Part 46

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 also both say that recovery is possible. This view is sustained by the results of certain autopsies. In one of these, reported by Buhl, 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.

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 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.

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 reports a case in which the perforation appeared to be caused by the administration of an enema.

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, 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.

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, 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.

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, Hayem, Trousseau, 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. A. Martin 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 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.

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.]

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 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.

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, 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 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.

Menstruation occasionally occurs during typhoid fever, and may be profuse. Bartels, 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.