Bartholomew's Hospital Report_, vol. xii.]
Degeneration of the muscular tissue of the heart is probably present
in some degree in every case of typhoid fever, being, of course, most
marked in the severest cases. There would seem, however, to be no
special tendency to disease of its valves or membranes. Arterial
thrombosis or embolism, giving rise to gangrene of the part supplied
by the obstructed artery, is of occasional occurrence. Patry,[59]
Hayem,[60] Trousseau,[61] and others report or refer to several cases
in which gangrene of the leg, hand, or cheek was observed, and among
others a case in which sphacelus depending upon obstruction of the
carotid artery, the result, as Patry thought, of arteritis, commenced
in the left ear, and extended from there to the forehead and
cheek.[62] A. Martin[63] reports the case of a woman who expelled from
the vagina a fetid-smelling structure of cylindrical form, which
proved to be the cervix of the uterus, with the upper part of the
vagina, and in whom menstruation was not re-established until after
the performance of an operation. Spillmann[64] has also called
attention to the occurrence of gangrene of the vagina and vulva in
cases of typhoid fever. {294} This complication is generally met with
toward the end of the febrile period.
[Footnote 59: _Archives générales de Médicine_, 1863, vol. i. pp.
129-549.]
[Footnote 60: _Loc. cit._]
[Footnote 61: _Clinique médicale_.]
[Footnote 62: Since the above was written Barié has called attention
in the _Revue de Médicine_, Jan. and Feb., 1884, to the frequency with
which acute inflammation of the arteries occurs as a sequel of typhoid
fever. The author, whose investigations were limited to the larger
arteries, found that the vessels generally implicated are in the order
of their frequency, the posterior tibial, the femoral, and the dorsal
artery of the foot. The affection is usually unilateral, appears
during convalescence or when the patient leaves his bed, and occurs
just as often after light as after severe cases. He distinguishes two
varieties: 1, acute obliterating arteritis, and, 2, acute parietal
arteritis. The first variety is characterized by embryonal
infiltration of all the tissues, by disappearance of the smoothness of
the intima, which becomes uneven and granular, and by the formation of
a secondary thrombus, and almost invariably terminates in dry
gangrene. The second is merely an inflammation without such a clot,
and always terminates in recovery without gangrene.
The symptoms of obliterating arteritis are--pain, more or less sudden
in its onset, directly over the course of affected vessels, and
increased by pressure, by the erect position, and by walking;
diminution, and then absence, of pulsation; swelling of the limb,
without oedema or redness; and, later, the appearance of bluish
mottling of the surface, and, more rarely, of patches of purpura;
lowering of the temperature, with or without troubles of sensibility,
such as formication, anæsthesia, etc., and the appearance of a hard
and painful cord, due to the formation of the thrombus. In the
parietal form the diminution of the pulsations is sometimes preceded
by a considerable exaggeration of their amplitude, and, while the
temperature on the affected side is usually lowered, it may sometimes
be increased.]
[Footnote 63: _Centralblatt f. Gynakol_, 1881.]
[Footnote 64: _Archives générale_, Mars, 1881.]
Venous thrombosis, the result of weakness of the heart's action, is
more frequently observed. It occurs generally during the convalescence
of cases which have run a severe course, and usually affects the veins
of the lower extremities. I have seen both the femoral veins
obstructed from this cause at the same time. All the cases which have
come under my own observation have ended in recovery, and only 2 of 31
collected by Liebermeister terminated fatally. Death occurred in 3 of
the 17 cases collected by Murchison, but in none of them was this
result attributable to this complication alone. There is, however,
always danger of a portion of the thrombus becoming detached and
producing embolism of the pulmonary artery.
Pyæmia is said by Murchison and other authors to be an occasional
complication, but it is certainly rare in this country. In the milder
cases abscesses form during convalescence beneath the skin in
different parts of the body. In the more severe cases pus is deposited
in the joints or in the internal organs. Albert Robin[65] has reported
two cases in which there was suppurative joint affection. In one of
these the joints of the fingers and toes, with the sheaths of the
corresponding extensor tendons and both knee-joints and one
shoulder-joint, were affected. In the other the left knee was filled
with pus. In both cases the fever soon assumed an adynamic character.
[Footnote 65: _Gazette de Paris_, 1881.]
Laryngitis may sometimes occur in the course of typhoid fever, and
when it assumes the diphtheritic form and runs on to the formation of
ulcers is a very serious complication of typhoid fever, as it is not
infrequently accompanied by oedema of the glottis and gives rise to
the necessity for tracheotomy. It is fortunately, at least in its
worst forms, rare in this country. In Germany, judging from the number
of cases collected by Hoffmann and Griesinger, it is of more common
occurrence. The ulcers are oftener met with in some epidemics than in
others. During the winter of 1860-61, which I passed in Vienna, the
frequency with which they occurred was the subject of remark among
those who were in attendance upon the various clinics.
I have already called attention to the frequency with which bronchitis
in some form or other attends upon typhoid fever. When it invades the
smaller bronchial tubes it occasionally gives rise to lobular
pneumonia or to collapse of some of the lobules of the lung. Lobar
pneumonia may also occur in the course of typhoid fever. It was
observed 52 times in 1420 cases of typhoid fever under treatment at
the Basle hospital from 1865-68. When it comes on late in the disease,
especially if the patient is comatose, or even semi-conscious, it may
be entirely overlooked, unless the lungs are carefully examined, as it
often does not reveal itself to us by any of the ordinary symptoms. It
may, however, occur early, and I have known it so prominent in the
beginning of an attack that the existence of typhoid fever was not
suspected. It sometimes terminates in abscess or gangrene, but is more
usually followed by chronic pneumonia, which may eventually either end
in recovery or lay the foundation for phthisis. Pleurisy with effusion
is also not an uncommon complication. It was observed, according to
Liebermeister, at the hospital at Basle 64 {295} times in 1743 cases
of fever. It is also a serious complication, as 21 of the 64 cases
terminated fatally. Murchison refers to three cases in which it was
followed by empyema. Other morbid conditions of the respiratory organs
which may occur as complications of typhoid fever are oedema,
infarction, hypostatic congestion of the lungs, emphysema, and
pneumothorax. Acute miliary tuberculosis is also an occasional
complication, but is oftener met with as a sequel. According to
Liebermeister, the tendency to pulmonary complications has diminished
since the introduction of the cold-water treatment.
Catarrhal or diphtheritic inflammation of the fauces and pharynx
occurs in a large number of cases, and frequently gives rise to a
great deal of difficulty in swallowing. Indeed, it has been so
frequently observed in some epidemics that a few writers have regarded
it as a symptom rather than a complication of the disease. Either of
the varieties of inflammation may extend through the Eustachian tube
to the middle ear and be the cause of deafness, which usually passes
off as the inflammation subsides. Occasionally, however, the affection
of the middle ear gives rise to perforation of the tympanum or to
caries of the petrous portion of the temporal bone.
Murchison says he has known the symptoms of and lesions of dysentery
to coexist with those of typhoid fever in several cases, and
Liebermeister asserts that diphtheria of the intestinal mucous
membrane is an occasional sequel to severe cases, especially when
other mucous membranes are the seat of diphtheritic inflammation. In a
few instances which have come under his observation it had given rise
to perforation of the bowel or to gangrene of the intestinal mucous
membrane.
Jaundice occasionally occurs in the course of the disease. I have
never happened to see this complication, and am inclined to think it
is rare in this country. Liebermeister, however, met with it 6 times
in 1420 cases, and Griesinger 10 times in 600 cases. Hoffmann found it
in 10 of 250 fatal cases, and Murchison was able to collect 9 cases,
all of which but one terminated in death. Several of Griesinger's
cases, however, ended in recovery. In a few cases the jaundice may be
attributed to catarrh of the biliary ducts, but this solution of the
question will not explain those cases in which the feces remain
colored throughout. In fatal cases marked degeneration of the liver
has been found, which Liebermeister regards as of similar character to
that which occurs in acute yellow atrophy. In two of Murchison's cases
the liver was small and its secreting cells loaded with oil. In most
cases it does not appear until late in the disease, but it has been
observed as early as the fifth day.
Abscess of the liver and diphtheritic inflammation of the mucous
membrane of the gall-bladder are among the rarer sequelæ of typhoid
fever.
Peritonitis is the most serious of all the complications of typhoid
fever. Its most common cause is perforation of the bowel, but it may
also be due to the extension of inflammation to the peritoneal
membrane without ulceration. Liebermeister believes that it is
sometimes the result of the typhoid infiltration so frequent in
various tissues of the body taking place in the serous membrane. In
other cases it arises from the rupture of softened mesenteric glands,
of softened {296} infarctions in the spleen, or of the abscesses which
are sometimes the consequence of the circumscribed inflammation by
which perforation is occasionally prevented from proving immediately
fatal. Less frequent causes of it are rupture of the gall-bladder,
with the escape of gall-stones into the cavity of the abdomen,
abscesses of the ovary, and abscesses in the walls of the urinary
bladder. It is said by Murchison to have been in one case the result
of a pseudo-abscess in the sheath of the rectus muscle bursting
inward.
Swelling of the parotid gland occasionally occurs in typhoid fever,
but is much less common than in typhus. It is most frequently met with
in bad cases about the end of the third week or later, and generally
involves one side only. The swelling is hard and firm in the
beginning, and may terminate in resolution or suppuration. I have seen
it three times only, twice in my own practice, and once in that of a
medical friend. One of my cases was fatal, the other ended in
recovery, as did, I believe, the third case. Murchison saw it in only
6 cases, 5 of which were fatal. According to Hoffmann,[66] 16 cases of
suppurative parotitis were found at Basle among about 1600 typhoid
fever patients, 7 of the 16 ending fatally. Parotitis without
suppuration occurred three times. In 15 cases the attack was confined
to one side, 9 times to the right and 6 to the left; in 4 it was
double. Trousseau[67] looks upon these swellings as a very grave
accident, and says that he has scarcely ever seen a case recover in
which it has occurred, either in the course of typhoid fever or any
other disease. Chomel, on the other hand, is said to have regarded
them as critical and auspicious.
[Footnote 66: Quoted by Liebermeister.]
[Footnote 67: _Clinique médicale de l'Hôtel Dieu_, t. i. 1861.]
Menstruation occasionally occurs during typhoid fever, and may be
profuse. Bartels,[68] who has investigated the histories of 172
patients in reference to this point, says that the catamenia always
appear if the menstrual period falls within the first five days of the
fever, and that they do so in two-thirds of the cases if they are
expected between the sixth and fourteenth days. On the other hand,
menstruation does not occur if the time for it falls in the third
week. He says also that the catamenia generally appears about the time
they are expected, or later, and very seldom earlier. Liebermeister,
on the contrary, says that they often occur prematurely. Other uterine
hemorrhages seldom occur, and never in those who have ceased to
menstruate or in whom the function has not been established.
[Footnote 68: _Petersb. Med. Wochenschr._, 1881.]
Suppuration of Bartholini's glands is said by Speilman to have taken
place in one case.[69] In the fourth week the patient complained of
violent pains in the right nympha, which, upon examination, was found
to be swollen. A tumor as large as a nut, which was red and painful on
pressure, could also be felt in the vagina.
[Footnote 69: _Arch. générales_, Mars, 1882.]
Pregnancy was formerly thought to confer an entire immunity from
typhoid fever, but recent and accurate investigations have shown that
if this immunity really exists, it is only relative, not absolute.
Gusserow[70] says that the disease is more frequently met with in the
first half than in the latter half of pregnancy. Abortion under these
circumstances commonly occurs. Gusserow says that it takes place in
from 60 {297} to 80 per cent. of the cases. He believes it to be due
to the high temperature, which causes the death of the foetus, which
is then expelled from the uterus. In a few cases, however, the child
is born living. Of Murchison's 14 cases, 10 recovered, and two of the
ten patients carried the child, at the fourth and eighth months
respectively, throughout the attack. All the others miscarried or
aborted, only one of them being delivered of a living child. Out of 18
pregnant women[71] treated in the hospital of Basle for typhoid fever,
between the years 1865 and 1868, 15 miscarried or aborted. In the
three years following the introduction of the anti-pyretic treatment
only five cases of abortion occurred, and but one of these proved
fatal. This accident generally happens during the second or third week
of the fever. It is always a serious complication, and if it occurs in
the first three months of pregnancy it generally gives rise to profuse
hemorrhage, which is usually followed by a fall of temperature as
marked as that observed in hemorrhage from the intestines. Just as in
the latter case, the fall is only temporary, being soon succeeded by a
rapid rise of the temperature to its former height, or even beyond it.
[Footnote 70: _Schmidt's Jahrbuch_, Bd. 193, No. 1, 1880, from _Berl.
klin. Wochenschr._, 1880.]
[Footnote 71: Liebermeister, _loc. cit._]
The danger of bed-sores occurring in typhoid fever is in consequence
of the impaired nutrition of the tissues, the length of time the
disease lasts, and the great emaciation which usually attends
it--greater than in any other acute disease. They constitute a very
serious and troublesome complication, and may occur on any part of the
body subjected to pressure, but are most frequent over the sacrum and
trochanters. Oedema of the lower extremities from feebleness of the
circulation is occasionally observed in the convalescence from
protracted attacks. Lendel has published a series of 7 cases observed
at Rouen, in which the entire body became very oedematous in the
second or third week of the attack or during convalescence. In none of
the cases was the urine albuminous. All the patients recovered except
one, who died of peritonitis. Similar cases have been reported by
other observers. Barthez and Rilliet have seen several cases in
children.
Periostitis is an occasional sequel. I have seen it in one case only.
Sir James Paget,[72] who appears to have met with it in several cases,
says that it never occurs in the continuity of the fever, but always
when the patient is apparently convalescent, when his temperature is
normal and constant, and he is beginning to move about and to grow
stronger and stouter. Its most usual seat is the tibia, but it is also
met with in the femur, ulna, and parietal bone. Except in one case,
Sir James has never seen it in more than one bone in the same person.
It is always circumscribed within a space of from one to three inches
in extent, and usually subsides without necrosis or other abiding
change of structure; but in some cases the patient has remained for
some time subject to repeated attacks of pain and swelling of
periosteum. In the few cases, he says, in which the periostitis is
followed by necrosis the extent of dead bone has always been less than
that of the inflammation over it. Murchison, however, refers to two
cases of necrosis of the tibia, to one of the temporal bone, and to
two in which extensive necrosis of the lower jaw occurred. Gay[73]
also reports a case of extensive necrosis of the thigh-bone in a child
three years old, following an attack of typhoid fever.
[Footnote 72: _St. Bartholomew's Hospital Report_, vol. xxi.]
[Footnote 73: _Path. Trans. Lond._, vol. xx., p. 290.]
{298} Very frequently after an attack of typhoid fever the patient
evinces a tendency to grow stout, which is either continuous or else
is gradually lost after he fully recovers his health. This increase in
flesh is not always accompanied by a corresponding gain in physical
strength, and he may remain for a long time after convalescence is
apparently complete incapacitated for much bodily or mental exertion.
Sometimes, on the other hand, the patient, instead of gaining flesh
and strength, may continue weak and emaciated, even when he is taking
a full amount of nourishment, which he is, however, unable to
assimilate. Cases of this kind may terminate in phthisis, but they
occasionally prove fatal, without any discoverable lesion after death
except an abnormally smooth appearance of the mucous membrane of the
ileum and a shrivelled condition of the mesenteric glands.[74]
[Footnote 74: Murchison.]
Patients suffering from typhoid fever may occasionally contract other
specific diseases. Murchison has notes of eight cases in which the
eruption of this disease coexisted with that of scarlatina, and says
that it was not uncommon in the London Fever Hospital for a patient
suffering from the former disease to contract the latter. Similar
cases are recorded by other observers. Typhoid fever may also be
complicated with rubeola, pertussis, diphtheria, variola, and
vaccinia. I have repeatedly seen children convalescent from typhoid
fever in the hospitals of Paris contract one or other of the eruptive
fevers.
VARIETIES.--A great variety of forms of typhoid fever has been
described by various authors, but as many of them present few points
of difference from the usual form of the disease, it will not be
necessary to discuss them at any length. They derive their names from
some peculiarity of the mode of seizure, from the prominence of some
one symptom or set of symptoms, or from the presence of complications.
They are--(1) The adynamic form, in which prostration is marked in the
beginning and throughout the attack. (2) The ataxic or nervous form,
which is characterized by the predominance of delirium, subsultus
tendinum, and other nervous symptoms. (3) The hemorrhagic form, in
which there is a special tendency to hemorrhage from the different
mucous membranes. (4) The abdominal form, in which the abdominal
symptoms, such as diarrhoea and tympanites, are well developed. (5)
The thoracic form, so called from the presence of some thoracic
complication. (6) The gastric or bilious form, in which the disease is
complicated at its commencement by gastro-intestinal catarrh. La forme
muqueuse of French authors is probably identical with the above. (7)
The acute form, in which the disease begins abruptly and with great
violence, and runs a very rapid course, terminating usually in death
before the end of the first week or early in the second, before
ulceration can have taken place. Delirium is an early and prominent
symptom in this form, so that it has sometimes been mistaken for
meningitis.
Certain forms of the disease deserve a little fuller consideration.
One of the most important of these is the abortive form, in which, as
its names implies, the fever is cut short in its course, and in which
there is every reason to believe that infiltration of Peyer's glands
takes place as usual, but that the subsequent course of the disease is
different, the glands undergoing resolution instead of advancing to
ulceration. The majority {299} of observers agree that in the
beginning there is nothing to distinguish such attacks from those
which follow their usual course. Liebermeister and Jaccoud state,
however, that their commencement is usually more abrupt than in the
ordinary variety, the former asserting that the temperature generally
reaches its maximum earlier, and the same opinion is expressed by
other authors. They are occasionally characterized by severe symptoms,
including a high temperature. In the few cases which have come under
my own observation the symptoms have been mild, but they were
sufficiently developed to leave no doubt on the mind as to the nature
of the disease. In a case which aborted on the twelfth day there were
hebetude, diarrhoea, tympany, and rose-colored spots persisting even
after the subsidence of the fever. Constipation would appear, however,
to be more frequent than diarrhoea in this class of cases. The
subsidence of the fever may occur at any time between the seventh and
fourteenth days; Griesinger has seen it occur as early as the fifth
day. Sometimes the defervescence occurs abruptly, with copious
perspiration; at others it is gradual and similar to that which takes
place in ordinary attacks. Between the abortive form of typhoid fever
and simple continued fever there are, of course, many points of
resemblance, but cases of the former may generally be recognized by
the presence of this rose-colored eruption and enlargement of the
spleen, or, where these are absent, by their occurring in the same
house or under the same circumstances as typical cases of the disease.