
symptoms of the disease, and usually persists as long as the fever
lasts. It is sometimes accompanied by positive loathing for food, but
generally there is no great difficulty in persuading the patient to
take the necessary amount of nourishment. During convalescence the
appetite returns, and is occasionally immoderate, so that it is
frequently necessary to curb it lest harm should be done by over
indulgence.
Thirst, usually proportionate to the degree of fever, is also present
in the beginning of the fever. Later, when the patient sinks into a
semi-unconscious condition and becomes insensible to the wants of the
system, he will cease to call for water, although it is still urgently
needed.
Nausea and vomiting sometimes occur at the beginning of the disease,
but they have not been such frequent symptoms in my experience as they
would appear to have been in that of Murchison, who says that they are
of such common occurrence that the patient is often supposed at first
to be suffering merely from a bilious attack. He does not regard them,
when occurring at this stage, as serious symptoms. Indeed, he
expresses the belief that the subsequent course of the disease is
sometimes favorably modified by them. They may also occur later in the
disease, and are then of grave import, as they are not infrequently
the consequence of peritonitis. Louis regarded vomiting as a grave
symptom, but it is probable it occurred in the cases from which he
makes his deductions late in the course of the disease. It may
sometimes occur during convalescence, and may then interfere very
materially with the proper nutrition of the patient. The matter
vomited usually consists of a greenish bilious fluid, with the food
last taken. In some cases blood has been thrown up.
The tongue at the beginning of an attack of typhoid fever is usually
moist and coated with a thin white fur, and in mild cases may retain
these characters until the close. Even in some cases which terminate
fatally in the course of the second week, the tongue, with the
exception of being less moist than in health, may present no marked
deviation from this appearance. Generally, however, as the disease
progresses, and sometimes as early as the tenth day, it becomes dry
and brownish, and is protruded with a tremulous motion. Still later it
tends to cover itself with a thick brown coating. This coating is
disposed principally along the middle of the organ, leaving uncovered
the edges and tip, which are very apt to be unnaturally red in color.
The bare portion at the tip is often rudely triangular in shape--a
point which is regarded as of some importance in the diagnosis of the
disease by Da Costa. In bad cases, during the course of the third week
the tongue is frequently crossed by cracks and fissures, which are the
cause of much discomfort to the patient, and when deep may bleed and
leave behind them scars which are recognizable during the remainder of
his life. In other cases the tongue is dry, brown, and shrivelled, or
covered with a tenacious, viscid secretion which renders it difficult
to protrude it.
In favorable cases, as convalescence approaches the tongue regains by
degrees its normal appearance. At first the only noticeable change may
{286} be that the organ is a little less dry than before. In a few
days it will be observed to have become moist and to be gradually
throwing off its coating. The process is, however, a slow one, and
one, moreover, subject to frequent interruption. Very often, when it
seems nearly completed it will be suddenly arrested, and the tongue
become dry and brown. Sometimes, instead of cleaning itself gradually,
the tongue throws off its coating in large flakes, leaving the mucous
membrane red and shining, as if deprived of its papillary structure.
Wood was accustomed to teach that if the tongue when thus cleaned
remained moist convalescence might be expected, but would always be
tedious. This is an observation the correctness of which I have had
abundant opportunity to confirm. If anything happens, however, to
interfere with the progress of convalescence, it not infrequently
becomes dry and coats itself over again. When the restoration to
health is retarded by the continuance of diarrhoea or by the
occurrence of any intercurrent affection, the tongue will often become
pale and flabby and be the seat of superficial ulcerations or of
aphthous exudations.
The mucous membrane of the posterior fauces is also often red and dry
and covered with a glutinous secretion, which often materially
interferes with swallowing. The lips and teeth are in bad cases
encrusted with sordes, and the former are dry and cracked, and bleed
readily when picked.