typhoid fever, having been noted by Murchison in 79 out of 100 cases,
and by Hale in 130 out of 179 cases, and in only 43 of the remainder
of his cases is it expressly stated to have been absent. My own
experience leads me to believe that it is present in even a larger
proportion of cases; in fact, that it is rarely absent. It is, as a
rule, later in making its appearance than the other abdominal
symptoms, showing itself usually about the end of the first or the
beginning of the second week. It is generally most marked in grave
cases, especially those attended by severe diarrhoea, but I have seen
it highly developed in cases in which the symptom was not present at
all or but little developed. It may vary, moreover, frequently in
degree at different times in the same case, but when once present
generally persists until convalescence is established or death occurs.
When extreme, it may give rise to distressing dyspnoea by preventing
the descent of the diaphragm.
The meteorism is usually preceded and accompanied by gurgling and
tenderness on pressure in the right iliac fossa. The former of these
symptoms is most marked in cases in which diarrhoea exists, and is
caused by the presence of liquid and gas in the lower part of the
ileum. The tenderness is unquestionably due to the presence of ulcers
in the same part of the bowel. There is also occasionally pain in the
region of the umbilicus, but this is a much less frequent symptom.
Enlargement of the spleen was noted by Hale as being present in some
of the cases which he has described. It is a frequent symptom of the
disease, and may be generally demonstrated by percussion in the course
of the second week. It has not, however, often happened to me to be
able to feel the organ enlarged through the abdominal walls, as
Murchison asserts he has been able to do. Indeed, tympanites is
usually present in a sufficient degree to render this difficult. The
enlargement {287} occurs more frequently in persons under thirty years
of age than in those over it.
Diarrhoea is one of the most frequent symptoms of the disease,
especially in severe cases, and there are very few mild cases in which
it does not occur at some period of their course. Louis noted it in
all but three of his fatal cases, Murchison in 93 out of 100, and M.
Barth in 96 out of 101. It varies in different cases in severity, in
duration, and in the time at which it appears. It may be one of the
earliest symptoms, presenting itself frequently on the first day, and
often being the only one which occasions uneasiness to the patient or
his physician. At other times its appearance may be postponed until
the end of the first week, or even until the patient is apparently
entering on convalescence. It may be mild in the beginning and become
more severe as the disease progresses, or after having been at first
acute may cease spontaneously in a few days to occasion any
uneasiness. In degree it may vary from two stools to three or four, or
even twenty, in the course of the twenty-four hours. It is absent in a
few cases, but in many even of these cases the bowels will be found to
act inordinately after a very moderate dose of purgative medicine. I
have known, for instance, the administration of a single teaspoonful
of castor oil to be followed by five or six stools in an adult.
Constipation does, however, actually exist in a certain number of
cases. Murchison has known the bowels in cases in which a relapse has
occurred to be constipated in the primary attack and relaxed in the
relapse. There is no relation between the severity of the diarrhoea
and the extent of the local lesion. Although oftenest met with in mild
cases, constipation has existed in cases in which perforation of the
bowel or intestinal hemorrhage has occurred during life, or very
extensive lesions been found after death.
The stools are fetid and ammoniacal, and are alkaline in reaction,
instead of acid as in health. They are usually liquid and of the color
of yellow ochre. Murchison says that they separate, on standing, into
two layers--a supernatant fluid and a flaky sediment--but that,
occasionally, instead of being watery they are pultaceous, frothy, and
fermenting, and so light as to float in water. I have myself often
seen the appearance which Bartlett compares to that of new cider. They
may contain blood, and when they do, occasionally present the
appearance of coffee-grounds. They are not infrequently, in grave
cases, passed involuntarily.
Intestinal hemorrhage is fortunately not a frequent symptom of typhoid
fever. It may occur as early as the fifth or sixth day, but is more
common after the middle of the second week or in the third or fourth
week. In 60 cases observed by Murchison in which the hemorrhage
exceeded six ounces it began during the second week (mostly toward its
close) in 8; during the third week in 28; during the fourth in 17;
during the fifth in 1; during the sixth in 3; during the seventh in 1;
and during the eighth week in 1; while in one case the date of its
occurrence is not noted. In the cases observed by Liebermeister and
Griesinger, 113 in all, the bleeding took place in a much larger
proportion of cases at an early period of the disease, occurring in as
many as 43 in the second week, and in only 27 during the third. In 7
cases in which I had the opportunity of observing it in patients under
my own care it occurred on the seventeenth day in 1; on the
twenty-third day in 1; during the {288} third week in 2; during the
fifth week in 2; and on the fifth day of a relapse in 1. There may be
a single hemorrhage, or the bleeding may be repeated one or more
times. In 5 of my cases there was a second hemorrhage, and in 2 of
them a third; and in several of Murchison's cases it recurred at
varying intervals after its first appearance.
When the bleeding occurs early in the disease it is usually
insignificant in amount, and is due either to extreme congestion of
the mucous membrane of the intestine, giving rise to rupture of the
capillaries, or to disintegration of the blood, allowing its ready
passage through the walls of the vessels. In the latter case it
usually coexists with petechiæ or a hemorrhage from some other part of
the body, as, for instance, epistaxis or hematuria. After the middle
of the second week the hemorrhage is generally the result of the
laying open of a small artery, either by the detachment of a slough
from one of the glands of Peyer or by the involvement of its walls in
the ulcerative process. It is then often profuse, and may even reach
several pints in quantity. Murchison has, however, seen profuse
hemorrhage at such an early stage of the disease that it was
impossible that ulceration could have taken place. The blood is not
always voided immediately after a hemorrhage has taken place; it may
be retained for some days. Indeed, if the amount be large the patient
may die within a few hours of its occurrence without any appearance of
blood externally. This is, however, rare; it is more usual for the
hemorrhage to be repeated before death takes place, but the occurrence
of the bleeding may be suspected in such cases by the abrupt fall of
temperature, sometimes below the normal standard, and by the extreme
prostration and pallor which come on suddenly without other assignable
cause. The depression of the temperature does not continue long. It
generally reaches its former elevation, or even exceeds it, in the
course of twenty-four hours.
There would appear to be a slight difference in the frequency with
which intestinal hemorrhage occurs in different times and at different
places. Murchison noted it in 58 cases of 1564, or 3.77 per cent.;
Louis in 8 cases of 134, or 5.9 per cent.; Liebermeister in 127 cases
of 1743, or 7.3 per cent.; Griesinger in 32 cases of 600, or 5.3 per
cent.; and I have noted it 7 times in 81 cases, or in about 8.5 per
cent. Liebermeister makes it twice as frequent in women as in men. It
seems to be much less common in children than in adults, for in 252
patients under fifteen years of age observed by Taupin, Rilliet, and
Barthez it occurred in 1 only. There is considerable diversity of
opinion among observers in regard to the importance of this symptom.
Murchison lost 32 of his 60 cases. In 11 of the 32 fatal cases the
immediate cause of death was peritonitis; in 14 of the remaining 21
cases the patients died within three days of the bleeding, and in 8 of
the 14 within a few hours. Of Liebermeister's 127 cases 49, and of
Griesinger's 32 cases 10, terminated fatally; 3 of my own cases ended
in death, but none of them until several days had elapsed after the
bleeding. In the face of facts such as these there have not been
wanting authors to assert that the effect of the hemorrhage was
sometimes beneficial. Chief among these are the celebrated Irish
physician Graves and his devoted admirer Trousseau. There may
occasionally be a slight subsidence of the nervous symptoms upon the
occurrence of a hemorrhage, consequent upon the reduction of
temperature {289} which usually accompanies it, but this relief is
only temporary, and procured at too great expense to be really of
service to the patient.
The bleeding is most frequently observed in bad cases. All the cases
which were under my care in which it occurred were of great severity
from the very start. In 18 of Murchison's 60 cases the antecedent
symptoms were mild. In 3 of my cases there was severe diarrhoea. In 2
of the other cases, 1 of which was fatal, the bowels were constipated,
and in another one, also fatal, they were slightly loose. In 8 of
Murchison's cases, 6 of which were fatal, the bowels had been
constipated up to the time of its occurrence. The blood, if voided
immediately after its escape into the intestines, is generally fluid
and bright red in color. When retained for a day or two it is passed
in dark clots, and if retained longer than this it is usually mixed
with fecal matter when discharged from the bowels, and gives the
stools a tarry appearance and consistence, which is not always
recognized by inexperienced attendants as due to blood.
It has been asserted that intestinal hemorrhage has become more
frequent since the introduction of the cold-water treatment, but
Liebermeister shows this to be an error, for he has found that of 861
cases treated before the introduction of this treatment, 72, or 8.4
per cent., had intestinal hemorrhage, but that of 882 cases treated
since its introduction hemorrhage occurred in 55, or in 6.2 per cent.
Other methods of treatment have also been charged with inducing a
tendency to hemorrhage, but probably not upon more substantial grounds
than the above.
The occurrence of perforation may be suspected when the patient is
suddenly seized with acute pain in the abdomen, accompanied by
symptoms of collapse and occasionally by rigors. The fall of
temperature is often considerable. Liebermeister refers to one case in
which it was as much as 5-1/2°, or from 104° to 98-1/2°. Very soon the
abdomen becomes tender on pressure, and, if it were not so before,
hard and tympanitic; the pulse grows frequent, small, and sometimes
almost imperceptible; the breathing is thoracic; the physiognomy
expresses great suffering; the features are contracted, and the face
is bathed in profuse perspiration. Nausea and vomiting come on soon
after inflammation has commenced, and rapidly exhaust the patient. The
decubitus is dorsal, and the legs are generally drawn up so as to
relax the abdominal muscles. Prostration rapidly increases until death
puts an end to the patient's sufferings. Occasionally, the symptoms
are more obscure. Pain and rigors may both be wanting, and nothing but
the extreme prostration, the frequent and feeble pulse, and the
distended condition of the abdomen will indicate the gravity of the
danger. This is not infrequently the case in delirious patients. Death
may take place during the collapse, but this is rare. It more
frequently takes place on the second or third day; on the other hand,
it may be postponed until much later. Liebermeister and Murchison
refer to cases in which there was an interval of two or three weeks
between the first symptom of perforation and the fatal result.
Perforation of the intestine was formerly regarded as an inevitably
fatal accident, but this view is no longer entertained. I have had
under my observation cases in which all the symptoms of this accident
were present, and in which recovery took place. In some of these cases
there {290} may have been an error of diagnosis, but all of them will
not admit of this explanation. Moreover, cases of a similar character
have been reported by physicians whose skill in diagnosis is
universally recognized. Thus, Murchison reports six such cases,
Tweedie two, and Wood one. Liebermeister and Bristowe[53] also both
say that recovery is possible. This view is sustained by the results
of certain autopsies. In one of these, reported by Buhl,[54] a
perforation was found completely closed by adhesions to the mesentery,
and in others reported by Murchison partial adhesion had taken place
between the edges of the perforation and the abdominal walls or to an
adjoining coil of intestine. Occasionally, the inflammation excited by
the perforation may be circumscribed and terminate in an abscess,
which may permit recovery by discharging itself into the bowel or
externally. At other times, however, it ruptures into the peritoneal
cavity, when death speedily ensues.
[Footnote 53: _Transactions of the Pathological Society of London_,
vol. xi. p. 115.]
[Footnote 54: Cited by Murchison.]
Perforation is, fortunately, not a frequent accident in typhoid fever.
It was the cause of death in 20 only of 250 fatal cases collected by
Hoffmann. It occurred, according to Liebermeister, in only 26 cases, 3
of which ended in recovery, in more than 2000 cases observed at the
hospital at Basle. Murchison observed it 48 times in 1580 cases,
Griesinger 14 times in 118 cases, and Flint twice in 73 cases.
Murchison found that in a total of 1721 autopsies, the details of
which were collected from various sources, it was the cause of death
in 196, or 11.38 per cent. It would appear to be rather more common on
the continent of Europe than in England or in this country.
Perforation is much more frequently met with in men than in women. The
patients were men in 15 of 21 of Liebermeister's cases, in 51 of 73 of
Murchison's, and in 72 of 106 cases collected by Näcke. It is rarer in
children than in adults. Rilliet, Barthez, and Taupin met with it only
three times in 232 children under treatment. Murchison has, however,
had a fatal case in a child of five years of age. It is also not
common after forty years of age, but does occasionally occur, although
the contrary has been asserted.
Perforation is most likely to happen during or after the third week of
the disease, but it has been met with as early as the eighth day, as
in a case reported by Peacock. On the other hand, in three cases cited
by Morin[55] it did not occur until the seventy-second, seventy-sixth,
and one hundred and tenth day, respectively. Instances are on record
in which it has taken place after the patient was supposed to be
thoroughly convalescent and had returned to his occupation. When it
occurs early it is due to the separation of a slough. After the middle
or end of the third week it is probably always the result of the
extension of the ulcerative process to the peritoneal coat. In a large
proportion of cases the perforation has been preceded by symptoms of
great gravity, such as severe diarrhoea, great tympany and tenderness
of the abdomen, and intestinal hemorrhage, but in a certain number of
instances the cases in which it has occurred have been of a mild
character, the patient in many of them not considering himself sick
enough to take to his bed or even to abstain from his daily labor.
After death the perforating ulcer has been found to be the only one.
[Footnote 55: Quoted by Murchison.]
The most frequent causes of perforation are the irritation arising
from {291} indigestible and unsuitable food, distension of the bowels
by feces or gas, vomiting, and movements on the part of the patient.
Liebermeister calls attention to the frequency with which ascarides
are found in the intestines of those who die of perforation, and is
inclined to think they may have something to do with causing it.
Morin[56] reports a case in which the perforation appeared to be
caused by the administration of an enema.
[Footnote 56: Quoted by Murchison.]
For our knowledge of the changes in the composition of the urine we
are largely indebted to Parkes and certain German observers. As the
disease generally begins insidiously, the condition of the urine
before the attack and during the first two or three days has not been
ascertained with certainty. During the latter part of the first week
the amount of water is greatly diminished, occasionally falling to
one-fourth or one-sixth of the usual quantity. In the second and third
weeks it increases, and at the end of the fourth week may again be
normal. The amount may, however, vary from day to day, but its
variations do not stand in close relation to those of the febrile
heat; that is, the thermometer may mark one day 104°, and the next day
100°, while the amount of urine remains the same. Still, when the
temperature begins to fall permanently it increases at once, or,
according to Thierfelder, two or three days after. The specific
gravity is usually high in almost all cases in which the urine is
scanty, and may be as high 1038. With the establishment of
convalescence the specific gravity often diminishes before the water
begins to increase. In other words, the lessening of the solids of the
urine frequently takes place prior to the increase of the water.
The reaction of the urine is very acid in the beginning, but the
acidity is not due to an increased secretion of acid, but simply to
concentration. Later it may become alkaline, and even ammoniacal. The
color of the urine is darker than in health during the early part of
the febrile period. This is due partly to concentration, and partly to
increased disintegration of the blood-corpuscles, which is a
consequence of the fever.
The quantity of urea is augmented during the fever, and especially
during the first week, when the water and chlorides of sodium are most
diminished. As a general rule, the higher the temperature the greater
the amount of urea. It may, however, be very much diminished during
the presence of inflammatory complications. On the other hand, it is
not affected by diarrhoea. Uric acid is uniformly increased, the
amount of increase being relatively greater than that of the urea; it
is often doubled, and sometimes the increase is even more than this.
This increase takes place, according to Zimmer, up to the fourteenth
day. It diminishes after this, and during convalescence may fall below
the normal amount. Copious deposits of urates may occur at any time in
the course of the disease. The chloride of sodium is usually
diminished in amount. This diminution is partly due to a less amount
of this salt being taken with the food, and partly to the fact that
large quantities of it pass away with the stools. As the diminution
cannot always be fully accounted for in this way, it would appear that
it is also stored up in the body during the fever. In cases in which
sweating and purging are absent the sulphuric acid is increased in
amount. The phosphoric acid is at first slightly diminished, but later
undergoes an increase. The hippuric acid is also diminished.
{292} Parkes found albumen in the urine in 7 out of 21 cases. In 5 of
these it was temporary, and entirely disappeared before the patients
left the hospital. Becquerel found it in 8 out of 38 cases, Andral in
only 4 out of 34 cases. Griesinger found it commonly, though it was
usually temporary. He met with only four or five cases in which it was
never present. Kerchensteiner found albumen in a fourth part of the
severe cases. Brattler noticed it in 9 out of 23 cases. I have very
frequently found it myself, but it has always been in my cases a
temporary phenomenon. Desquamative nephritis may occur occasionally in
the course of typhoid fever, and give rise to the appearance of a
large amount of albumen in the urine, and also occasionally of blood.
Renal epithelia and casts are sometimes seen in cases in which there
is albuminuria, but usually soon disappear. Zimmermann asserts that in
all but very slight cases casts may be found even when no albumen can
be detected. The statement is probably too general, but there is no
doubt of the occasional presence of casts under these circumstances.
Bladder epithelia and pus-cells are seen in a few cases in small
quantities, but decided cystitis is rare, unless it has ensued upon
retention of urine. Sugar has not been found except in the urine of
diabetic patients, who may have happened to contract typhoid fever. In
these patients the sugar diminishes, and is sometimes wholly absent
during the continuance of the fever. Leucin and tyrosin have been
found by Frerichs, but at present no observations have been made as to
the frequency or import of their occurrence.
In many cases, when the prostration is extreme, the urine is passed
involuntarily, but in some of these cases the incontinence of the
urine is only apparent, and is really the result of over-distension of
the bladder. This is a condition which is very apt to be overlooked,
and I have known paralysis of the bladder to result in consequence of
this neglect, and to continue sometimes after convalescence has been
established.
COMPLICATIONS AND SEQUELÆ.--Although cerebral symptoms are among the
commonest manifestations of the disturbing effects produced in the
economy by the typhoid fever poison, they are almost always
independent of inflammation of the brain and its membranes. In a few
cases, however, the lesions of meningitis have been found after death.
In some of these it has come on without assignable cause, in others it
has been the consequence of pyæmia, of tubercles, or of the extension
of inflammation from the petrous portion of the temporal bone.
Occasionally, during convalescence, some impairment of the intellect
is observed. This may consist in simply some loss of memory or
childishness of manner. At other times delusions of a mild form are
present, or else the patient is liable to attacks of acute mania,
sometimes violent, coming on suddenly and without fever. In a few
instances the moral sense seems to have been perverted, as in the case
reported by Dr. Nathan Smith, already referred to, in which a young
man of previously good character developed a propensity to steal after
his attack. Recovery with the re-establishment of the physical health
almost occurs in these cases. Murchison says he knows of no case in
which this condition has been permanent. On the other hand, Dr. C. M.
Campbell,[57] who had the opportunity of observing an attack of
typhoid fever among some insane patients {293} at the Durham County
Asylum, reports that the mental state was in no case injuriously
affected by the disease, but, on the contrary, underwent a marked
improvement in several of the cases. Indeed, in two of the cases, in
which the prognosis had become very unfavorable, mental recovery began
during the attack of fever.
[Footnote 57: _The Journal of Mental Science_, July, 1882.]
Paralysis, muscular tremors, and chorea are also occasionally observed
after attacks of typhoid fever. According to Murchison, paralysis does
not supervene until several weeks after the commencement of
convalescence. It may last for several weeks or months, but recovery
in the majority of instances eventually takes place. According to
Nothnägel,[58] the most common form is paraplegia, but it may also
take the form of hemiplegia, strabismus, paralysis of the portio dura,
motor paralysis of individual spinal nerves, such as the ulnar or
peroneal, or local anæsthesia. On the other hand, neuralgias and
disturbances of sensation are not common sequelæ of typhoid fever.