discovered. {309} They occur in patients of both sexes and of all ages
with about the same frequency. They have been attributed to errors of
diet, mental and bodily fatigue, and the like, but, while we know that
causes of this character often provoke recrudescences of fever, and
can understand that they may act as exciting causes of a relapse in
cases in which the predisposition exists, it does not seem possible
that they should by themselves be able to bring back all the
characteristic symptoms of a specific disease. It has been maintained
by some authors that a relapse indicates that a new infection has
taken place; but this hypothesis, even if we admit that it accounts
for those cases in which the patient is allowed to remain in the place
in which he has acquired the disease, does not explain those in which
he is removed during the first attack to a hospital where all the
sanitary arrangements are presumably perfect. Griesinger has
endeavored to explain relapses occurring in hospitals by suggesting
that they may possibly be due to a fresh contagion from other patients
with typhoid fever in the same ward; but this explanation is rendered
improbable by the fact that relapses have occurred when cases have
been thoroughly isolated. As I have already said, during a long
connection with the Pennsylvania Hospital I have only known a single
case of typhoid fever to originate within its walls, although relapses
probably occur in its wards with the same frequency as in other
hospitals. To adopt Griesinger's explanation, it would therefore be
necessary to assume that a patient just recovered from an attack of
the disease is more susceptible to the action of its contagion than
patients suffering from other disease; which seems improbable, to say
the least. It has also been maintained that relapses are due to the
inoculation of the previously healthy Peyer's patches by the typhoid
poison which is thrown off with the sloughs from those first affected.
Maclagan alleges that relapses are more frequently met with in cases
in which constipation is present in the primary attack, a condition
which he regards as favorable to absorption; but this is opposed to
the experience of almost every one who has paid any attention to the
subject. In the cases which have come under my own observation it
certainly was not the case, diarrhoea having been present in all of
them. It is more likely, as suggested by Liebermeister, that part of
the poison remains latent somewhere in the body, not developed,
destroyed, nor expelled during the first attack, but brought later
into activity by some exciting cause. Da Costa adopts this view, and
says that relapses of typhoid fever are not unlike the outbreaks of
malarial fever which occur after worry or fatigue and when there has
been no chance for a fresh infection. Different plans of treatment
have at various times been charged with increasing the predisposition
to relapses. This is especially true of the cold-water treatment, and
the records at the hospital at Basle show that the proportion of
relapses and the number of deaths from them are both increased under
the use of cold water. Liebermeister thinks, however, that this does
not necessarily prove that this treatment favors the occurrence of
relapses, since before the introduction of this plan of treatment many
more typhoid fever patients died in the first attack of the disease.
Employing those cases only for statistical purposes in which the
patients have survived the first attack, he finds that the difference
at once disappears, there being 9 per cent. of relapses before the use
of cold water, and 10.3 per cent. after its use.
{310} Gerhardt[89] asserts that in cases in which relapses occur the
enlargement of the spleen does not diminish during the non-febrile
period that intervenes between the original attack and the relapse.
[Footnote 89: _Ziemssen's Cyclopædia_, vol. i. p. 193.]
Da Costa[90] has shown that the appearance of the white line and
furrow left by the primary attack, to which attention has already been
drawn, may sometimes be of service to us in diagnosis when we see the
patient for the first time during the relapse. In a case which was
recently under my care their appearance certainly rendered the nature
of the previous illness from which the patient had suffered much
clearer than it would otherwise have been.
[Footnote 90: _Transactions of the College of Physicians of
Philadelphia_, 3d S., vol. iii.]
DURATION.--The mode of invasion of typhoid fever is generally so
insidious, and the first symptoms so little pronounced, that the
patient, even if free from mental hebetude and confusion at the time
when he first comes under the care of a physician, is usually unable
to fix with certainty the time of the beginning of his illness. This
inability is of course most marked in what are known as walking cases,
in which, notwithstanding that the disease is far advanced, the
patient continues to pursue his ordinary avocations or at least
refuses to go to bed. In a few cases, however, either in consequence
of the violence of the first symptoms or from some other cause,
opportunity is afforded to the physician of observing the disease from
its onset. In many others the date of commencement may be
approximately ascertained. The average duration of such cases, if
uncomplicated, has been found to be between three and four weeks.
According to Bartlett, the average duration of 255 cases at the
Massachusetts General Hospital between the years 1824 and 1835,
inclusive, was twenty-two days. It was a little less than this in
patients under twenty-one years of age, and a little more in those
over. As these cases occurred before the introduction into use of the
clinical thermometer, and as the commencement of convalescence is
fixed in them at the time when the patients were able to take a little
solid food, it is possible the fever may have continued in them some
time after convalescence was supposed to have been established. Of 200
cases which ended in recovery, and in which Murchison was able to
ascertain with precision the date of commencement, the duration was 10
to 14 days in 7 cases, 15 to 21 days in 49 cases, 22 to 28 days in 111
cases, and 29 to 35 days in 33 cases. The mean duration of these 200
cases was 24.3 days, while that of 112 fatal cases was 27.67 days.
From the same author we learn that the average stay in hospital of 500
cases which recovered was 31.24 days, and of 100 fatal cases was 16.52
days, while the average duration of the illness before admission in
the 600 cases was 10.78 days. During the twenty years from Jan. 1,
1862, to Dec. 31, 1881, 621 cases of typhoid fever, 121 of which were
fatal, were admitted into the Pennsylvania Hospital. No notes of many
of these cases were taken, and of some of the others the notes are
incomplete or inaccessible, so that they cannot, unfortunately, be
used for the purpose of determining the duration of the disease. The
books of the hospital, however, show the length of time each patient
remained in the wards. From these we learn that the average stay of
the 500 patients who recovered was 43.5 days, while that of the 121
patients who died was only 8.75 days, and that of these a large number
(28) died within {311} 48 hours after their admission to the hospital.
As a rule, patients are retained at the Pennsylvania Hospital until
they are fully able to return to work, while at the English and
continental hospitals it is usual to discharge them when they cease to
need active treatment. This circumstance probably explains the much
greater average duration of the cases admitted to the Pennsylvania
Hospital than that of the cases referred to by Murchison. In the
abortive form the duration of the disease may not exceed ten days, and
there are authors who contend that it may occasionally be very much
less.
Death may occur at almost any time in the course of typhoid fever. I
have never seen it myself take place before the seventh day. Murchison
reports two cases in one of which the disease terminated fatally
within twenty-seven hours of its commencement, and in the other on the
second day. Instances are more numerous in which death has occurred on
the fourth, fifth, or sixth day, but still they are comparatively
infrequent, and, as a rule, the fatal termination takes place most
frequently during the course of the third week. On the other hand,
death may sometimes occur at a very much later period. This is, of
course, the case when it occurs during a relapse, but if the fever
continues after the third week the patient may sometimes die from
exhaustion or from the intercurrence of a complication. Death may also
be the result of a sequela long after the disease has run its course.
DIAGNOSIS.--The insidious invasion of typhoid fever, together with the
absence of pathognomonic symptoms in the beginning, always renders the
diagnosis difficult, and sometimes impossible, during the first week.
Still, even at this time the existence of the disease may be suspected
if the frequent use of the thermometer reveals from day to day a
gradual increase of the fever and the existence of evening
exacerbations followed by morning remissions, the temperature rising
each evening from a degree to two degrees higher than it had done the
preceding evening. If in addition to this character of the pyrexia
there are diarrhoea with ochrey-yellow stools or an increased
susceptibility to the action of cathartic medicines, epistaxis,
enlargement of the spleen, slight fulness of the abdomen, with
tenderness and gurgling in the right iliac region, slight hebetude and
some confusion of ideas upon awakening, the diagnosis becomes more
probable. During the next week the symptoms are usually much more
characteristic. The presence of marked abdominal symptoms, together
with the eruption of rose-colored spots, will generally render the
recognition of the disease at this time an easy matter. There are,
however, a few cases in which no rose-colored spots can be found, and
in which the abdominal symptoms, if they exist at all, are so little
marked that they do not arrest attention. Even in these cases the
temperature record, when carefully studied, will often throw a good
deal of light upon the nature of the disease. If the febrile movement
resembles that usual in typhoid fever, if it has continued for more
than a week, if the patient has not been recently exposed to malarial
influences, and presents no symptoms of local disease, the diagnosis
may still be made with at least an approach to certainty.
The following are the diseases which are most likely to be mistaken
for typhoid fever:
Typhus fever has a course which is so essentially different from {312}
that of typhoid that in well-marked cases it would scarcely be
possible to mistake one for the other. Cases, however, do occur which,
in consequence of a very profuse and dark-colored eruption in the
latter, or of the existence of abdominal symptoms in the former,
present at first a good deal of difficulty in diagnosis. The invasion
of the former is more abrupt and its duration shorter than in typhoid
fever. The eruption is usually also much more copious, and appears in
the former as early as the fourth, fifth, or sixth day, while that of
the latter is rarely observed before the seventh day. The fever in the
former is much more nearly continued in type than that of the latter.
Defervescence occurs in the former by crisis; in the latter, by lysis.
The expression of the physiognomy is different in the two diseases. In
typhus there is a uniform dusky hue of the face, with injection of the
conjunctivæ and contraction of the pupils. In typhoid fever the pupils
are often widely dilated, the conjunctivæ clear, and the face pallid,
with the exception of a circumscribed flush on each cheek. Diarrhoea
is much less frequent in the former than in the latter, and when it
does occur is not accompanied by ochrey-yellow stools. Epistaxis,
tympanites, pain, and gurgling in the right iliac region, and
intestinal hemorrhage, common symptoms in the latter, are very
infrequently met with in the former. On the other hand, petechiæ and
vibices, which are of almost constant occurrence in the former, are
rarely met with in the latter. The circumstances also under which the
two diseases are contracted are different. Typhus originates from
overcrowding or is due to direct contagion. The origin of typhoid
fever is often involved in more obscurity, but it can generally be
traced either to a polluted water-supply or to defective drainage.
Relapsing fever, with due care, is not likely to be confounded with
typhoid fever. The abrupt commencement of the former, the high fever,
lasting for from five to seven days only, and terminating by crisis
with a profuse sweat, and the period of complete apyrexia of a week's
duration, followed by the relapse in which the temperature rises even
higher than in the primary paroxysm, and which also terminates by
crisis, form a chain of symptoms which has no counterpart in the
latter. The mind in relapsing fever is usually clear, there being none
of the hebetude and mental confusion commonly observed in typhoid
fever. The rose-colored eruption is, moreover, wanting, and diarrhoea
and tympanites are absent. On the other hand, jaundice and tenderness
in the epigastric zone are more common than in typhoid fever.
Influenza sometimes, Murchison says, when epidemic, closely simulates
typhoid fever, but as the two diseases occur in this country the
resemblance between them is not often sufficiently strong to lead the
careful observer astray. In both there are fever, prostration,
sleeplessness, delirium and sweating, and occasionally deafness,
diarrhoea, epistaxis, and a dry red tongue; but the onset of the
attack in the former is more abrupt, its duration shorter, and
subsequent convalescence more rapid than in typhoid fever. The
prostration, too, is more decided in proportion to the degree of fever
present. Coryza and bronchial catarrh are much more marked symptoms in
the former than in the latter, while hyperæsthesia of the surface,
which is present in almost every case of influenza, is only rarely met
with in typhoid fever.
Remittent and typhoid fevers often prevail together in the malarious
{313} districts of this country, and, as they present many points of
resemblance, they are sometimes with difficulty distinguished from
each other. They both may begin with nausea and vomiting; abdominal
and cerebral symptoms are common to both, and so is enlargement of the
spleen. The typhoid state may supervene in either, and in both the
febrile movement is remittent in character. In remittent fever,
however, the remissions are more marked, and are usually accompanied
with more profuse sweating, than in typhoid fever. Jaundice and other
symptoms of hepatic derangement are also more common, and the pains in
the back and limbs are more frequent and more severe. The effect, too,
of quinine in producing a permanent reduction of the temperature, is
generally more decided. On the other hand, the rose-colored eruption
of typhoid fever is never present in pure remittent fever.
Occasionally, in cases of the variety of typhoid fever known as
typho-malarial fever, the symptoms of the latter may be so prominent
as entirely to mask those of the former. In such cases the discovery
of a few rose-colored spots somewhere on the surface will clearly
reveal the true nature of the disease.
Epidemic cerebro-spinal meningitis differs from typhoid fever by its
more abrupt invasion, by the retraction of the head which rapidly
supervenes, and by the appearance a short time afterward upon
different parts of the body of petechiæ, which are not likely, even at
first, to be mistaken for the rose-colored spots of typhoid fever. The
fever has, moreover, no constant character, but is remarkable, on the
contrary, for its great irregularity. The duration of the disease is
in fatal cases much shorter, death taking place not infrequently
within the first week, and occasionally as early as the second or
third day. On the other hand, the duration in cases which recover may
be even longer than in typhoid fever.
Simple continued fever may readily be mistaken in the beginning for
typhoid fever, especially in those cases complicated by diarrhoea,
but, as a general rule, the different character of the febrile
movement, its more abrupt commencement and termination, and its
shorter duration, together with the absence of the rose-colored
eruption, will usually serve to distinguish it.
The eruptive fevers are always readily distinguishable at the period
of invasion from typhoid fever, and the mistake of confounding them
with the latter disease may generally be avoided by a close study of
the character of the pyrexia. In the eruptive fevers the temperature
rises abruptly, frequently attaining its maximum in the course of
twenty-four hours, and sometimes in very much less time. There are
also in all of them early symptoms which indicate pretty clearly their
true nature, as, for instance, the sore throat of scarlatina, the
naso-pulmonary catarrh of measles, and the rachialgia of small-pox.
The uncertainty, moreover, is of short duration, as the characteristic
eruption appears in all of them before the fourth day.
Acute tuberculosis of the lungs is the condition which in my
experience has been the most difficult to distinguish from typhoid
fever. Indeed, in some cases which have come under my observation
physicians of recognized skill as diagnosticians have been unable to
make the discrimination until after the death of the patient. Muscular
prostration, a dry brown tongue, delirium, stupor, bronchitic râles,
dyspnoea, and even cyanosis, are symptoms frequently met with in both
diseases, so that when the {314} rose-colored eruption and enlargement
of the spleen happen to be wanting in typhoid fever, or diarrhoea and
tympany present in acute tuberculosis, as they may be, the distinction
is often impossible. The diagnosis may, however, even in these cases,
be sometimes made after a careful study of the temperature range,
which in acute tuberculosis is irregular and rarely presents any
resemblance to that which is typical of typhoid fever.
Acute tubercular meningitis has also many symptoms in common with
typhoid fever, such as high fever, headache, vomiting, delirium, and
stupor, but in the former disease the rose-colored eruption,
epistaxis, enlargement of the spleen, and intestinal hemorrhage do not
occur. Diarrhoea is also rare, and the abdomen, instead of being
tympanitic, is flat, and in many cases even scaphoid. The headache,
too, is much more acute than in typhoid fever, and is very apt to be
associated with retraction of the head. Here, again, the frequent use
of the thermometer will yield very important results in diagnosis, as
the temperature range in tubercular meningitis is always irregular and
does not present any resemblance to that usually observed in typhoid
fever.
Several of the inflammations, especially when associated with the
typhoid state, have so many symptoms in common with typhoid fever that
they may very readily be mistaken for one another by a careless
observer. I have known, for instance, the general disease to be
entirely overlooked in a case of typhoid fever complicated by
pneumonia, and, on the other hand, it has sometimes been supposed to
be present in a case of pure typhoid pneumonia. Gastro-enteritis is
another disease which is also occasionally confounded with typhoid
fever. The diagnosis in these cases will rest principally upon the
presence or absence of epistaxis, enlargement of the spleen,
tympanites, the rose-colored eruption, and of a temperature range
presenting some similarity to that usual in typhoid fever.
Trichiniasis is not likely to give rise to much difficulty in
diagnosis, for although vomiting, diarrhoea, and the typhoid state
occur in it as well as in typhoid fever, the former disease may
usually be recognized by the severe muscular pains and the local
oedema which are constant accompaniments of it, and by the absence of
the characteristic symptoms of the latter.
PROGNOSIS.--There is no other disease in which the physician should be
more careful in making a positive prognosis than in typhoid fever. On
the one hand, accidents of a fatal character frequently occur in cases
which are apparently progressing favorably, and, on the other,
recovery has often taken place after all hope of it had been
abandoned. But, although it is impossible to foretell with absolute
certainty the result in any particular case, there are certain
symptoms which furnish very important indications for prognosis, and
the proper appreciation of which will generally enable us to arrive at
a correct conclusion as regards the gravity of the disease. Prominent
among these is the character of the pyrexia. A fever characterized by
high temperature should always give occasion for great anxiety. This
is very fully shown by the statistics of the hospital at Basle. Thus
of those patients in whom the temperature did not reach 104°, only 9.6
per cent. died; of those in which it reached or exceeded 104°, 29.1
per cent. died; and, finally, of those in whose axilla the temperature
rose to or above 105.8°, more than half died. {315} Wunderlich has
arrived at very nearly the same conclusions, for he says that the
prognosis is very unfavorable when the temperature rises to 106.16°,
that the deaths are almost twice as numerous as the recoveries when it
rises to 107.06°, and that recoveries are rare when it rises to
107.24°. Murchison has, however, known recovery to follow a
temperature of 108°. The highest temperature recorded in any of my
cases was 106° F. In this case, which proved fatal, the temperature
reached 105° F. five times. In three other cases, in all of which
recovery took place, a temperature of 105.5° F. was observed. In
twelve cases the temperature reached 105° F. on more than one
occasion. Six of these ended fatally; in the others the patients
recovered.
The prognosis is more unfavorable in a fever in which the temperature
is continuously high, and in which the morning remissions are slight
or wanting, than in one in which the daily fluctuations are greater,
even though the temperature may reach a higher point during the
evening exacerbations in the latter variety than is attained at any
time in the former. Occasional remissions, even if produced by quinia
or other remedies, are to be regarded as favorable omens, as they
indicate that the fever tends to subside. A high morning temperature
ought, therefore, to give rise to more alarm than a high evening
temperature. The prognosis is grave when the morning temperature rises
to 104° or is persistently above 103°. Murchison says that recovery is
rare after a morning temperature of 105°. Fiedler[91] saw, with a
single exception, all patients die whose temperature in the morning
rose to or exceeded 106.25°, while of those whose temperature in the
morning rose to 105.44°, if only on one day, more than half died. Any
marked deviation from the usual temperature range in the course of the
fever is unfavorable. A rapid rise of temperature indicates increased
danger: it may be due to the occurrence of a complication or of some
other cause acting unfavorably upon the patient. A sudden and decided
fall should excite even more alarm, as it is generally the consequence
of a free intestinal hemorrhage. A temporary abatement of the fever,
with amelioration of the other symptoms, occurring between the tenth
and twentieth days, and giving rise to the hope that convalescence is
about to commence, but followed by a return of the symptoms in an
aggravated form, is also unfavorable. Such cases, according to Chomel,
Louis, Bartlett, and Murchison, almost invariably terminate fatally.
[Footnote 91: Quoted by Liebermeister.]