_Ziemssen's Cyclopædia_ to a class of cases which, he thinks, is also
caused by the typhoid infection, and of which the prominent feature is
the insignificance of the fever or the entire absence of it which
characterizes them. Such cases appear to be of frequent occurrence in
Basle. Many of them, he says, never show during their entire course
any rise of the temperature, or occasionally a slight elevation only,
but an enlargement of the spleen could generally be detected, and
occasionally an unmistakable rose-colored eruption. The action of the
bowels was usually irregular; sometimes there was diarrhoea, and
sometimes, on the other hand, obstinate constipation. The other
symptoms were prostration, pains throughout the body, often headache,
persistent loss of appetite, with more or less swollen and furred
tongue, and markedly diminished frequency of the pulse, which
disappears with convalescence, while its quality is not appreciably
altered. The long duration of an apparently trifling indisposition he
considers as especially characteristic. Cayley also refers to cases,
and even epidemics, of typhoid fever in which the temperature has been
below the normal throughout the whole course of the attack. Strube[75]
had the opportunity of observing such an outbreak during the siege of
Paris by the Germans in 1870. "In many of the cases," he says, "the
temperature throughout was subnormal, and in others never exceeded the
normal point. The roseola was usually profuse; the nerve symptoms were
of marked severity, and were in inverse ratio to the temperature,
consisting of violent delirium alternating with stupor; the duration
of the fever was very short, defervescence usually taking place at the
end of a fortnight. Of the 23 fatal cases, in 20 death took place
during the first fourteen days. The abdominal {300} symptoms were
slight, but the characteristic lesions were found on post-mortem
examination. All the cases were characterized by great prostration.
These cases presented some features which were probably due to this
peculiarity of the temperature; thus, the pulse was but little
accelerated, seldom exceeding a hundred; the tongue did not become dry
and brown; and the enlargement of the spleen was either absent or much
less marked than usual. Strube attributed the peculiar features of
this epidemic to the depressed condition of the troops; they had been
exposed to great hardships on the way to Paris, over-fatigued by
forced marches, and very insufficiently supplied with food."
[Footnote 75: Quoted by Dr. Cayley.]
A mild form of the disease has been described by certain authors, in
which the symptoms, although not severe, are characteristic, and in
which there is therefore, with due care, little danger of making a
mistake in diagnosis. It therefore seems an unnecessary refinement to
set apart such cases under a separate head.
The latent form, or the typhus ambulatorius of the Germans, is of more
importance from the fact that the symptoms are so mild, or that so
many of the ordinary symptoms are wanting or masked by those due to
complications, that there is great danger of regarding the attack as
of little moment. In many cases there is no symptom present but
prostration and fever to indicate that the patient is ill, and these
may be so slight that he may positively refuse to go to his bed, and
may even insist upon pursuing his ordinary avocation, in the midst of
which he is often suddenly seized with alarming symptoms, such as
violent delirium, intestinal hemorrhage, or, what is more common,
those due to perforation of the bowel. Still, even in these cases a
careful examination will often disclose the presence of some symptom
which had failed before to attract attention, and which will often
reveal to us the true nature of the disease. I was myself the subject
of such an attack nearly twenty years ago. Supposing that the
excessive prostration from which I was suffering was due to overwork
at a large army hospital in the neighborhood of Philadelphia, I
determined to seek repose in travel and in change of scene. On the eve
of doing so I fortunately sent for a medical friend, who, after a
thorough investigation of my symptoms, succeeded in finding a few
rose-colored spots upon my abdomen. The attack subsequently ran a mild
but well-marked course. Occasionally, the symptoms due to a
complication so predominate over those arising from the disease itself
that they completely mask it. I have known bronchitis so severe as to
divert in this way the attention of a skilful diagnostician from the
primary disease. When vomiting, together with other symptoms of
hepatic derangement, is especially prominent in the beginning of
typhoid fever, the mistake is not infrequently made of attributing
these symptoms to a "bilious attack."
TYPHO-MALARIAL FEVER.--Under this name, which was originally suggested
by J. J. Woodward, Surgeon U.S.A., early in the summer of 1862, as a
designation for a class of cases in which the symptoms of typhoid
fever are associated with those of remittent, and which was especially
common among the soldiers of the United States Army during the late
Civil War, are probably included at least two distinct conditions:
1st, remittent fever, in which the disease, on account of the
depressing circumstances surrounding the patient, assumes {301} a
typhoid form; and, 2d, typhoid fever, occurring in a patient who has
also been exposed to malarial influence. This association of diseases
is of course not new, or even undescribed before this name was
suggested for it. Woodward thinks that he has found enough in the
description of Röderer and Wagler to justify him in concluding that
the epidemic which occurred at Göttingen in 1762 was really of this
character. There would seem also to be no doubt from the descriptions
of Dawson[76] and Davis[77] that the fever which decimated the British
army in the Walcheren expedition was typhoid fever, modified by the
malarial influence to which the soldiers were subjected. The latter of
these authors says that the ileum and jejunum in the bodies of those
who died of this disease were frequently found interspersed with
tubercles, inflamed and ulcerated in different parts.
[Footnote 76: _Observations on the Walcheren Diseases_, Ipswich, 1810,
by G. P. Dawson.]
[Footnote 77: _A Scientific and Popular View of the Fever of
Walcheren_, J. B. Davis, London, 1810.]
In our own country the occasional association of these two diseases
has also long been recognized. Drake describes it under the name of
remitto-typhoid, and Dickson seems to have been perfectly familiar
with it, for he says that typhoid lesions will sometimes be found in
the bodies of those dead of bilious remittent. Levick recognized the
presence of the symptoms of both diseases in some patients who were
under his care as early as the spring of 1862, and proposed the name
of miasmatic typhoid fever for this class of cases in the following
June.[78] Meredith Clymer has also frequently met with cases in which
the symptoms of the two diseases were coexistent.[79]
[Footnote 78: _Med. and Surg. Reporter_, June 21, 1862.]
[Footnote 79: _The Science and Practice of Medicine_, by William
Aitken, M.D., 3d Amer. ed.; with additions by Meredith Clymer, M.D.,
Philadelphia, 1872.]
As is indicated by the name given to it, the symptoms in this form of
typhoid fever are modified by the presence of malarial poisoning. The
cases always manifest a decided tendency to periodicity, the evening
exacerbations are more decided than in the ordinary form, the
remissions are often ushered in with a profuse sweating, gastric and
hepatic derangements are more marked, and headache is more severe.
There is frequently less mental hebetude or dulness than in ordinary
typhoid fever. In some of the cases observed by Levick[80] the
symptoms were those of pernicious congestive remittent fever, such as
copious serous discharges, not unlike those of Asiatic cholera,
colliquative sweats, and other symptoms of exhaustion.
[Footnote 80: _Amer. Journal of the Med. Sci._, April, 1864.]
TYPHOID FEVER IN CHILDREN.--It was formerly thought that infants and
very young children were not often the subjects of typhoid fever, but,
so far is this opinion from being correct, it is now known that they
are especially liable to suffer from it. The rose-colored eruption is
more often wanting in them than in adults, and the fever more apt to
assume a distinctly remittent type; and hence, no doubt, the
difficulty which is often experienced in diagnosticating this fever
from other forms of fever in children. There is no doubt that many
cases which have been described by authors under the head of infantile
remittent fever are really examples of typhoid fever modified simply
by the age of the patient. It may occur in infants not more than six
months old, and is not infrequent in {302} children of two or three
years of age. Henoch,[81] who has had the opportunity of observing a
large number of cases, says that the rise of temperature is commonly
more abrupt in children than in adults, and that the disease generally
runs its course in a shorter time. The pulse is more frequent, and may
be as high as 144 in cases in which the prognosis is not grave.
Dicrotism is very rare. Slowness and irregularity of the pulse, like
that observed in basillar meningitis, he has never seen. The nervous
symptoms are not so pronounced even when the temperature is high, and
they bear no relation in severity to the height of the temperature.
Diarrhoea in the cases observed by Henoch was often absent during the
whole course of the attack, and the stools were often brownish or
greenish instead of yellow.
[Footnote 81: _Charité Ann._, 1875.]
TYPHOID FEVER OF AGED PERSONS.--The modifications which the disease
undergoes when it occurs in patients advanced in life are precisely
those to be expected from the diminished activity of the processes of
life in them, as compared with those of younger persons. The febrile
movement is generally prolonged, although of low grade, the
temperature rarely rising high, and frequently during convalescence
sinking below the normal. The diarrhoea is commonly not so severe, the
delirium so violent, or the rose-colored eruption so often present. On
the other hand, adynamic symptoms, such as excessive prostration,
tremors, subsultus tendinum, and the like, are frequently prominent
from the beginning of the attack.
Several authors, among whom may be mentioned Arnat,[82]
Hornburger,[83] and Greenhow,[84] have described a renal form of
typhoid fever. In this form the urine is blood red in color or like
dark broth. It often contains albumen during the first week of this
disease, usually hyaline or more or less granular casts, and
occasionally red blood-discs, white cells, epithelia of kidneys and
bladder, and epithelial detritus. The specific gravity is high, and
the quantity is usually diminished. The prominent symptoms are pain in
the region of the kidneys, oedema of face, tense and frequent pulse,
great prostration, profuse epistaxis, violent delirium, and
hyperpyrexia. The temperature may be 105.8°. On the other hand, the
intestinal symptoms are less marked. In fatal cases the lesions of
intestinal nephritis have been found at the autopsy.
[Footnote 82: Thesis, _Sur la Fievre typhoide à forme renale_.]
[Footnote 83: _Berlin klin. Wochenschrift_, 1881.]
[Footnote 84: _Transactions of Clinical Society of London_, 1880.]
RELAPSES.--Much difference of opinion will be found to exist among
authors in regard to the frequency with which relapses occur in
typhoid fever, and this difference does not appear to be due to any
greater frequency of this accident in some countries than in others,
since Liebermeister met with them in 8.6 per cent. of the cases
treated at the hospital at Basle, while, according to other German
observers quoted by him, they occur in 6.3 per cent. (Gerhardt), in 11
per cent. (Bäumler), and in 3.3 per cent. (Biermer). Murchison noted
them in 80 of 2591 cases in the London Fever Hospital, or in 3 per
cent., and Maclagan in 13 of 128 cases at Dundee, or in 10 per cent.
about. Immermann[85] of Basle says that they occur in 15 per cent. of
the cases, and that in very unfavorable years the proportion may be as
high as 18 or 19 per cent. Prof. Henoch[86] observed relapses in 16
cases out of 96, or 16.6 per cent. In my own {303} practice they have
not been very numerous. I find that in 80 cases of which I have full
notes they are recorded five times, or in 6.25 per cent., and I
believe this ratio correctly represents the frequency with which they
have happened in all the other cases which have come under my care.
Part of this difference of opinion is unquestionably attributable to
the fact that under the term relapse are sometimes included two
distinct conditions: (1) Mere recrudescences of fever, which occur
during the stage of defervescence or that of convalescence, and which
are provoked by errors of diet, mental or bodily fatigue, or some
other irritating cause. They usually last a day or two, and are
entirely distinct from (2), true relapses, in which all the
characteristic symptoms of the primary attack are reproduced, and
which commonly occur some time after the disease has apparently run
its course. There is occasionally no distinct apyretic interval
between the two attacks, but in by far the greater number of instances
the relapse occurs in the second or third week, or even later, after
the establishment of convalescence. In 20 cases reported by W. M. Ord
and Seymour Taylor[87] the relapse occurred in the third week of the
disease in 1; in the fourth week in 5; in the sixth week in 3; in the
seventh week in 7; in the eighth week in 3; in the ninth week in 1.
James Jackson refers to a case in which the date of the relapse is not
given, but in which he was able to detect the rose-colored eruption in
the sixty-sixth day[88] from the commencement of the disease. In my
five cases the relapse occurred on the seventh, eighth, ninth,
eleventh, and twentieth day after the apparent establishment of
convalescence. In these cases the duration of the relapse was 11, 13,
17, 20, and 13 days respectively. The highest temperature noted in any
of the relapses was 105°, which occurred in two cases. In both of
these this temperature had also occurred in the original attacks. In
one of the others, however, a temperature of over 104° F. was
repeatedly observed in the relapse, while in the primary attack it had
never risen above 102°.
[Footnote 85: _Schweiz. Corr. Bl._, viii. 1878.]
[Footnote 86: _Charité Ann._, ii. 1875.]
[Footnote 87: _St. Thomas's Hospital Report_, vol. ix., London, 1879.]
[Footnote 88: Since the above was written I have had under my care a
case of typhoid fever in which a third relapse occurred nearly four
months after the patient, a woman aged thirty years, was first taken
ill. The following is a brief abstract of the history of this
remarkable case: The original attack began about Sept. 20, 1883, was
of moderate severity, and lasted between three and four weeks.
Convalescence, which seems to have been nearly complete, as the
patient had left her bed, was interrupted on Nov. 1st by a relapse,
during which she was admitted into the Pennsylvania Hospital. This
relapse was severe, and before it had entirely run its course was
itself interrupted, on Nov. 17th, by an intercurrent relapse, which
lasted two weeks. During these two relapses extensive bed-sores formed
upon the nates, occasioning more or less irritation and consequent
febrile reaction. On Jan. 11, 1884, a third relapse occurred. This
relapse was accompanied by diarrhoea, rose-colored spots, tympany, dry
and brown tongue, and other characteristic symptoms of typhoid fever,
the diagnosis being fully concurred in by my colleague, Dr. Morris
Longstreth, who saw the case with me. Convalescence was again
interrupted on Feb. 13th by fever, which continued for two weeks, but
which possessed none of the characters of typhoid fever, and was
clearly due to imprudence on the part of the patient. The patient is
now (April 25, 1884) entirely well, and will shortly be discharged
from the hospital.]
The onset of a relapse is usually much more abrupt than that of the
original attack. It is rarely preceded by prodromata. The temperature
rises more rapidly and attains its maximum earlier, which may be much
greater than in the original attack. In one case under my care it
reached 105° on the evening of the first day, and temperatures of
103.5° and 104° on the evening of the second day are not infrequent.
{304} The rose-colored eruption appears earlier. In 38 cases
investigated by Murchison with reference to this point, it appeared on
the third day in 7; on the fourth in 8; on the fifth in 7; on the
sixth in 2; on the seventh in 12; and at a later date in 2. In the
case the history of which is given below it was detected on the second
day. The delirium also comes on sooner. The relapse is usually less
severe, and is of shorter duration, than the primary attack. All my
cases terminated in recovery. Occasionally, however, it is much more
severe. In one case in which the primary attack was so mild that the
patient could scarcely be persuaded to remain in bed, the relapse was
so severe that for many days it was uncertain whether the patient
would recover. In another intestinal hemorrhages to an alarming extent
occurred on two occasions. Moreover, of Murchison's 53 cases, 7 were
fatal; in 2 of the cases death was due to perforation; in 2 to
peritonitis, induced by infarction of the spleen; and in 1 to
abortion; and of Ebstein's 13 cases, 3 were also fatal. Occasionally,
a second, and it is said even a third, relapse is noted. In one of Da
Costa's cases hemorrhage from the bowels took place during a second
relapse.
[Illustration: FIG. 15. Pulse.]
The following histories and temperature charts illustrate the
prominent peculiarities of relapses occurring in typhoid fever:
TYPHOID FEVER (with a relapse).--G---- L----, æt. 20, single, seaman,
Italian, admitted March 6, 1878; April 30, 1878, left in ward. Patient
is unable to speak English. The following history is obtained through
an interpreter: His family history is good, and he is naturally a
healthy man, never having had any serious illness--no venereal
disease, no cough or rheumatism, no intermittent fever, and he has not
been in the habit of drinking to excess. His vessel has been lying off
Gloucester Point, and two seamen have recently been similarly affected
on another vessel anchored near by. For about two weeks he has had
malaise, but not until three days ago was he so ill that he was
obliged to give up work. He was then taken with cough, chills followed
by fever, diarrhoea, headache, and pain in the abdomen. Has had no
epistaxis or vomiting.
Upon admission patient has fever, his face is flushed, his tongue
coated with a brown fur in the centre, dry, fissured, and red and
glossy at the tip and edges. He has hebetude and some delirium, though
not very active; he is deaf. His abdomen is somewhat tense and
tympanitic, and covered with very numerous rose-colored spots, which
disappear momentarily on pressure; they are also distributed over
thighs and chest. There seems to be no tenderness on pressure over
abdomen, and there is no gurgling felt. Has moderate diarrhoea, having
about three stools daily, which are light yellow in color and are
loose and fetid. Urine cloudy orange red, acid, 1021. No albumen.
{305} _3.7_. Ord. Ol. Terebinth. gtt. x; Acid. Muriat. dil. gtt. v
every two hours, with Quinine gr. viij daily, and restricted diet.
_3.8_. Tongue not so dry; is better. Whiskey fl. oz. ij.
_3.9_. Temperature elevated. Ord. to be sponged.
_3.10_. Has had four stools in the last twenty-four hours. Some
sonorous râles over chest posteriorly. Sponging to be repeated when
temperature rises.
_3.11_. There is some subsultus. There are more numerous râles heard
over chest posteriorly.
Ord. whiskey fl. oz. v daily; turpentine stupes to chest. His
diarrhoea is better; considerable hebetude.
_3.12_. Tongue is not so dry, and is cleaner. The spots over his body
are beginning to assume more the appearance of petechiæ. They are
found everywhere on his body. Has had but one stool within the last
twenty-four hours.
_3.13_. He is brighter; skin feels better; tongue cleaner; pulse but
80. Fewer râles heard in chest. No change in his treatment.
_3.14_. Spots disappearing. Two stools in last twenty-four hours, not
so loose in character. Pulse dicrotic.
_3.15_. There is no tympany. Had one natural stool yesterday. Sudaminæ
over abdomen.
_3.16_. Doing well. Pulse very slow.
_3.17_. Tongue moist and clean; no diarrhoea.
_3.18_. No diarrhoea; spots are still to be seen, but are fading every
day.
_3.20_. Takes a little lemon-juice, as the gums are disposed to be a
little spongy.
Stop turpentine and muriatic acid.
_3.25_. Bowels somewhat constipated.
Ord. enema of castor oil.
_3.26_. Stop quinine; give whiskey fl. oz. iij only. Allowed chicken
and two eggs daily.
Ord. Tr. Cinch. Co. fl. drachms ij s.t.d.
_4.4_. Slight chill, headache, and pain in side. Temp. 101°.
_4.5_. Temp. normal again; as well as before.
_4.8_. Has been up for a week, and steadily gaining in strength,
except the slight attack on the 4th, when to-day, without his having
taken any indigestible food, or indeed any reason to which it could be
assigned, he was seized with a relapse, his temperature rising to
105°, but being reduced a half degree by sponging.
_4.9_. Spots have again appeared in great numbers, and they are very
large. Last evening his temperature reached 104-3/4°, and was reduced
to 101° by sponging.
_4.10_. Doing very well; spots are still making their appearance.
_4.12_. Diarrhoea not at all excessive.
_4.15_. Spots are very numerous.
_4.20_. Temperature nearly normal.
_4.25_. Doing perfectly well; up and about.
_4.30_. Left in ward, upon completion of my term of service.
{306} [Illustration: FIG. 16. Chart of temperature in typhoid fever
with relapse.--Original attack.]
[Illustration: FIG. 17. Chart of temperature in typhoid fever with
relapse.--Relapse.]
ABORTIVE ATTACK, FOLLOWED BY TYPICAL ATTACK.--Thomas Rogers, October
15, born in Philadelphia, assistant nurse. Admitted {307} January 25,
1883; discharged March 26, 1883, cured. Father died of hemorrhage from
the lungs; mother living and healthy. Two years ago he sustained a
compound fracture of the left leg from a bale of cotton falling on
him; otherwise he has always enjoyed good health. For the past three
months he has been assisting the nurse in the receiving ward of this
hospital. Four days before admission, without unusual exposure, he had
a slight chill, and felt cold for several hours. This was followed by
fever and a feeling of weakness. He also had slight headache and the
bowels were constipated; no epistaxis.
Upon admission patient has a good deal of hebetude, face flushed,
temperature 102°, pulse 106, tongue slightly coated, moist. Has slight
pain in right lumbar region, but no distension of abdomen. Urine
negative.
Ord. quinine gr. viij. daily; liq. ammon. acet. fl. drachms ij. q.q.h.
_Jan. 29th_. More hebetude; tongue more coated with brownish fur, red
at tip; bowels continue costive; opened by an enema.
_31st_. Is brighter and better. One doubtful rose-colored spot seen on
abdomen.
_Feb. 4th_. The morning temperatures for the past two days have been
subnormal and the evening rise is very slight. All the symptoms also
indicate the approach of convalescence.
_6th_. More fever; pulse weaker; functional murmur heard over heart;
sudamina out over abdomen. Ord. whiskey fl. oz. ij.
_8th_. Some fulness of abdomen; had three loose yellowish-colored
stools in the last twelve hours.
_9th_. A few doubtful rose spots out over abdomen and back; sudamina
still abundant.
_10th_. More tympany; numerous rose-colored spots out over abdomen and
back; slight epistaxis and bronchitis.
_11th_. Pulse more feeble; still slight diarrhoea. Increase whiskey to
fl. oz. iv.
_15th_. Has a good deal of hebetude, but no headache; fewer spots;
pulse weaker; temperature lower. Increase whiskey to fl. oz. vj.
_17th_. Temperature high again; most of the spots have disappeared;
slight epistaxis and subsultus; no delirium; bowels not open for two
days.
_20th_. Temperature falling; spots disappearing; still fulness of
abdomen.
_25th_. Temperature has been subnormal for several days, and he is
doing well; tongue cleaning. Has emaciated a good deal, and is weak.
_March 1st_. Is convalescent; tongue has lost its redness.
_8th_. Continues to improve; allowed semi-solid food.
_17th_. Is now quite well; has gained a good deal in flesh, and is
stronger.
{308} [Illustration: FIG. 18. Temperature chart of typhoid
fever.--Abortive attack, followed by typical attack.]
The examination of the bodies of those who have died during a relapse
reveals the presence of two sets of lesions in the cicatrizing ulcers
of the primary attack and the recent ulcerations of the relapse. The
latter are usually less extensive, and are found to be situated at a
greater distance from the lower end of the small intestine, than the
former, for the reason that the Peyer's patches most remote from the
ileo-cæcal valve are least apt to be affected in the primary attack.