RCif^l intiieCttpoflirtjigDrk College of $i)p£(ician£( anb ^urgeonsi Hibrarp KK'hLUC.'-ICH: p. GAY, M. D. UNIVERSITY OF CALIFORNIA, BRRKJSI.'GY, CAL,. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/medicalcomplicat1909hare THE MKDICAI; COMI'liKJATIOXS A(J(J1I)EKTS AM) SI':(^|;ELS OF TYPHOID FEVER OTHER EXANTHEMATA BY HOBART AMORY HARE, M.D., B.Sc. PROFESSOR OF THERAPEUTICS IN THE JEFFERSON' MEDICAL COLLEGE OF PHILADELPHIA PHYSICIAN TO THE JEFFERSON COLLEGE HOSPITAL; ONE TIME CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE UNIVERSITY OF PENNSYLVANIA AND E. J. G. BEARDSLEY, M.D., L.R.C.P. (Lond.) ASSISTANT PHYSICIAN TO THE OUT-PATIENT DEPARTMENT OF THE JEFFERSON MEDICAL COLLEGE hospital; ASSISTANT DEMONSTRATOR OF PHYSICAL DIAGNOSIS AND CLINICAL MEDICINE AT THE JEFFERSON MEDICAL COLLEGE PHYSICIAN TO THE HENRY PHIPPS INSTITUTE WITH A SPECIAL CHAPTER ON THE MENTAL DISTURBANCES FOLLOWING TYPHOID FEVER BY F. X. DERCUM, M.D. professor OF MENTAL AND NERVOUS DISEASES IN THE JEFFERSON MEDICAL COLLEGE WITH 26 ILLUSTRATIONS AND 2 PLATES LEA ifc FEBIGER PHILADELPHIA AXD XEW YORK Entered according to Act of Congress, in the year 1909, by LEA & FEBIGER, in the Office of the Librarian of Congress. All rights reserved. THIS ESSAY IS DEDICATED W. W. KEEN, M.D., LL.D. EMERITUS PROFESSOR OF THE PRINCIPLES OF SURGERY AND OF CLINICAL SURGERY JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA PREFACE TO SECOND EDITION. At the })r('soiit time there are few diseases so widespread as typhoid fever, and the Hterature concerning it is very great. Systems of medicine and text-books innumerable deal with its ordinary manifestations, and touch, necessarily but briefly, upon its accidents, its complications, and its secjuels. Anyone who has had even a limited experience with typhoid fever has met with cases in which the manifestations wandered so far from the classical descriptions of the disease as to be puzzling and obscure, or with instances in which the malady has been so altered in its course by intercurrent affections as to be unusual and to call forth all the diagnostic knowledge and therapeutic skill of the physician. The following pages deal with these aberrant forms of the dis- ease and the courses wdiich they pursue. The preceding paragraph, taken from the preface of the first edition of this book, gives in a concise form the reason for the appearance of the present volume. During the ten years which have elapsed since the first edition appeared the literature dealing with typhoid fever has greatly increased, and the advances which have been made in the study of the disease by bacteriological methods have added to our knowledge of many of its complica- tions and sequels. The present time, therefore, seemed auspicious to bring the text of the first edition up to date, and this has been accomplished with the assistance of the junior author. During the last decade much interest has also been taken in the complications and sequels of the exanthema tons fevers other than typhoid, and for this reason chapters dealing with these phases of variola, scarlet fever, measles, chickenpox, and rubella have been carefully prepared and added to the original text. So far as we know^, no other book is devoted solely to this im- portant part of medical practice, and the authors hope that a vi PREFACE TO SECOND EDIT 10 X presentation of the literature as it exists today, combined witli a statement of their own experience in hospital and private practice, will prove useful to other members of the medical profession. As mental disorders not rarely ToIIdw, anil sometimes com- plicate, ty})hoid fever, Dr. F. X. Dercum, Professor of Mental and Nervous Diseases in the Jefferson Medical College, has added an interesting and instructive chapter on these states, for which we wish to express our cordial tlianks. H. A. H. E. J. G. B. Philadelphia, September, 1909. CONTENTS. PAKT I. THE MEDICAL COMPTJCATIOXS AND SEQUELS OF TYniOlD Oil ENTERIC FEVER. CHAPTER T. General Considerations 1 ~ CHAPTER II. Varieties of Onset 41 CHAPTER III. The Aberrant Symptoms, States, or Complications of the Well-developed Stage of the Disease 68 CHAPTER IV. The Complications of the Period of Convalescence 182 CHAPTER V. The Conditions which Resemble Typhoid Fever 266 CILAPTER VI. Duration and Immunity to Second Attacks 276 CHAPTER VII. The Mental Complications 282 viii COXTEXTS PAET II. COMPLICATIONS AND SEQUELS OF THE ERUPTIVE FEVERS OTHER THAN TYPHOID FEVER. CHAPTER I. ^■AHIOLA 301 CHAPTER II. Scarlet Fever 317 CHAPTER III. Measles 348 CHAPTER IV. Varicella (Chickexpox) 373 CHAPTER V. Rubella . . ' . 384 PAii^i^ J. THE MEDKAL (X)MIMJ(JATI()NS AND SEQCELS OF TVIMIOII) on ExNTEIlIC FEVER. CHAPTER I. GENERAL CONSIDERATIONS. It may be said by those who are disposed to \)e critical, that an essay deahng with the mecHcal compHcations and sequels of typhoid fever must of necessity deal with the disease in so wide and general a manner as to include practically all that we know concerning it; but, while this is to a certain extent true, on the other hand, it is manifest that the important subjects of etiology and pathology will not find space for their consideration, and that the simple unaltered forms of the malady will only have to be described sufficiently to indicate the real variations. No one who has had any experience with this disease can fail to have noted that it pre- sents widely different symptoms in degree and in kind, not only in different epidemics, but in different individuals, and in the same individual at different periods of a single attack. In some patients the illness is so mild as to be only a moderate indisposition ; in others so malignant that death speedily ensues; and yet in nearly all cases there are certain manifestations which when grouped together render it possible to make a diagnosis fairly certain. A febrile course, characterized by malaise, headache, fever, drowsiness, intestinal disorder, enlargement of the spleen and liver, the erup- tion of rose spots, the positive blood culture, and the confirmatory Widal test, may be considered to represent true uncomplicated typhoid fever; and with cases presenting these general symptoms this essay wall not deal. On the other hand, the object in view is to discuss three classes of the manifestations of t^'phoid infection, 2 18 GENERAL CO.XSIDERATJOXS namely; (a) those ordinarv syinptoins of onset and complete devel- opment which, bv reason of nuxK'ration or modilication or exag- geration, become interestino- or dangerous in themselves; (6) those which are so rarely met with during onset or the course of the malady in ordinary cases that they can be considered as distinctly complica- ting conditions; and (c) those results of the disease which, coming on after it is about to cease in itself, still retard or interfere with the rajnd and normal return of the patient to perfect health. We are well awaie that at certain })oints it will seem that the dividing line between the ordinary symjitoms and those considered in these pages is overstepped, antl while it is not our intention to avoid this overstepping when the complete discussion of the condi- tion is necessary to a thorough study of the process under considera- tion, these ordinary symptoms will not, as a rule, be fully considered. Diminution of Morbidity and Mortality. — Before proceeding to a clinical study of the disease, it is interesting to note that its / severity and mortality are distinctly on the wane. While isolated epidemics may range in severity from mild to severe, and produce a mortality from less than 1 per cent, to almost 50 per cent., the average being at one time about 25 per cent., the general mortality is now much less than this, often only 10 per cent., and in private houses where the family is well enough placed to give the patient every aid, it is often less than 5 per cent., even when the treatment instituted is not all that could be desired. I These changes have been produced by improved sanitation, a natural modification in the severity of the infection, coupled, per- haps, with an increased resistance on the part of the individual, and by better treatment, and, as they bear an interesting relation to other modifications of the malady, may be discussed at this point with propriety. In regard to the effect of improved sanitation it can be pointed out that Mosny has shown that the death-rate of Vienna decreased from 12.05 per 10,000 to 1 .1 after a pure water supply. In Dantzic the mortality fell from 10 per 10,000 to 2.4, and finally to 1.5 per 10,000. In Stockholm it fell from 5.1 in 1877 to 1.7 in 1887. So, too, in Boston from 17.4 in 1846-49 to 1.05 in 1907. The follow- ing table is of interest in this connection: DIMINUTION o/<' Moim/urr)' AXh \inirr. 1 /./'/■ y I!) Mortality in Miinkii (•'IIOM 1S.",1 i<- 1'.K17 I'lT 100,(1(11) IVr 100,000 Year. liiliahil.antti. Annual . iiilialiil'iHH. '>'car. InliabilantH. A iiiiiial. inli.-il.it'iil". 1851, 123,<)57 123 !!!).() 1880, 223,700 100 72.0 1852, 125,588 152 121.0 1881, 230,028 11 18.(i 1853, 127,219 2,35 181.0 IH82. 2.30,400 \2 18.0 1854, 128,850 293 227.0 IH83, 242,800 ■\r, 19,0 1855, 130,481 253 193.0 1884, 249,200 34 1 1,0 185G, 132,1.12 384 291.0 1885, 255,600 45 18.0 1857, 133,847 390 291.0 1886, 202,000 55 21.0 1858, 135,733 453 334.0 1887, 208,400 28 10.0 1859, 137,005 240 175.0 1888,' 292,800 31 10.5 1860, 140,624 163 109.0 1889, 300,000 31 10.1 1861, 144,334 172 119.0 1890, 331,000 28 8.5 1862, 148,200 300 202.0 1891, 357,000 24 0.4 1863, 154,602 ' 252 163.0 1892, 372,000 11 3.0 1804, 160,828 397 247.0 1,S93, 385,00(1 .57 14.8 1865, 167,054 338 202.0 1894, 39:'.,000 10 2.5 1866, 168,265 342 203.0 1805. 400,(100 1.", 2.5 1867, 169,476 88 52.0 1896, 412,000 14 3.4 1868, 170,688 136 80.0 1897, 4.30,000 23 5.0 1869, 170,000 190 111.0 1898, 446,000 14 3.0 1870, 170,000 254 149.0 1899, 460,000 15 3.0 1871, 170,000 220 129.0 1900, 490,000 28 6.0 1872, 169,693 407 240.0 1901, .503,000 24 5.0 1873, 175,500 230 131.1 1902, 509,000 15 3.0 1874, 181,300 289 159.0 1903, 515,000 19 3.0 1875, 187,200 227 121.0 1904, 524,000 18 3.0 1876, 193,024 130 67.0 1905, 5.34,000 16 3.0 1877, 205,000 173 84.0 1906, 544,000 11 2.0 1878, 211,300 116 55.0 1907, 560,000 15 3.0 1879, 217,400 236 109.0 The eiJect of improved sanitation i.s to decrease the virulency and dose of infection, and for this reason there follows a decreased severity of illness and a decreased percentage of mortality. Not only are these facts true of the cities just named, but it is also true that the severity and mortality of typhoid fever are steadily decreasing all over the world, as is shown by the following inter- esting tables of Dreschfeld in regard to England up to 1892 in general and London and ^Manchester up to 1907, the statistics since 1892 being collected by the authors. A similar diminution in mortality has occurred in Chicago, Berlin, New York, and Philadelphia. 1 This table is taken from Pettenkofer"? "Munich a Heahhy City,"' up to 1887 inclusive, after 1887 from returns obtained from the Statistical Bm-eau. 20 GEXERAL CONSIDERATIONS Annual Mortality, per Million Persons Living, from Fever in England. I'eriod. Enteric cases. 1838 1228 1839 1010 1840 1089 1841 932 1842 1004 1843 1844 1845 1846 1847 1807 1848 1266 1849 1044 1850 865 1851 997 1852 1022 1853 1008 1854 1015 1855 875 1856 847 1857 988 1858 918 1859 806 1860 652 1861 767 1862 919 1863 874 1864 960 1865 1089 Period. Enteric cases. 1806 986 1807 778 1868 895 1869 390 1870 388 1871 371 1872 377 1873 376 1874 374 1875 371 1876 309 1877 279 1878 306 1879 231 1880 261 1881 212 1882 229 1883 228 1884 236 1885 175 1886 184 1887 185 1888 172 1889 176 1890 179 1891 168 1892 137 Death-rate from Enteric Fever in London and Manchester PER Million, Year. 1871 1872 1873 1874 1875 1876 1877 1878 1879 1880 1881 1882 1883 1884 1885 1886 1887 1888 1889 London. Manchester. Year. 267 450 1890 242 400 1891 269 460 1892 256 390 1893 235 440 1894 217 420 1895 251 290 1896 283 310 1897 229 180 1898 186 260 1899 254 170 1900 252 250 1901 247 200 1902 234 190 1903 150 170 1904 154 290 1905 151 310 1906 169 330 1907 130 310 London. Manchester. 146 270 132 370 102 240 161 250 147 170 143 180 130 220 132 180 131 220 180 130 170 140 118 140 126 120 83 170 65 120 53 90 57 140 40 60 DIMINUTION <>!<' MOIU'.IDITY AND MOIiTAlJTY 21 Figs. 2 and .'> illiislnilc \\\v rruirkcd dccmasc of inorhdily IVoiri typhoid fever in I'crliii id'Icr I lie water supply was fillcred. 'J'he decrease in mortality in IMiiladelpln'a is sliown in the fli;ir( ^Fig. 4) in broken and conij)lete lines. In rhiladelphia after 1898 the morbidity rate advanced until, Fir;. 1 1 1,000 1 2,000 1 3,000 1 4,000 1 5,000 1 6,000 1 7,000 1 ,000 1 9,000 10,000 00 CO 00 CO 00 i 00 in Ol CO CO CO 00 CO CT) CO § 5 CM O 8 en s ID 1 ■ 1 ■ 1 J ■ J 1 ll r 1 r 1 1 1 1 Mortality in Chicago of typhoid fever. In 1891 and 1S92 the water was contaminated with sewage and the death-rate was about 1 to 450 to 1500. With a change in water supply the mortality has fallen to 1 to 6000 or even 1 to 9000. (Seibert.) 22 GENERAL COXSIDERATIONS in 1900, we find llu' iiiuiilicr of cases recorded a.s 9721. Tliere were 1063 deaths, giviii": a mortality rate of only 10.93 per cent., which, with the exce})tioii of the rate for 1905 (10. .jS per cent.), is the lowest mortality rate for this disease that riiiladelphia has known. The decrease in the mimhcr of typhoid fever patients reported in 1907 and 1908 was dne to the imjiroved water supply in tho.se Fig. 3 OD il 5S 1- :/• ■* ■^ ^ -* oe OO 3D C« :«^ o X 1 1 i 1000 I ~'U00 1 .JOOO 1 i 4000 1 5U00 1 0000 1 rooo 1 8000 1 !)C00 1 1001 Ml 1 » «> a» QO QC oc on a> » an 1000 2000 3000 4000 5000 COOO rooo 8000 9000 10000 1 -p ■n ■ J I'lo. 2. — .Mortality of tyi>lioici fever in Berlin before supply of ilrinkitiK water was filteied. In tlie decade 1843 to 18.53 tlie average yearly mortality was 1 i)er 900 of inhabitants. l''iG. 3. — Mortality of tj-phoid fever in Berlin after water was filtered. (Seibert.) Ut^' DIMINUTION ()!■• M( ihT.I I )!'!' V AND MOiriMJIV 2:', Vu:. 4 NUMBER OF CASES. 2 1 01 1 i 00 00 to 00 3! 00 IjO s 00 00 00 00 g O) 1 1 1 i 1 1 i BETWEEN UUOO-JOJOO 25 t 9100-9600 24 A 8600-9100 23 • \\ 8100-8600 22 A '\ 7600-8100 21 1 \ \ ^ I 7100-7600 20 1 \ ^ \ 1 6600-7100 19 \ 1 1 V. V 1 I 6100-6600 18 ' \ V. J \ 5600-6100 17 \l \ \ \ 5100-5600 16 V \/ y'^> ■> , J 4000-5100 15 * • V \ I i / i 1 4100-1600 14 A k J \ y ( ' 3600-4100 13 J \ y \. r / /\i 3100-3600 12 4 V A r \ V s \ / i 2600-3100 11 \ V A / V, w \ .^ / 2100-2600 10 1 V ^*s V I* w rvi v J,-* i i 1 Chart showing the morbidity and mortality of typhoid fever in Pliiladelphia. Xotwith- .standing the increased morbidity, it will be seen from the dotted line that the mortality per cent, has constantly decreased. Solid line, morbidity. Dotted line, mortality. Typhoid Fever in Philadelphia. Year. Cases. 1888 3573 1889 4631 1890 3182 1891 " 3531 1892 2304 1893 2519 1894 2357 1895 2748 1896 2490 1897 2994 1898 4749 1899 7985 1900 3227 1901 3669 1902 5006 1903 8701 1904 6587 1905 6458 1906 9721 1907 6712 1908 3562 Mortality Deaths. Per cent. 785 21.9 736 15.8 566 20.9 683 19.3 440 19.1 456 18.1 370 15.7 469 17.0 402 16.1 401 13.3 566 11.9 948 11.87 449 13.91 444 12.10 588 11.74 957 10.99 744 11.29 684 10.58 1063 10.93 890 11.65 533 14.96 24 GENERAL CONSIDERATIONS sections of the city which received filtered water. The decrease in the wards of the city suppHed entirely by filtered water has been most satisfactory, amounting, in several instances, to 60 per cent, of the former rate. It is, of course, hardly to be expected that any marked decrease in the number of typhoid fever cases will be observed until the entire city is supplied with properly filtered water. Fig. 6 NUMBER OF CASES >- -j ^, "■ o o ^ cc < u >- 00 00 00 1 o 00 Si 00 CJ 00 CO CO CO in CT> OD CO cn 00 00 00 00 8 1 CM O CO o en S en in o a> U3 O 1- o 00 o 300-320 •^.SO-SOO 23 ?? — = ^ ^ ^ = = = = = = = = = = = = = 260-280 240-260 220-240 21 20 19 — = = ^ ^ ^ = ^ ^ = 1 = ^ aE = 1 1 200-220 180-200 160-180 17 16 — = ^ = SI =i ^ = 1 V zi; i ^ 110-160 15 ^ ^ :=:= — Y = S = u = = = — ni ^ = = 120-140 14 ^ ^ z=z 1=1 ^ =. m m ^ = =i=^ ^ := = 100-120 13 =^ =^ = = = e = =z = = = ^ = P ^ ^ 80-100 12 ^ ^ = ^ = = ^= ^= S = — t = S = 60-80 11 1 = i ^ = M 1 E 3s; = w 1 = ^ 20-40 9 — = = ^ ^ = = M ^ = ^ = = ii:i Chart showing increased morbidity but decreased mortality per cent, at the Philadelphia Hospital for twenty years (1888-1908). Solid line, morbidity. Dotted line, mortality. These statistics for Philadelphia go back as far as the compara- tive records extend, and do not include the 1348 soldiers with typhoid fever who returned from the Spanish-American war in 1898, but only the regular population of the city. If the soldiers are added to the number of 1348, we find that 6097 cases of enteric fever occurred in Philadelphia in 1898. The mortality of the city population was 11.91, that of the soldiers, 5.41, which would make the total percentage 10.47 in 6097 cases. The low mortality of the soldiers is a tribute to hospital treatment, for in many cases these men were transported hundreds of miles when very ill, and, as a rule, had not had the food and care which are so necessary to the safe conduct of a typhoid case DIMINUTION O/'' MOIUilhrrV AN I) MOiri'MJ'I'Y 25 NUMBER OF CASES. 1 o tjl 00 CM 00 CO CO 00 UO 00 00 00 CO i i 1 i 1 i i 1 2500 r s 2100 / \ 2300 ) , 2200 V '^. 2100 1 V s. 2000 / 1900 / 1800 / 1700 / 1600 / 1500 A 1 ' 1400 A A J 1300 A A / V 1200 / \/ V / 1100 / V \ s / 1000 \ / ■^ 900 \ V - /^ 800 V Chart showing increasing number of cases annually in New York. Part of the increase at least is due to great increase of population. Typhoid Fever in Manhattan AND Bronx (Old City of New York).^ Year. Cases. Deaths. Death-rate. Case fatality. Per cent. Population. 1893 .... 1008 381 2.16 37.7 1,758,010 1894 . 792 326 1.80 41.1 1,809,353 1895 . 965 322 1.71 33.3 1,879,195 1896 . 1002 297 1.53 29.6 1,934,077 1897 . 1004 299 1.50 29.7 1,990,562 1898 . 1535 376 1.83 24.4 2,048,830 1899 . 1290 294 1.38 22.7 2,117,106 1900 . 1759 372 1.81 21.1 2,055,714 1901 . 1945 412 1.94 21.1 2,118,209 1902 . 2629 400 1.83 15.2 2,182,836 1903 . 2462 350 1.55 14.2 2,249,680 1904 . 2136 309 1.33 14.4 2,318,831 1905 . 2194 310 1.21 14,1 2,390,382 1906 . 2014 369 1,50 13.3 2,464,432 1907 . 2771 420 1.65 15.1 2.541,084 1 This table is taken from an article entitled during 1905," by J. S. Billings, Jr., M.D. 'Typhoid Fever in the City of New York 26 GENERAL CONSIDERATIONS These tables, as to mortality, are supported bv tlie statement of Billings, that in Norway from 1888 to 1891 the mortality from typhoid fever was 755 in 74G7 cases, or less than 10 per cent. In the ]\Iaiilstone epidemic the death-rate in 1885 cases was only 7.5 per cent., and a similar mortality obtained at Plymouth, Pa. The death-rate in the Worthing epidemic of about lOCO cases was 13 per cent. Fig. 7 ANNUAL DEATHS PERCENT 00 00 CO CC 00 o CO 5i CO CM o 00 CO CO CO in CO GO CO 00 at Ol CO o o 5 Ol CM O CO o Ol o Ol o en o Ol o Ol 41 A 40 A 39 / \ 38 / \ 37 / \ 36 / \ 35 / \ 34 / \ 33 \ / \ 32 \ A ' \ 31 \ A / \ 30 \ , r ^ \ y 29 V V \ 28 Y V ^\ 27 \ 26 I 25 \ 24 \ 23 V, 22 \ 21 \ / 20 \ 19 \ 18 ) fs 17 \ r s 16 \ 1 15 V / 14 **>»- -4 Chart showing decreasing death-rate from typhoid fever in New York City. Bryant^ states that out of 608 cases treated in Guy's Hospital from 1879 to 1893, 14 per cent. died. Again, in the Gazette Medicale des Hopitaux of July 10, 1890, we learn that a collective investigation in France showed that, whereas in the period from 1866 to 1881 the mortality from typhoid I Bryant. Guy's Hospital Reports, 1893. DJMINUrioS OF MOHIilhll'V A SI) MOiriALITY 27 Wiis 21..') JHT ccnl.; fioiii ISS2 (o ISSS j(. was I I.I \n-y rent., and In ISSO, VAJ) per ccnl. We may assume, then, tliat the (miinarv mortality of" typhoid fever is at ])reseiit less than IT) per cent, in the general run o'i cases, and that in jrood hospitals and |)rivate practice with ^^ood nursing, it varies from 1 to 10 per cent., the more so as many years ago, before the disease had become moch'fied, Murchision })laccd it at 17.45 among 27,951 cases in England. The following statistics of patients treated by general methods show this to be true, and with or without baths a simihir decrease in mortality is evident: Cases. Basel (Liebernieister) 22.3 Basel (Liebermeister) 239 Maidstone, England 1,88.5 Boston (Mason) 676 Homerton (Collie) 677 Glasgow (Collie) 618 Soci^t(5 Mddieale des Hopitaux (1879)i 1,979 Jaccoud 66.5 Riess 900 Boston (Shattuck) 237 Germany (?) Brand has collected . 19,017 Mortality. Per cent. Treatment. 11.7 Calomel. 14.6 Iodide. 7. .5 General. 10.4 General. 9.5 General. 8.2 General. 12.47 10.8 General. 7..5 Tepid baths. 9.8 Expectantly and cold sponging. 7.8 All kinds of cold baths. 27,116 10.02 In other words, 27,116 cases in Switzerland, America, England, Germany, and France show that good nursing and careful non- meddlesome treatment will give a mortality of al^oiit 10 per cent. The wide distribution of these cases and the large number of clinicians o-ive us a standard averao-e. At Basel, in 1S73, under the cold bath, there were 163 cases, with a mortality of 10.4 per cent. ; during the same year at Glas- gow without baths, 275 cases, with a mortality of 9.4 per cent.; and 305 at Homerton, with a mortality of 9.5 per cent. In 1S74 at Basel the water cases were 200, with a mortality of 10.5 per cent. ; at Homerton, 372, with a mortahty of 9.6 per cent. ; at Glas- gow, 343, with a mortality of 7 per cent. 1 These statistics are based upon the fact that twenty-one chiefs of hospital service reported to the Societe M^dicale des Hopitaux (1890) 916 cases with 114 deaths, or 12.44 per cent, under general treatment; and for 1888 and 1889, this report also mentions 1063 cases so treated, with 133 deaths, or 12.51 per cent. 2S GENERAL CONSIDERATIONS Mortality No. of cases. Treatment. Per cent. Basel (1873) 163 Bath 10.4 Glasgow . " 275 General 9.4 Homerton " 305 General 9.5 Basel (1S74) 200 Bath 10.5 Glasgow " 343 General 7.0 Homerton " 372 General 9.6 More recently other epidemics have shown the same decrease in mortahty rates. In the New Haven (Conn.) epidemic of 1901 there were 514 cases and a mortahty rate of 12.2 per cent. In the Ithaca epidemic of 1903, there w^ere 1350 cases and a mortahty rate of 6.09. In the Scranton epidemic of 1906 there were 1155 cases and 9.9 per cent, mortahty, while in the epidemic at Butler, Pa., in 1903, there were 1270 cases, with the very low mortality of 4.4 per cent. Of the fact that a change in type has taken place in enteric fever we do not think there can be any doubt, and no one who has watched the disease during the last twenty-five years, or even for a shorter period than this, can fail to note the difference in its char- acter. Particular attention has been called to this fact by Sidney Phillips^ and James F. Goodhart.^ The latter writer says: "I agree in toto with what Dr. Sidney Pliillips said to us, that 'typhoid fever tends to vary with the conditions associated with its origin, and though such variations are slight individually and gradual in evidence in their sum, they suffice in time to produce a considerable modification of the original disease.' There is considerable differ- ence in the symptoms described fifty or even twenty-five years ago and those occurring today. The difference is marked in the lessened severity of the abdominal symptoms; the tongue is now often moist throughout the disease, instead of dry and baked; tympanites and diarrhoea are much less pronounced ; probably also hemorrhage and perforation are less common; tremors and dilata- tion of the pupils are now uncommon; and, instead of noisy, active delirium, the mind is often clear tliroughout even fatal cases. The typhoid state with the patient sunk deep in bed, unable to move himself and unconscious or semiconscious for days, is now quite 1 Phillips. British Medical Journal, November 12, 1898. 2 Goodhart. Ibid., January 28, 1899. MOIUilDI'I'V IS (IIILhllOOl) 20 except ioiiul. Dr. I'liillips iiltrihuU's this 'to ;i lessened tei.stines,' iirxl ar^nies that if so iniu-h variation of type liiis taken phiec in m, (piarter of a eentiiry, mueh more hits ;< >h '.'/^ Not only rnjiy typhoid IVvcr occur in very yonn;/ cliildrcn, but it is to be rcnicnil)crc(| lluit tlii.s source of infecfion nmy cause tfie disease ainon<^- ndulls. Tlnis i'oobhyer' records ;in in^t;lncc in which out of a family of ei<(ht persons five became infected through an infant of eight months. The child had been restless and had constant diarrhoea, but the fact that it was suffering from typhoirJ fever was not recognized. That severe ty})hoid fever may occur very early in life is shown by the statement of Osier, that j)erforalion of the bowel from this cause has occuri'cd in a child (Ia'c days old, aiid lvirl<' has rcj)orted a case to Keating of fatal inteslinal licniorrlian(- due to typhoid fever at twenty-two months. Griffith" has also reported cases of perforation during typhoid fever in children, while Elsberg^ found 25 cases in cliildren under fifteen years of age, in a series of 2S9 operations for perforation. Griffith* was able to find records of 94 instances of perforation in children ill of typhoid fever. Czarnik^ reported two cases in which there was a successful operation for repair of the perforation during typhoid fever in children. Brelet'' found in the literature accounts of 30 sudden deaths during typhoid fever in children, while Velich^ noted 10 deaths between the ages of three and thirteen years during this disease, and quotes Mousson's statistics of 60 cases of typhoid in children, with one sudden death, and Stowell's series of 61 cases of typhoid in children, wdth one sudden death. Woodward* has reported two cases of hemorrhagic typhoid fever in children, which is a type rarely seen, particularly in this class of patients. Further than tliis, Sbrana,^ who has treated seventy-two cases of typhoid fever in children in Tunis, tells us that a symptom which was never lacking was splenomegaly appreciable from the fifth or sixth day of the fever. The nervous symptoms were more 1 Boobbyer. British Medical Journal, January 26, 1S90. - Griffith. Archives of Pediatrics, January, 190S. ' Elsberg. Quoted by Czarnik. * Griffith. Archives of Pediatrics, January, 1908. ^ Czarnik. Lwowski tygodnik Lekarski, 1906, No. -40. 6 Brelet. Arch. Gen. de M,:, Til tlic first cdilioii of jlii.s cssjiy llircc f)ji|((',s wmihl luivf iiifliKJcd all the recorded cases of typhoid Ivvcr in children, Ixit during' die ten years that have ela[)sed the siihjecl has iinderirone f-arct'iil investigation, and al present i( would rcfpiire an entire cjiapter to review the lari^x- nnniix-rs ol" cas«'s of inidonhletl lyj>lioid lever in infants and yonn,\) lK)S|)i(;il lor tlie insane at In(lc|) / } A k ^ / V s y / •s V y / y' __ j^ ^ ^ '' 1 / / 1 / _ Chart showing the increasing mortality of typhoid with advancing years. (Curschmann.) Osier states that of 829 cases of typhoid fever treated at the Johns Hopkins Hospital, there were 6 between fifty and sixty years of age and 6 between sixty and seventy. Two of these cases were not recognized during life. In the New York Board of Health report, of a total of 3634 deaths due to typhoid fever, from 1S87 to 1S96, there were 9o deaths in persons over sixty-five and 414 between fortv-five antl sixtv-five vears. 40 GENERAL CONSIDERATIONS Short Incubation. — While it is generally true thcat the period of incubation of t>phoitl fever extends over a period from ten days to two weeks, recent reports indicate that in certain instances this period may cover only a few days. Thus, Janehen-Graz^ has reported thirty-six cases of typhoid fever occurring among soldiers, in whom definite proof was adduced that they had all become infected at the same time by drinking infected water. As a result the incubation period in three cases was only two days, in seven cases three days, in six cases four days, and in thirteen cases five to seven days. Two unusual opportunities for studying the incubation period of this disease have been recorded by Voisin.^ The first case was that of a girl aged nineteen years, who swallowed a virulent culture of typhoid bacilli vdth suicidal intent. On the third day after the germs were swallowed the patient began to complain of headache, the next day a slight temperature developed. For two days head- ache and temperature continued and there was malaise and general discomfort; on the seventh day abdominal pain developed. On the eighth day she was worse, and had a few rose spots. There was marked depression on the ninth day, tongue dry and coated, and there was pain in the right iliac fossae. The spleen was enlarged and the Widal reaction positive 1 to 15, but negative 1 to 50. The course of the fever was a typical one, and the patient recovered. In the second case,^ a young Russian physician accidentally infected himself with typhoid bacilli by aspirating a small amount of a bouillon culture into his mouth while making a Widal test. He immediately rinsed his mouth with bichloride solution, but typical typhoid fever developed. The first symptom appeared upon the fifth day and rose spots and a splenic tumor could be determined upon the thirteenth day. ' Janelien-Graz. Miinchener medicinische Wochenschnft, 1898, p. 936. 2 Dufloeq and Voisin. Archiv. G^nwer, unless some other (h'soiihr can he discovered to explain the height of the fever. Jt is \\<'ll to state that by morning temperature we mean the t(;mperature about 9 A.M.; by evening temperatiu'c, lh;i( .-ihonl i» i-.m." The.se views certainly do not hold true today for tlie ordinary types of the disease. Attention has already been called to the very low temperature seen in the mild forms of the disease amJ to the high fever sometimes met with even in the so-called abortive cases. Diu'ing the stage of onset variations in the temperature of the patient may be due to complicating states which are about to be described, or they are perversions of the ordinary temperatui-e of the initial days, occurring without assignable cause. The presence of a consolidation in the lung, of a pleurisy, or of a serious lesion in any one of the organs of the body, may entirely alter the chart in this period of the malady; and predominant localized symptoms may still further mask the case. Tliis is well shown by the following case recorded h\ ^lovvis} Aside from its obscure mode of onset, this case is also of interest, since, as a rule, gall-bladder infection manifests itself after an attack of typhoid fever rather than before : On September 21, 1898, he was called in consultation by Dr. R. E. Doran, of Willard State Hospital, to see ]\L-. J. L. B., twenty- six years of age, who had been suddenly seized forty-eiglit hours previously, with a sharp pain below the right inferior costal mar- gins, which rapidly extended as an acute general peritonitis, with a temperature reacliing 102°, but apparently without accom- panying rigors. The patient was constipated until the day on wliich Dr. INIorris arrived. On examination a mass was easily palpated at the site of the gall-bladder, and the peritonitis seemed 1 Morris. New York Medical Journal, Januarj- 2S, 1S99. 46 VARIETIES OF ONSET to be most intense at that point. They diagnosticated empyema of the gall-l)hulder and operated. The peritonenm was deeply congested and was covered with coagnhUed lynij)h in the vicinity of the oall-hhulder. The i>all-l)hid(ler was (h'stended with a mix- ture of thin, greenisli mncns and thick, tenacions yeUow pus. Dr. Morris did not have his culture-tubes at hand, and no bacterio- logical examination of the pus was obtained, much to his regret. He drained the wound and the gall-bladder with a small wick drain and closed the incision, excepting for the drainage opening. On the evening of the day of operation the temperature rose to 103° and dropped on the following morning to 100°; the pulse to 88; the respirations to 24. On the evening of the second day after operation the temperature rose to 106°. Up to tliis time the l)owels had not moved, but two high enemata of Epsom salt caused a number of loose movements, and the symptoms of dan- gerously progressive infection subsided rapidly. After this the symptoms of typhoid fever supervened, and the case ran a typical course as one of typhoid fever, ending in recovery in about four weeks, excepting for a small biliary fistula, which closed spontaneously. In nervous cliildren or women the irritation of the heat centres often results in a sudden rise like that which is met with in the more acute maladies of an infectious type. And it is a well-known fact that typhoid fever in children is more apt to be ushered in by a chill and high fever than it is in adults, as has been well pointed out by Jacobi and J. Lewis Smith. A case of this character is reported by (niinon,^ in which a child of two and one-half years was seized with high fever and with all the symptoms of pernicious malarial infection. Nine days later it suffered from collapse with all its characteristic symptoms, and the day following passed stools wdiich were typhoid in appearance. Collapse again occurred, and on the twelfth day symptoms of meningitis developed. Finally, a rose rash appeared, the spleen and liver were found to be enlarged, and the case proved itself to be one of immistakable typhoid fever. The early age of the chikl, the sudden onset, the flushed face, the i Guinon. Revue Mensuelle des Maladies I'Enfaiice, 1897, p 23(1. TFMI'l<:RATUIil<: \AU/ATI(K\S hIidM Tlir: I SIM. I .\ OSSI/I' 17 lii^'li fVvcr, (lie colljipsc, iiiid, (iii;illv, llic inciiiiiof'jil symptom- ;ii<- of interest. Ill some instances in wliicli lii;^!! ninpcniluiv- i-: nolcil when tlie ])liysici;ui first sees the j);itienl, it is not in re;ility llie earlifst perversion of norniiil (emperalure in tlial ;i mild :\\u\ nnnrdieefj fever lias been |)rescn( for some days, even iIioumIi die pnticnl lias felt perfectly well. Hi^h initial teniperatnres should place die j>liy>ici;iii on hi.-> guard, heciuise they may mean severe infection or srjme ^rave complication which he must search for and ijiscovcr, and partic- ularly is this the case if the initial temperature is ushered in or is followed by a chill or ri<^or. In some of these ca.ses careful study of the history of the patient \\\\\ reveal an exposure to malarial infection, and an examination of the blood may reveal the presence of the malarial parasite, although, as pointefl out farther on, this organism is apt to be absent from the blood during the active period of typhoid fever. The more sudden the appearance of the disease, and the more rapid the rise of temperature in the beginning of the first week, so much the more should one expect in general a short and even abortive attack, and the more rapidly the temperatiu-e falls, as the end of the first week is approached, the l)etter the prognosis, particularly if the daily fluctuations are marked. Very sudden development of true hyperpyrexia at this stage, unless it is due to some severe complication, is very rare. Chills. — In some instances, not commonly met with, typhoid fever uncomplicated by other states is ushered in by severe chills. As already pointed out, these are most apt to appear in children, and they may indicate the development of some coincident infection. Chills may, however, be due to the typhoid infection itself. They are met with more frequently at the onset of a relapse than at the primary onset. In a case under our care, a man of thirty-five years, after several days of malaise, without fever, was seized with a violent rigor and at once became so ill that he was forced to go to bed, where he passed through a severe attack of the disease. Osier, in his consideration of chills in typhoid fever, diAides them into six classes. (1) Where the chills occur at the onset of the 48 VARIETIES OF ONSET disease; (2) at the onset of the relapse; (3) as aresuU of treatment; (4) ^^^th the onset of comphcations; (5) septic chills during con- valescence in protracted cases; and (6) chills due to concurrent malaria. In the series of 829 cases reported by Osier, chilly sensa- tions were noted during the prodromal period in 213 instances. Under the name of "sudoral typhoid fever," Jaccoud recorded in La Semaine Mcdicale for March 12, 1897, his belief in this special type, in which cliills and sweats are prominent symp- toms. The onset of the malady is sudden, and is accompanied by severe headache in the retroorbital and occipital regions with shivering, fever, and sweats, so that the patient resembles one suffering from an intermittent malarial attack. These attacks are often quotidian, and the febrile movement is hyperpyretic. The peculiar symptoms cease by the fifth day, and are followed by the usual course of typhoid fever. Quinine does no good in these cases, and they are not due to malarial infection. A second form is characterized by the primary appearance of headache and fever followed by sweating, which is profuse and asserts itself much later than in the form just described. The febrile movement is distinctly intermittent in type, but not so markedly so as in the form just named. In other cases, in place of a marked rigor, the patient has a subjective sensation of coldness in some part of the body, which can also be perceived by the physician if he touches the spot. In these forms the irregular manifestations may last three weeks and then gradually cease in the fourth week. Sometimes these cases are, however, very prolonged, and Borelli has reported instances lasting seventy or ninety days. Indeed, Jaccoud regards the length of the attack as characteristic. There are practically no complications. Albuminuria is extremely rare, but intestinal hemorrhage of mild degree is not uncommon. Peri- tonitis from perforation, Jaccoud asserts, is quite unknown in these forms, and he regards "sudoral typhoid fever" as a mild type of the disease. Notwithstanding the close resemblance of these types to double infection by the malarial organism and the typhoid bacillus, both Jaccoud and Borelli believe them to be pure typhoid fever, because they occur in persons who have never been exposed to malarial infection, and because quinine is useless. TEMPEHATUJiJ'J V A HI AT IONS FliOM 'I'll I; CSUAL IS OSSHT \[) The differcntiiil diiif^nosis is iicc'cs.sfirjly (Jifliculi in idc c;!!!-.- stages of the disease, although in general Jaceoiid would have us beheve that it is easy. It must (Jepeiid hirgely upon the aljsenee of any history of ninhnijd exj)()sin(', upon complete d<-vcK)pnifnt of most of the characteristic signs of typhoid fever, and, fin;dly, upon the al)sence of any signs of tlie niidMri;d organism in the blood and the presence of the Widal reaction. In cases of "abor- tive sudoral typhoid fever," in which the disease runs a very short course and stops abruptly, the diagnf)sis is very flifficult. Jacr-oud describes such a case as follows: "In the patient referred to, the headache and the temperature chart justified the diagnosis of mild typhoid fever, but the diges- tive organs were intact; there was no abdominal tympanism and no diarrhoea. The spleen was of perfectly normal size, the tongue a little dry, but otherwise showed absolutely none of the charac- teristics of typhoid fever. There was absolutely nothing in the limgs. The fever alone, and the slightly stupefied appearance of the patient, led us to assume the existence of some typhoid infec- tion. There also existed on his body a measly eruption; but this was a superadded element, due probably to the large doses of anti- pyrine which he had taken, and also to some alcoholic frictions, which had been given. Besides, he was a grocer by trade, and grocers are specially exposed to skin irritations which not infre- quently give rise to cutaneous affections. On the first days he had presented a certain degree of ocular catarrh, with redness of the conjunctiva and watery eyes. Then abundant perspiration appeared on the forehead, the nose, and the chest, drenching those parts completely. The fever developed in this way for ten days, the headache was general and persistent, but not very intense, and during the whole of this time there was nothing worthy of note, except the hypersudation and the rubeolar eruption. "The case was evidently one of abortive typhoid fever of the sudoral variety, and could be classed in the mixed form wliich I have described. There was one abnormal point, viz., the subsi- dence of the fever, wliich was complete on the tenth day. Such rapid termination, not very unusual in ordinary t%-phoid fever, is, I repeat, almost exceptional in sudoral typhoid. The differential 4 50 VAIUETJES OF ONSET diagnosis between sndoral typhoid and malaria, i. e., typhonialaria, is, on the whole, easy, and hesitation between the two cannot last long, the administration of quinine salts, which are without action on sudoral typhoid, setdes the question." The violent headache of so-called sudoral typhoid fever, which is sometimes the only ])rodrome, may lead one to think of influ- enza, and in particular of tlic nervous form of that disease; but in influenza the pain is not localized in the head alone. It ap- pears early and is very intense, but is also general all over the body; the temperature may remain normal, or, if there is fever, the temperature-curve is totally different from that of tyj)hoid fever. The evolution of the influenza itself, which is in general of short dm'ation when it remains uncomplicated, helps considerably in the differential diagnosis. One might be misled into diagnosticating measles when, along with the ocular catarrh, there is a discrete eruption of rose-colored spots, or else a true roseolar eruption like that of the patient under consideration. The absence, however, of all eruption on the face and neck and of severe bronchopulmonary catarrh, the insignificance of the ocular catarrh, and the character of the tem- perature-chart, all enable us, Jaccoud thinks, to eliminate this disease without much difficulty. The senior author had under liis care during the winter, 1898-99, a case which followed this com'se: A man of twenty-five years, a cigarmaker by occupation, was taken ill with what was supposed to be ''malaria" or "la grippe" on February 4, but felt better and returned to work on the 6th. On the 7th he felt very ill, and entered the wards on the 8th. At this time he had marked swelling, as if from a phlebitis, of the left leg, which entirely disappeared in twenty-four hours. He presented all the characteristic symptoms of ordinary typhoid fever by the tenth day of the disease, but his temperature made the folloA\ang extraordinary chart, each rise being followed by profuse sweating. He also had profuse night-sweats. He never had typhoid fever before, nor were there any signs of tuberculosis or ulcerative endocarditis. His blood showed no signs of the malarial organism and gave the Widal reaction on the thirteenth day. UNSI'lllATOUY CON 1)11' IONS IN ONSHT 51 It is of interest to iiolc llinl diifinn- ihc icn years since the first edition of tin's work appciircd di<-i(' liiivc jippf.-ircrl in fiie French ine(h'("i,l journals oecitsional accoinil.s of (liis so-called "sudoral Via. 10 MOVEMtNTB - - - - - " - - - - - - - - - - URINE DAILY AM'T ■?. 'i\ ;? !^ s '■% '•2 n o :f ,- i'i s ?; 3 S » F. 100'^ 105° 104- 103° 102'^ 101° 100° 99° 98° 97° Pulse. Resp. Dato. u i i !j 5 \ ^ S 5 >! » s % •S ■a i i •o ^ i H ^ H ; J ^ i 2 ; 5 n 3j >< - - ~ - — - - - - - - - - - - ' 11 z fl rt g n 1 .'. ' ■^ 1 .^1 ^ — T - y .- - — - — — 1 ' i / \ / t 1 ( I f 1 1 / V / 1 I 11 1 t 1 1 / \ I / / 1 V I / 1 : ■ 1 n / ^ I / . 1 1 ' 1 1 ■'i' \ ' f 1 J V 1 \ / 1 p f \ 1 \ 1 ■^ -^ ^ 1 V \ 1 \ 1 \ 1 / ij 1 \ 1 \ 1 II / \ I 1 ZJ :I3Z 1 1 1 I J 1 1 I 1 I ,1^ 1 L " f >y \ 1 1 g § o o ?, usually HS iiif^'li as 120 (o l.'IO, ;u)(i rcsllcssiicss vvns f()ii.st;iiit. At times, particularly iil iii[;lil, (here Wfis (Icliriiiiii. An (•xiiiiiiiKilion of her chest rcvciilcd ;i( llic ri^^lil inidfllc lohc il:c [diysical si^us of consolidation- lliiit is, hroiicliiiil brciidiinif, diilncss on jxtcms- sion, and al)scncc of vesicuiiir s()nno Spoken of, niuncly, lli;il due lo doiihlc inrcchon will: ihc pccific organism of crouj)oi IS pnciiiiioiiiii ;iii(l (li;i( of l\|»lii)ii| fever. Sufli cases have been dcsciilx-d j)i(,rl,iciilarly by Cliiiiilcinf ^c In iifli instances the febrile movement of the jjnenmonia ni<;r^re the ninth day, or the Widal test gives a positive reactifm, whic-h it rarely does in the early days of the malady. Acute pleurisy, like acute pneumonia, may usher in enteric fever, being due to ordinary causes or to tyj)hoi{l fever infection of the pleura. Thus, Talamon^ has reconied a case of enteric fever in which the onset was characterized by acute pleurisy, but the con- dition differed from that ordinarily seen in this affection by reason of the intensity and persistency of the fever, and by the general depression and sleeplessness, headache, and vertigo. Talamon insists that there is a distinct difference to be noted between pleurotyphoid and acute febrile pleurisy, for in the typhoidal infection the general symptoms are out of all proportion to the physical signs. The only condition which may closely resemble pleurotyphoid is tuberculous pleurisy, but in tuberculous pleurisy the temperature is remittent, whereas that of typhoid is rarely so. Finally, the development of the other symptoms of typhoid fever will clear up the diagnosis. A very much more rare respiratory disorder \\hich may usher in typhoid fever is that chain of symptoms known as laryngo- typhoid, in which great hoarseness or aphonia develops with dis- tinct evidence of acute laryngitis. These cases are quite different from those of severe ulcerating laryngitis seen in the advanced stages of the disease, and which will be considered later on in the chapters on the well-developed and convalescing stages of the disease. Such instances are well illustrated by a patient described by Bayer.^ A physician presented himself for treatment because of aphonia and difficulty in swallowing, wliich was fomid to be due to acute laryngopharyngitis. These local symptoms were 1 Talamon. La M^decine Moderne, May 28, 1892. ^ Bayer. Revue de Laryngologie, d'Otologie et de Rhinologie, July 15, 1893. 56 VARIETIKS OF OX SET improvetl by treatiut'iit, but in a few ilays the man was seized with a severe chill, followed by fever and pain in the throat, an exami- nation of which revealed a nvmiber of small superficial ulcers on the soft palate- and on the pharynx; later the characteristic rose spots appeared on the slsin. ]\Iore interestino- than all, ])article.s of tissue removed from the heads of the ulcers just named contained the bacillus of Ebertii. 'l\\v iuHamniation exteudetl to the middle ear, and deafness resulted. The patient finally died from intestinal hemorrhage and pneumonia. The finding of the bacillus in such cases would enable an early diagnosis to be made. Lewry^ has also reported a case of so-called laryng()tyj)hus occurring in a child of one year; death occurred on the eighth day, and the autopsy, in addition to revealing the intestinal lesions of t}^hoid fever, showed fibrinous laryngitis. Stordeur" and Lemaitre^ report cases of "laryngotyphus" in adults. Blum^ has also reported several cases of ulcerating angina in typhoid fever. Almost ecjualiy rarely does a severe bronchitis usher in typhoid fever as a true primary manifestation, although, as the disease progresses, more or less bronchial inflammation is usually found. Symptoms of Onset in the Kidneys. — In very rare instances typhoid fever develops with marked evidences of acute nephritis, the lu'ine being smoky or bloody in appearance, and containing albumin and casts. This form is sometimes called "nephro- typhoid," and Ijy the French "flcvre typhoide a forme renalc." Among: the first of the cases of this character in the literature are two by Immermann,^ while the first to describe the condition as a special disorder was Gubler;" later, Robin, a pupil of Gubler, com- pleted the description made by his teacher, and proposed the name "nephrotyphoid." Kussmaul^ was one of the first in Germany to direct attention to the Gubler-Robin type, but was not inclined to consider it a particular form of the disease in the sense adopted by some French physicians. Nephrotyphoid fever, as described by » Lewry. Archiv f. kinderheilkunde, 1888, Band xl, Heft 3. * Stordeur. Soc. d' Anatomic et Pathologie, January 21, 1907. ' Lemaitre. Ibid., December 13, 1907. * Blum. Semaine M6d., Paris., 1908, xxviii, 37. ' Immermann. Jahresbericht der Medic-in. Abtheilung des Burgerspital zu Basel, 1872. * Gubler. Diet. des. science med., article Albuminuria. 1 Kussmaul. Homburger, Berliner klin. Wocli., 1881, Nos. 20, 21, 22. SYMPTOMS OF ONSHT IN '/'///■: ALI M FST Ml Y 'lUAC'l' ",7 Gul)ler, is made up f)f' tlio.s(! citscs of the disciisf; in wliifli flio curliest symploiiis are (hose relatiii<( (o the kidneys. According to Anuit,' (li<' iirinc is in\;ifi;d)ly clijiriu-leri/fd l»y its intensely hloody eolor and the |)resen(,'(; (jf lar^(! amounts (;!' alhiiinin, with numerous tube easts, hlood eorj)nseles, epitlieHal eells, and their degeneration produets. In nddilion, there is said to be from the onset remarkably high fever, wilh cmly ;ind profound stupor, but with the absenee of the nsuni nbdominid symptoms of the typical case of typhoid fever. GaillanP reported to the Soci^t^ M^dicale des Ilopitaux, for Bagot, the following interesting case of hsematuria ushering in typhoid fever. The patient was a lad of ten and one-half years, who was taken ill on June 2TDh. en fomie renale, These, Paris, 1878. 2 Gaillard. La Presse M«5dicale, February 11, 1899. 58 VARIETIES OF ONSET from general wretchetlness, febrile movement, a heavily coated tongue, impaired hearing, and mental hebetiule. A case of this character was uiuler the care of the senior author when the first eilition of this hook appeared. A woman, aged thirty years, was taken ill with what appeared to be a severe attack of acute tonsillitis with high fever. As the fever failed to disappear with the subsidence of the tonsillar swelling and pain, and as an epidemic of typhoid fever was present, her blood was examined for the Widal reaction. It was found, and simultaneously other symptoms of enteric fever developed. A peculiar form of ulceration of the pharynx has been recorded by Bouveret,^ Devignac, Dengnet, Wagner, and Cahn. They call it "pharyngotyphoid." The ulcers are superficial, clean-cut, and appear chiefly on the soft palate. (See also later chapters.) (For oesophageal lesions, see the next chapter.) Probably the most common perversions of the early manifesta- tions of enteric fever are to be found in association with the func- tions of the gastro-intestinal tract. So common are they, and so localized are the dominant symptoms in these cases, that the malady seems quite distinct from true typhoid fever, and is often called the gastric form of typhoid fever. In some instances, it is true, fever of mild degree develops in cases of gastric catarrh of a more or less severe form, but they are not characterized by the profound degree of illness seen in the gastric type of enteric fever, in which persistent vomiting and epigastric disturbance followed by diarrhoea are the main symptoms in the early or initial stages. Such gastric types are more commonly met with in children. As well pointed out by Bristowe, undoubted enteric fever in cliildhood, at which age recovery commonly occurs even if the disease is overlooked, is often called, for want of a better name and a certain diagnosis, by the conscience-quieting term of "infantile remittent fever," "bilious fever," and "gastric fever," or even "worm fever." (See Frequency of Enteric Fever in Childhood, in Chapter I.) The gastric manifestations when severe are, perhaps, more readily discovered to be due to enteric fever than if the infection be I Bouveret. Berliner klin. Woehenschrift 1S85, No. 14. SYMPTOMS OF ONS/'JT IN 'I' I IF ALIMENT MiY T If. ACT :,\) mild, for, if tliis be so, the oilier lyphoid syiriplonis ;ire not iri;irk(;d. These gastric syinptoins iire rarely met with in (lie grciit eilies of the eastern part of (lie lliii(('(l Sdiles, jukI v;iry in rlidVr^'nl ♦■piderm'cs, although they are asserted by Aliirehison to have been eommonly met with in his experience. On the other hand, Hutchinson, in his classic article in l^epper's System of Medicine, tells us that these acute gastric symptoms with nausea and iulisc Aoiiii(ing have been unusual in his exj)erience. When vomiting ushers in (he disease in a child it does not seem to be as evil a j)rognostic sign as when this symptom begins the attack in ;i!i ;i(hil(. The senior author saw several years ago, in consultation with Dr. C^rville Horwitz, a case in which persistent vomiting was the first sign of the disease, and preceded a very severe illness. Vomiting in a child is readily produced by any disturbing ailment, but in an adult it probably results from a more or less profound infection, and rapidly caases exhaustion if it is persistent, as it is apt to be in tliis class of patients. When the vomiting is mild, or, in other words, is repeated but once or twice, it is not, of course, of any gravity, and no less an authority than Murchison intimates that such cases often seem to be bene- fited by it if it be not too persistent. Severe and continued vomiting in a case free from malaria and showing persistent febrile movement ought to arouse the suspicion of typhoid infection to a sufficient degree to cause the physician to be on the watch for further confirmatory symptoms, particularly if the illness is not relieved by the ordinary measures. Another variety of onset, represented by disturbance of the gastro-intestinal functions, is that characterized by the sudden development of violent diarrhoea of the serous type, instead of the constipation usually met with during the first week of the disease. Such cases are not common, but are represented by the follo\A"ing case in our own experience. A man of thu'ty-five years, apparently in perfect health, and whose appetite had been excellent up to and including the morning of the beginning of his illness, began to suffer after a moderately heavy luncheon from slight headache, which he attributed to indigestion, to which he was subject. He ate no supper because of nausea, and was seized at twelve o'clock midnight with an active, watery diarrhoea, resembling a mild attack of cholera 60 VARIETIES OF ONSET morbus, in that tlie abdominal pain was not very severe. No vomitinir occurred. Bv the use of chlorodvne in full doses he was able to remain out of bed for four days, but at the end of that time was seized with a severe rigor, followed by moderate fever rising to 104°. He then developed mild typhoid symptoms, but ten days after the fever ceased, suffered from a severe relapse. It was found that just thirteen days prior to the diarrhoea he had eaten raw clams contaminated by sewage, and that eight other persons who ate of the same lot of clams also had the disease. The active diarrhoea in this case, followed by wretchedness and general malaise, was naturally supposed to be in no way coiuiected with a definite and specific infection. Still another case of this kind is that of a patient admitted to the senior author's wards with a history that up to January 10 he had been in good health, but on that day, while working in a sugar-house, and exposed to liigh temperature, he had taken large draughts of cold water, which speedily produced symptoms of cholera morbus,, followed by headache and anorexia, and these again hy the early symptoms of enteric fever, which caused him to come under our care a week later with, as additional symptoms, signs of conges- tion of the middle lobe of the right lung. Rose spots appeared on the ninth day of his illness. Pepper and StengeP have reported seven cases of abrupt onset in typhoid fever, and they assert that Moore, in his Text-hook of Eruptive and Continuous Fevers, published in 1S92, is the only authority who calls particular attention to these cases in which the disease begins abruptly and with vehemence, characterized by decided rigors, violent headache, and rapid rise of temperature. Moore thinks that the whole course of the disease is becoming more typhus-like than formerly. Pepper and Stengel's seven cases may be divided into two classes: those in which the prelimi- nary symptoms were simply gastro-intestinal in character, vomit- ing, purgation, and high fever being present, and others in which violent headache and catarrh of the throat, nose, and bronchial tubes was marked. ' Pepper and Stengel. Philadelphia Medical Journal, vol. i, No. 2. ^SYMPTOMS OF ONSF/r CONNFCTFU WIT 1 1 SFUVOdS SYSTFM ()] Symptoms of Onset Connected with the Nervous System. - Of tlic iicivoiis iiiHiiircsbid'oii.s of (ypli(»i(i iiiva.si(;ii lliicc cliicl' (y|>»,*.s Miiiy be nuMitioncd, iiiuncly: (a) 'J'hjif in wliicli the });itif'nt siiflVT.s from (Iclusions or iil)cri';itioii of iiiiiid ;iii(l u;iiii|cis from lioiiif' until he l)econie.s so ill as to fall ami be taken to a licjspital, or, perhaps, loses his life through exhaustion, or accident due to his stupid mental state, or l)y means of deliberate suicide, (h) The second class is that in uliicli Jicnte maniacal symptonas ensue. (c) The third class is that in which evidences of meningitis are marked; so marked that true meningitis is supposed to be y)r('sent, or in its place meningitis secondary to cr()ii])()iis jHicumom'a. In many of these cases there is little doubt that the jjulmonary lesions of typhoid infection are responsible for the meningeal signs, while, on the other hand, it is possi})le for direct infection of the men- inges by the typhoid organism to occur, although this is rare. (See farther on.) Some years ago one of us (Hare) and Patek reported two cases, and collected a number of others of mental disturbance at the onset of the disease which we^ found in the literature of the subject: Murchison^ reports the case of a German who w^as much excited over the Franco-Prussian War. After about four days of dis- comfort and malaise, he suddenly passed into a state of acute maniacal delirium, requiring two men to control him. There was an absolute refusal of food, a temperature of 102°, with a dry tongue and rapid pulse, shght diarrhoea, and no spots. The patient w^as subdued by large doses of chloral, and the fever ran its course. The same author also states that in several instances he has known acute mania to develop on the first day of an enteric fever, and that under these circumstances the case is very apt to be mistaken for insanity. Wilson^ asserts that delirium may be an early symptom of enteric fever, and quotes Riberalba, who reported four cases which were delirious on admission to the hospital. Louis saw two cases w^iich were delirious on the first nio-ht of their illness. Bristowe 1 Hare and Patek. :Medical News, 1S92. 2 Murcliison. Lancet, 1870, vol. ii, p. 807. 3 Wilson. Philadelphia Medical Times, 1884-85, vol xv, p. 577-5S1. 62 VARIETIES OF ONSET has also reported a case in wliic h maniacal delirium existed on the second day. Mottet mentions an instance of typlioid fever com- plicated ■with mania to such a marked extent that the patient was placeil in an asylum before the true nature of the ailment was discovered, and Ilenrot antl Buccpioy have seen the disease ushered in with the delirium of grantleur. Finally, Daly^ records an instance in which aggressive mania came on on the fifth day, fol- lowing a condition of stupor. One of us (Beartlsley) saw the following case in 1903: The patient was a man, aged thirty-two years, who had never sulf'ered from any previous illness and had heen perfectly well mentally and physically until a week preceding his admittance to the hos- pital. Three weeks preceding his illness his wife was taken ill with typhoid fever. She was pregnant at this time, and in the tliird week aborted. A few days following this occurrence it was noticed that the husband was despondent and silent, but little was thought of this, as the friends knew how bitter a disappointment the loss of the child was to him. Two days after this change in the mental attitude of the man he was suddenly seized with homicidal mania and attempted to kill his wife by beating her with a chair, and assaulted those who came to her rescue. Examination revealed a roseolar eruption upon liis abdomen and back. The patient died four days after being removed to the hospital, and the autopsy revealed the characteristic lesions of typhoid fever. From a careful examination of a large amount of literature we are convinced that prodromal insanity in enteric fever is most rare and, when it occurs, is almost always fatal, while the insanity which is in the nature of a sequel may be looked upon as devoid of danger to mind or body. In very rare instances, delirium may be almost the first symp- tom of typhoid fever. Indeed, it may actually precede the devel- opment of pyrexia; thus, in seventeen cases which have been col- lected from literature by Aschaffenbourg,^ seven were charac- terized by the development of delirium before the fever, and the latest period at which it was observed among these cases of early 1 Daly. The Medical New.s, 1882, vol. xl, p. 68. * Aschaffenbourg. Archives de Neurologic, March, 1895. SVM/'TOM.S OF (>^SI<:T CON N KCT HI) Wl'l'll NHH. VOUS S VSThWf i\?, (Iclii'iiiin wn.s llic end of (lie fir.sl week. >\.s ;i rule, (Ik; dcliriijiri lasted only a lew diiys, hnl, (he nior(;ilil,y vvjis lii^li, .six of tlif; sevoii(('(>n ])aticiits dyiiin;. Airion<( tlicsc cases tlie delirium occurred in two I'ornis, either (lie |);i(ieiils were exeeedint^ly restless and violent, finally becoming torpid, or there was a condition of confu- sional insanity, in which the patients sang, prayed, danced, or were gay or sad. The following cases met with by the senior author and J^atek are of interest: Amiie M., aged twenty-four years, wa.s admitted to St. Agnes' Hosi)ital, March IS, LSOl. She had been feeling badly for some time, but undl loin- days previously had been able to do her work. On the 14tli she had a severe headache, vomited a little, suffered from pain in the stomach, and had some diarrhoea, these symptoms being followed on the subsequent day by not very profuse epistaxis. She walked a considerable distance to the hos- pital, and on her admission, at 10 p.m., her temperature was found to be 105°. The resident physician found that her tongue was thickly coated, dry, and brown. On the next day, when seen in the wards, the tongue was unusually clean even for that of a healthy person. The patient was delirious and so violent that it required several persons to keep her in bed. The tempera- ture, after an unusually prolonged and severe struggle, was found to be 106°. At tliis time every symptom of typhoid fever was completely masked by the insanity. The bowels were moved and the passages were of normal consistency and color. The urine was somewhat scanty and high colored, and the pulse full and strong. There were no rose spots or other enteric symptoms. At the end of twenty-four hours the patient, still being in a condition of ^ild insanity, was removed to a cell, the impression being that it might be a case of hysterical mania with hyperpyrexia. Twenty-fom' hours later the insanity had disappeared, and the t}-phoid symptoms as- serted themselves; the delirium became more quiet and muttering, and she was taken back to the wards. Durino- the following^ week she was constantly delirious, and frequently maniacal, although there were short momentary intervals of sanity. Diu-ing this time a large number of rose spots appeared on the abdomen and chest. 64 VAEIETIES OF ONSET the tongue became lieavily and typically furred, the temperature followetl a characteristic course, the typhoid odor was present, and an occasional nose-bleed helped to confirm the diagnosis of typhoid fever. She rai)i(lly became worse, and died thirteen days after admission, without becoming sane, except for the bi-ief intervals named. The second case is as follows : jNIr. A., a resident of Milwaukee, aged thirty-four years; mar- ried; one child. A sister died of convulsions of imknown nature but a short time before the onset of his illness. Family history otherwise negative. At the age of seventeen years the patient, according to the statement of his physician, had an attack of typhoid fever, attended with as much, if not more, delirious excitement than this, the second attack. The history of the case begins with the circumstance that Mr, A. was nursing his wife, who was down with a mild attack of typhoid. The })atient's first complaint was of headache and insomnia. The visiting physician, seeing him on the following day, ordered him to bed, recognizing the case as one of typhoid fever, rather because of the existence of a like case in the same house and from the mere complaint of malaise, than from any symptoms particularly characteristic of the disease. The patient obeyed the instructions of the physician, and went to bed, still complaining of insomnia. Hardly had he fallen into a mild slumber when, not more than an hoiu* later, he sud- denly awoke, delirious, and grew steadily more so. During the following night he became maniacal, rushed to the room of the nurse (she had been procured since the husband's illness), burst open the door, threw the nurse to the floor, and assaulted her in a most violent manner, kicking and striking her, and accusing her of wishing to harm his wife and child. The nurse finally man- aged to escape, and ran for the physician, who lived across the street. In the meantime the patient jumped through a window leading to a small balcony over the front portico, and leaped to the ground, where he was found a few minutes later by the physi- cian. Strange to say, the man suffered little injury, being slightly bruised by the fall, and somewhat cut by the glass; but stranger still was the fact that he was now quite rational, telling the physi- SYMPTOM S OF ONHliT CONN I'^CT HI) WITH N/'JUVOf/S SYSTf'JM 05 ciaii all tliiit had tran.sj)irc(l and wliai lie li;id done 'i'iic paiicnt was again ])ut to Ixvl, now iij)|)iir('nlly (\\uic < oniforhdjlf'. 'JMu; physician left him (o sec the wife in ;in ;idjoinin^f room. Ihirrlly, however, had he gone wlicji Mr. A. .snd(h-iily sj)r;ing from th(; bed, rushed into the kitchen, where he seized ;i large knife, and then hurried back, bent upon assaulting du; physician. He was, however, overpowered and again forced to bed. He now rested comfortably, and when seen the following day was df>ing well. That evening a condition of hyperj)yrexia suddenly intervened, and in a few hours the jjatient was dead. The following case is of interest in this connection, and was seen by the senior author through the courtesy of Dr. Higbee, of Philadelphia, who called him in consultation. An unusually large, muscular man, al)out thirty-five years of age, after two or three days of wretchedness and malaise, with slight headache, developed fever of moderate degree on the fourth day, and that evening became maniacally delirious, so that it required four of five of his fellow-workmen to hold him in bed. On these workmen becoming exhausted, the following night two male nurses were put in charge of liim, but he fought them so vigorously that they refused to take care of the patient when the morning arrived, as they stated he was so powerful that he tlirew them all about the room. When seen after two nights of violent delirium of this character, he was perfectly himself, mentally, and described liis condition and liis sensations, using unusually good English for a man in his walk of life, and evidently having an intelligent idea of the chief symptoms to which he was subject. He had no recollection of his delirium, but he had been told bv his ^\ife of the strugo-les that ther had had with him on the previous night. A careful examination of his chest revealed at the apex of the right lung, anteriorly, a small patch where there was impaired resonance and the other physical signs of pulmonary consolidation, and after consultation we agreed that it was one of those cases of pneumonia in which there was a remarkably small pulmonary lesion, accompanied by severe meningeal and cerebral symptoms. Some- tliing about the case, however, made us suspicious of a t^'phoid 5 66 VARIETIES OF ONSET infection, and wliile there were no .symptoms of typhoid fever pres- ent that coiikl be pointed to, we were suspicious of the development of tliis disease. That evening the man again became maniacally delirious to such an extent that his family recognized that it was impossible to keep him at home, and he was admitted to the hospital, where he died in forty-eight hours from exhaustion. The autop.sy revealed typical typhoid ulceration of the bowel and other pathological evidences of well-marked tyi)hoid fever. This case illustrates very well not only the fact that pneinnonia and typhoid infection may exist side by side, the pulmonary con- dition being, perhaps, directly due to the infection of the bacillus of Eberth, but also that cerebral symptoms of great severity may usher in both typhoid fever and pneumonia. Osier records two cases of curious aberrant mental state in tlie stage of onset. In one, a young girl began her illness by doing- odd things and having laughing and crying spells; the other, also a young woman, was distinctly "off her head," so that she was regarded as an ordinary case of insanity. There is still another nervous type of onset which is exceed- ingly rare, namely, that of rapidly developing stupor and coma. Very rarely in children the disease is ushered in by a convul- sion, as in a case recorded by Osier, and in the case of convul- sions reported by Green, and detailed in an earlier part of this essay. Convulsions when met with in adults are usually seen in the later portions of the disease, and depend upon embolism or thrombosis of important cereljral vessels. The Skin in the Stage of Onset. — As is well known, the char- acteristic rash of typhoid fever does not make its appearance, as a rule, until the seventh or ninth day, and, therefore, it cannot be considered a symptom of onset in typhoid fever. Cases do occur, however, in which in this stage of the disease aberrant rashes develop. Thus the senior author had under his care a man of twenty-two years, who entered the hospital on the third day of his illness so covered by a profuse scarlatiniform rash that a differential diagnosis as to its true character was impossible. It persisted for three days, and then gradually faded, and the case ran a course of typical typhoitl fever. (See the chapters on the skin in the well- developed and convalescent stages.) 77//'; SKIN IN TUI'l STACi: OF ONSFT 67 The junior author, during a service in llic ,Sf:iil(i I'cvcr Wards at the Municipnl II(),sj)itiil of rhila(i(;lj>hiii, siiw ;i(, their homes three cases of typhoid fever in chiNhHui in vvliom there was a pro- dromal scarhitini form i;i.sli which in every way corresponded tolhf; rash of scarlet fever, and had it not been for a careful infjuiiy into the previous Jiistory of these patients they would have been taken into the hospital as scarlet fever subjects. In reference to these rashes, Dr. IJurvill-IIohnes, who spent three years at the Municipal Hospital, informs us that durinf^ this period he saw three similar cases, one of which, enterinf^ the hospital because of an error in diagnosis, was exposed to and contracted scarlet fever, thus giving an excellent exam[)Ie of (he similarity of the two rashes. Remlinger^ has carefully studied these prodromal rashes of typhoid fever, and has reported that in the 49 examples that he was able to find in the literature, there were 31 examples of morbiUiform rashes, 4 of scarlatinal rash, and 14 in which there was a mixture of the two types. 1 Remlinger. Revue de Medecine, 1906. CHAPTER TIT. THE ABERRANT SYMPTOMS, STATES, OR COMPLICATIONS OF THE WELL DEVELOPED STAGE OF THE DISEASE. Temperature in the Developed Disease. — We may pass on, then, to a consideration of excessive symptoms and com})lications of the developed disease, and its febrile process natnrally first attracts attention. Before we attempt to study the unusual febrile condi- tions seen in patients who have passed the stage of onset and are in the well-developed period of the malady, it may be well to con- sider briefly the normal or usual febrile movement. This Striimpel well describes when he says that the second division of the curve represents the so-called fastigium, and corresponds to the height of the disease. "During this time the fever presents in most of the severer cases the general character oi febris continua — that is, the spontaneous remissions of the fever seldom exceed 2°. Almost always the lower temperatures come in the morning hours and the liigher in the evening. In cases of average severity the morning remissions touch 102° to 103°, and the evening exacerbations 104° to 105°. Temperatures which reach or exceed 106° are seen only in very severe cases. Considerable morning remissions are always a favorable symptom, while morning tem- peratures of 104°, or higher, generally show the case to be severe The duration of the fastigium varies with the severity and obsti- nacy of the case. It may last only a few days or one and a half to two weeks; in violent cases still longer." Ampugnani^ has proved that the natural maximiun occurs between 3 and 6 p.m., and tlie natural minimum between 5 and 8. A.M. At the end of the fastigium the temperature gradually falls by lysis until it reaches the normal, or perhaps more frequently 1 Ampugnani. London Medical Record, January, 1889. TEMi'i<:i{.A'i'Uiii<: IN rill': dicvkloi'i:!) nishiASh: no there is hd'orc \\\v lysis jiiiollici- period vsliidi li:i , Ixiii f.-iUcil hy Wniidcrlicli (lie " jiiiiM^iioiis period," in wliieli llie inoniiri^ Icm- pcrutures arc cacli day almosi rionnal and llie eveiiin/f f,eiri[)('ra- tures only sli •K^Vg =i=: -t ^ = = nr ;j — = " •K-.T i = = : ■^ ~ en •K^VR _ ~ = = - •K'.l 1 >. -r' "■ fo •K-VR "" KMi ►=r- ■i CB •K-VR ~ ~ r = - K-J / |>i i= - 22 ■K-VG 3X~i ~ =! = - -K-J G i= ;^ '" To ■K-V6 Tl •K-je i= C "" _; 3, - - OS •K-VR . •K-J 6 i: -P- GT •K-VG — z= = - -K-Jfi :: r SI •K-VG ~ > •K-JG < ^ n •K-V 6 > ■R-J 6 = a::; OT ■R-ve LO: = -K-JR c 4= — — ^ ~ ?T -K-VG ^^-7 = x •K-J 8 4= - — "" ' l-I K-VG """*■ -K-J fi !■ c|c - CI ■K-y 6 "T-" » ■KJ6 < ST -KVR > K-J 6 -K-JG ■ e "" OT •K-VG ■^ •KJB < •R^ve > -HJG ^ 8 •R"V6 > -K-J 8 r-'' I o o o o o :, o ° (B ,,' ^^ CO CM t— O Cn CO '■^■r U-S O C3 C3 O C33 C35 C» Q Q TEMPl'JUATUliJ'J IN TJJ/'J DI'AICLOI'I':!) hISHASI-: 7| yet at times it m;i,y beeorne in itself" (|jiii(ren;u,s \>y r<;;i.sf;ii of its Iiei<(ht. Sometimes, tiioiif^ii rarely, as in I lie (Jays of rxisef, we meet (liiriii(( the fastif^ium, without tiie presentee of an a(l(h'lion;il exeiting cause over and above the ordinary typhoid infection, \\i(h f,a.ses in which there is (k^veloped a distinct hyper[)yrexia jniioniidii^' to 105°, or even, very rar(;ly, to 110°. Such hiI' I,!) i)isr:.\sH ~.>, C()inf)li('ji,lHif^ sfjiics wliifli nrc prodiiclivc ol' fchrilc iiio\ciii<-;il will be (iiscusscd later on wlicii sliidyin^r (Jic lesions Joini'l in \;irions organs. Of the cases in wliicli (he (cniixTudn-c is o'i low (je^rce ;iikI mild, much may be said. In llie lirsl place, in very rare insfanee.s cases occur in wliicli there is not only no fever, but jie(u;dlv a rori- dition of subnormal temperature from the beginnin^j, lo die end of the attack. Thus, in several cases under our care, some years since, there was a characteristic temperature curve in form, but not in degree, the morning temperature being distinctly subnormal and the evening temperature normal, and in which the rel nin to health consisted in a "lysis," so to speak, in which the temperature gradually rose to normal instead of falling. Again, almost equally rarely there is no temperature movement whatever in the sense that the temperature is either above or below normal. Cases of this type have been recognized for many years by close students of the disease, but are not commonly recognized by the general practitioner, who is taught in the medical schools to regard fever as a necessary symptom of this malady. Many years ago the elder Miescher recognized these cases, and Liebermeister recorded, in 1869, 139 cases of "afebrile abdominal catarrh," which he thinks were in large part due to typhoid infection, and, in 1870, 111 cases of the same character. Many of these cases showed evident enlargement of the spleen, and in some instances a roseola. Straube^ has described fourteen cases in which no fever was pres- ent, although at times the temperature was subnormal, and in which, nevertheless, the other characteristic symptoms of enteric fever were present to so marked a degree that they could not be mistaken for any other disease. The mortality in these cases was no less than 14.1 per cent. So, too, FraentzeP has recorded forty- one cases treated in a field hospital during the Franco-Prussian War, in three of wliich the fever did not exceed 99.1°, and in the rest did not rise above 102.2°, and yet in wliich the mortahty was 39 per cent, for the forty-one patients. Guiteras^ records a case, in 1 Straube. Berliner klin. Wochensclirift, 1S71, No. 30. 2 Fraentzel. Zeitsclirift fiir klinische Medizin, ISSl, p. 226. 2 Guit^ras. 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Ll'^CO C-J >— C3 03 OD r— P ^ — ^ O C3 C3 C3 CD cn C3 03u--^5- >> "■ 76 WELL-DEVELOPED STAGE OF THE DISEASE which lie diagnosticated the condition as intestinal obstruction, in wliieh the patient died of peritonitis, and at the autopsy the lesions of typhoid fever were found, although no fever had been present. Vallin^ records a case of death due to perforation in an afebrile typhoid fever patient, and another of intestinal hemor- rhage in a similar case, and the senior author has seen several afebrile cases in one epidemic. In still another epidemic another instance was met with, which has been recorded in the Memphis Lancet for July, 1898. (See farther on.) In La Provence Medicale for November 26, 1897, Weil and Fiery reported a case of apyretic typhoid fever, which they considered in every way typical in other respects. Godfrey Carter^ has reported another case of this kind, while Judd"^ had under his observation a young woman who after exposure to typhoid fever developed all the classical signs and symptoms of the disease except the fever. The patient was placed in bed and carefully observed. There was no temperature until the seventeenth day of the illness, when the patient developed tenderness over her saphenous vein and her temperatiu"e rose to 101.6°. Four days later the temperature became normal, and convalescence became established. Gerhardt* and Dreschfeld^ have also reported cases of this char- acter, and there has even been reported an epidemic of apyretic al typhoid fever by Fraentzel.® It is interesting to note that the course of these ap}Tetic cases was quite as severe as the cases having fever. Two cases of apyretic typhoid fever have also been recorded by Wendland.^ These cases were confirmed by autopsy, and illus- trate, at least to the satisfaction of Wendland, that temperature is not a true index of the severity of the disease. Similar cases have been recorded by Fisk, of Denver, and they are represented by the following case: The patient was a male with a negative history, except that he 1 Vallin. Archives G^n^rales de M^d., November, 1893, see also Liebermeister and Hagenbach, Aus der med. Klin, zu Basel, 1869, p. 9. 2 Carter. British Medical Journal, October 10, 1908. 3 Judd. British Medical Journal, December 3, 1904. * Gerhardt. Charitd Annalen. '' Dreschfeld. Practitioner, 1893. « Fraentzel. Ztsch. f. klin. Med., 1880. 7 Wendland. Deutsche med. Zeitung, August 29, 1893. TJ'JMPJ'JUA'j'U/a'j IN riii<: n/'JVJ-jj/U'hh i)isi:.\sr: 77 had true typhus fever jit t^n years. On ndmi ; inn Ik- Ii.kI ;i tem- perature of 98.4°; pulse, H4; resi)ir;i,ti()iis, ^i); llic ton^nic ua.s eoated, showing distinct red tif) and edge; lie had an apathetic appearance, iind (•()ni|)l;iined of licidnclic; llie pu[)il.s were dilated, there were tenderness iuid i;iMolin!;- in tlie right iliac; fossa. He still had constipation, but when by inedicalion tlu; bowels were acted upon, the fecal matter was of pea-soup color and lifpiid. There was an eruption of "rose spots;" the spleen was normal. Upon the patient's abdomen and back were found numerous pale blue spots — taclie hleudtre. Close inspection showed evidences of pediculosis, several ova being attached to hairs. Later it was noted that the spleen was slightly enlarged, also that the palms showed the characteristic yellow tint; constipation still existed, but the pulse was not so rapid as on admission. The urine was yellow; specific gravity, 1020; acid, no sugar, no albumin. Later the headache nearly disappeared, but stupor still con- tinued. The diagnosis was afebrile typhoid. Dreschfeld also mentions this form of apyrexial typhoid fever. The accompanying temperature-chart (Fig. 14) is an interesting illustration of this type of case. Under the name of typhus levissimus, Griesinger first described forms of enteric fever in which the febrile movement was not only very mild, but in which the symptoms in general were of the most moderate form, the entire course of the disease lasting only eight to fourteen days. Warren Coleman^ has recently called attention to certain cases of "short duration typhoid fever," and has given an excellent review of the literature. He found that in the earlier days short duration typhoid did exist, but was seldom recognized. Louis- saw one of these cases wliich perforated and came to autopsy. Wegelin,^ in 1854, Griesinger,-* in 1864, jNIurcliison,'^ in 1873, and Liebermeister,*' in 1874, described cases of t^-phoid fever which were 1 Warren Coleman. Amer. Jour. Med. Sci., June 1909. * Louis. Reclierches sur la maladie fi&vre tj-phoide, Paris. 1S41. 3 Wegelin. Zurich Theses, 1S54. ^ Griesinger. Infktskrankh. 1S64. 5 Murchison. Continued Fevers of Great Britain, 1S73. 8 Liebermeister. Ziemssen's Path., 1S7-1. ' z.\ ov *•• - ^. Ofl r.5 vuaa^ irj ^ ^ If 09 "sT ■-• T.\ •ll-T J -,- m » -.1 c i Of ■9 "S5 t ■H-v ^ L ^ ■ •d s <\ C5 '" »5 V. ot -K-T f M ,- nt •KM 9 i s PR 09 ~~' 5 vui^n^ •W-T 9 1 > sv "in-'na^ KM 9 i 'S. n zz I ■' K-T s 1 <•': •K-J C 1 \ OR 0; 0; % IR •K-T ^■ 1 -; n vuutu^ K^J C CR 0; I".' OR »■» . 1 _£ K-,, C 1 »R 00 • ~ 05 CI- K-T < 1 ^ IS K-a 9 RR fO 55 95 vmsn^ K-T S H •K^.l Q 1 K •K^.l ,-, < IR O'.i ¥1 05 rnnn^I •K-T ,-. > 1 w K-.l (-. < OR 0; "^ C5 vi,i,.u3 K-v r, i> "rmanri ■K-.l ,-, C! 0- 00 f-5 fZ K-T r. > oc f: lu K-.l C A f" 55 95 luu.inj K-T r, > 0; 55 01 •K-.l r. ^ •n t-o 55 55 umanj •K^T r. > 00 55 or -KJ C /- - 0- I-O 55 15 i!tn.in3 ■K-T I-, K-.I (-, ^ c- ~r\ 55 05 IB •K-T r, ^ > r.o 55 OE ■K\t r. l<" \z fo 55 CI Tmanji -K^T ,-, ^ fO 55 DS •K-J r, ^ r; 00 00" --^ SI r>mna5t R-T r, > on ■K' r, .-. r ". 00 1-1- a rD.anj •K-T L K. •K^j r, '^ N^ - - ir. PC 55 01 Tiuwaj •K-T r, _ Jii oc 55 -- ■Tt .1 (-, K 1 OJ oc 1-5 CI rm.iiirt K-V ,-, > oc 1-5 nr. ■K ■( r. < --- r.I "0 f5 n TTtnnn^f •R-v r, N^ oc t5 ir. SI 00 1-5 Rl tjmacg PC I-5 on •K-„,-,, ;i 00 1-5 51 roisn^ / oc f5 or ■K-J r, 1 ■... /„ 01 fO f5 11 rman^ ■K-T r, ■' ''^ r.o 1-5 If: -•-■• ^ CI 1-0 1-5 01 Timnng ■K T . ^ :o f5 K 7 n i-o >o 1 ''' 1:0,303 ■K-T 1- -C Of •K-H f, . ..u > Rl 50 55 S Timaur, -K-T r. <: i-O uu in •K-a c > ■ ; ' 51 00 55 UUIDCJI •K^T r, 1 1 ^ ' ' I-O 55 ir •K-j r, > 1 II TrT 4"- «ai30;j -K-T r. < •K-.I r, !>-. 01 90 Vo ir t Ct: •K-T r, < T;Di3n:j N 1 RO 55 ^ K RO 55 •"•■' '■ : /-'' ' 1 R "oo fS R nuMng •=- -p- •K-,i r, 1 '- so 55 5 umang ■K-T ,-, 1 ,^^ 0; 55 ■K^j r, •> 09 oF f5 I ■K-T r, , /' fo ■K^j r, 1 < ll"r T5" IR •K^T I-, T ' ■K^.i r, l!_ •: \ 01 K OR tuinu^ •K-T r, \ ~> so " •K^.I '-I- ^ 00 to ^5 05 •K'v r, 1 1 •K^.i r. J-1 ' i > - ('9" f5 95" 8! •K^T n ■ 1 I 1 / •K^J I-, 1 ' i--r:^ I or. 19 "95" K l^oi.tluij.v uo II 1 1 til 3 :>- u-' 1 k i -s 1 f 1 •3 ^ « ° TJ'JMP/'JU.ATi//a<: IN Till': dhv I'li.oi'i:!) ijisI'.asi: 70 of sliort (liinilioii, and von .liii-(^^ciiscii' snid lli;il iIk- uIi()Ic (li«fu-y of infc(;(:ive discMScs wus imlciuiMc if llic cxi ,(y die inl rod i if lion of the Widal reaction iido iiiedicine die mild roiin.s of die disease liuve been niueli more readily diseovered. 1 .emoiiie,^ Catriji,'' an Frosch. Arch. d. mM. et phar. mil. 1903, xiii, 393. 8 Bates. Jour. Amer. Med. Assoc, 1909, lii, 1903. ' Debrie. Arch, de la direction du service de sante du 14 Corps d'Axmee, 1902. "• Briggs. Amer. Med., 1904, viii, 639. 80 WELL-DEVELOPED STAGE OF THE DISEASE as to be curiosities, and are so rare that the })n)hal)ihties in an obscure case are against their presence. Only the clear and un- doubted development of a sufficient number of symptoms coupled, if possible, with a positive reaction with the Widal test and with a history of recent possible typhoid infection, should cause the physician to reach a diagnosis of these types of enteric fever. In aged persons enteric fever is usually mild in its temperature curves, and the characteristic febrile movement is so irregular and distorted as to be devoid of much diagnostic value. Fio. 15 F. 104° 103° 102° 101° 100° 99° 98° 97° Dny of Dis. — ~i— — 1 ^ 1 ^ ^ ■"" - ^ ^ ■^ ^ 1 1 1 i l\ j \ / J V \ s, 1 \ -ii 1 I 1 s •-J \ ) '- \ ■^ ^ o- \ — - — ^ s s s A / \, /^ '> ^ \ ,/ \ \ — 1 \ CO -^ =^ CO c o ^., 2 2 = 1 Abortive typhoid fever ending bj' the seventh day, and by crisis instead of lysis. In some cases the fever is peculiar in that it fails to follow the so-called normal rise in the evening and slightly lower degree in the morning, and is supplanted by an inverse type in which the morn- ing temperature is highest. Su-ch an occurrence took place in the case reported to us by Krusen, which is quoted in Chapter I. Chills. — In this connection, too, it must be remembered that in some cases (not many), during the course of the second week, the fever develops a type closely resembling that seen in remittent malarial fever. According to many writers on diseases of children, TEMPEIiATdUl': IN Till': DHV Hl/)l'i:i) hi Si: ASH SI this form oi lyplioid U-wr is \)\ no niciiiis cjnc in ihi.s class of patients. Again, as tiiis week or Ihc lliiid wed, ends, the fel)rile movement may even he (Hsliiiclly h'kc that, of ;i ii);il;iti;il iii(r-i- mittent without there heiiig ;uiy inahirial iiifeefion. Slr-iimpej speaks of such, eases in which distinct reniitteiice occurred, and of ofhers in which die fever was coinph'tely iuterniident, tiie afternof^n tenij)erature for two or three weeks being as high as 104°, yet followed by morning temperatures at the normal point, and Pe})per has expressed the belief that these great variations are in part the result of marked sepsis and intesliiud nlceratioii. Thus he has seen as much as 7° variation occur for several days in succession. Such variations should never be considered curiosities in typhoid fever, but should stimulate the medical attendant to increased endeavor to discover a septic source other than the intestinal lesions as, for example, a septic gall-bladder or kidney. They may occur, however, in cases without complicating diseases or lesions, as is shown in Fig. lo. In this man's case the blood was examined repeatedly for the malarial organism, with negative results, and there was no history of exposure to it. Cases of this type are also recorded by Herringham, who dis- cusses these temperature variations in St. Bartholomew's Hospital Reports for 1896. In one of these a woman, aged thirty-three years, had severe rigors followed by high fever on the evening of the twenty-third and the morning and evening of the twenty- fourth day of the disease. These rigors were followed by a fall of fever, wliich amounted to a crisis, and speedy convalescence ensued. In still another case chills and fever occurred on the thirty-first, tliirty-fifth, and thirty-sixth day of the illness, fol- lowed by two attacks on the thirty-eighth day. These were in turn followed by crisis and recovery. In the other cases reported by Herringham a rigor occurred in one during the acme and later during lysis; in another at the onset of lysis; in another in lysis; in another a number of rigors occm-red in acme and severe rigors in lysis, probably due to thrombosis. Osier has also reported a case of this type.^ Chiu'ch" has recorded a case in wliich a girl 1 Osier. Johns Hopkins Hospital Reports, 1895, No. 5. = Church. St. Bartholomew's Hospital Reports, 1S96. 82 WELL-DEVELOPED STAGE OF THE DISEASE ■"■JC , 1 - ' 1 ~n => ' 8?r n: Of •" z\ < '' •"■■'ot >» fCl 7T- 0»0 ^ "s, k;i Zf 05-0 _ _^ _ _ - 1 OCT ^^ •KT6 "^ — ■" ~ on iff TIT 1 s ~. ^ ?i.T 81- OTO > f-;^! 71- W9 1 _ _ - - - Oi;i OCI 7T- 8E TH-TO i •KT f 1 / OCI 8C of-c *L - - _ _ __ «:i 8E OoT z ~ = = Ji'l 9E •K'T f 1 _ _ - - - - " 071 oc oe-:i 1 H cTa^Qu M ^ ;v 81 9n OE KK r.i I 1 1 - - - - - _ _ _ 1 u t: ■K-J f, ~ ^ z -< k:i RTI 87 •KdO ■=; r •Kdf ? Ool 87 ■K JI 1 a ^ on 87 •"■'c — fs K\ 8Z •K-Tri »s fill 87 ■n-rz ,^ b 1 il Pll 87 V K r.I ^ ^ Oil oc •K-d6 1 < 811 87 •KJO 1 ^ »> 0Z\ f-e •B-dE N "s Ool tfi •k;i \ ^ ^ Kl f'C ■K-T6 91 801 J-7 •WT 9 ^ _ UJ SOI T-7 •K-J9 _ - - - ' 31 »f-l OS ■JI-T9 ' ^ "" on ojr •K-d 9 ■> ■-. J ■-J n f-.-l 98 •K-T9 > 0?I 97 ■K-J 9 1 ^ CI o?r 87 •ll'9 , \>, RTI J-7 •Kjg / 21 8T1 0£ ■n-y^ ^- L ^ 0?1 7£ •KM 9 < 11 Of-1 OS •KT 9 _ £>■ 801 08 •K-.IO IC ~^ 01 fi7-\ Of; •K-T 9 ! 1 \ oKT oc •K-d 9 N k~ c o<-i oc •K-T9 1 ^ ^ - => 071 87 •Kd 9 t^ _ 8 K'l Of •IIT9 _. -^ bx 711 07 ■Kd9 H c^ ■^ I on T-7 *K"» 9 ^ 7 o<-i <-7 •K-d 9 h -J - ^ 9 701 07 ^Sl ~ ~ -T UOI, ^ o > o a TEMPERATUUK IN T/U'J l)l':V l':i/)l'h:iJ /j/S/:ASh Ki •B-r c / 1 W T^ •WTO ^ w; : H 1 •B'TC - ' - ^ - - - - - - - r - - - - - \7. w «! •MUSI !« KI •B.i n " 4> 1 1 on |fB! ■RMO t^l •BMC 1 1 > Kl «l ■ St < *0T Ira •BT n ^ Of, ]W ■B..0 } ^ m\]d7. •B-r c ( f.Z (xn 001 •»"!!I \ ■B-.in sj ?n «! ■RMO k 01! re ■B JC '> ' on W ■Biil < •« SOI «! ■ni 6 -J U &a zr. n •BT9 < 7m w. •B-TR M ZZ or, tz ■KB 51 ^ on fZ •B-^e S '^ ^ ?.OTiOZ •BJ9 ^ l> 801 m B J C H.1 og "31 nn f^ •KT(5 k ! 701 ' W •BTO > 1 COT '"•? ■n T c - (-1 IS RII [f-^ ■KB 51 J _ _ _ - _ - '- -< om ' f? ■K J 6 ^- ■*" " K-I I SI- ■B J 9 n ~ r-- ._ n 'in .■•■>)jv GOT 1 00 ■BMO ~ -*- -j - L- -U _ _ ■H J R I'V^f " n( T - "" V 801 i t-S •B51 ^ 801 if-J •B-T n ./- f Oil t5 ■RTO ^ m: ' -■<- •BTg < oil , r^r KB 51 > ► 0? oil sc •RV!C r OSI ■ tj -B-jg ^ onigs ■K-as ^ *\ zn-i \zz •B51 ^ _ — — - I* 1 gnjt-o ■B-T6 /^ 1 OEli^S •■■T9 ' (L p _ __ _1I? 10 jajH' 1 1 ! 0£T 1 fZ ■B-TO inji.-j -'■"j-'vq ~ -^ ►-' ^ J_ 1 •B-TS > 61 on >K, KB5T ^ ^ -- on 'Es K-J6 ^ - -« r- on 6-; •B-J 1 / r- " onoE W9 / i on oc 05-9 J ^ V 1 OEi or^ •wag , I1"I.T J-^l.IV K:T joP •Bd5 uuio-;,i;..na iyt-^-j-4-. ~ ^ 1 U."g g S S S 5 1 g g si^i" >> Q 84 WELL-DEVELOPED STAGE OF THE DISEASE had twenty-two rigors in a priniarv attack in fourteen days, twenty- five in fifteen days in a first relapse, and six in eleven days in a second relapse. (See page 47.) It is well to recall the fact insisted upon by no less an authority than Janeway/ that the use of the coal-tar products in the course of enteric fever may have a chill-producing effect, and it is well know n (hat the external use of guaiacol may produce severe rigors. In some cases presenting such rigors there is present a true double infection of typhoid and malarial fever. (See farther on.) There are a number of conditions which result in producing a marked and sudden fall of temperature during the periods of the fastigiinn and defervescence aside from the sudden drop, rarely seen, in which the fever ends by crisis instead of lysis, the patient passing into convalescence at once. The most important of these causes, both because of their degree and because of what they indi- cate, are hemorrhage from the bowel, or, if it be profuse, that from any other part of the body, perforation of the bowel and the rigor preceding a complicating infection such as pneumonia, the begin- ning of a relapse or the eft'ect of powerful antipyretic drugs. Often great falls in temperature take place when the tyj^hoid infection is associated with malarial infection, as already intimated. (See farther on.) In the case of a complicating disease, a few hours' tlelay in recognizing its presence may not make much difference to the physician or patient; but, on the other hand, the early recognition of hemorrhage or perforation may save the patient's life. The symptoms of perforation, associated with the fall of fever, are prominent and will be considered under the head of gastro-intes- tinal accidents; but in the case of intestinal hemorrhage, the fall may occur some time, it may be several hours, before the appear- ance of a bloody stool enforces the belief upon the nurse that hem- orrhage is present. For this reason an unexplained marked fall of temperature should always be regarded with suspicion, and the appearance of the next stool watched with interest. The pulse should be carefully studied for signs of loss of blood, and the facial ' Janeway. Transactions of the Association of American Physicians, 1894. DIFFEUENTIAI. DIAdSOSIS rh'OM (ri'lll:!; \l M..\ I )l i:S sr> expression und color of llic li|)S iind (onij;iic flosely wjilflicd. I)' the patient is conscious and ciij)iU)ie ol" f^iviii^^ exfircssion (o his sensa- tions, he may comphiin of a sensalicjn of fiiinlness or of sirjkin^; or if the hemorrhage is very profuse, the patient may pa,s.s raf)idly into a state of colhipse or shock, owing to the extravasation of Mood into the small and large howcl, dying almost sinniltaneously with the gnsii of hiood from die reel um. Thus we have seen a case apparently passing safely through a moderately severe attack of enteric fever suddenly develop the symptoms named, present all signs of marked exsanguination, and then pass into the bed an enormous volume of h;df-elo((ed l)l()od, which extended frf>m the anus to the heels, at the same moment developing gasping respira- tion, profound syncope, and seeming to be /// arliculo mortis. So, too, we have seen hypodermoclysis, actively employed, result in the recovery of patients so greatly exsanguinated that death seemed inevitable. In some instances, however, even profuse intestinal hemorrhage recurring again and again, fails to cause a very great fall in the temperature, or keeps it low Ijut for a short time. Sometimes well-developed signs of collapse appear in the course of typhoid fever without indicating any serious accident in the course of the disease which could produce these symptoms. In this state the patient develops a rapid pulse, shallow respirations, pallor and lividity, accompanied, it may be, by a rigor. There is usually a marked fall of temperature. Herringham^ asserts that these symptoms have no eflFect on the prognosis, and that treat- ment is practically unavailing. On the other hand, they may mean that the patient is in grave danger, as has been pointed out by Landouzy and Siredey.^ (See circulatory changes in the well- developed and convalescing stages of the disease.) Dijfferential Diagnosis from Other Maladies. — How far con- stant fever occurring day after day, and associated with mani- festations of general loss of strength and debihty can be rehed upon in the diagnosis of typhoid fever, is hard to determine. Certain it is, that if a physician makes a diagnosis of enteric 1 Herringliam. St. Bartholomew's Hospital Reports, 1S96. - Landouzy and Siredey. Re\Tie de M^deeine, 18S7, p. S04. 80 WELL-DEVELOPED STAGE OF THE DISEASE fever upon these symptoms alone, Avithout hearing in mind the fact that simihir comhtions are equally well developed under other forms of infection, he will find himself in error in not a few instances. Chief among these may he mentioned tuberculosis of the lungs or peritoneum, miliary tuberculosis, that form of influenza in which the chief symptoms are abdominal, cases of ulcerative endocarditis, lymphosarcoma and carcinoma of the liver, septicfemia and pyaemia, malaria, rare forms of scarlet fever and meningitis, and those of cliolecystitis with ulceration, as from impacted gallstones. It must not be forgotten, too, that syphilitic fever may in very susceptible persons resemble typhoid infection. The febrile movement, rose rash, if it be scanty, malaise, and signs of general infection may readily mislead the physician. Again, in the more advanced stage (tertiary) of sypliilis prolonged low septic fever may be present. Finally, let it not be forgotten that trichiniasis^ may resemble t}^hoid fever, for in it we have fever, pains in the limbs and back, headache, stupor, and nausea, with pain in the belly and diarrhoea. Points in differential diagnosis in this condition are the pres- ence of leulvocytosis (particularly in eosinophiles), and its absence in typhoid fever, and puffiness of the bridge of the nose and about the eyes is seen in trichiniasis. Not only may the fever of these states be moderate and pro- longed and the evidences of asthenia marked, but enlargement of the spleen, diarrhoea, and tympanites may be present. The diffi- culties in differential diagnosis in cases of suspected gall-bladder disease are increased by the fact that such disease often has its origin in an old infection of the gall-bladder due to an attack of typhoid fever months or years before, the bacillus of Eberth being present in this viscus during the entire interval, or in other cases it invades the gall-bladder at the onset of the infection of the entire body, and so emphasizes the hepatic symptoms. I'urther than this, cases which have previously had enteric fever may also give the Widal test, although the immediate cause of the attack may be localized in the manner named. These forms of infection wall be considered later on. Reference has already been made to the possibility of the febrile 1 Osier. American Journal of the Medical Sciences, March, 1899. D/FF/'Jh'h'N'J'/A/j blACNOSIS I'ltOM O'/'l//:/,' M M.\ I >l l':S S? movcTnont re.seiii})liii^ lliiil, ol' iiia,lari;il \(-\('V. In oiim- cases Uiis iiircction is truly j)r('S('ii(:, l)iit in others tlic (ciiipciiiiuic-cliurt is that of ail Irrco'iilai' typlioid fever. These facts hi'in^ iis face to I'aee with a (liseiission f»f' a siihjeet about which great diversity of opinion exists, and has existed for years, namely, the cjuestion of that condition which has been called " typhonialarial fever." At the f)resent time il may be asserted as a fact that a separate disease entity of this c-haracter does not exist. Recent discoveries in the natural history fjf these diseases, particularly the recognition of the malarial germ, the use of the Widal test, and the finding of the bacillus of Eberth in the blood have enabled us to make an absolute diagnosis in cases in which it has heretofore been impossible. There is no doubt whatever that uncomplicated typhoid infection may result in the production of a fever which closely follows the remittent and intermittent malarial types. This is often asso- ciated with so much gastric disturbance and so lacking in the more prominent typhoid symptoms that the picture of malarial fever seems clear, while the picture of typhoid fever is clouded. (See also chapter on diseases which resemble typhoid fever.) Again, there can be no doubt that cases of true malarial infection occur in which the symptoms so closely resemble those of typhoid fever that a purely clinical diagnosis is almost impossible, particu- larly if an epidemic of typhoid fever is in full swing at the time. As already shown, there can be no doubt that mild grades of typhoid infection take place in which the only symptom is a fever which runs a moderate com"se and is accompanied by a certain degree of general debility. These forms often begin rather abruptly, with a slight chill, or gradually the patient feels less and less well until he takes to his bed. Such cases are characterized by well-marked remissions, it may be, and suffer from somewhat indefinite symptoms difficult of classification. They do not respond to quinine, nor do they show any typhoid symptoms other than those named. The diagnosis arrived at will depend largely upon whether the physician is practising in the North or the South, and is treating many cases of enteric fever or many of remittent fever, unless he is skilful with his microscope, in which case a careful SS WELL-DEVELOPED STAGE OF THE DISEASE blood examination or the "Widal reaction of typhoid fever will, in a majority of cases, at some time settle the diagnosis for liim, or an autopsy will show typhoid lesions. Or, on tlie other hand, he may find the malarial organism in the blood, which will prove that this infection is present, although it will not exclude typhoid fever, just as the Widal test will not exclude malarial infection. Atkinson has well described that form of typhoid fever resem- bling malarial fever of the remittent type in the following words: "From beginning to end the patient may develop no symptom that could not belong to this disorder (malarial fever), except the persistence of fever under strongly antimalarial treatment and the occasional occurrence of circumstances that point to a typhoid origin. There is no intellectual cloudiness or hebetude of expres- sion. Sleep is but slightly disturbed. The tongue remains moist, and coated A^ith a thin whitish or yellowish fur; the appetite per- sists very often in some degree. There is almost never epistaxis. Constipation is commonly observed, diarrhoea very rarely. There are no bloody stools, no tympanites, no iliac tenderness or gurgling. Rose spots are much more often absent than present. The patient can be restrained in bed with difficulty or under protest. Slight enlargement of the spleen may occasionally be detected, but is more frequently not observed. More severe cases, beginning more or less abruptly, develop primarily the symptoms of remittent fever, and diagnostic doubts only arise when the absolute resistance to antiperiodic treatment and the gradual appearance of ty})hoid symptoms excite suspicions of the incorrectness of the original diagnosis." Finally, there can also be no doubt that it is possible for the patient to have a double infection with the bacillus of Eberth and the Plasmodium of Laveran, in which case, however, the malarial manifestations are usually dwarfed by the typhoid poison, and only are marked at the onset of the enteric fever and at its termi- nation. To this mixed infection the term " typhomalarial fever" may be correcdy applied to indicate not a separate disease, but a double infection. Etymologically, this term might also be used to define a condition of malarial fever in which, because of pro- COURSE OF TIII<: FKV/'JJi IN h'hLA'I'IOS VO I'UOCSOHIH 89 found (lcl)ili(y, the piiticnt is in a typlioid state — that i.s, in a condition of whi(;h tyj)lioi(l fever i.s a (y|)f'. The term " typlio- malarial fever" shouhl he discarded, or nmitcd in its use to the dou})le infection just described. Jolmston has well said, "As at present employed, the term tyi)lionialarial fever has no determined meaning, leads to confu- sion and misunderstanding, is a cover for uncertainty and ignorance, and should he discouraged and ahandoned." (For a description of infectious processes complicating (yphoifl fever, see text farther on.) The Course of the Fever in Relation to Prognosis. — It ha.s already been pointed out that fever of sudden onset, soon followed by a fall or affected by marked remissions during the stage of onset, is a favorable rather than unfavorable omen. A some- what similar statement holds true in regard to the fever of the well-developed disease in which the presence of persistently high morning and evening temperature, the variation Ijetween the two being but slight, possesses an evil significance, while, on the other hand, marked differences between these points are considered of good omen. Tliis is so because remissions indicate that the infec- tion is not virulent, or resistance is adequate, and because remissions permit the body to make repairs to enable it to stand another rise, whereas the constant maintenance of high fever seriously impairs the vitality of the tissues. This temporary reduction of fever is probably one of the ^^■ays in which the cold bath does good. In regard to the prognostic value of high temperatures we find considerable unanimity of opinion. Liebermeister, in studying 400 cases, found that of those whose temperatm-es rose to 104° or more, 9.6 per cent, died; of those whose fever exceeded this degree, 29.1 per cent, died; and of those whose axillary tempera- ture exceeded 105.S°, more than half died. Fiedler^ found that when the temperature reached 106° more than half died, and Wunderlich states that at 106.1° the danger is considerable, at 107° the deaths are almost t\\ice as numerous as the recoveries, and at 107.2° and over recovery is rare. Concerning the influence of high morning temperatures, Fiedler says that practically all 1 Fiedler. Deutsehes Arch, fur klin. Medicin. Band i, p. 534. ora ,--tirr^-H^ ^•- : tr os-o 1 ,•:-: ■ (1^ •«•'« Z*"^^-^^^^-^ ^.^ ,-..■, i l<- •"•■'> /, orv ^ ..-.^ - , T. 050 ; 1 i__ (HII n;; •— 'fT=fi- KH n;: •KY C \ ~"*---^ (ii; !!?. •. . 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In the Miiidslone' epidenn'e only one de;idi oceniied in 81 cases, the teni])eriitnre of which reaehed less than KJJ'^, whereas nine deaths occurred in patients who had fever at some time above 104°. A case is recorded of recovery after a tpmj)erature of 1 \{)°? While acute hyperpyrexia may l)e an evil omen in enlerie fever, long-continued, moderately high fever is, pei"lia|)S, more harmful. In the Boylston Prize l^lssay of Harvard University lor ]Sf)0, on ^'Fever," the senior author used these words in speaking of this subject: "Closely allied to this question of hyperpyrexia is that which asks us to define what we mean by hyperpyrexia. As given in most works on fever, this term is applied to any state in which the temperature reaches 100° or 107°; but in reality the figures have little to do, except in an indirect way, with what the student or physician wishes to know-. A temperature of 106° in a young healthy man suffering from an acute attack of some short-lived disease does not mean very great danger; but a temperature of 103°, day after day in typhoid fever, does mean danger, and must be carefully attended to. In simple continued fever 106° is a hyperpyrexia; in typhoid, or other low fever, 103° is a hyper- pyrexia. The question is not one of actual degrees Falu-enheit, but rather as to whether the temperature present is doing any harm." Very great differences are to be found in different patients in respect to the persistency of liigh fever under the application of hydrotherapy. In some instances active bathing serves to reduce the fever but slightly; in others, moderate measures produce a marked effect. As an illustration of the great fall produced by sponging with ice-water for twenty minutes, with active friction, leference may be had to the above chart (Fig. 18), in wliich it is seen that as great a fall as 8° occm'red. One is tempted to inquire how low it would have fallen had the routine method of plunging every patient sick "uith typhoid fever been institvued. Yet the patient was an unusually heavily built, stalwart youth of 1 Poole. Guy's Hospital Reports, 1S9S. Wronglj- labelled on cover, 1S96. 2 St. Thomas' Hospital Reports, 1S95, p. 248. 94 WELL-DEVELOPED STAGE OF THE DISEASE twenty years, well nourished, and in good condition for bathing. Further, he came under care hy the thirtl day of his iUness. Respiratory System in the Developed Stage of the Disease. — ^^riie respiratory functions of patients sufi'ering from tyj)hoid fever are not materially disturbed unless some complicating affection of the lungs or nearby organs develop. Beyond a slight (juickening of the respirations, varying from two to eight a minute, as the result of the fever, they maintain an even rhythm. The develop- ment, therefore, of rapid or noisy breathing is indicative of some pulmonary, cardiac, or renal complication, and deserves close scrutiny and study. Before discussing the graver respiratory complications of thi.s malady, there are, however, several minor facts in connection with this part of the body which deserve notice. One of the first of these is the curious fact that coryza is almost never met with in typhoid fever in any of its stages, and its presence with other signs pointing to enteric fever stands against the presence of this malady. Epistaxis. — Another point of interest is the frequency of epistaxis,. which is chiefly met with in the first week of the disease, as already pointed out, and which is also seen quite commonly later on, prob- ably being produced in most instances by the patient picking the nose to remove crusts, while in the early stages it is a means that the system takes for relieving the frontal headache and con- gestion which are so common at that time. J. M. Da Costa^ pre- sented in a clinic two patients who had this symptom late in the disease. The first patient had been ill twenty-nine days, and his temperature had reached normal. The epistaxis was violent, last- ing half an hour, and several ounces of blood w^ere lost. Cerebral symptoms were relieved, and the man made good progress after- ward. The second patient had profuse epistaxis during the fourth week of the disease, after symptoms of typhoid fever had practi- cally ceased. Late epistaxis is more apt to occur, in Da Costa's opinion, after severe cerebral symptoms, wliich are thus relieved. In still other cases the hemorrhage from the nose is part of the manifestation of a general hemorrhagic diathesis. Very rarely is 1 J. M. Da Costa. Medical Fortnightly, February 1, 1899. 77//'; lU'.si'iiiATOL'V s)',sti':m in tiih I)I':v i:i.()I-i:i) staci-: ().-> the symptojii excessive v\Hn\\i\\ l,o rc(|iiiic ;i'livc iiilcil'eicnce, uikJ still more rarely does it cause death. Thus, oiil of 1420 cases seen by Liebermeister, epistaxis look phicc in 107 cases, l)ut death occurred from this cause in only two, and this is probably a high percentage. Jn Osier's series of .S20 ca.ses epistaxis occurrcfj in 1S2. There have occasionally been seen cases of typhoid r(\(i- cDm- j)licated with Ludwig's angina. Murray^ rejjorts such a case which caused (X'dema of the glottis, and Robertson'' and Biedert report the development of an angina which proved fatal ten hours after the onset of the complication. Laryngitis. — I^aryngeal inflammation as a comy)lication of typhoid fever was first observed and reported by Bayle.^ He re- ported two cases, both fatal. One died after an unsuccessful attempt at relief by tracheotomy, the other died without any effort at operative interference. An occasional case w^as reported from 1808 on in the French literature, and in 1818 Joseph Frank, of Leipzig (quoted by Rieser), reported two cases based upon the autopsy find- ings of Pommers and Horn. Louis, in 1829, reported four cases with autopsy findings, and in the same year Pockel, a German military surgeon, performed the second tracheotomy in typhoid laryngitis. The operation gave immediate relief and the patient recovered. This was the first successful tracheotomy performed for this condition. Rokitansky, of Vienna, in 1842, was the first pathologist to care- fully study the laryngeal complications of typhoid fever. The earlier pathologists, although they recognized the lesions, were of the opinion that they were due to secondary infections. Roki- tansky, however, referred to the lesions as the result of the effect of the typhoid poison in every way analogous to the developments in the intestinal mucosa. W. W. Keen,^ of Philadelphia, in 1876, summarized the htera- ture relating to this condition and was able to collect 169 cases. These cases he classified clinically and pathologically, giving the most complete consideration of the subject wliich had appeared up to that date. In 1884 Luning, without knowledge of Keen's 1 Murray. British Medical Journal, September 13, 1902. - Robertson. Amer. Jour. Med. Sci., January 1902. 5 Bayle. Societe de Medecine de Paris, ISOS. * Keen's Toner Lectures. 96 WELL-DEVELOPED STAGE OF THE DISEASE publication, reviewed the literature, collecting 192 cases and adding 14 from his own knowledge. In 1896 Keen's classical publication "The Surgical Complications of Typhoid Fever" completed the author's earlier work and added to the number of cases those reported by Luning as well as such cases as had been subsequently reported, his total being 221 cases. Since this last review Homer Dupuy,^ in 1903, reported one case and added 34 collected ones, while llieser,"' in a more recent report, has added 2 personal cases and collated the recent literature, bring- ing the total number of cases reported to 281. A glance at the numl)er of cases reported will convince anyone that the complications affecting the larynx during typhoid fever are not as rare as we once thought, and it is somewhat difficult to understand the rarity of the laryngeal lesion in certain series of cases. Schulz, who analyzed 4094 cases of typhoid fever which occurred in Homburg in 1886 and 1887, does not record any cases of perichondritis of the larynx, and Jacob does not mention this complication. On the other hand, Hoffmann found laryngeal ulcers in 28 cases out of 250 autopsies upon typhoid fever subjects, and Griesinger found them in 26 per cent, of the cases that died. These statistics bear out our belief that in the severe forms of tvphoid fever resulting in death, laryngeal lesions are commonly present. Every writer who has made a special study of this complication is impressed with the fact that pathological involve- ment of the larynx is much more frecjuent than is clinically recognized. In regard to the cause of laryngeal involvement, it may be that the friction and irritation produced by the acts of phonation, swallow- ing and coughing act upon a surface wliich is already suffering from the effects of the typhoid toxemia, but there can be no question that the specific organism of the disease is really accountable for the lesions. Schulz,^ Williams,'' and Weil"^ have been able to isolate the germ in sections from the larynx, and grow them in pure culture, 1 Dupuy. New Orleans Medical and Surgical Magazine, 1903. 2 Rieser. American Journal of the Medical Sciences, February, 1908. ' Schulz. Berliner klin. Wochenblatter, Band xxxv. * Williams. Diseases of the Upper Respiratory Tract. ^ Weil. Transactions of the New York Pathological Society, 1905. 27/Zi' JiJ'JSi'iKATOh'.)' s)'S'/'/':m IN Tiih: i)h:v i-:i.()i' i:ij ,<'r.\',i. w-j and ITcrlx'rt and Ivii^biruin,' jis well us -Juck.sfjii," f;iiltiv;ilf;ri tlic specific or<^anisin in ])nr(; (aniline from the })u.s of a [)criclif>n(irial laryngeal abscess. Thermic influences may also exert ;i predi.s- ])()sing inflnence. J)ittrich'' asserts that the innannnatory process is (hic lo the dorsal position of the ])atient, and is more j)arlicnlMrly dne to the pressure of the laryngeal cartilages, piirliciihnly fhc cricoid rings, against the vertehral colnnm. As the resnit of this pressure, Dittrich believes that the vitality of the cartilages is iiii|)aired and microorganisms find this damaged tissue vulneraljlc This theory seems to us of little value. In an inaugural thesis uj)on ulcerations of the larynx during typhoid fever, Gruder'* describes three types. In one the specific ulcers occur simultaneously with those in the bowel. In the second class there are simple catarrhal manifestations with a tendency to ulceration. Both of these classes involve the posterior wall of the larynx on the aryepiglottic fold. The third class described by Gruder is one in which ulcers form at the margin of the epiglottis. These latter ulcers usually occur singly. Keen, in 1876, classified the lesions as inflammatory or submu- cous laryngitis, ulcerative laryngitis, and laryngeal perichondritis, none of which forms can be sharply outlined, they at times over- lapping one another. The frequency of its occurrence is given by Luning as 12 per cent, basing liis statistics on 1032 autopsies. Of the 2C0O Munich cases, 10.7 per cent, showed laryngeal ulcers, and Baer, in 89 autopsies, found laryngeal lesions in 3.4 per cent, of them. Liining divided the 12 per cent, of laryngeal lesions into 1.5 per cent, of simple or submucous laryngitis, and a little over 5 per cent, each of ulcerative larvnoitis and larvngeal perichondritis. In over 40CO autopsies collected by Liining the posterior laryn- geal wall at the insertion of the vocal cords, involving the cricoid cartilage, was the seat of the lesion in 60 per cent, of cases. The arytenoid cartilages and interspace were next most frequently ' Herbert and Liebman. Chicago Medical Recorder, September, 1905. ^ Jackson. American Journal of the Medical Sciences, Xovember, 1905. ^ Dittrich. Handbuch der Special Path, und Ther., Band i. p. 311. * Gruder. Centralblatt f. Bacteriol. and Parasit.. February 17, 1S91. 7 98 WELL-DEVELOPED STAGE OF THE DISEASE involved. The arvteno-epi(i;lotti(lean folds, epiglottis, and the thyroid cartilages being ali'eoted in the order named. Clievalier Jackson, in his series of 360 laryngological examina- tions in patients ill of typhoid fever, found ulcers present in GS cases, affecting the epiglottis forty-two times, aryteno-epiglottidean folds 22 times, interarytenoid space 18 times, and arytenoid car- tilage 10 times. Basing his views upon his statistics, and in particular upon four- teen original cases, Liining^ gives the following graphic word-picture of the condition: "Physician and patient together rejoice over the daily progress toward convalescence; of the still slight but persistent trouble in the throat, scarcely a word is said, until all at once — an expo- sure to cold, a little walk, is then usually blamed for it — the hoarseness increases, and swallowing becomes markedly })ainful. The picture now quickly alters. Soon, often witliin a few hours, come dyspnoea and suffocating attacks. Sometimes even during the very jfirst day the anxious scene of laryngeal stenosis sets in, with stridor, inspiratory depression of the neck and chest wall — the unrest of despair, a struggle ^dth death. The face becomes livid; the respiration becomes rapid, wearisome; the auxiliary muscles of respiration are all called into play; sometimes the respirations are prolonged and noisy. The patient can find no rest; the dyspnoea even prevents the taking of nourishment; the expectoration of the increasing mucus becomes imperfect; soon attacks of suffocation recur. Either a tracheotomy must now be done immediately, or the patient, if he is weak, may choke to death, even in the first attack. More commonly, however, the attack subsides, and a slight improvement with a short sleep will ensue. Expectoration of bloody mucus, masses of pus, and, in some cases, even of pieces of cartilage, diminish the symptoms, and show at the same time that the real cause of the dyspnoea is not a catarrhal oedema or dropsical swelling, but a destructive ulceration, even of the cartilages. Often, also, there is severe fever. Thus pass on, it may be, even days and weeks, easy breathing alternating with the suffocative attacks. The alterna- ' Luning. Archiv fur klin. Cliirurgie, 1884, vol. xxx, p. 225. Tiiic u/':sr/h'AT(jh',y s)'st/':m in th/'J dkvI'Ii.oi'i:!) sta(;i-: divided iiilo (lio.sc occiirriiifi; iil (he ousel, of llic illness ;iiid tlio^cr OCCUrriii. 'I In- stools, urine, and tears r(ui oil" involiinliirily, and iinnonriff; a s|K;(;dy dis- solution, as the vast treinl)lint(s ;ind twit(;hinn;s of llie iktvcs ;ind tendons are preludes to a ^cnci;!! eonvulsioii, wliifli :it onff n.ips off the thread of Hfe. In one or oilier of tliese ways are the sick carried off, after haviii*;" lannuislicd on for fourfeen, ei^ditofTi, or twenty days, nay, sometimes for miicli longer." EndocAEDITIS. — The bacillus of Ebertli lias been is(jlated from the endocardium of a patient dying of this disease in but few instances (by (jlirode and Vincent), but the usual cause of the complication is a mixed infection. In Osier's first case, which he saw in the Philadelphia Hospital in 1886, the infection was unusually intense, so much so that the cjuestion was raised as to the possibility of the presence of malignant endocarditis. Griesingcr, Liebermeister, and Bochut (all quoted by Curschmami in Xoth- nagel's Encyclopcodia of Practical Medicine) have reported cases of ulcerative endocarditis occurring during the course of typhoid fever, and such reports of cardiac complications are becoming more frequent in current literature, which fact reveals not so much the increase in the occurrence of such complications, but that more careful physical examinations are being made. Acute endocarditis complicating typhoid fever has been reported by Carbone,^ The patient was a young woman who had the classical symptoms and lesions of typhoid fever, and from whose endo- cardium typhoid bacilli were obtained. These bacilli w^ere injected intravenously in various animals, producing the same lesion. ConnelP has also recorded a case of infectious endocarditis in typhoid fever, due to the staphylococcus and involving the mitral and tricuspid valves. Osier met with but tliree cases of acute endocarditis in his 1500 cases of typhoid fever, while von Jaksch observed 15 cases, in a German clinic, in a series of 793 patients. Thayer^ found in his exhaustive study of the cardiac complica- tions of typhoid fever that 12 of the 188 cases which were kept under observation for three months to fourteen years after their 1 Carbone. Gazette Medica di Torino, 1892, No. 23. - Connell. Montreal Medical Journal, August, 1S96. ' Thayer. American Journal of the Medical Sciences, 1904, cxxvii, pp. 391-422. 112 WELL-DEVELOPED STAGE OF THE DISEASE attack of typhoid fever, had signs which led him to beUeve that an organic cardiac lesion was caused by the primary iUness. The Blood in the Developed Stage of Typhoid Fever. — In typhoid fever in the first two weeks of the disease we usually find little if any change in the red corpuscles, unless an active diarrha^a be present, in Avhich case there may be concentration of the blood cells. In the tliu'd week the red cells begin to decrease, and may get as low as in cases of pernicious anaMiiia. The lowest point is reached about the end of the fii'st week of convalescence, when they gradually begin to increase. The hannoglobin follows the red cells, as might be expected, and the degree of the ana^nia is in direct proportion to the severity of the infection in most instances. Emerson^ has recorded two cases of typhoid fever with interest- ing blood crises in which cases the erythrocytes were apparently disintegrated by the toxin of the Bacillus typhosus. The most noteworthy fact about the blood in this fever is that, as a rule, there is no constant increase in the leukocytes unless some intercurrent inflammation is set up. Cabot asserts, however, that sometimes leukocytosis does occm* without any complication that can be found. On the other hand, in patients profoundly asthenic from this disease complications may not cause leukocytosis. As an illustration of the manner in which these accidents may produce blood chano-es, the following; table of Cabot is of interest: Leukocytes. Perforation. Case I (a). Five days before operation .... 8,300 (6). At time of perforation 24,000 Case II At time of perforation 18,500 Phlebitis. Case I (o). Two days before onset 6,400 (6). At time of onset 12,900 (c). One week later 10,100 Case II (a). One week before onset 4,800 (6). At time of onset 16,200 Otitis media. Case I (a). At entrance 5,300 (6). Mastoid abscess 16,400 Case II (a). At entrance 8,400 (6). Two weeks later, after opening drum mem- brane (seropurulent discharge) . . . 11,200 Case III (a). At entrance 7,320 (fc). Otitis 14,000 Cabot states that a freely discharging otitis soon ceased to cause leukocytosis — e. g., a case of serous otitis media seven days after I Emerson. Bulletin of the Johns Hopkins Hospital, October, 1907. Till'] BLOOD IN TIII'J Di: V ICLOI'HI) ST A OIJ OF T ) ' I'llni h /'/', Vi:i! | | ?, puncture, but still (li,scliiiclio- nuclear cells which is characteristic. The value of discovering alterations in I lie blood in tyj;lioiri fever is very great for diagnostic purposes. Increased leukocyto.sis gives us reason to believe that there is present, and makes us search for, some complicatijig inflammatory focus, such as pneu- monia, perforation, cholecystitis, phlebitis, or abscess in any part of the body, as in the liver. Further, it may render a case of suspected typhoid fever clearly one of appendicitis or some other acute inflammatory affection. The study of leukocytosis is useless to us in separating malarial fever from typhoid fever, for in neither affection does it occur, and the same statement holds true as to tuberculosis unless the latter is accompanied by coincident infections with pus organisms, when leukocytosis may be present.^ The blood in typhoid fever should not be examined after a bath, as tliis may cause a temporary leukocytosis in the peripheral vessels. Bacteremia. — In the first edition of this essay the senior author was able to report but one case in wliich a positive blood culture had been found. Tliis report was by De Grandmaison and Cartier," who reported the case of a woman admitted to the hospital suflfering from the results of an abortion. She presented typical symptoms of typhoid fever. Her blood gave a positive Widal reaction, and from it they obtained a pure culture of the bacillus of Eberth. During the ten years that have passed since this case was published, and particularly since the studies of Schottmiiller, who, in 1902, was the first to prove that in typhoid fever we are dealing -^-ith a bacteremia, there have occurred so many cases in which the bacil- lus of Eberth has been recovered from the blood that to give the 1 Valuable studies of these questions are those of Cabot, from whose book on the blood we have quoted, and those of Thayer, Johns Hopkins Hospital Reports, vol. iv, p. S3. Also Ouskow and Aporti and Radaeli, Eleventh Congress for Medical Science, Rome, March, 1S94. " De Grandmaison and Cartier. La Presse M^dicale, February 1, 1899. 8 114 WELL-DEVELOPED STAGE OF THE DISEASE references to this work alone wonkl re(|uire a great deal of space. It is sufficient to state that all observers who have studied typhoitl fever by cultural methods agree that over 80 per cent, of the cases reveal the bacillus in the blooil. It has lieen the experience of all laboratory workers in this particular fiekl, that by blood culture the bacillus can often be found before the fifth day of the disease. To those particularly interested in the subject of blood cultures in typhoid fever we refer to re\'iews by Conradi/ Castellani," Kayser,^ IMuller and Graff/ Fornet,^ Schottmiiller," Coleman and Buxton/ Cole/ and Peabody.® The Spleen. — The changes produced in the spleen are usually developed early in the disease. In no other disease condition, except malaria and the septic fevers, is this organ so constantly enlarged as in typhoid fever. In addition to the frequency of enlargement of the spleen, its early occurrence, its relatively long duration, and its constant reappearance in relapses make splenic enlargement especially indicative, when combined with suspicious symptoms, of typhoid fever. The frequency of enlargement of the spleen during typhoid fever cannot be estimated with accuracy by physical examination, although in the great majority of cases the spleen is palpable after the first week of illness and continues so until convalescence. Curschmann^'^ states that in 300 successive autopsies upon typhoid fever subjects there were large splenic tumors in 127, tumors of moderate or considerable size in 173. In no case was enlarge- ment of the spleen wanting. Curschmann also states that in 577 autopsies upon typhoid fever subjects at Hamburg there was absence of splenic enlargement noted in 49. A general idea of the statistics of splenic enlargement is obtained by comparing the estimates made at Hamburg and Leipzig. In 1 Conradi. Deutsch. med. Wocli., 1907, p. 1684. 2 Castellani. Centralbl. f. Allg. Path. u. pathol. Anat., 1900, vol. ii, p. 456. 3 Kayser. Munch, med. Woch., 1906, pp. 823 and 1953. < Muller and Graff. Centralbl. f. Bakt., 1907, No. 43, p. 856. ' Fornet. Miinch. med. Woch., 1906, p. 1053. « Sehottmuller. Deut. med. Woch., 1900, vol. xxvi, p. 511. 7 Coleman and Buxton. American Journal of tlie Medical Sciences, June, 1907. 8 Cole. Johns Hopkins Hospital Bulletin, 1901, vol. xii, p. 203. ' Peabody. Journal of the American Medical Association, September 19, 1908. !■> Curschmann. Nothnagel's Encyclopa;dia. GENITO-UUINARV TRACT IN TIIH l>i:V i:LOI'I:I) STAC'/: | i."; 2205 Ciiscs in i,]\('. I l!uiil)iii'<^' I I().s|)iliil, s[)lciiif: (iimor Wiis rlciiifHi- strated in LSfjO, or Sl.^) per cciiL; \v;is |);il|);il»|c in '.')].2 \>rv ccitt.; and uncertain or wanlinlf5, or 15.7 per cent. Jii Leipzig, among 1626 cases, splenic tumor was demonstrable in 1051, or 69.4 per cent.; was uncertain or not demonstrable in 575, or 30.0 per cent. These data were obtained from statistics covering a period of thirteen years, and were made by a number of different observers. Under the name splenotyphoid, lOiselt' has described a condi- tion in which, according to his description, the spleen bears the brunt of the affection and the intestinal complications are absent. The spleen may be very much enlarged, and there may be a peri- splenitis with adhesions. In another form the spleen becomes enormous in size, with effusions into the splenic pulp accompanied by high fever lasting for several weeks, and in the tliird variety the spleen is not so large, but the fever is a very early symptom. In this type a relapsing fever occurs, but Eiselt asserts that the spirilla of Obermeier have not been found in the blood in these cases, and that they are truly typhoid, because of the intestinal lesions found in some of the fatal cases in the latter forms of the disease and by reason of the source of infection. Hoffmann found 9 cases of infarction of this organ in 250 autop- sies, and 7 of these died in the fourth week. Griesinger believed infarction of the spleen to be present in 7 per cent, of fatal cases, and Liebermeister believed these lesions to be responsible for the production of peritonitis in many cases where this condition arises independently of perforation. Sometimes the infarction results in the formation of a large abscess filling the greater part of the organ. Liebermeister records a case in wliich after death from general peritonitis the spleen, wliich was three times its natural size, was found transformed into a huge abscess, making seven-eio;hths of its bulk. No perforation of the abscess wall had occurred. The Genito-urinary Tract in the Well-developed Stage of the Disease. — It has already been pointed out in an earlier chapter that acute nephritis may usher in an attack of typhoid fever, but 1 Eiselt. La Semaine Medicale, August 27, 1S91. 116 WELL-DEVELOPED STAGE OF THE DISEASE such an occurrence is very uncommon, and the development of a nephritis in the hiter stages of the disease is ahnost as rare. In such a case the presence of albmnin, casts, blood cells, and, per- haps, pure -blood in the urine may make a diagnosis easy. Cm'ionsly enough, the amount of blood in the urine in such cases is no guide to their severity, because unless the flow of blood has been sufficiently great to decrease the patient's strength it does not represent the degree of renal involvement. Further, it is to be remembered that in some cases in wliicli there is marked ha?ma- turia the autopsy fails to reveal marked renal change, or instead of nephritis an infarction. Such cases have been reported by Homburo-er and bv Duckworth, bv Sorel,^ and bv other writers. o • » «. In cases in wliich there are tube casts and other signs of acute diffuse nepliritis, the prognosis may be grave. Osier reports two cases w'hich died. Amat had ten deaths in twelve cases, while Waffner had five consecutive recoveries. Hemorrhagic nephritis has been recorded by Stevens- in associa- ation with ursemic symptoms. Relief came by a profuse hemor- rhao-e from the bowels, and recoverv occurred. Rostoski^ reports two cases of renal typhoid fever as follows: A patient was admitted with severe headache and bronchitis. The urine contained blood, albumin, and epithelial casts. A few days later the characteristic rash and diarrhoea appeared. Widal's reaction gave a positive result. In this case the nephritis passed into the chronic form of the disease. A woman, a^ed twentv-six vears, was admitted with urine con- taining blood and albumin, and subsequendy epithelial casts. About three wrecks after the commencement of the disease Widal's reaction was obtained, and two days later typhoid bacilli were cul- tivated from the urine. Five days afterward the patient had severe abdominal pain, with vomiting, and moderate collapse. On the next day the whole of the abdomen was exquisitely tender. 1 These authors are quoted by Hewetson in his article " The Urine and the Occur- rence of Renal Complications in Typhoid Fever," in vol. iv, Johns Hopkins Hospital Reports. 2 Stevens. University Medical Magazine, May, 1896. 3 Rostoski. These cases are also to be found in an abstract in the British Medical Journal of April, 1899. GENirO UUINAIIY TRACT IN 77/ A' 1)EVFJ/)I'I:I) STAC I: \ 17 A lilHc Inter :iii ini|);iir<'hoid fever without possessing any grave prognostic import, but the gravity of the case is in direct ratio, as a rule, to the cjuantity of the albumin. Among patients with large amounts of albumin the mortality is usually very high. Pyuria and bacilluria arise in typhoid fever either from the kidneys (very rarely) or from the bladder. Pyuria varies in severity from the presence of a few pus cells, which are found with diffi- culty by the microscope, to marked pyuria. The best study of this subject is probably that of Blumer.^ He found no less than 16 cases in 60 typhoid fever patients, or nearly 17 per cent. In some the pus was found present when the patient came under observation; in 4 cases it appeared between the tenth and fifteenth days; in 3 between the twenty-second and twenty-eighth days, and in 1 on the forty-second day. Its duration varied from a few days to three months. In nearly all his cases the pus was present in full amount. In some it gradually increased; in others it came in large amount at once. The organisms found in the urine were the colon bacillus, the typhoid bacillus, Staphylococcus albus, and an unidentified coccus. The colon bacillus was found in seven cases; the typhoid bacillus twice, and the staphylococcus once. These observations are important, because it has been said by Karlinski, of Krakow, that he has found the Eberth bacillus in no less than 50 per cent, of all cases. In all probability the 1 Rostoski. Munehener medicinisclie Wochensclirift , February 14, 1899. Tliis valuable paper contains references to the literature of the subject. The title of the paper, ' 'Zur Kenntniss die Typhus Renalis," refers to nephritis complicating typhoid fever, and not that of the form of onset called ' 'nephrotyphus." - Hanford. London Lancet, April 28, 1889. ^ Blumer. Johns Hopkins Hospital Reports, 1895, vol. v. 120 WELL-DEVELOPED STAGE OF THE DISEASE differentiation between the colon bacillus and that of typhoid fever was not properly carried out. IJrownlee and Chapman^ have reported iive cases of pyelitis during the disease, this condition usually being associated with nephritis. No ease of pyelitis due to the bacillus of Eberth alone had been reported up to 1S9S, which is interesting in view of the well- known fact that this bacillus was frequently found in the kidney after death, and was always found in the renal lymphomata of this disease. Typhoid bacilli Avere found in the kidney of one case at autopsy. Konjajeff- asserts that the discovery of this bacillus in the urine indicates the development of these lymphomata in the kidney; but this is improbable, since post-typhoidal pyelitis, not due to this organism, of a membranous type may develop and be associated with a membranous cystitis. Richardson^ found typhoid bacilli present in the urine of nine out of twenty-eight cases of typhoid fever. They were always in large numbers and in practically pure cultures, and they appeared in the later stages of the disease and persisted in most cases far into convalescence. Their presence is nearly always associated with albuminuria and casts. In a still later report Richardson'* reports sixty-six further cases, of which, fourteen showed the presence of bacilli in the urine. ConnelP studied a series of fifty consecutive cases of typhoid fever, and found the typhoid bacillus in the urine of eleven cases. This work was very carefully carried out, there having been made 323 examinations. This writer has also made a careful study of the literature of typhoid bacilluria. He collected a "series of cases of typhoid fever, sufficiently examined to detect any lasting bacil- luria, and of such a type and at such a recent period as to make the identifications of the bacilli trustworthy." He took 631 cases to make up his series, of which 150 showed typhoid bacilli in the urine, and he draws the conclusion that typhoid bacilli can be detected in the in-ine of 24 per cent, of all cases of typhoid fever. It may be stated therefore that the bacilli invade the urine and 1 Brownlee and Chapman. Glasgow Medical Journal, December, 190G. * Konjajeff. Centralblatt fur BakterioloKie, 1889. 5 Richardson. Journal of Experimental Medicine, 1898, vol. iii. ' Ihid., 1899, vol. iv. ° Connell. American Journal of the Medical Sciences, May, 1909. fjENITO^UUINARY TRACT IN Tllh: I ) i:V 1:1.01' FJ) STAf.h' ]2] 9,re detected most IVc((ii('iitly in llic dccliniiio- shiffc of ilic disoa.se, at id)()nt the tiiiK! when the teinpeiatun; Ijeeoines jiorimil, ■,i\t\\()U^]\ they may be found earlier in tlie (Jisciise, ii.s reported l)y Seliichhold/ Jacobi,^ Lesieur and Machand,'' and Coimell. The bacilli usually persist in the urine for several weeks, and disappear spoutMueously in most cases. There are, however, a cousideral)le number of cases that persist for months and even years, causing the patient to be a serious menace to the public health. Rousig' examined the lu-ine of 10 CJcrman soldiers who had returned from the siege of Pekin six months after their attacks of typhoid fever, and in one case found the urine swarming with typhoid bacilli. Houston'' found typhoid bacilli present in pure culture in the urine of a patient three years after his typhoid fever, and Youno-'s case was known to have bacilli in his urine for nine years.® Liebtrau reports, among other cases of typhoid carriers, one who after nine years showed typhoid bacilli in the urine.' Petruschky^ has estimated that in one case a single cubic centi- meter of urine contained 170,000,000 typhoid bacilli, and Gwyn* estimated 500,000,000 per cubic centimeter in another case. Horton Smith^** examined the urine of seven typhoid patients, with three positive results, and he remarks that the micro-organisms may be so numerous as to cause distinct turbidity of the urine. Petruschky^^ has pointed out that the bacillus of typhoid is often found in the urine some weeks after the temperature is normal. To sum up the evidence from a clinical point of view, w^e find that pyuria in typhoid fever is not a grave sign, but that if the specific bacillus is found in the urine the patient must be kept under observation until it disappears, since it may lead to serious mischief. 1 Schichhold. Deut. Arcliiv f. klin. Med., 1899, Lxiv. 505. 2 Jacobi. Deut. Archiv f. klin. Med., 1902, Ixxii, 442. ' Leiseur and Marchand. Hygiene g^n. et appliq., Paris. 1906, i, 546. * Rousig. Infect.-Krankheit. der Harnorgans. Berlin, 1S9S. « Houston. British Jledical Journal, 1899, i, 79. 8 Young. Johns Hopkins Hospital Reports, 1900, \in. 401. ' Liebtrau. Arbeit, a. d. Kaiser. Gesundheitsamte, 1906. xxiv, 341. s Petruschky. Centralblatt fiir Bakteriologie, 1898, xxiii. s Gwyn. Johns Hopkins Medical Bulletin, 1900, viii, 389. 10 Horton Smith. Transactions of Medical and Surgical Society, London, 1897 11 Petruschky. Centralblatt fiir Bakteriologie, 1892, xiv. 122 WELL-DEVELOPED STAGE OF THE DISEASE Pyonephrosis has been recorded by Fernel' aiul ]\Iurray.- The patient of Fernel, who had previous to typhoid fever suffered from intermittent hydronephrosis, developed a fluctuating abdom- inal tumor, which proved to be a pyonephrosis containing a pure culture of the l)acillus of Eberth. Cystitis. — It is surprising that, despite the abundant literature concerning the presence of the Bacillus typhosus in the urine of patients ill of typhoid fever, as well as during convalescence from this disease, so few cases of cystitis are caused by this bacterium. Vincent,^ in 1200 cases of typhoid fever, noted only two cases of acute cystitis due to the typhoid organism, which appeared during convalescence. Rousig* reported a case in w^hich the patient, a man, aged fifty-three years, noted during convalescence from typhoid fever that his urine was milky in appearance. Several months after this he began to have vesical pain and frequency of urination. Cultures from the urine of this patient revealed a pure culture of the typhoid bacillus. A suprapubic cystotomy was per- formed and the bladder was found contracted, the mucous mem- brane greatly inflamed and the site of many ulcerations. At autopsy both kidneys were found to contain many small abscesses. Young^ has reported a remarkable case in which the patient suffered from a cystitis due to the typhoid bacillus for nine years following an attack of typhoid fever. During this time typhoid bacilli, in pure culture, were repeatedly found in the urine. Cystoscopic examination revealed the presence of a chronic inflammation of the mucosa and numerous small ulcers. Brown" records a case with similar cystoscopic and bacterio- logical findings, apparently arising from the use of an infected catheter, and Houston^ also reports a case of severe cystitis occurring during typhoid fever. Sato^ has also reported a case of this kind. In Houston's case of typhoid cystitis, a woman, aged thirty-five ' Fernel. Gazette des Hopitaux, 1897, No. 10. - Murray. Quoted by Connell, American Journal of the Medical Sciences, May, 1909. 2 Vincent. Stances de la soc. de biologic, 1901, liii, 275; also loc. cit., 1903, Iv, 365. * Rousig. Infect.-Krankheit. der Harnorgans, Berlin, 1898. ' Young. Johns Hopkins Hospital Reports, 1900, viii, 401. Brow-n. Medical Record, 1900, Ivii, 405. ^ Houston. British Medical Journal, 1899, i, 79. 8 Sato. Hefukwa kid Hiuiokikwa Zarshi, Tokyo, 1907, vii, 521. THE ALJMKNTAUY CANAL IN Tlll<: /j/:V h'LOrh'D STArj/'J ]2'.>, yeiirs, li.ul siid'cfcd from cyslili.s lor ;i lon^ [xTiod of (ii/H-; llx- urine was stroii^'ly acid, turbid, coiilaincd a small fjiianlily of albumin as wt'U us s<|ii;uii()ms (■[)i(J)cliiim, lcuk(j(:yl<,s, and som*: bacteria. A bacillus witli all the (-liaraclcristics of that of typhf^id was cultivated, and hci* blood oav(; a. marked (yplioid icaction of l.Ol, A second exaininalion of her urine piodneed similar resnlts; although the patient was kept in the hospilal for six weeks, there were no other typhoid symptoms and no febrile movement. In all probability this is a case in which the disease had been so mild at some previous time as not to attract attention, but the bladder infection had persisted. Polyuria. — Profuse urinary flow is sometimes seen in the lafler part of defervescence and in convalescence. It may amount to ninety ounces in twenty-four hours for many days. This has usually no great significance. Fussell, Carmany, and Hudson^ have reported a case of polyuria during typhoid fever of a very unusual type. This patient early in the disease was observed to be passing large quan- tities of urine, and this continued through the course of the disease and into convalescence. Many nervous symptoms were also pres- ent. These writers review the literature of this unicjue complica- tion. Wilson^ has also reported, within a few weeks of the report above mentioned, a case who showed this symptom all through an attack of typhoid fever. The greatest amount passed in any one day was 215 ounces. Patients suffering from this condition have been known to pass 10,000 c.c. in twenty-four hours. Hutchinson^ has reported a case of diabetes mellitus following t^'phoid fever. The Alimentary Canal in the Developed Stage. — Refer- ence has already been made to pharyngeal typhoid lesions in the stage of onset. A more or less severe inflammation of the pharynx is to be found in nearly all severe cases of typhoid fever if it is sought for, and it is sometimes sufficiently marked to cause the patient to complain of his throat. Letulle,^ under the name "pharyngotyphoid" has recently called particular attention to 1 Fussell, Carmany, and Hudson. Medical News, September 17, 1904. 2 Wilson. Jledical News, November 19, 1904. ^ Hutchinson. British Medical Journal, January 14, 1S9S. ■• LetuUe. La Presse Medicale, October 15, 1907. 124 WELL-DEVELOPED STAGE OF THE DISEASE cases in which there is severe inflaniination of the ])harvii\', and he cites a case which showed marked ulceration, due to tlie ty])hoid bacillus, upon the uvula and other ulcers upon the pillars of the fauces. Ouskow/ in a study of 439 autopsies representing 6513 cases of typhoid fever, noted that in the majority of the cases the pharynx was reddened and covered in part Avith a membrane difiiciilt to remove. In only four cases were the ulcers of any depth, and in two cases there was a phlegmonous process. As a rule, the lesions con- sist in congestion of the mucous membrane with swelling of the glands in this part of a character similar to that met with in other parts of the alimentary canal. Pharyngeal symptoms may develop in convalescence (which see); sometimes membranous pharyn- gitis coming on in the third week may cause death, and Taupin- records a case in which it asserted itself in a case of typhoid fever complicated w^ith measles. Gerloczy,^ a physician of Budapest, has recorded a case of a girl, aged fourteen years, wdio suffered from typical typhoid fever with swelling of the submaxillary glands and the development of a membrane in the pharynx. The case had pulmonary oedema and membranous pharyngitis, laryngitis, and bronchitis. Not only are inflammatory changes found in the pharynx in this stage of typhoid fever, but also in the oesophagus, where, of course, they are apt to be more moderate than in the pharynx because of the lack of lymphoid tissue. Usually swelling of the glands in the mucous membrane is to be found on inspection. As the disease progresses these changes may become ulcerative and severe. In Baer's^ interesting account concerning 83 cases of typhoid fever w^ith unusual distribution of the ulcers, there were ten instances of ulcers in the oesophagus. MitchelP has reviewed this subject, and states that in 56 autopsies in the Johns Hopkins Hospital, representing between 700 and 800 cases of typhoid fever, oesopha- geal ulceration occurred but once, although the oesophagus was 1 Ouskow. Archives des Sciences Biologique, 1893, T. 2, No. 1. - Taupin. Journal des Connaissances McSd. Chir'urgicale, 1839. ^ Gerloczy. Deutsche med. Wochenschrift, April 14, 1893. ■* Baer. American Journal of the Medical Sciences, May, 1904. 5 Mitchell. Studies in Typhoid Fever, No. 3 Johns Hopkins Bulletin. THE ALIMENTARY CANAL IN THE l)EVE[J il'ED ST ACE 125 always ciU'cl'iilly cxjimiiK-d. Louis' jiiid Jciijkt" 1i;i\c seen f;i-,c.s of typhoid ulceration of the (I'sophagus, and iloderer and Wagner have seen a\sophan;itis, as have also Kichhorsf^ anrl lieirner, and again, ChaiiHer and Cornil have d('SCTil)ed a coinHlifin of infih ra- tion of the mucous membrane of iIh; ovsofjhiigus v\idi a fonn;itiori of miliary abscess. These changes will be fV^nnd discussed in the chapter dealing witli the stage of convalescence. Stomach. — Symptoms peculiar to the stomach are comparatively rarely met with in typhoid fever, unless dietetic errors have caused them, or unless by the excessive use of drugs or stimulants its func- tions become perverted. On the other hand, when gastric symptoms arise, either as the result of the causes just named, or because of some unusual feature of the disease, they are apt to be not only annoying but difficult of control. Aside from moderate gastric catarrh due to the fever and associated with a condition of insuffi- cient and inefficient gastric juice, which is peculiarly marked in these cases, the unusual symptoms vary from hiccough, which is really an affection of the diaphragm produced by a reflex from the stomach in many cases, to vomiting, and from discomfort in the epigastrium to severe pain. Disregarding the moderate form of hiccough seen so often accompanying ordinary indigestion, we now and again meet with cases in w-hich this symptom becomes not only annoying but exceedingly dangerous, in that it causes rapid exhaustion and failure of the heart, apparently by some associated vagal neurosis, over and above the great drain upon the patient's strength. Numerous cases are on record in which this complication has resulted in great danger or even in death. Vomiting in typhoid fever may be an unimportant or very grave complication. Often it occurs because of indigestion or irritability of the stomach, and stops as soon as the diet is altered or the quality and mode of using stimulants is changed. Its gravity depends largely upon its persistency, because if it ensues on taking food the patient speedily dies from lack of nourishment; and if it is of the 1 Louis. Reclierches anatomiques, patliologiques et tlierapeutique sur la fievre typhoid (1841). Translated by Henry I. Bowdich, Part 2, Art. 2. - Jenner. Edinburgh Monthly of Medical Science, 1S50, vol. 10, p. 311. 2 Eichhorst. Handbueh der specielleu Patliologie uud Therapie, Funfte auflage, 1S97. Band iv, 416. 12o WELL-DEVELOPED STAGE OF THE DISEASE incessant type, resembling the status epilepticus in its constancy and spasmodic character, the patient retching incessantly, whether the stomach is empty or not, death is imminent because of direct exhaustion.. Such cases are not common, but when they occur the prognosis must be very grave. Sometimes it would seem as if tlie vomiting was caused by a neurosis or by poisoning of the vomiting- centre in the medulla. Still more rarely in typhoid fever the vomiting arises from ulcer of the stoniacli. Hemorrhage from the stomach is very rare in typhoid fever and is almost unknown. Pepper states that typical typhoid ulcers may be found in the stomach, and from them it is possible that hemor- rhage may occur. Soltau Fenwick^ has recorded a case in which typhoid gastric ulcers nearly perforated, and another in which they did perforate, but peritonitis was prevented by the liver becoming adherent to the stomach. Death occurred in this case from profuse hemorrhage from one of these ulcers. We have only met w^ith one case in which h?ematemesis took place. A w^oman, aged twenty-eight years, who was seized with a very severe attack of the disease, died at the end of the first w^eek imme- diately after vomiting a large amount of blood and passing a great quantity by the bowel. No autopsy was held, and in all probability the blood had entered the stomach from the small bowel. The following cases are those of Fenwick's: A girl, aged eight years, succumbed during the third week of enteric fever. On examination of the stomach, four well-defined ulcers were found in the pyloric region, one of which presented a loosely adherent slough. The edges of the ulcers were sharply defined and somewhat undermined, while their bases were situated in the submucous and muscular coats of the organ. On micro- scopic examination the lymphoid tissue of the stomach was found to be enormously increased, and the supposition that the ulcers originated in disease of the solitary glands was confirmed by the appearance of the smallest one. From these facts it would appear that under certain circumstances disease of the solitary gastric ' Fenwick. Disorders of Digestion in Infancy and Childliood, 1897, p. 386. THE ALJMKNTAIIY CANAL IN Till': DEVELOPED STAGE yjl glands iDiiy ^'ivc rise, to ii I'onn of |»cir(jr;iliii;^ iilrcr of iIk- t(,in;i()i whic;h closely rescinblcs the idiopatliie type of the disease. "A girl, aged thirteen years, was admitted into the hos}>it;il with the symptoms of tyj)lioid fever of eight diiys* diirafion. \'orm'ting occurred once or twice, hut there was no coiiiplniiil of c|)iu-a.stric pain. At the end of the fourth week of the disease, when the tem- perature had begun to decline, the patient was suddeiily seized with severe hsematemesis, after which she became unconscious and died. At the necropsy the anterior wall of the stomach was found to be adherent to the under surface of the liver. Scattered over the inner surface of the stomach there were numerous shar[>Iy defined ulcers, the largest of which was about the size of a fioiin. The edges were tliin and undermined and the base was formed by the muscular or peritoneal coat. In the first part of the duodenum there was an ulcer of a similar character, while the whole of the intestine, from the jejunum to the rectum, was riddled with typical typhoid ulcers." Osier has reported the following cases to Keen : "John M., aged forty years, was admitted August 21, 1890, with a history of illness of some weeks' duration. The chief symptoms were headache and fever. The blood examination was negative. There was a very definite rose-colored eruption. The temperature was never high, not rising above 103°. On the 27th he vomited, and in one of the attacks he brought up a dark greenish- brown fluid containing red blood corpuscles in a condition of disin- tegration, and a clot of blood about 3 by 2 cm. in diameter. On the 29th, 30th, and 31st the stools were very dark in color, and evidently contained blood, and several times he vomited very dark material. He became very anaemic, but made a good recovery. "Alberta C, colored, aged twenty years, admitted June 14, 1S94. This patient was admitted in the third week of the disease. On that afternoon she had had a hemorrhage from the bowels. She was bleeding quite freely on admission. Between 6 and 8 p.m. she had five large stools of almost pure blood, with clots. Tlu-oughout the following day she was extremely feeble; temperature was normal; patient was delirious. On June 16 there was no further bleeding from the bowels. Toward evening the patient was delirious, and 12S WELL-DEVELOPED STAGE OF THE DISEASE her condition was verv had. At S.lo p.m. she vomited 100 c.c. of dark bloody fluid, which contained blood coloring matter and red blood corpuscles. She sank, and died that eveninp;. "Dr. H,, aged twenty-two years, admitted January 9, 1S9G. He had a very severe attack, with persistent fever, which resisted the baths. These, though given from the outset, did not check the onset of quite active delirium. On January 25, about the eighteenth day of the disease, the abdomen was a good deal distended; there was moderate diarrhoea and less delirium. He seemed to be doing very well. He had had no special gastric symptoms. In the after- noon he quite suddenly sprang up in bed and vomited a quantity of dark blood. The amount was diflficult to estimate, as it went all over the bedlinen. Part of it was collected, and Dr. Parsons estimated the amount to be about 200 c.c. It contained much debris and red blood corpuscles. The staining on the sheets was quite red. On the 26th the temperature was between 103° and 104°, and in the afternoon at 3.05 he vomited between 200 and 300 c.c. of almost pure, bright red blood. The pulse became more rapid, but these two hemorrhages did not appear to have any injurious influence. His temperature gradually fell and was normal on the 31st. He made an uninterrupted recovery after a most severe attack." Weiss^ records a case of a soldier, aged twenty-two years, who died from profuse gastric hemorrhage about the beginning of the third week of typhoid fever. This was preceded by intestinal hemorrhage. As no statement is made as to whether a postmortem confirmed the diagnosis, the case is to be considered as a doubtful one. INIillard^ reports a case of profuse hsematemesis two days before death from typhoid fever. The autopsy revealed extensive ulceration of the stomach extending to the cardiac orifice. Nicholls^ was able to find only four instances of haematemesis in his study of over 100 cases of hemorrhagic typhoid fever. Intestines. — One of the first facts which attracts our attention in regard to the intestine during typhoid fever is that many cases of 1 Weiss. Wiener med. Presse, 1888. - Millard. Quoted by Brouardel and Thornot, La Fifevre Typhoid, Paris, 1895. ^ Nicholls. Montreal Medical Journal, June, 1896. THE ALIMKNTAIiY CANAL [N Till-: DEV la.OI'Hh STAr;h' |2!) this disease are rccor-f led in vvliicli ;i( llic ;iiilo|),sy no si^nsof tyj^lioid fever could be found in the intestines. Some of diese Iiave not been as carefully studied as tliey should be, bul odicis are fcrf.'dtily authentic. Thus, Du (-azar has recorded two instances in which the closest postmortem inspection failed to sfiow intestinal lesions, yet typhoid bacilli, which res|)ondc(l to all tests, were found in the spleeji, and the symptoms of the (h'sease wen; present in life. 'J'he spleen, mesenteric glands, and ki(hieys were swollen iind congested. Bacilli of typhoid fever were ol)tained not only from an abscess in the spleen, but also from vegetations in the mitral valves and from a hemorrhagic placpie on the surface of die brain. Banti^ and Karlinski^ have reported similar cases not so well j^roved. Ivarlinski's cases numbered three. Nichols and Keenan' have reported nine cases of t\phoid fever without intestinal lesions. So, too, Flexner and Harris'^ have recorded such a case, and Chiari and Kraus met with seven instances out of nineteen cases of typhoid fever in five months. GoodalP reports two cases of enteric fever, fatal during the third and fifth week respectively, in which there was no intestinal ulcera- tion. The first patient was a boy, aged thirteen years, who had been ill a fortnight when admitted to the hospital; the second was a man, aged thirty years, who had already been ill ten days. Both of them showed all the clinical evidences of typhoid fever, and in each there was a swelling of Peyer's patches without ulceration. Similarly, Fagge^ records the case of a man, aged thirty-three years, who had typhoid fever, and whose only lesion in the intestine consisted of one ill-defined purplish-red patch about the size of a shilling, situated a foot above the valve and a little higher up; another patch with a brush surface, which was visible only when it was examined under water. So, too, in November, 1880, ^Nloore showed before the Patholoo-ical Societv of Dublin a case of enteric fever in 1 Du Cazal. Bulletin et Soc. Mdm. M^d. des Hop., 1S93, p. 243, and Le Bulletin Medi- cale, April 16, 1894. - Banti. Archiv. Italiennes de Biol., December, 1887. 2 Karlinski. Wiener med. Woclienschrift, 1S91, pp. 470 and 511, and 1897. ii. 1850. * Nichols and Keenan. Montreal Medical Journal, 1898. xxvii, 9. ' Flexner and Harris. Johns Hopkins Hospital Bulletin, 1897, viii, p. 259. ^ Goodall. Clinical Society's Transactions, 1897, vol. xxx. ^ Fagge. Pathological Soeietj-'s Transactions for 1876. 9 130 WELL-DEVELOPED STAGE OF THE DISEASE which there was no disease of the glands of the ileiiin, while the spleen was extremely large, soft, and friable, and Fever's patches were noted" appearing less distinct than usual, though with no hyperannia, and did not present the shaven-beard appearance. Sydney Phillips reported to the Clinical Society, in 1891, two cases, fatal after the third week, with no ulceration. Goodall points out that out of sixty-three autopsies he has held in cases of enteric fever at the Eastern Hospital he has met with absence of ulceration in five cases; in two of these death took place early, on the eighth and tenth days; in two others, as the result of some com- plication, on the thirty-second and seventy-third days. Other cases have been recorded by Beatty,^ Church, and Coup- land. Again, Hodenpyle,- of New York, has contributed a paper upon this subject, reporting a case of undoubted typhoid fever in which the intestinal lesions were absent. Brunschwig^ has also recorded a case of this kind, and HoeffeP has done likewise, there being in his case but slight swelling and reddening of a few Beyer's patches. Schultz claimed to have met with 21 cases out of 300 autopsies of this disease without the characteristic ulcers in the ileum; but there is doubt as to the correctness of his statement. Bryant^ reports the case of a child, aged twenty-one months, who died of typhoid fever at the end of the third week, and whose blood l)efore death gave the Widal test. The autopsy showed that the heart weighed one and one-half ounces, and appeared to be normal. The arteries, mouth, pharynx, oesophagus, and stomach were nor- mal in appearance. The ileum also appeared to be normal. There was no ulceration, and the Beyer's patches were not swollen or discolored. Nowhere in the intestine could any sign of recent typhoid ulceration be found, and there was not any appearance suggesting a healing or healed typhoid ulcer. The peritoneum W'as normal. The liver weighed sLxteen ounces, and had a normal appearance. The gall-bladder and pancreas were normal. The I Beatty. British Medical Journal, June 16, 1897, p. 148. - Hodenpyle. British Medical Journal, December 2.5, 1897. ' Brunschwig. ' 'Is the Lesion of Peyer's Patches a Constant SjTnptom of Typhoid Fever?" Strasburg Thesis for 1870. * Hoeffel. Gazette M(5dicale de Strassburg, 1871, No. 14, p. 167. * Bryant. Briti.sh Medical Journal, April 1, 1899. Till': ALIMENTARY CANAL IN TIIL DLV LLOI'LD HTACL \:>,\ mesenlcric ^liuids were iniicli (•iil;iif!Lrf(l to he in a condition of acute in/lammation; tli('re was no sign of suppuration or caseation in any of them. Tiie suprarenal capsules were normal Tiie kidneys weighed llnce ounces; they were \y.\\c. 'V\\<' sf>lcen was a little enlarged. That the ease was one of (nic lyphoid fever is proved Ijv the results of careful hactei-iological study of the tissues. As Bryant well says: "Nothing unusual was anticipated before the necropsy took place. It was expected that the usual typical ulceration of the Peyer's patches of the lower part of the ileum would be found, and great surprise was expressed when no swelling, discoloration, ulceration, or other abnormalities whatsoever could be detected in the Peyer's patches, solitary glands, or mucous membrane of any part of the intestine. I thought at first an erroneous diagnosis had been made, and suggested that the symptoms might have been accounted for by the bronchopneumonia which was found, although the character of the pyrexia was against this view. After finding the enlarged mesenteric glands, I suggested that, after all, it was most probably an anomalous case of typhoid fever without any lesion of the intestinal mucous membrane. Cultures from the enlarged mesenteric glands yielded an almost pure culture of the Bacillus typhi abdominalis. The slight clotting of the milk inocu- lated from the first broth culture taken directly from the glands was probably due to a slight contamination with the Bacillus coli communis. It will be noticed that coagulation did not take place until after fortv-eight hours, and then it was onlv slight. I could not find any colonies of the Bacillus coli communis on the gelatin plates, although I looked and carefully examined for them, so that if present originally the number must have been insignificant. The bacillus obtained from the gelatin plates gave the character- istic positive and negative reactions of the Bacillus typhi abdomi- nalis, namely, did not produce gas in any media, did not cause milk to clot, did not produce indol, did not produce acid, did not liquefy gelatin, and, further, these bacilli obtained from a recent culture and treated with both 50 per cent, and 5 per cent, serum V') 132 WELL-DEVELOPED STAGE OF THE DISEASE from a ty})lu)itl patient, and also from an immunized rabbit, t'lumj)ed together in a manner eliariieteristie of the Baeiihis typhi abdoniinahs." Thiie/ ill 1889, described a case in wliich (huing hfe the fever was of a recurrent type, and the spleen was found to be considerably enlarged. At the necropsy slight swelling only of Peyer's patches was found. The Bacillus typhi abdoniinahs is stated to have been obtained from the spleen and kidneys, but is not sufficiently identi- fied as such. Vaillard,- in 1890, reported the case of a young soldier who died after an illness of three days' duration. The chief symptoms were headache, epistaxis, pyrexia, constipation, retraction of the neck, and coma. At the necropsy congestion of the lungs and meninges was found, but there was no intestinal lesion. The Bacillus typhi abdoniinahs was obtained by culture from the spleen, lungs, and spinal cord; streptococci were also obtained from the spleen and meninges. (niarnieri,^ in 1892, described a case of typhoid fever which during life presented the characteristic symptoms of the disease. No intestinal lesion, however, was found at the necropsy, but the Bacillus typhi abdominalis was obtained by culture from the biliary passages, liver, and spleen. ^'incent,^ in 1893, described the case of a man, aged thirty-five years, who died about the twelfth day after the onset of a severe ilhiess characterized by pyrexia, diarrhoea, purpura, and coma. At the necropsy the Peyer's patches were found to be normal; the mucous membrane of the intestine, however, was congested. The spleen weighed 230 grams; the mesenteric glands were not enlarged; bilateral pulmonary congestion was found. The Bacil- lus typhi abdominalis and streptococci were obtained from the spleen, liver, kidney, and heart. Osier mentions a somewhat similar case. The patient was a man, aged sixty years, who was admitted into the hospital under his care. ' Thue. Jaliresbericht iiber die Fortschritte (Baumgarten), 1889, 196. - Vaillard. La Semaine Mddicale, March, 1890, p. 94. ' Guarnieri. Rivista G^n;.>, He IijmI Ix'cii ill for- ;il)()ti(, Iwo iiioiilhs, iiiHJ on iidmissioii ujisfoiiiK] (,() l)(^ .sullVriii^' IVoiii slioidicss of hrcjilli, iiiHJ prcsciilcd sij^ii.s of j)i)eum()iii{i airectiii^ tlic lovvcc lolx; of (lie \\\^\i liiii^. I)cii(li (of>k place twciity-four hours after admission. A diagnosis of senil<; pneumonia was made during life. At the necropsy the lower lolx; of the right lung showed fr-csii |)ii('ninonia passing on to ;i rondition of giingrene. There was wo inlestina! lesion. The organs wen; submitted to a bacteriological exann"iiation by Flexner, and ]>nre cultures of tlie Bacillus typhi abdominalis were f)b(ain(d tVoni thf- lungs and spleen. Mettenheimer^ records an epidemic of typhoid fever (jcciuring in the army in which in twenty-one cases the intestinal lesions were entirely limited to the colon. Banti^ and Karlinski' have also reported cases of this character. A case is recorded, in Cheadle's' service at St. Mary's Hospital, of a child, aged three years, who died of typhoid fever, and at the necropsy no ulceration was present in the intestine and Beyer's patches appeared to be normal. Beatty' records two cases with a similar condition present. Baer** has investigated the reports of a number of these cases, and came to the conclusion that there were but 28 cases, including the two reported by himself, that were investigated in such a manner as to be worthy of being placed upon record as cases of true infection with the Bacillus typhosus and not revealing at autopsy any sign of intestinal ulceration. It is our opinion that there is a far e-reater number of cases of this kind than is generallv believed. DiARRHGEA is Speedily ceasing to be a fairly constant symptom of the disease. As a matter of fact, it is in a very large proportion of cases supplanted by constipation from the beginning to the end of the malady, although classical worlvs nearly all regard looseness of the bowels, amounting to three or four stools a day, as the usual condition in average attacks. This is particularly the case in the 1 Mettenlieimer. Jaliresberichte iiber die Gesammte Med., 1872, Bd. 2, p. 235. = Banti. La Riforma M^dica, 1887, p. 1448. ' Karlinski. Wiener med. Wocheii., 1891, pp. 470 and 511. ^ Cheadle. The Lancet, Julj^ 31, 1897, p. 254. 5 Beatty. British Medical Journal. January 16, 1897. '^ Baer. American Journal of the Medical Sciences, May, 1904. 134 WELL-DEVELOPED STAGE OF THE DISEASE typhoid fever of chiUiren, in whom constipation occurs even more commonly than in adults. Students very often seem to have the idea that the absence of diarrhoea in a given case is an important point against the diagnosis of typhoid fever. On the contrary, it is so often absent that its absence is of no negative vakie whatever, aUhough its presence possesses more importance. Certainly, constipation is much the more frequent state as we meet the disease in Philadelphia, and as Osier well points out, diarrhoea occurs in Baltimore in not more than 30 per cent, of his cases, and is an active form in only about 12 per cent. So, too, we find that in Curschmann's^ clinic, from 1880 to 1892, diarrhoea was met with in only 25 per cent, of the cases (1626 cases). Phillips tells us that of 200 consecutive cases in St. IMary's Hospital, London, diarrhoea occurred in 115, constipation in 48, but in many of these cases diarrhoea had been set up by a purge given before the diagnosis was made, so that his experience in no way militates against the statistics just cited. In the ^Maidstone' epidemic 50 per cent, of the cases were con- stipated. Murchison found it in 93 out of 100 cases. "When the diarrhoea is excessive, amounting to ten and twenty stools a day, the diet has usually been faulty in the extreme, or ulceration of the large bowel, amounting to a dysenteric state, is generally present. The character of the stools is usually, in the cases with moderate diarrhoea, quite typical, but green stools in typhoid fever are occasionally met with. They have been referred to by Dreschfeld in AUbutt's System of Medicine, the discoloration being seen during convalescence. QuilP has recorded a case in which bright-green material was vomited on the eighth day, and later the patient passed bright green fluid stools. There w'as great pain in the back. Garrod, Drysdale, and Kanthack* report three cases. The stools resembled chopped parsley, and the liquid por- tion of the stools when filtered off contained biliverdin, which was probably responsible for the discoloration of the excreta. 1 Curschmaim. Deutsche Archiv f. klin. Medicin, 1895. 2 Poole. Guy's Hospital Reports, 1898. (Wrongly labelled on cover, 1896.) 3 Quill. British Medical .Journal, October 22, 1898, p. 12.52. ■* Garrod, Drysdale, and Kanthack. St. Bartholomew's Ho-spital Reports, vol. xxxiii. THE ALIMENTARY CANAL IN THE l>EVEI/)l'EI) ^TAdE \'.>,ri The ii(!.\'t poiiil, (() he considered in (lii-, eonnc-l ion i^ wliellier diarrhcra is a sign of inild or severe iiif'eelion. The consensus of opinion seerns to be that diarrhasa is usually more active in serious cases. Whether this is an instance of "purging as an effort iit eHmination," a favorite theory witli those vvlio are fond of using purgatives and so-calhid intestinal antiseptics, with the idea tlint by so doing they eliminate poisons and prevent their ffjrmafion, or whether it is a manifestation of severe ulceration of the bowel with an associated catarrh, is difficult to determine. Ord' agrees with the view that diarrh(jca is usually associated with ulceration, and his opinion has been confirmed by the autopsies he ha.s seen. Peabody is diametrically opposed to this view. 'J'hat Ord's view is not correct seems proved by the fact tliat advanced ulceration is often found in cases which have not had diarrhrjea, and cases of marked diarrhoea are seen in which the autopsy does not reveal much intestinal ulceration. In Bryant's case, already quoted, diarrhoea was active, yet no intestinal lesions were found. In all probability diarrhoea is neither indicative of a severe nor a light attack in many cases, although if it be violent the exhaustion pro- duced by the discharges may seriously imperil tlie patient's chances of recovery. This view is strongly advocated by Sydney Phillips, who regards diarrhoea as a symptom adding danger to the progress of the typhoid, as he believes it prevents absorption of nutrin-tent and drains the body of fluid; he is therefore distinctly opposed to the so-called "purgative treatment." Tympanites. — Closely allied to this question of diarrhoea is that of the gravity of tympanites, a condition almost always present at some time during the course of even the mildest attacks, and, as a rule, less frequently present in cases with active diarrhoea than in those with constipation, although a great accumulation of gas in the intestines is also met with in some instances in which the bowels are moving quite frequently. As a rule, such passages are small in quantity, and are usually quite fetid. The gravity of tympanites as a symptom depends chiefly upon its ability to do harm, and this harm is in direct proportion to the degree of its interference by pressure with the functions of the thoracic and 1 Ord. Transactions Association of American Physicians, ISSS, vol. iii. 136 WELL-DEVELOPED STAGE OF THE DISEASE abdominal organs; tliat is. the strain put. In the distention. uj)on those parts of the bowel wall which are weakened bv ulceration and in danger of perforation from this cause, or to the stretching of the floor of an ulcer, thereby inducing hemorrhage. The degree of tympanites is not always a definite guide as to the damage it may do. It may be extreme in one case and moderate in another, and yet in the first instance very little harm seems to be done by it, Avliile in the second instance, either by reason of cardiac susceptibility or peculiar application of the pressure, the injury may be grave. While, therefore, the evil effects of tympanites are, as a rule, in direct ratio to its degree, cases are continually met with in which it is excessive and yet in which no bad results ensue. "When the tympanites is very excessive constij)ation may restilt from paralytic distention of the gut, and, on the other hand, the paralysis or relaxation of the bowel may, by preventing peristalsis, permit the accumulation of gas. Pain in the abdomen is very distinctly a symptom of the early stages of the disease, and in many cases is due to gas produced by fermentation. The pain is usually wandering, is not constantly in one spot, and if it becomes fixed it probably depends upon a localized complication. Pressure upon the belly wall is apt to increase the pain. It is, however, a noteworthy fact that later on in the disease, when tympanites is often excessive and the bowel greatly distended, there is apt to be little or no pain even on press- ure, perhaps because the atony of the muscular coat of the bowel prevents griping, and the tenderness of the first stage of swelling and inflammation is supplanted by a state of local and general nervous torpor. Hemorrhages. — The frequency with which hemorrhages occur varies greatly in different epidemics, independently of any specific line of treatment over and above rest in bed. Lack of such rest at any stage of the malady certainly predisposes the patient to this accident. A considerable amount of statistical evidence also indicates that the use of cold bathing as a therapeutic measure in this disease increases the frequency of this complication. In 861 cases of this disease without the cold bath, in Lieber- X THE ALIMENTARY CANAL IN TIIH l>i:V HLOI'LI) STAdL ]:>,7 meister's clinic ui B;i,scl, IiciihmiIi;i;;cs occiirrcd 72 tiiiir-s, f^r X.4 per cent. Griesinger met with 32 ca,se,s in 'ioo, oi- in ').'.', jxt fcnl.; and TiOiiis found them in 5.0 per cent., exfludinn mild cases; Hci'^r, in ]()2() cases, n)ct with ihein in 5.5 jht c( ni. TIk- yoinifjcr \\ iin- derlieh has recorded OS cmscs of lyplioid I'cvcr wilhoiit ilic hath, with heniori'hage in 2 cases, or ahout 2 per cent. KndV I'onnd in his study of intestinal hemorrhage in tyj>h(jid fever that it (jccurred in 4.24 per cent, of cases, and, curiously enough, that women were more frequently attacked than men, while, on the other hand, more males died from this accident than females. He does not think that the prognosis depends directly upon the amount of blfKjd lost. We find, therefore, that in 1559 cases treated without the cold hath there were 00 hemorrhagic cases, or 5.2 per cent. On the other hand, we find that in bathed patients AVunderlich, Jr., records 155 cases with 16 hemorrhagic patients, or 10.3 per cent. Immermann, at Basel, records 146 cases with 6 hemorrhages, or 4.1 per cent.; and Liebermeister, 882 cases with 45 hemor- rhages — 1183 cases, or 6.8 per cent. This is shown best by the following table : Without Bath. Cases. Hemorrhages. Per cent. Liebermeister 861 72 8.4 Griesinger 600 32 5.3 Wunderlich, Jr 98 2 2.0 Total 1559 106 5.2 With Bath. Cases. Hemorrhages. Per cent. Liebermeister 882 55 6.2 Immermann 146 6 4.1 Wunderlich, Jr 155 16 10.3 Total 1183 77 6.8 To these may be added: In America, with baths, Wilson's 140 cases with 10 hemorrhages, or 7 per cent.; Osier's 356 cases with 12 hemorrhages, or 3.4 per cent.^ It is interesting to note in this connection that Fitz places the general frequency in bathed cases at 5 per cent, and Loomis at 5 per cent. It is, however, only fair to state that Goltdammer, from 1 Kraft Centralblatt f. die med. Wissenschaften, 1893, p. 137. = Only 299 were bathed. + 138 WELL-DEVELOPED STAGE OF THE DISEASE nearly 20,000 cases, concludes that the baths do not increase hemor- rhages. Brand claims that they are less frequent in the bath treat- ment, as do also Tripier and Bouveret; but Roland G. Curtin tells us that upon investigation he found that since the cokl-water treat- ment has been instituted the number of hemorrhagic cases has con- siderably increased, according to the hospital records that furnish his data, and in addition the mortality of the hemorrhagic cases is largely increased, viz., from five in seventeen, less than one-half, to twenty-five in forty-three cases, or over one-half; and, further, on inquiry he found that in two of his tabulated cases the hemor- rhage seemingly took place while the patient was in a bath, and in one case immediately after a bath. . An important point in this connection is the question as to the real danger to the patient from hemorrhage. In this opinions greatly differ. Thus, Fitz tells us that it is always a serious symp- tom, but rarely fatal in private life; but that it may be very dis- astrous is shown by the fact that Liebermeister mentions 49 deaths due to this cause out of 127 deaths; jNIurchison, 53 deaths from hemorrhage out of 100 deaths; and Homolle, 44 per cent, in 498 deaths. Osier asserts that death occurs in from 35 to 50 per cent, of hemorrhagic cases. Out of Griesinger's 32 cases, 10 died, 7 of these within four days of the hemorrhage. Liebermeister tells us that among his own cases, 38.6 per cent, died when they had hemorrhage, as against 11 per cent, without this accident, and Tyson tells us that the 7 per cent, of mortality in his cases under the bath treatment was due entirely to hemorrhage or perforation. It is evident that Osier's percentage is about correct. On the other hand, it has been noted by some clinicians that if the hemorrhages are not sufficient to produce profound exhaustion the patient often does better after their occurrence than before. This fact was at one time insisted upon by Dr. Alfred Stills, and it is certainly true in a certain proportion of cases. While, as a general rule, the danger is in direct ratio to the quantity of blood lost, recovery may occur even after enormous quantities have been passed. We have had a case which recovered in which no less than four pints of blood escaped from the bowel at one bleeding, and Phillips and Wakefield, in 1882, saw a patient THE ALIMENTARY CANAL IN Till-: hl'A' i:!/)!' i:i) ST ACL \:',U who bled "(wo cliiuiilxTriils" ;iimI recoverefl. Miuli (Icjjcufl . u|)')ii the vitality of the patient, the state of his hlood wlien taken ill, and the defi;r(;(^ to whieh (U'<^enerative changes icsiilting from the disease have taken plitee in vital organs. As a rule, bleeding from the bowel in tyjjiioid f«\ci- ii rises from ulceration of an arterial twig, but cases do occur where blood comes from a vein which has been opened by ulceration. I'hilHps has re- corded such an instance. In children liemorrhages from the bowel are more nire thiin in adults because the intestinal lesions are not sf) marked, as a ruie. As an illustration of how rarely intestinal hemorrhage c-ompli- cates typhoid fever in children, the statement of Simon that in twenty-one years of practice he had encountered only three cases is of interest. Hillier, on the other hand, met with hemorrhage in 4 out of 30 cases. The younger the child the less is the liability to this accident. Perforation of the Intestine. — Perforation of the bowel in typhoid fever bears no relation to the severity of the general symp- toms. In many cases the reporting physician states that the attack ■of enteric fever was mild, so that in 444 cases collected by Fitz, fully 200 were of this class. In 14 of the cases the patients belonged to the class known as "walking typhoid" cases. Thus, Bennett^ reports the case of a man who, because of cardiac dropsy, was admitted to St. Thomas' Hospital. He was purged and allowed to eat heartily. Two weeks later he began to suffer from abdominal pam, and the next day death took place from perforation due to typhoid fever. No typhoid symptoms had been observed. Finncane^ reports a case of a man apparently well until two days before death, when t^'phoid perforations occurred, and Ivleinwachter^ speaks of a woman who until forty-eight hours before her death was at business, and who was suddenly stricken and died from this cause. When perforation occurs the symptoms are apt to be ushered in by agonizing pain, usually felt in the appendicular region, which may be severe enough to rouse the patient from a considerable ^ Bennett. Transactions of the Pathological Society, London, 1866, x^•ii, 121. - Finncane. Lancet, 1SS9, ii, 793. ^ Kleinwachter. Wienei- med. Press, ISSO, xxi, 337. 140 WELL-DEVELOPED STAGE OF THE DISEASE degree of coma. The belly 'wall .speedily becomes tense and then tympanitic, and all the symptoms of a general diffuse peritonitis speedily ensue. Tlu» jxdii may, however, not be persistent, but pa.ss away or become modihed, as the peritoneal inflammation resulting from the escape of fecal matter becomes more and more septic. The pulse becomes rapid and running, and collapse may speedily assert it.self. When this occurs death speedily comes on, the patient dying in a few hoiu's, or, again, he may rally and survive for several days. Early death is, however, the more common result. Thus in the collection of thirty-four cases made by Fitz,^ of Boston, 37.3 per cent, died on the first day, 29.5 per cent, on the second day, and 83.4 per cent, in the first week. During the second week nine died, in the third week four died, and two other cases lived thirty and thirty-eight days respectively. If collapse does not ensue, the rally of the system results in a rise of the temperature to a point higher than before the accident, and this mo^■ement is often accompanied by chills and rigors. Usually by the second or third day the peritoneal symptoms become more and more marked, the condition of the patient more and more asthenic and depressed, and death results by the fourth day from a general peritonitis Avith toxaemia from the absorption of toxic materials. In other cases the onset of the perforation is insidious, the belly before the perforation may have been moderately tym- panitic, but now^ becomes intensely hard and swollen; the pain, which in some cases is so severe, does not develop, but the great fall in fever, followed by a rise, and this again by rigors, it may be, give evidence of the grave accident which has occurred. The pulse becomes increasingly rapid and running, and the respirations more and more costal and less and less diaphragmatic, until the patient sinks out of life, without much, if any, suffering, in much the same manner as one sees death come to a case of difi'use septic peritonitis due to a pus-tube or an old appendicitis. In such cases the perfora- tion is usually very small, and is so surrounded by adhesions that the escape of the intestinal contents is very gradual and insidious, infecting the peritoneum without the escaping fluid being copious 1 Fitz. Transactions of the Association of American Physicians, 1891 , vol. vi. THE ALIM/'JNTAIiV CANAL IN TIIH DIIV i:!/)!'!!!) STACI-: \\\ enough to produce oi-c;i( \y,\\\\ uv widcsixciid \\\\cc\'\i>\\. '\'\\\> po-^i- l)ili(y of jM'rronilioii of IIk- bowel l,;ikiii^ phice insidiously luis l;esc .signs, or alterations in temperature." The first ty})e of ease is illusli-ated by thai of a medieid sfudent nnd(>rthe senior author's care, who while eonvaleseing from a very mild attack of the disease, and who had had a normal tenifx-rature for several days, was seized at midnight with agonizing pain in the epigastrium, so severe that he implored his father to relieve him or kill him in order to stop his suffering. He rapidly passed into collapse, and died in eight hours. The insidious form is shown by the case of a man who came under the senior author's care in the third week of the disease, much exhausted and emaciated, but without very high fever at any time. At the end of the fourth week he seemed to be doing very well, but his temperature, which had been approaching the normal, suddenly rose to 104°, accompanying a chill; his belly became enormously distended, his breathing became more and more costal, and he died at the end of the third day from exhaustion and asthenia, with all the physical signs of perforation. Both of these cases occurred before the days of operative interference in this condition. In this connection it is interesting to note that a sudden fall in temperature is not a symptom necessary to the diagnosis of intes- tinal perforation. On the contrary, there are many cases on record in which a rise of temperature follows this accident. Thus, Lere- boullet^ states that in all the cases of perforation he has met with there has been a rise, not a fall, and he quotes Lorain, Brouardel and Thoinot, Griesinger, Amould, Lemoine, and Homolle as agreeing with him. INIonod^ also reports such a case. Dieulafoy* goes so far as to assert very positively that peritonitis 1 Phillips. British ISIedical Journal, November 12, 1S9S. - LerebouJlet. Academie de Medecine de Paris, October 27 and Xovember 3, 1896. Dis- cussion of a paper entitled "De I'lntervention Chirurgicale dans les Peritonites de la Fievre Typhoide," by Dieulafoy. 5 Monod. Ibid. * Dieulafoy. Ibid. 142 WELL-DEVELOPED STAGE OF THE DISEASE from perforation very rarely announces itself acutely, with sudden pain and marked constitutional symptoms. On the other hand, its onset is generally insidious. The sensibility of the patient is blunted, the peritoneal infection takes place slowly, and the actual occurrence of perforation may escape unnoticed. Although such cases, due to pin-hole perforation, may occur, they cannot be considered common. Fitz mentions 56 cases in which the onset of symptoms of per- foration Avere severe; 15 in which it was gradual or latent, and 5 in which there was no sign of perforation. Such cases as the last named are recorded by Laboulbdne,^ who tells us that there was no sign of perforation save a chilliness of the skin and a slight fall of fever. Barth" makes a similar report, and Jenner^ reports a case which left bed on the ninth day and died some hours later of perforation, there being no complaint of pain made. What the ordinary percentage of perforation is is in some doubt, but according to Murchison,^ it is in the neighborhood of 3 per cent. Schulz^ found it in 1.2 per cent of 3686 cases of typhoid fever in Hamburg in 1886 and 1887, and Liebermeister" in 1.3 per cent, in 2000 cases in Basel in 1865 to 1872. Berg, in 1626 cases, met with it in 2.2 per cent., and this is about the percentage reached by Osier in cases bathed and not bathed. The percentage mortality of this accident is very high. Of 1721 autopsies, the percentage was 11.3, according to INIurchison. According to Holscher it was found, in 2000 Munich cases, 114 times (5.7 per cent.), and in 20 out of 80 of his cases which ended in death. In 4680 cases tabulated by different writers, Fitz found the proportion to be 6.58 per cent., which agrees with Holscher's statistics. Hoffmann found that out of 250 deaths in typhoid fever, 20 were due to perforation. Perforation is very much more frequently seen in men than in women. Fitz, in 444 cases, found 71 per cent, in men and 29 per > Laboulbdne. L'Union M^dicale, 1S77, xxiii, 389. 2 Earth. Bulletin de la Soc. Anat., 1884, lix, 142. 3 Jenner. Medical Times, 1850, xxii, 298. * Murchison. Continued Fevers of Great Britain. ' Sclmlz. Centralblatt fiir Allegemeine path. Anat., 1891 , ii, 289. ' Liebermeister. Ziemssen's Encyclopajdia, vol. i THE ALIMENTARY CANAL IN THE hIA IILOI'ED STAf.L \ y.', cent, ill woiiicii. In '21 ciiscs of |)crroi;ilioii in I5;i :*l, I.'; \vcr<- nif-n and were women, juid (iriesinircr, in J 4 oases, liud 10 men and 4 women. Mureliison also i'onnd In 24 cases 10 men anrl S women, although the general morlalil y of t he disease among wfjiiifii was sliglitly higher than among men. So, too, Bristowe, of London, met with this accident in men in 11 cases out of 15, and, again, Nacke^ collected lOG perforation cases, in which 72 were in men and 34 in women. The period of the disease in wliicli jx-rforation most commonly takes place is at the end of the third week or latei-. Thus, in twenty- two cases in which reliable information could he obtained by Liebermeister, perforation took place at the end of the second week twice, during the latter half of the third week six times, in the fourth week twice, in the fifth week six times, in the sixth and seventh weeks twice each, and later than this twice. Nacke found it 84 times out of 185 cases in the first two weeks, and 00 later; 62 out of 117 cases in the first four weeks and 55 later. More accurate statistics are those of Fitz, who in 103 cases obtained facts shown in the following table : Date of Occurrence in Perforation. First week Second Third Fourth Fifth Sixth Seventh Cases., 4 32 48 42. 27 21 5 Eighth Ninth Tenth Eleventh Twelfth Sixteenth Cafes week 3 The part of the bowel most frequently perforated in 136 cases was the ileum in 106 cases, the colon in 12 cases, and the vermi- form appendix in 15 (Liebermeister). Hoffmann- tells us that out of 20 cases the perforation occurred once near the ileoci^cal valve, four times at four to six inches above, nine times at eight to twenty inches, twice at four and a half to six feet above, once at ten feet above, and in one case there were no less than twentv-five to thirtv 1 Nacke. Ueber die Darmperforation ini Typhus Abdominalis, Dissertation, Wurzburg, 1893. * Hoffmann. Untersuch. und der path. Anat. Verand. d. Organe beim Abd. Tji^hus. 1S69. 144 WELL-DEVELOPED STAGE OF THE DISEASE perforations in the jejunum. In 167 cases collected by Fitz, the perforation occurred in the ileum in 136 instances ((S1.4 per cent.), in the large intestine in 20 (12.9 per cent.), in the vermiform appen- dix in .3 cases, in ^Meckel's diviM-ticulum in 4, and in the jejunum in 2. In 19 cases there were two perforations, in 3 five perforations, and in 4 four. Another case with multiple orifices has been cited, A very extraordinary case is that reported by Heagler.^ A woman suffering from ventral hernia was attacked with typhoid fever, and perforation of the ileum occurred in the hernial sac. This resulted in sloughing, and a fecal fistula of large size was formed. Great emaciation ensued, hut the w^oman recovered. An interesting case of typhoid fever with secondary lesions involving the left half of the scrotum has been reported by Spencer.- The patient was thought to be suffering from influenza; and had suffered from a hernia in the left inguinal region for nine years. \Vlien first seen at the hospital the left half of the scrotum was greatly swollen and distended, the skin being oedematous; the swollen area was tympanitic on percussion, opaque to light, and fluctuated, and at the inguipal region there was a firm mass to which an impulse was transmitted on coughing. An incision was made from which pus, gas, and sloughing omentum came away. The patient died seventeen days later, and the postmortem revealed the fact that the condition of the scrotum had been due to the per- foration of a typhoid ulcer. In children this accident is very much more rare than it is in adults. J. Lewis Smith states that it is met with only once in 232 cases. Wolberg found no such accident in 277 cases of the disease in children at Warsaw. Fitz gives the following table as to age incidence : Age at which Perforation Occurs. 1 to 10 years 7=3.6 per cent. 10 " 20 " 46 = 23.8 20 " 30 " 77 = 39.8 30 " 40 '• 45 = 23.3 40 " 50 '• 14 = 7.2 50 " 60 •• 2 = 1.0 60 '• 70 " 1 = 0.5 1 Heagler. Correspondenzblatt fiir Schweizer Aerzte, 1896, No. 17. - Spencer. London Lancet, April 10, 1897. THE AIJM/'JNTA/iV CANAL IN Till': DhlV ELOI'HI) STAfJI'J H5 Jii lliis coiincclion (lie jiccoiiiil, ^^ivcn iriuiiy years ago l>y Tii njjin' of iiitcstiiijil perforation in cliildren is of great interest. lie tells u.s that he saw two such cases, and that four such were reported in 1834, 1835, and 1838 by Ilusson and Barrier. Thr(;e of these were gravely ill, and when perforation occurred they j)assed inlo ffillapse and died. In tli(! two Tiiupin saw atrocious pain (Jevelojjcd in the right flank and collapse ensued. Death occurred in thirty-six hours, with all the signs of peritonitis. Elsherg- was able to find the reports of 25 operations for perfora- tion of the intestine during typhoid fever in children under fifteen years of age. Patterson^ has collected 68 additional cases with a mortality rate of 45.58 per cent. Griffith^ has reported six instances of this complication in children, and is of the opinion that the com- plication exists much more frequently than is generally believed. Paton^ reported an operation for perforation in a child, aged seven years, with subsequent recovery of the patient, while Schofield's patient" was but twenty months old. Altogether there have been reported in the literature over 100 instances of perforation of the bowel in children during typhoid fever. The greater number of these reports have been published during the last ten years, during which time the profession have had their attention directed to the prevalence of typhoid fever in children. To one unacquainted with the subject it would seem that there could be no question as to the danger of death from perforation, in 1891 Reeves stated that he had seen five cases presenting all the signs of perforation, and yet the patients recovered. At the same meeting Loomis said he had never seen recoverv after the presence of unmistakable signs of perforation. The latter view was that held by most of the earlier WTiters; but Buhl, in 1857, recorded a case in which death did not succeed perforation for forty-five days, and then as the result of hemorrhage from a mesenteric artery. The autopsy showed that a perforation had 1 Taupin. Journal des Connaissances Med. Chi., 1839. 2 Elsberg. Quoted by Patterson in American Journal of Medical Sciences, May, 1909 'Patterson. American Journal of the Medical Sciences, May, 1909. * Griffith. Philadelphia Medical Journal, February 25, 1905. * Paton. British Medical Journal, February 25, 1905, « Schofield. British Medical Journal, May 24, 1906. 10 146 WELL-DEVELOPED STAGE OF THE DISEASE occ'urretl. l>iit had been closed. Murchison states that rare cases are met a\ ith in which recovery takes phice. At the present time it is a well-recognized fact that cases may recover, but that, as ]\Iurchison. says, they are rare, unless surgical aid is given the patient very sot)n after the accident. (See operative interference.) Perforation does not always produce death, because it may not cause anything more than a very localized abscess, owing to a protective peritonitis which walls off the general cavity from infection. Eisner^ reports such cases, and Pearson^ records a case in which during relapse an ileocsecal abscess formed, the pus having a fecal odor. In another case^ a man had a perityphlitis on the twentv-eighth day, and passed two ounces of pus by the rectum on the fiftieth day. Keen records a case in which an abscess formed in the right side, which opened into the ascending colon, and finally a fecal fistula developed. He also records a case sent him by Dr. Schureraen, of Tom's River, N. J., of an abscess which opened near the anus, giving vent to a great deal of pus, in the third week of the disease. Later, another opening formed. jMajor* records a case in which collapse occurred on the eighteenth day of the disease, and three weeks later an abscess biu-st into the rectum, and the patient recovered. Low's^ case had symptoms of perforation in the third week, and peritonitis. Later, an abscess burst through the abdominal wall, but the patient recovered. Again, in Lehman's case perforation occurred at the end of the third week, and death occurred a month later. Li the abdominal pus the bacillus of Eberth was found. Schmidt" has recorded a case of pyopneumothorax subphrenicus, from which three quarts of pus containing a pure culture of the bacillus of Eberth was obtained. That death does not always follow rapidly after perforation of the bowel in typhoid fever is also proved by a case reported by O'Carroll,^ in which perforation of the intestine occurred on the 1 Eisner. Transactions of tlie Medical Society of the State of New York, 1892, 314 2 Pearson. British Medical Journal, 1891, i, 861. 3 Adam. Australian Medical ,Journal, 1887, ix, 182. * Major. British Medical .lournal, 1891. i. 18. ^ Low. Ibid., 1881, ii, 122 8 Schmidt. Deutsche medicinische Wochenschrift, 1896, No. 32. ' O'Carroll. British Medical Journal, February 13, 1893. Till': ALIMENTAUY CANAL IN Till': ni:\ i:I/)I'I:Ij STACI: 147 thirty-sixth diiy, uiid llic paliciit (Ji(J not die unlil ihc hl'tj-iiintli day, when an adhesive; peritonitis was found, ;ind ;in ahsees.s wliieh had been walled ofl" I'roni (he rest of the p(;ritonc-nrn. All of iIk; intestinal nlcers except the one which had fx'rfonifcd had hc;dc(J. Without douht Jiiatiy of the cases of so-called perforation wliic}i have l)een reported as endin^- f;ivoral)Iy have been eases in which tiiere was no j)erl'oration, and only a mf)re or less severe loeali/efl peritonitis. The symptoms of tliis condition may be so precisely those of perforation, that an autopsy or exploratory incision may be needed to differentiate them, and peritonitis may arise from so many intra-alidominal lesions that its presence from these causes nnist always be suspected. Cases of recovery from perforation, without surgical aid, are, however, so rare as to be regarded as curiosities. The prognostic and therapeutic view of cases of perforation are well expressed by the following quotations from Gairdner, Fitz, Keen, and others: Gairdner^ says: "What, then, is the proportion of cases which recover without surgical interference when symptoms of general peritonitis have set in? "It is difficult to estimate the proportion numerically, but such recoveries are certainly exceedingly rare. Thus, Todd and Jenner,^ in a long life of large experience, saw one case each; Tweedie, 2; Murchison carefully collected six cases, but only two were his own. "A fair number of cases may be found in medical literature, reported with more or less accuracy, but it is seldom that an indi- vidual experience includes more than one case, while many of large experience have seen no such cases, and even doubt the possibility of recovery after perforation of the intestine freely into the peritoneal cavity. Now, Murchison, at p. 524 of the secojid edition of his work on continued fevers, states that in ten years, between the pub- lication of the first and second editions of that work, he had attended 'more than two thousand cases' of enteric fever; certainly, he must ' Gairdner. Glasgow Medical Journal, vol. xlvii, p. 100. - Todd and Jenner. Collected Essays and Lectures on Fevers, pp. 311 and4S4, London, Rivington, Percival & Co., 1893. 148 WELL-DEVELOPED STAGE OF THE DISEASE have attended even more before the puhlicatioii of the lirst edition; so tliat his personal experience ii|) (o tliat time may fairly be put down as at least five thousand. In another place he estimates the occurrence of perforation of the intestii^e in his cases at a fraction over 3 per cent., so that in about 150 of these cases that accident must have occurred. Two only, as we have seen, recovered. "If, then, the number of unsuccessful laparotomies published be trebled, so as to make sure of including those unpublished, roughly this gives fifty-four unsuccessful cases and five successful cases. "^^htn it is remembered that little selection has been made in the cases operated on (Van Hook's dictum is, 'the only contra- indication is a moribund condition of the patient'), it may be claimed that the 'prentice hand' of surgery has considerably improved on the very best treatment by other means." On the other hand Fitz says: "It appears that of 27 cases of peritonitis in typhoid fever, wdiatever may have been the cause though often attributed to intestinal perforation, 3 recovered after operation, 17 after resolu- tion, and 9 after the spontaneous discharge of the pus. The com- parison of this series of cases with those showing the results of early laparotomy for symptoms suggesting typhoid perforation, indicates that the appropriate treatment for this complication would be delay until a probable encapsulated exudation proved unduly slow in absorption. An immediate or early laparotomy for the relief of the peritonitis seems advisable only when the patient's condition is exceptionally good. Should the signs of the exudation persist for a week or more, and the general con- dition of the patient permit an incision, surgical treatment would then be strongly advisable. That the patient may live for weeks after perforation has taken place is illustrated by the cases of Buhl and Hofimann already mentioned. "In brief, immediate laparotomy for the relief of suspected intestinal perforation in typhoid fever is only advised in the milder casts of this disease. In all others, evidence of a circumscribed peritonitis is to be awaited, and may be expected in the course of a few days. Surgical relief to this condition should then be urged as soon as the strength of the patient will warrant." THE ALIMENTARY CANAE IN THE DEVELOI'EI) STACE MQ We en(lix, as flid also Sailer, and in a pa[)er on typhoid ulcer (;i' the (jesophagus, Uie.srnan incidentally mentioned apj)CMdi( iihir typhoid ulcer as being also present in his case. Keen has well said, therefore, in his essay, that in all cases of operation for inlesfinal perforation in typhoid fever the surgeon should examine the appendix to discover if it is diseased. In Keen's table of operations done for intestinal perforation, cases of asso- ciated appendicular lesions are recorded by Bontecou,' Kimura,^ and AlexandrofP (there were three large perforations of the appen- dix in this case). Although the subject of appendicitis complicating tyj)hoid fever had been discussed previously, the greater number of the contri- butions upon this subject have been published since 1900. Scott,* in his study of 9713 cases of typhoid fever at the Pennsylvania Hospital, found that in this series there occurred 382 cases of per- foration, in 17 of which, or 4.4 per cent., the appendix was the only site of perforation, while 16 per cent, of the cases diagnosticated perforation was in reality due to diseased appendices, and in 5 cases there were found typhoid ulcers in the appendix. Ashhurst" was able to find 82 instances of lesions in the appendix, while in the series of 83 cases studied at autopsy by Baer,^ he found 5 lesions in the appendix. Deaver,^ Franjois,^ Frazier and Thomas,® Hopfen- hausen/° Rolleston," Patterson, ^^ and others have written of the appendicular complications of typhoid fever, and Deaver was able to collect 40 cases of perforation of this organ during typhoid fever and 41 cases in which the organ was inflamed. Of the 40 cases 1 Bontecou. Journal of American Medical Association, January 28, 188S, p. 106. 2 Kimura. Sei-i-kwai Medical Journal, 1890, ix, 55. 3 Alexandroff. Report of Hospital St. Olga, in Moscow, 1890, p. 198. ■• Scott. University of Pennsylvania Medical Magazine, .January 9. 1905. ' Ashhurst. American Journal of the Medical Sciences, April, 1908. 6 Baer. Ibid., May, 1904. ^ Deaver. Appendicitis, etc., Philadelphia, 1905. s Francois. L'appendicite au cours de la fie\Te tj-phoide, Paris, 1904. ^ Frazier and Thomas. Universitj- of Pennsylvania Jledical Bulletin, July and August, 1907. 10 Hopfenhausen. Rev. Med. de la Suisse Romande, 1899, 19, 105. 11 Rolleston. Lancet, May 29, 1898. 1- Patterson. American Journal of the Medical Sciences, Mav. 1909. 156 WELL-DEVELOPED STAGE OF THE DISEASE which perforated, 7 were operated upon, with 4 deatlis; the remain- ing 33 cases all died. Thirty of Deaver's 41 cases which showed inflammation of the appendix were subjected to operation, with 4 deaths; of the 10 cases not operated upon, 9 died. Patterson was able to collect 15 cases of perforation of the appendix in addition to the 40 cases collected by Deaver. All were operated upon, with 4 deaths — a mortality of 33.33 per cent. Patterson also collected 22 additional cases of appendicular inflammation, all of which cases were operated upon, with 4 deaths — a mortality rate of 18.18 per cent. Additional cases have been chiefly collected by Kelynack,^ who points out that INIurchison^ saw 2 cases of appendicular ulcera- tion, one in a girl, aged thirteen years, four ulcers being present. Two small perforations were found in it. Norman Moore^ records 4 cases. Death was due in 2 of them to perforation of the appendix; another had an ulcer at the tip of the organ. Fitz found in 257 cases of appendicular perforation only 3 due to typhoid fever, and in a later paper,^ in 167 cases, 5 instances with this lesion. The reports of Morin^ and Heschl" give a much hgher percentage. Thus, Morin, in 67 collected cases, found 12 examples of appendicular perforation, or 18.75 per cent., and Heschl, in 56 cases, found this lesion in 8, or 14.3 per cent. McArdle^ has also reported a case. On the other hand, perforation in this part is more apt to be followed by recovery than elsewhere, and this may explain why it is that the best postmortem records are so scant in this respect. Fitz asserts that the more closely the symptoms of perforation resemble those of appendicitis the more favorable is the prognosis. Rolleston^ states that in 14 out of 60 cases of enteric fever seen at St. George's Hospital, London, changes were found in the appendix. 1 Kelynack. Pathology of the Vermiform Appendix, London, 1892. 2 Murchison. The Continued Fevers, 1873, 2d ed., p. 623, and Trans. Pathological Society, London, 1866, xvii, 127 ' Moore. Tran.s. Pathological Society, London, 1883, xxxiv, 113. * Fitz. Trans Association of American Physicians, 1891. ' Morin. Thfese de Paris, 1869. 8 Heschl. Schmidt's Jahrbucher, 1853, Ixxx, p. 42 ' McArdle. Trans. Royal Academy of Medicine, Ireland, 1888, vi, 392. 8 Rolleston. Lancet, 1898, vol. i, p. 1401. 77//'; AfJMJ<;NTAh',Y C'ANAf. IN TIIH DHV ICLOI'I'ID i^TACE jr>7 In T) llicrc w;is (iiMicraclioii, in 7 iil''cr;il ion, jind m '1 jj'iTociI ion. Perforation of the bowel occuiicd in IS of llie.sc (iO cases — a very high j)crc('nta<(('. In the very interesting piijx-i- hy Ilopfenliiinscn' on tliis (opic, already quoted, she tells us that she eoliec^ted sdilislics conccining the appendix in ■ Protocoles des institute pathologique de I'Hopital Municipal d'Obouchow et de I'Hopital Municipal de Ste. Marie-Madeleine, 1SS9-1S97. ' Hopfenliausen. Revue M(?dicale de la Suisse Romande, February 20, 1S99. 158 WELL-DEVELOPED STAGE OF THE DISEASE vears; in 1 in one year; in 3 from three to .six months; in 1 during typhoid fever. In only one instance was the appendicitis near enough to the attack of typhoid fever to bear the true relationship of cause and effect, namely, that of Bossard,' in which perityphlitis followed in the same month. The senior author had under his care the following illustrative case without abscess: A boy, aged nine years, because of ill health, was taken to the seashore, witli the hope that it would benefit him. During the first week at Atlantic City he suffered from continued fever, ranging from 102° to 103°, for which no adequate cause could be discovered. His fever then disap- peared suddenly, and was absent for a week, during which time he ate heartily and seemed to improve greatly in health. During his third week at Atlantic City, however, the fever returned in an irregular form, and he complained at times of violent pain in his abdomen. At this time there was marked tenderness in the right iliac fossa, particularly in the neighborhood of McBurney's point, and also posteriorly, back of the appendix. There was also some rigidity of the muscles on the right side over the appendix. His temperature varied from 103° to 104°, but he was not particu- larly restless. His tongue was fairly clean, but there was a com- plete loss of appetite. At this time the appendicular trouble did not seem sufficient to account for his high temperature, but a careful examination of every organ of his body and of the blood failed to^ reveal any cause for the pyrexia. At the end of the first week in bed his tongue became foul, his lips covered with sordes, the tem- perature on one or two occasions rose nearly to 105°, and he devel- oped the typical rose spots of typhoid fever, the appendicular irritation and inflammation having been treated during the pre- ceding week by the application of ice-bags. One week after the symptoms of typhoid fever became well marked, distinct appen- dicular tenderness partly disappeared, and at the end of the third week had entirely disappeared. Recovery followed. A case such as this is of interest because it illustrates the fact that it is sometimes necessary to make a differential diagnosis iBossard. Ueber die Verchwiirung unci Durchborung desWurmfortsatzes. Thesis, Zurich,. 1869. 77//'; N/<:nvo(/s svst/'LM 159 between (.yplioid I'cvcr iuid npixndicil is, ;uir| ||i;il, lyplioid I'rjver and appendicitis may exist side \>y side. Ascites. — MePliedran/ of MontrenI, luis rcfcjilly rej>ortefl four eases of ascites diirinn- iiiicoinf)Iicjitcd typlujifl fever. 'J'liis corn- plication appeared durino' (lie lieijrlit of (lie feWrile |)roeess, existed for some days, and disappeared without any cause for its iippejir- ance beiiin; found. Nervous System in the Developed Stage of the Disease. Delirium. — 'i'lie tiervous disturbances vary ^readw In tlif; average ease tliere is in the early j)art of the onset no inenfal change, save that of unfitness for mental occupation, with dreamful sleep which is apt to be restless. Later, the patient continually dozes oflF, yet awakens easily, and for a moment may be a little confused between the mental impressions left on his brain by the dream and the conditions he finds about him on returning to consciousness. Still later, if the attack is marked, he becomes more apathetic when awake, less easily aroused when asleep, and often delirious in his sleep, his dreams being evidently vivid, so that he keeps muttering the conversation he thinks he is actually having, or calls out loudly, as his dream seems to lead him to a point where an imperative call or sudden action is needed. Sometimes the delusions in the delirium amount to imperative conceptions, and the patient believes that he is away from home and must return there at once, or that he is being restrained by force, or, again, that some member of his family is in distress and needs his aid or is calling for him. Often this form of mental disturbance is painful to witness, difficult to overcome, and harassing to the patient. In these cases the hands may be moved continually, as if to illustrate the views of the patient. Such cases are apt to be grave if for no other reason than that they exhaust themselves if relief is not given. The more encouraging type of delirium is of the quiet, muttering form, as if the patient was gently "talking in his sleep" as in health, and this may be taken as the natural form of delirium in the disease. Later, the stupid condition may become more and more marked in some cases, and absolute mental stillness is reached, in which only hard shaking or loud calling will arouse the patient. 1 MePliedran American Journal of the Medical Sciences, November, 1908. 160 WELL-DEVELOPED STAGE OF THE DISEASE On the other hand, even in severe cases the mental state often remains but Httle disturbed throughout the entire iUness, and in the majority the beginning mental apathy is largely put aside by the proper use, of cold sponging or plunging. Aside from the mental hebetude of most cases of typhoid fever, which may be considered to represent the ordinary mental signs of this disease, we may have remarkable clearness of intellect, so that at no time, even when waking from a heavy sleep, is the patient's mind clouded, but it is a curious fact that some of these patients who seem to be mentally clear all through an attack state after it is over that they have a very indistinct recollection of the occurrences which took place. There can be no doubt that, as a rule, the mental state is a fair index to the severity of the malady, and, therefore, the greater the perversion of the mental process the more grave the prognosis. So far as delirium itself is concerned, Liebermeister found that in 983 cases without noteworthy brain symptoms only about 3.5 per cent, died; that in 191 cases with mild delirium at times, 19.8 per cent, died, and in 43 cases in which stupor or coma was present, 70 per cent. died. Zenner^ asserts that in cases of severe delirium the mortality reaches 50 per cent., and when the delirium is complicated by stupor, almost 70 per cent.; that the mortality of initial delirium approximates 30 per cent., while that occurring during the first week of the fever is over 40 per cent. It seems to us that these statistics give a false impression as to the danger of these symptoms of the disease. These figures, however, express the gravity of marked mental symptoms, and also throw light on the relative frequency of the mild and severe affec- tions of the brain. Delirium is largely dependent upon the susceptibility of the individual to the infection and to the febrile movement. Many persons are readily made "flighty," to use the popular term, by fever of less than 103°, while others withstand greater fever than this with impunity. A delirium in a child, of the active talkative or complaining type, does not possess grave significance if the fever be high enough to be its cause, since the mental disturbance is probably due to the temperature, or if this symptom occurs in a 1 Zenner. American Lancet, January, 1889. 77/ A' N/'j/iVOf/s hysti<:m 161 nervotis woman or inmi i(, is nol ol" is^vcui iiri|)()i(;iiKc unless if. bf; so persistent and lon^ coiiliinicd lli;il ihc loss ol" siccj) jiiid i.i'k of rest exhausts the patient. A form of (Iciii-iiim, iisimlly seen in liyslftic;il women ;in(| eliil- dren, whieh resembles tiie condilion of (lie j>atierit suffering from belladonna poisoninj^, sometimes oeeurs, in which there is mueh restlessness and tossing of the body, with great volubility and incoherent screaming, which may seem most alarming, but which is not as dangerous an omen as its severity would indicate. As it is usually seen in the early stages it in no wise is indicative of pro- found nervous exhaustion, but rather of an ill-balanced nervous system upset by the nervous disturbance of the infection. In severe cases that condition of ceaseless mental activity in a semistuporous mind, called "coma vigil," is often present. It is an indication of grave infection, as a rule. Striimpel asserts that "actual insanity is not infrequent during the course of typhoid fever," and that it generally takes the form of a melancholia. Taty^ records a case of what he calls the melan- cholic form of typhoid fever, the diagnosis being confirmed by the Widal reaction and other characteristic symptoms. The patient was restless, had loss of appetite, was delirious, and had great mental depression. There was absolute mutism when she was examined, and she refused both food and drink, but sleep was relatively good. In another case there were visual hallucinations and delirium, with melancholic conceptions, and vague ideas of persecution. Striimpel also records a case of hysterical insanity in a young girl, which broke out during the course of the fever. (For post-typhoid insanity, see last chapter, by Dr. Dercum.) Hysterical convulsions have been recorded as complicating the developed stage of typhoid fever; thus Remond and Coumenges' record two cases of this character. In one, a young woman of distinctly neurotic character, who had never suffered from convul- sions, however, developed on the fifteenth day of the disease uncon- sciousness, a thready pulse, embarrassed respiration, and severe hiccough, so that the physician thought the patient was about to die, when the scene suddenly changed, the body was stiffened, and 1 Taty. Lyon Medicale, 1S97, p. 291. - Remond and Coiunenges. Medical Bulletin, June, 1895. 11 162 WELL-DEVELOPED STAGE OF THE DISEASE a violent hysterical convulsion came on. Repeated attacks occurred on subsequent days until death occurred from exhaustion. Durino; February, 1899. one of us (Hare) saw, in consultation with Dr. Loux, of Philadelphia, a oiH in the third week of tyj)hoid fever with typical hysteria, as shown in (he facial expression and in the attitude of her botly. Her arms were abducted, her forearms completely flexed at a right angle with the arms, and her hands completely flexed at a right angle with the forearms. This case showed, nevertheless, evidences of profound toxaemia, and died a few days later. When first taken ill she was very hysterical, cried and screamed, and repeatedly asserted if she got typhoid fever she would die. Hysterical symptoms may be present in children. Thus, De Witt* reports the case of a boy, aged twelve years, who suffered on the twenty-third day from marked hysterical symptoms, supra-orbital neuralgia, and pain and stiffness in the back, the symptoms coming on simultaneously with high temperature. Headache. — The headache, usually frontal and severe, in the early days of onset, may continue as an annoying symptom all through the attack, but rarely possesses its severe characteristics after the first week. Under certain circumstances, however, it remains severe, and is worthy of relief and careful study, since it may be due to periostitis of the skull, to abscess of the middle ear or brain, or to urtemia. A combination of more or less active delirium with restlessness and disturbed sleep and severe pain in the head should make a careful search for a local cause necessary. In some cases the pain extends from the head down the spine, even to the sacrum, and from there down the legs, particularly along the posterior parts and in the bones. This pain is chiefly seen in onset and in early stages, and is generally absent by the third week. Meningitis. — Rarely in the course of typhoid fever of the uncomplicated form symptoms of irritation or inflammation of the meninges of the brain develop, and it is important to remember that these symptoms may arise from several causes. The most common of these is congestion and engorgement of the meningeal vessels without any true inflammatory process; the next most com- mon form is that due to the extension of an infection from abscess 1 De Witt. Bulletin de I'Acad^inie Royal de Mddecine de Belgique, November 17, 1889. THE NKRVOIJS SVSThWf ](;:', in flic middle CMP; Hie lliiid roriii is di;il in wliirji dicrc is inrcrtion willi the .streplococcns or pncnniococcus, ;ind \cry nirdy \\c find ;i ni<'ninn;i(i,s due lo (lie biicilliis of I'llx'ftli. ( ).slcf records Uirce cases in which he inade autopsies in susjX'cted tyj^lxjid nicnin^n'fis and found no true inflammation, and as long ago as 1839 Tanpin called attention to the diflercnce at autopsy between the appearance of the meninges of the brain in death with meningeal symptoms due to typhoid fever and those due to true meningitis. Jn tyjjhoid fever in children he states that tlie condition is one of effusion uidiont hypenemia. Meningitis in children complicating typhoid fever was written upon as long ago as 1825 by Senn/ of Geneva. Three of his cases are evidently cases of typhoid fever, while in others there is doubt as to their authenticity, and there is still less evidence that real meningitis was actually present, even though the symptoms were those of meningeal irritation. Keller" asserts that true meningitis in a child can be differentiated from typhoid fever with meningeal symptoms by the fact that "Kernig's sign" is present in meningitis and absent in enteric fever. The meningeal symptoms vary greatly in their severity accord- ing to the meningeal lesions which may be present. In the majority of instances the chief signs are headache, delirium, some muscular rigidity, particularly in the neck, and, it may be, "lead-pipe" rigidity in the arms and legs. In other instances the patient is too deeply stupefied by the poison of the disease to complain of head- ache, but may show headache by rubbing his hands over his head and groaning, after which he may pass into coma, which deepens until death occurs. Very rarely does the pure symptom-complex of true acute meningitis develop, and until the characteristic squint, retraction of the head, and pupillary signs are present, the physician must not hasten to a diagnosis of meningitis. On the other hand, the symptoms already named may be so typical that if the patient is brought to a hospital late in his illness without a history, he may present so little of the typhoid appearance and so much that of meningitis that a mistake in diagnosis is readily 1 Senn. Recherclies sur la Meningite Signe des Enfants, 1S25. - Keller. Revue des Maladies de TEnfanee, September, 1S9S, p. 450. 164 WELL-DfJVELOPED STAGE OF THE DISEASE made. To tjiiote Hirt:^ "Of all diseases typhoid fever is most likely to be taken for meningitis," and, again, he tells ns that "we might believe that at least the characteristic temperature-curve, the splenic enlargement, and the rose spots would be sufficient to make a mistake impossible." But this is by no means always the case; there are instances in which typhoid fever cannot with certainty be excluded, and then the differential diagnosis is impossible, except by the Widal test or cultures from the blood. So certain, however, is Money^ of the assertion of Hughlings Jackson, that the knee-jerk is not absent in typhoid fever, that he uses this sign as a point in differential diagnosis. Thus, in tuber- culous meningitis he states that it disappears and then reappears every few days, and that this inconsistency of the reflex favors the diagnosis of tuberculous meningitis rather than typhoid fever. The possibility of confusing meningitis or, rather, meningeal symptoms with those of typhoid fever was long ago discussed by Taupin in 1839, and he points out that in such cases the patient has, in meningitis due to typhoid fever, no convulsions, no strabismus, and no paralysis, whereas the child with true meningitis has all these signs, and in addition a variable pulse, a scaphoid belly, an absence of pulmonary catarrh, and a face which is alternately red and pale. Illustrative of the supposed rarity of true typhoid meningitis, however, it is of interest to note that from 1855 to 1887 there are only five cases of this affection referred to in the Index Cata- logue of the Surgeon-General's Office, and as none of these were tested bacteriologically they cannot be considered bona fide. That meningitis due to any cause in typhoid fever is rare is shown by the fact that out of 2000 cases in Munich, only eleven are recorded as suffering from meningitis. Still more rarely is the meningitis due to the bacillus of Eberth, for Wolff, ^ in 174 cases of typhoid fever which were subjected to bacteriological examination, only found 2.87 per cent, in which the specific bacillus could be found in the meninges. Within the last few years this subject has been admirably ' Hirt Nervous Diseases, American edition, p. 18. 2 Money. Tlie Lancet, 1889. » Wolff. Berliner klinische Woclienschrift, 1897, No. 10. 77//-; NMRVOUS SVSTh'M Ifio discussed by ( )liliii;iclicr,' of ()lii(), iitid In' K'ccii,' of I'lnlu- (l('l[)}iiji. Olilrnaclicr himself reeonls (wo cases in wliieli dutin^ tlu! course of typlioid f(!V(!r menin^(;ul syinplorris (l(;veIoj>e(J, and in whicli careful bacteriological research revealed heyoiid all douht the bacillus of Eberth in tlu; in(uiinges. In still Miiodier case recorded by Ohlrnncher there was foinid a mixed iid'eefion by flii.s bacillus and the streptococcus. Only a limited number of true meningeal infections by the bacillus of Eberth of an undoubted character have been recorded, which is a point of great interest. In all of these the dura mater and pia mater appear to be equally affected, and the effusion was in at least six of the cases purulent. Illustrative cases of this character are taken as follows from Ohlmacher's paper: "A case of meningitis occurring in the course of typhoid fever was described by Kamen,^ in 1890, in a soldier who entered the hospital after having been ill for five days. A severe headache set in three days later, followed by delirium and unconsciousness, and death occurred eight days after admission to the hospital. Aside from acute splenic tumor and a single typhoid ulcer near the csecal junction of the ileum, the postmortem examination showed an extensive purulent leptomeningitis. The cultures obtained from the spleen, mesenteric glands, and meninges were identical, though only the potato test was mentioned as having been employed for identification. The following year Fernet^ reported the case of a woman who developed headache, delirium, strabismus, exophthal- mos, retention of urine, and irregularity of the pupils in the course of typhoid fever. At autopsy the characteristic changes of t^'phoid fever were found in the abdominal cavity, and a diffuse serous meningitis was also present. It is claimed that typhoid bacilli were isolated from the meningeal fluid, though no mention is made of special tests. Silva^ likewise observed at autopsy in a female epileptic, aged ten years, a serohemorrhagic leptomeningitis with a lobar pneumonia and the ordinary evidences of t}'phoid fever. * Ohimacher. Journal of the American Medical Association, 1S97, p. 419. 2 Keen. Surgical Complications of Typhoid Fever. Kamen. International Ivliu. Rundschau, 1890, vol. iv, No. 3. p. 9S; No. 4, p. 156. 4 Fernet. Le Bulletin Medical, 1891, p. 653. 6 Silva. Riforma Mediea, 1891, vol. iii, No. 210. 166 ^y ELL-DEVELOP ED STAGE OF THE DISEASE Typhoid bacilli were isolated from the nioninoes and carefully identified. Still another case was reported by Honl/ who found a diffuse purulent leptomeningitis in a twenty-one-year-old woman, who (lied in the course of typhoid fever. An exhaustive differential examination showed the only bacterial species ()l)taiiuHl from the meningeal exudate to be Bacillus typhosus. "Cases essentially similar to those just noted have been reported since 1892 by Vincent,'- Hintze,^ Mensi and Carbone,^ Stuhlen,^ Tictine,® Kuhnau,^ and a second one by Kamen.* "Tictine reported two cases which came under his ol)servation, and he also produced a purulent meningitis in animals by means of sulxlural inoculations with typhoid cultures. The second one of his cases differs from all others in that the patient was perfectly conscious during the last week of his life. "Profound unconsciousness, delirium, coma, and often reten- tion of urine are the symptoms most often described in these cases. Other symptoms which might suggest an actual meningitis are usually insignificant, and can scarcely be looked upon as of diag- nostic import. To this rule, however, the case mentioned by Mensi and Carbone is a notable exception. Their patient was a girl, aged six years, who had been ill nine days before entering the hospital. The patient ran the course of a moderate attack of typhoid fever, reaching the stage of apyrexia four weeks after coming to the hospital. Four days later a violent chill occurred, with intense headache and a temperature of 39.2° C. Delirium, opisthotonos, contractions, amblyopia, and dilated non-responsive pupils were successively noted, together with a herpes labialis, paresis of right face, and retraction of abdominal wall. Great prostration followed, and death occurred four days after the onset of this relapse. The autopsy showed a fibrinopurulent cerebro- spinal meningitis, with dilatation of the lateral ventricles, and a bronchitis of the medium and smaller bronchioles. Numerous 1 Honl. Centralblatt fiir BacterioloKie, 1893, Band xiv, p. 767. * Vincent. Schmidt's Jahrbucher, 1893, Band ccxxxvii. No. 2. ' Hintze. Centralblatt fiir Bacteriologie, 1893, Band xiv, No. 14. * Mensi and Carbone Kifornia Medica, 1893, i, 14. ' Stulilen. Berliner klin. Wochenschrift, 1894, No. 15. "Tictine. Archives de Med. Experiment, 1894, vi, 1. 7 Kuhnau. Berliner klin. Wochenschrift, 1896, No. 2.5. * Kamen. Centralblatt fiir Bacteriologie, 1897, 1st abtheilung. Band xxi, Nos. 11 and 12. Till': ni<:r.V()ijs svsticm 107 typical typhoid ulcers iti tlic .stage of lie;iliiig were founfl In ihe ileuiii and colon; the Jnesentoric /^hiiid.s wen; svvolN-n and .-lol't, and there was sof'teninj)^ of the spleen. A tFiorongh l);icteriolf>/^ic;d examination of ihe nienino(>iil e.xndale resiilled in finrh'/i;.' (v|>li()id bacilli as the sole bactei'ia! inliahitanl." In rare cases where death has occnrre(| IVom ineninifili.s wilhont o enteric fever being suspected, (lie antoj)sy lias revealed the bacillus of Eberth to be its cause, as has been reported by Curschmann. Such instances have been recorded l)y Ohimacher and ;ire of irifer- est. He tells us that: "In the course of a study of meningitis, Neuniaini jiiifj Schaef- fer^ (LS87) found an extensive ])in'ulent leptomeningitis in a woman brought to the hospital unconscious, and who died in a few hours without furnishing any history. No lesions of typhoid fever were found, but pure cultures of a bacillus were obtained from tlie meninges, and these, the authors were led to believe, were of Bacillus typhosus, from the general character and from the positive results of the potato and fermentation differential tests. A verv similar case was reported soon after by Adenot," in which a woman presented profound symptoms of cerebral infection and died in eight days. Absolutely no typhoidal lesions were present in the intestines, spleen, and mesenteric glands, but from the seropuru- lent exudate in the soft meninges a bacillus resembling the typhoid organism was obtained. The only differential test here applied was the growth on potato, and we now know that this is not suJ9B- cient to identify the bacillus of typhoid fever. The case recorded by Balp^ also belongs in the same category with those of the authors just noted. He found a diffuse purulent meningitis in a patient dying five days after a fracture of the skull, and in the exudate a bacillus resembling the Eberth organism was found, together with a species of diplococcus. The phenol and indol tests are all that Balp mentions having used for differentiation." Kerr and Moffitt^ have reported the case of a man, aged twentv- eight years, who on admission was found in a stupid mental state. He 1 Neumann and Schaeffer. Virchow's Archiv 1887, Band cix, Heft 3, p. 477. - Adenot. Archives de Med. Experiment, et d'Anat. Pathol., 1889, i, 656. 3 Balp. Rivista Generale Ital. et de Chir. Med.. 1890. No. 17, p. 406. * Kerr and MofRtt. Journal of the American Medical Association, March IS, 1S99. 168 WELL-DEVELOPED STAGE OF THE DISEASE had been ill for a period of three or four weeks. He had been seized with o-eiieral weakness, fever, loss of appetite, headache, and pain in the right iliac region, no cough or nose-bleed. The cause of his entrance to the hospital was the pain in the right iliac region, weak- ness, and headache. He was found to be slightly demented, and answered questions slowly, articulating poorly, but there was no real aphasia. The fever ran an erratic course, resembling tuber- culous meningitis more closely than typhoid fever. The pulse was fairly slow and dicrotic. There were no spots and no eye symp- toms; there was persistent diarrhoea of the pea-soup variety, and rapid emaciation; the Widal test was obtained, and autopsy showed a few old ulcers in the right ileum which were certainly six or eight weeks old; the brain was covered with a thick pm-ulent exudate, yellow-red in color. Cultures were made which showed motile bacilli giving the negative glucose test, but clumping Avith typhoid serum. Boden^ has reported the case of a fourteen-year-old child who suffered from typhoid fever and was admitted to the Augusta Hospital of Cologne at approximately the end of the first week of the disease. There was hypera^sthesia of the entire body, and cyanosis. Two days later there was a severe epileptic attack and deep stupor, with left-sided abducens and facial paralysis, with loss of pupillary reflex and the patellar reflex. Death occurred three days later, and the autopsy revealed marked typhoid fever of the first week, and meningitis serosa, a large amount of clear serum being present at the base of the brain. The brain w'as normal, the ventricles were distended. From the fluid in the ventricles a pure culture of the bacillus of Eberth was obtained; this fluid also gave the Widal test. Boden states that only five cases of this character have been reported, namely, those of Stuhlen, Kugnan, Daddi, Hintz, and Honl. Dubert, in 1901, made "Meningitis during the Course of Typhoid Fever" the theme of his Paris Thesis, and Cole^ reviewed the litera- ture in reporting his case from the Johns Hopkins Hospital. He mentions 14 cases reported by various authors in which there had been present fibrinopurulent or hemorrhagic purulent meningitis, 1 Boden. Miincliener medicinisclie Wochensi.-hrift, February 28, 1899. 2 Cole. .lohn.s Hopkins Hospital Reports, 1905. THE NERVOUS SYSTEM K;0 with (^('iicriil lyplioid lesions. Ilcjilso iih-iiIiohs I.'» oIIht rnsfs ol' simikir [)unjl('iit inciiinoitis, in wliicli, however, (lie in, without the usual intestinal lesions of the disease, and have been able to isolate the bacillus typhosus from the exudate of the local lesion. The more frequent use of lumbar puncture as an aid to accurate diagnosis has been an important feature in revealing the true nature of some of these obscure meningeal cases. The meningitis complicating typhoid fever usually develops in the third or fourth week, and in the great majority of instances in which the complication has appeared the patient was under thirty years, and usually between twenty and thirty years, the period in which typhoid fever is most commonly seen. In every case of true typhoid meningitis, so far as recorded, death has occurred, but this is a statement which does not possess as great prognostic value as would appear at first glance, since an absolute diagnosis of true typhoid meningitis can only be made during life by lumbar puncture, the positive test being the bacterio- logical examination of the meningeal fluid. Nevertheless, the presence of marked meningeal symptoms is of the gravest import in all cases. Very rarely, because of degenerative changes in the vessels, a hemorrhagic effusion into the meninges of the brain takes place, but this does not commonly produce marked symptoms unless it is profuse. Under the name of "irritation of the brain with depression of temperature," a condition has been described by Liebermeister, which comes on in about the second week of the disease when the 1 Nevunann and Schaeffer. Virchow's Archiv, 1SS7, Band cix. 2 Ravena. II Polyclinico, May, 1904. 5 Staubi. Deut. Arch. f. klin. Med., vol. Ixx.xii. * Henry and Rosenberger. American Journal of the Medical Sciences, February, 1908. ' Lavenson. University of Pennsylvania Medical Bulletin, April, 190S. 170 WELL-DEVELOPED STAGE OF THE DISEASE svinptoiiis are most violent, ami in j)atifnts who liave had pro- lonijecl liit^h temperature. The pupils lose their reaction to light, and svuiptonis of nienini;-eal irritation develop, or in their })laee marked mental clianti'es occur, the i)atient heconiiiii;' maniacal or deeply melancholic. INIore noteworthy than all, the temperature suddenly falls almost to normal, and remains there for several davs, as long as the symptoms named continue, when it rises again to the j)()iiUs usually met with at that ])cri()d of the malady, and proceeds as before. Such cases are very rare. In his enormous experience, Liebermeister only met with "eight or ten cases." Cerebral Thrombosis and Embolism. — Richardson^ has recorded a case of a man, aged forty-three years, who in the third week of the disease sufi'ered from intense headache, chiefly in the left temporal region, accompanied by collapse and a subnormal temperature. He rallied under stimulating treatment, but two davs later there was marked coma, contracted pupils, particularly that on the right side. Convulsive movements were also present on the left side, chiefly in the leg. Later, the right side of the body was involved. He died five days after this complication arose, and the autopsy revealed no signs of meningitis, but the veins of the pia mater were distended with five clots, one of which was particularly large and lay along the Rolandic fissure. The sinuses were patulous. In the first left temporal convolution there w^as a small abscess. No clots were found in the sinuses. There are three interesting points in this case: First, the development of convulsions of a more or less localized character in the course of typhoid fever; second, the fact that there was general thrombosis of the intracranial veins without the sinuses being involved; and third, the entire absence of an> signs of meningitis at the autopsy, although the symptoms during life seemed to indicate the presence of this condition. This last fact is of particular interest in view of the fact w^orthy of recollection, and already pointed out, that although meningeal symptoms may be well marked in enteric fever, true meningitis is comparatively rare. Quite as important is the fact that the lesion was in the veins. When it is remembered that throml^osis of the cerebral sinuses is the usual lesion, that such an authority as Gowers^ questions 1 Richardson. Journal of Nervous and Mental Disease* * Cowers. Diseases of the Nervous System. rilN N/'JRVOUS SYSTEM 171 wlicdicr [)i'Itn;iry venous I liroinljosis ever occurs wlllioiil inir^ i,lir(>iiil)osi,s, iuid lliat Miic(!WCM,' in his cl;issic;il work on tlic sur^^crv of (lie ln'itin iUid cord, says nodn'n^r of niuranfic priinarv vr-noiis tlii'onihosis, (lie rai'ily of lliis condidon is notcvvordiy. Ilirl' says it ina.y occur in the veins as well as (lie sinuses, l)ui l)aMa,' li(;.sen- thal/ Gray,'' and Brill" fail to describe it. Thrombosis of the cere})ral sinuses is usually said lo be due lo an exhausting disease or to inrecdon. In such a case as that just described both these factors were j)reseiil. Finally, it is interesting to note that an addidonal factor I/i diis case still further eomj)lieated the clinical diagnosis, namely, a history that the patient had had two severe head injuries, one twelve years before and one two months before. A case of possible thrombosis occurred some time since in the wards of the Jefferson Hospital, in the person of a student, aged twenty years. He came under observation on the third day of his illness, and for the next eleven days passed through a marked but moderate attack of typhoid fever. On the fifteenth day of the disease he was suddenly seized with hurried stertorous breathing, rising from 26 to 48 respirations a minute, and his pulse rose from the neighbor- hood of 116 to 148, and finally to 160. He developed hemiplegia of the right side, unconsciousness, contracted pupils, and the eyeballs were deviated upward. Both pulmonary bases posteriorly filled up rapidly, becoming dull on percussion and developing coarse rales. The skin became cyanotic, and blood-stained mucus was expelled from the mouth by the stormy respirations. He died about ten hours after these symptoms began, with marked retraction of the head and neck. No autopsy was permitted, but from the symptoms we are inclined to regard the condition as due to embolus or throm- bus in the lung causing infarction, and in the cerebral vessels causing the paralytic and other nervous symptoms. Lopriore^ has reported a case of typhoid fever in a girl, aged ten years, in which on the seventeenth day of the disease the patient developed aphasia and great restlessness; the child could understand 1 Macewen. Diseases of the Nervous System. 2Hirt. Ibid. ^ D^na. Ibid. •» Rosenthal. Ibid. = Gray. Ibid. ** Brill. Article in Dercum's Diseases of the Nervous System. ' Lopriore. Gazzetta degli ospedali e deUe cliniche, January 5, 1899, p. 25. 172 WELL-DEVELOPED STAGE OF THE DISEASE what was saitl to it, and there was no j)aralysis of any of its hmbs; the motor aphasia, however, histed for a period of a month and a hah', when tlie ehikl was gradually taught to speak again. Lopriore believes that this case was due to a microbic embolus, which plugged a branch of the Sylvian artery and thereby infiuenced the Broca centre. Convulsions, generalized or local, with coma and delirium, may arise from thrombosis of the cerebral sinuses or of the cerebral arteries, but they are very rare from any cause (see hemiplegia article for cases). Murchison only met with them in six cases out of 2960 cases. If due to the lesions named, they result in a fatal termination in the near future. In Osier's case death followed convulsions produced by thrombosis of the branches of the left middle cerebral artery in twelve hours. If they occur in neurotic children or females the outlook is not so gloomy, as they probably do not depend upon an actual lesion in the brain. Thus, West has recorded a case in which convulsions developed in the third week of typhoid fever in a child, recurring on two successive days. These were followed by hemiplegia, which, however, gradually disappeared in foiu- days. Recovery eventually took place. Bulbar Paralysis. — A possible cause of sudden death during t>^hoid fever, or in convalescence, is said to be bulbar paralysis. Thus, Latil^ mentions a woman, aged forty-two years, who suffered from a severe attack of typhoid fever with hyperpyrexia and extreme prostration, but not equally marked nervous symptoms. On the eighteenth day of the attack she suffered from paralysis of the bladder, and on the forty-second day from tetanic contraction of the masseter muscles, with dysphagia and a nasal voice. The res- piration became shallow and rapid, the patient seemed greatly oppressed, had an anxious face, and asphyxia so rapidly increased that death occurred in a few hours. It seems to us that there is grave doubt whether this case was not one of peripheral nerve paralysis rather than a central lesion, but that sudden death may occur from a small lesion occurring in the medulla is illustrated by a case which has been reported by Libouroux,^ in which sudden death occurred during the third week of the disease, and an autopsy ' Latil. Revue Gdn^rale de Clinique et de Th^rapeutique, March 21, 1890. 2 Libouroux. Gazette Hebdomadaire de Mddecine et de Cliirurgie, March 5, 1890. 77//'; Nl'J/iVOUS SV.STKM ]7'4 revealed ii sniiill li(iiiorili;i^c in (lie (loor of llic f"()ii((li vcuhif-lo. There was no other coiHlilion wliicli could ;Hroiini for flic .sudden death of the patient. Knee-jerks. — No less authorities than Iliij^lilin^s Jaeksfjn and Angel Money have stated (liat luiee-jerks are never hrst in ent(;rie fever. This is scarcely correct, for we have seen cases, not ex- cessively ill, in which they were al)sent for days at a time as completely as in ataxia oi- some cases of (habetes. Restlessness and Insomnia, often complained of by the patient, is much more rare than the complaints would indicate. Watchful nurses will report repeatedly and truthfully that such patients sleep the greater part of the night and day, and the lack of sleep is either a delusion or else the few waking moments seem pro- longed into hours to the patient. On the other hand, persistent insomnia marked by unnatural quiet, the patient lying with the eyes closed, may lead the careless attendant to report prolonged sleep, when in reality true sleeplessness is present. When insom- nia is due to feeble circulation, the use of alcohol stimulation will usually relieve the condition, and morphine may be useful. We come, then, to the consideration of subsultus tendinum and carphologia. Both of these are signs of grave illness, particu- larly the latter, but they are neither of them as mortal in their prognostic import as the older authors thought, foi^^tients with these symptoms often get well. Epilepsy. — Tyson asserts that in cases of t}^hoid fever in which the patient also suffers from epilepsy, the epileptic attacks are apt to be greatly multiplied in the early periods of the disease; to cease as the disease progresses, and to remain absent until convalescence is established. Neuritis. — Neuritis may come on in typhoid fever in the latter part of the third week or in the fourth week, but it is generally a complication noted during convalescence. (See chapter on Convalescence.) Almost, if not equally rarely, pain in the muscles is developed as the result of a myositis. Paralysis. — Paralysis arising from t>'phoid fever usually comes on during the very latest stage of the disease or in convalescence, and is so distinctly an after-symptom, as a rule, that it will be 174 WELL-DEVELOPED STAGE OF THE DISEASE considered under the division in which the hite eouiplications and sequels are discussed. Rarely, however, as will be pointed out, the loss of power may occur in the middle of the febrile attack. As an evidence of the rarity of extensive and permanent paralysis of the extremities complicating or following tyj)hoid fever, we may quote the statement of Alexander, who, during an experience of ten years and a half in the medical clinics at Breslau, did not meet with a single case of paralysis among 3900 typhoid patients. (Hemiplegia in typhoid fever is discussed later on in the volume). The Skin in the Well-developed Stage of the Disease.— The rash of typhoid, which usually develops al)Out the seventh or ninth day, is usually characterized by its rose-spot appearance. A delicate pink hyperjcmia of the skin is all that it amounts to in many cases, and the rash may be so sparse as only to be found by the most careful examination of the whole body, when a few spots will reward the search. They are usually found on the belly, the chest, or the back. In other cases the spots are very profuse, being present literally by the thousand. This is rare. During certain epidemics the writers have been impressed by the fact that the rash has been unusually profuse and exceedingly coarse. The individ- ual spots have been not only large and well defined, but distinctly elevated and maculopapular to an extraordinary extent. Further, in these cases repeated crops of this roseola have repeatedly appeared as the disease progressed. The rose rash of enteric fever, however, is so typically separated as to its various spots, and there is so little coalescence, that few of the general forms of rose rash resemble it. In rare instances, however, the rash does coalesce, and then may resemble measles, and in still other cases where its papular form is lacking this coalescence may render it very much like that of scarlet fever. If the case is enteric fever, the abdominal symp- toms point to that cause of the rash; while, on the other hand, if it is scarlet fever, the throat symptoms will point to this malady. In those cases in which marked pharyngeal irritation ushers in typhoid fever, however, the diagnosis may be very difficult. Recently a patient under our care suffered from a mild attack of typhoid fever lasting seventeen days, and ten days later was sud- denly seized by a high temperature and general illness. When ,S7aA^ IN WET J. I)Kvi<:t/)P[':d STAaE of disease 175 he came iiiidcr ohscrvulion a scfond \\\\u- he IkkI ;i jHofiise rasli over Ill's body; liis eyes were injeelcd, ;iiid on I Ik- iniieous riierri- brane of the palate and on tlu; lool" of tlx- moiidj diere was a profuse punetated eruption. 'J'Ik; siibsecjucnf course of (his case showed that he was sufferinjr from ;i nu'ld typlioid relapse.* The rash of typhoid fever is not a (constant symptom, and may appear on the arms and even the hands, instead of on the trunk. In 199 cases under Osier, l.'i.l per cent. h;id no rash. Abnormal eruptions occurriuf^ in typhoid fever in children were described as long ago as 1839 by Taupin,^ who tells us that a uniform erythema resembling scarlet fever may be present, but is not followed by desquamation or cedema. He also says' that he has never seen a vesicular rash such as has been described before his time by Prosper Dor. The other forms of aberrant rash in typhoid fever are usually developed later than the tenth day. They consist in small hemor- rhagic exudations or petechise. In other cases they may be as large as a silver half-dollar, and do not disappear on pressure. It is as if the rash developed and then hemorrhage took place into the spot. Another form of skin manifestation in typhoid fever is the tache bleudtre. They were first described as occurritt^ in typhoid fever in 1837 by Piedagnel. We are confident that w^e have seen them in cases which were not infected by lice, but Hewetson* speaks as follows in respect to this question: "There exists a considerable difference of opinion as to the diagnostic value of these spots. JMany writers, particularly the English, believe that they are often seen in the early stages of typhoid fever, and have laid some stress upon their presence, although they admit their occasional occurrence with pediculi. Other observers, especially the French, claim that they do not exist unless pediculi, and more particularly the pediculi pubis, are present; that when the spots exist the pediculi or their nits can 1 For a discussion of the various fornix of roseolous rash see Hare's Text -book of Prac- tical Diagnosis, sixth edition. See also later chapter on Scarlet Fever and Measles. - Taupin Journal des Connaissances M (f) r; 0) 2 O CQ C/) h ^ rn ^ ?r UJ O D 05 O (/) n (D n , J 'O o CO c-*- •— •• D CQ H '^ ►J a Tl (D < T r > HKiN IN WKfj. i)i':\'i<:[/n'i':i) sta(;/': of dlsfasf J79 <)('CiliT('vcr, iU)(l Payne" re[)()rt,s one .sue!i ea.s(;. Ciirniichjiel' also has reported the case of a hoy, aged six years, who, after sufl'ering from scarlet fever and going on to the stage of desquamation, continued f(l)rile from oncoming ty{)hoid fever, and Cosgrove'' records five eases of concurrent scarlet and typhoid fever seen in the (Jork Street Hospital. In four of these the incuba- tion stages were concurrent, the scarlet fever heing secondary, so that the onset was simultaneous. This same author tells us that instead of increasing the severity of the typhoid, the scarlet fever seemed to abort it, though the cases were fairly severely ill. Coombs'' reports a case in which a boy, aged eleven years, who had scarlet fever, his family having typhoid fever, was seized on the seventeenth day of his illness by typhoid fever. Gabe" reports another case. The danger of confusing adventitious scarlatiniform rash in typhoid fever with that of scarlet fever was emphasized by ^lur- chison and by Moore^ and Jenner,^ and more recently by Bassett." Moore has also seen desquamation take place in this form of rash.^** The case of a child, aged eleven and a half years, has been reported by Chrystie,^^ which is of particular interest, because of the fact that measles developed during the attack of typhoid fever. Death occurred in convulsions. A similarly constituted attack of typhoid fever and measles is also recorded by Matiegka.^" The symptoms of enteric fever were well marked on the fourteenth day of the disease, when the eruption of measles appeared over the face and body. A similar case has been reported by Ringer,^^ in a girl, aged ten years, and Ringwood^* records a case in which the child had measles and enteric fever simultaneously, followed by a severe attack of diphtheria, scarlet fever, and chickenpox, all in the space of seven weeks. 1 Caiger. Lancet, 1S94, i, 1137. ^ p^yne. Ibid. ^ Carmichael. Ibid., p. 246 * Cosgrove. British Medical Journal, January 16, 1897, p. 29. 6 Coombs. Ibid., February 27, 1897. « Gabe. Loc. cit., April 3, 1897, p. 848. ' Moore Accidental Rashes in Typhoid Fever, Transactions Royal .Academy of Medicine in Ireland. 1889, vii, 10, and Eruptive and Continued Fevers, 1892, p. 371. 8 Jenner. Fevers, 1893. ^ Bassett. British Medical Journal, April 10, 1897. 1* Moore. Loc. cit., January 16, 1897. 11 Chrystie. University Medical Magazine, December, 1888. '^ Matiegka. Prager med. Wochenschrift, September 25, 1889. 13 Ringer. London Lancet, June 30, 1889. " Ringwood. Loc. cit., July 7, 1889. CHAPTER IV. THE COMPLICATIONS OF THE PERIOD OF CONVALESCENCE. Temperature, Recrudescence, and Relapse. — Recrudescence sifijnifies a teniporarv rise of fever lasting for a few days or a few hours, and is usually due to the ingestion of improper food, to ner- vous excitement, or, more rarely, it seems to arise from al)sor])tion from the intestinal canal of some toxic material which temporarily upsets the balance of heat production and heat dissipation. In several instances the senior author has seen full doses of strych- nine, given as a circulatory stimulant, produce repeated exacerba- tions of the normal temperature to the extent of 2° or 3° by reason of its irritant effect on the nervous system. As has already been stated, a true relapse cannot be said to have taken place until the physician is assured by another crop of rose rash, enlargement of the spleen, coated tongue, and persistent fever that a second attack is upon the patient. If these distinct signs of another infection are present, then the diagnosis is as complete as it can be made without the conclusive proof of a positive blood culture, which can only be made by a competent bacteriologist. An important confirmatory sign of the presence of a relapse during convalescence from typhoid fever is the reappearance of the diazo reaction when the urine is tested. Relapses occur in a fairly large percentage of cases, and seem particularly prone to take place in those in whom the primary attack of the malady has been mild. Indeed, the milder the attack, the more likelihood is there of relapse. Further than this, the use of the cold bath in treating the disease increases the fre- quency of relapse quite distinctly. What the average frequency of this unfortunate occurrence is is difficult to determine, because different epidemics differ greatly in the results they produce, so that in one epidemic relapses will occur with great constancy, and in another almost none will occur. Ord^ believes that relapses ' Ord. Transactions of Association of American Physicians, 1888, vol. iii. TEMPERATURE, RECRUDESCEiW(JE, AND RELARSE IS?, arc Miorc IVctjiicnl in cmscs wifli coiistipiilion llinii in those with diarrli(X';i, and (hat roinf'o(;(ion from within cxphiin.s their fre- quency in these instances. In our experience, rehipses liave br-en much more common in constipated cases. Warfield, in reporting an instance of typhoid fever with tfiree rehipscs, has called attention to the theory, as to the causation of rehipse, advocated l>y Stewart, which he has based upon the autopsy findings in 60 cases which (\'hh\ (hnint^^ rehipse in typhoir] fever. Stewart found tliiit SO jx-r cent, of these cases revealed recent lesions in the large intestine, while the small intestine contained lesions in the process of healing. These findings were compared by Stewart with the results of the examination of cases dying in the primary attack of fever in which the author found no lesion in the large intestine in 75 per cent, of cases. From these findings Stewart concluded that relapse in typhoid fever was due to the presence of lesions in the large intestine, a method of reasoning which is entirely fallacious and has no evidence to support it. A much more rational view would be that the continuance of the pathological process in the relapse gave time for greater destructive processes to take place in tissues in which lesions had not become severe when the relapse occurred. That Stewart's views are incorrect has been proved by the investigations of Warfield, who cites the findings at autopsy in cases dying during relapse at the Johns Hopkins Hospital, in two-thirds of which no lesion was found in the large intestine. A much more probable theory has been advanced by Durham as to the cause of relapse, who suggests that when ^eco^'ery takes place the intestine has developed enough protective substances to enable it to withstand the disease, whereas when relapse occurs the quantity and activity of these antibodies is sufficient to prevent death, but not sufficient to prevent relapse. In regard to the frequency of relapse it is interesting to note that no less an observer than Murchison places the average percentage at 3 per cent.; Gerhardt, in 4000 cases, 6.3 per cent.; Griesinger puts it at 6 per cent., and Strtimpel at 4 to 16 per cent. Berg^ met with relapse in 12 per cent, of 1626 cases in Curschmann's clinic from 1 Berg. Deutsche Arcliiv fiir klin. ^led., 1S95. 184 cn}fPLiCATinxs nrnixa coxvalescence 1880 to 1892. Eichhoivst, in 606 cases in Zuricli, found relapses in 4.2 per cent. Zennetz/ in 384 cases of typlioid fever, found 47 relapses, of Avhich 17 were entirely uncomplicated. In the Maid- stone epidemic relapses occurred in 16 per cent., and were more common in females than in males. Schmidt" found 49 cases of relapse in 561 cases of fever treated in Wagner's clinic from 1882 to 1886, or, if doubtful cases be excluded, 38 relapses, or a percentage of 6.8, Aviiicli practically agrees with the percentage obtained by Gerhardt, who, in the study of 4000 cases selected from various epidemics, obtained a percentage of 6.3, while Heman's percentage was 6.5, and Steinthal's 7.5. Liebermeister says: "In Basel, before the introduction of this (the bath) treat- ment, 861 typhoid fever patients gave us 64 relapses, or 7.4 per cent., two of which were fatal; after the introduction of this treatment, 882 typhoid fever patients gave 86 relapses, or 9.8 per cent., ten of which proved fatal. It appears, therefore, that the proportion of relapses and the number of deaths are both actually increased under the use of cold water." And discussing the prob- able bearing of these results, he adds: "At present the probability certainly seems to be in favor of the affirmative of the question (Does bathing increase the frequency of relapses ?) the more so as it appears that the frequency of relapses is greater in proportion as the antipyretic treatment has been the more systematically em- ployed." Biermer has also found relapses more frequent since the introduction of cold baths. Osier reports 1500 cases of typhoid fever, with 173 relapses, or 11.4 per cent., and states that he met with 14 cases of relapse in 100 patients that were bathed, or 8.7 per cent., but mentions five other cases of doubtful relapse which raises the percentage, while the limited number of bathed cases as compared to the large number of unbathed cases renders a comparison of the percentages of the relapses of limited value. Shattuck met with 21 in 129 cases, or 16 per cent., and eleven occurred before primary fever ceased. Wilson tells us that it occurred in 11.3 per cent, of his cases; Shattuck, 16 per cent.; Immermann, 15 to 18 per cent. ; Baumler, 1 1 per cent. ; and Jaccoud^ 1 Zennetz. Wiener med. Wochenschrift, September 21, 1S94. * Schmidt. Archiv fiir klin Medicin, Band xliii, Heft 3. TEMPi<:iiATUUi<:, i{i<:(;i{UI)i<:s(!I':n(:e, and rklai'si<: ],s5 9 per ccTii,., varyinji; rrom 7 (o IT) [xr fcul. A I I Ik- rtcshyterian Hospital in New York, (iilman 'riiompsoii fourn] Uir- iflajj.sf-.s in 193 bathed cases to be l.'J.r) per txiit., wliidi is 2 per ecnt. Iiiglier than 284 cases treated by all methods during the same time. There are certain peculiarities in the course of a relapse as to the f(>vcr, tlu; circulation, and the other fimctions which deserve attention. The fever usually rises more abruptly than in the origi- nal attack, and then speedily loses its high grade and becomes more moderate. Often it is more irregular and has greater remis- sions than the primary fever. Whether it be high or low, its course is usually shorter than the original period if that has been of stand- ard length or longer, but if the first attack has been quite short the relapse is not infrequently much longer. Thus, in one case recently seen by us, the primary fever lasted twelve days, and that of relapse nineteen days. Flint is the only author of note who thinks the relapse is generally worse than the primary attack. It is interesting to note that in Liebermeister's cases, out of 111 cases of simple relapse the fever was longer in duration than in the first attack in 37, shorter in 68, and of the same length in 2. In 29 of the cases the primary attack was mild, and in 82 severe, but the relapses were mild in 47 and severe in 64, and 7 of these died in the relapse. An important point to determine is the danger of relapse as to both complications and mortality. Here, again, the variation in the severity of the symptoms in relapse is so great that it is almost impossible to reach definite results. It is certain that relapses are not to be regarded lightly, and that they should be recognized with a certain degree of anxiety, even when they appear to be mild in type, because the exhausted state of the patient renders him more prone to complications and less able to withstand the general toxaemia of the new infection. This is well showai by the statistics at Basel, when out of 115 relapses hemorrhage from the bowel occurred four times, perfora- tion twice, thrombosis once, pulmonary consolidation nine times, nose-bleed seven times, bed-sores four times, abscesses five times, and petechise three times. 186 COMPLICATIONS DURING CONVALESCENCE To quote Liebermeister again: "If wc take the reports of the years 1S69, 1870, and 1872 at Basel, we find among 467 t}-phoid fever patients systematically treated with cold baths, 33 deatlis and 55 relapses, 6 of which were fatal; the frequency of relapses, therefore, counting only those patients wlio had survived the first attack, was in the proportion of 12.5 per cent., as against 9 per cent, before baths were used. The higher rate of mortality among the relapses is of so much greater import, in view of the fact that the relapses, too, were treated antipyretically, which ought rather to have ffiven us a lower death-rate." The time at which relapses occur is of interest. Usually they take place after the temperature has been normal several days, and in some instances much later than this. More rarely we meet with what has been well called "intercurrent relapse," in which the renewed activity of febrile movement and exacerbations of all the symptoms show that a second infection has been superimposed on the first. In children, relapses are, as a rule, more rarely met with than in adults, although this accident varies greatly in frequency. Among the older writers we find Rilliet and Barthez, who saw only three relapses in 111 patients, while, on the other hand, Henoch met with no less than 21 relapses in 137 cases, the relapses taking place after both severe and mild primary attacks, although the mild attacks were most commonly followed by this accident. Taupin, writing in 1839, records two cases of relapse in boys of thirteen and twelve years; both recovered. As with adults, the relapse usually takes place in children in from three to ten days after the primary fever has ceased, although it may occur in the course of the disease in the third week, or even in the fifth week. Henoch records one instance in which relapse took place in a child eighteen days after apyrexia had been established. Not only may a patient suffer from a single relapse, but rarely from several relapses. Hutchinson^ has recorded a case in which three well-marked relapses occurred, and Anders- has done so also. ' Hutchinson. American System of Medicine, Pepper, vol i, p. 303. 2 Anders. Medical and Surgical Reporter, July, 1882, p. 66. TEMPEIiATUlU':, U.I'XIfa/DMSC'/'JNC'/'J, ANT) li ELAPSE ]S7 The chart (sec l^'i<;.s 22, 2?>) shows (wo rr-hipses. In a case at i\\v Pciiiisylvjiiiiii, II()S|>i(;iI in 1 004, r|ijf)tcfl })y Dslfr in Ill's Practice of Medicine, the disease lastecJ elev(;ii months and four days, during which time there were six relapses. Multiple relapses have also been rvvttvAi-t] \)\ .lohn^lon.' In one case a patient, aged thirty-nine years, had twcj rehijjscs, Jind was in the hospital eighty-one days A second case had two relapses A third case after a primary attack had two relaf)ses, ;ind tlie f>atient was in tlie hospital 107 days. A case of typhoid fever is recorded by Carslaw,'' which sulicred from four relapses before ultimate recovery; and we have had patients under our care who suffered three relapses. Care must be observed, however, that all cases of returning pyrexia, after typhoid fever has run its course, are not considered relapses until the possibility of infection of another type is excluded. Often the fever is due to some suppurative process caused by one of the pyogenic bacteria or to a general bacteremia due to other organs than the typhoid bacillus. Rigors of considerable severity may occur during convalescence from typhoid fever without possessing any great significance. This is shown in the chart on page 188, and also in that on page 190 (Fig. 24). Osier reports two cases of chills without any distinct apparent cause in the later weeks of typhoid fever. In both these cases the chills were followed by hyperpyrexia. Similar cases are recorded by Herringham, Thus, he records an instance in which after a mild attack of fever a rigor occurred during the post-febrile period after an enema; another case in wdiich there were several attacks of pyrexia and one rigor during this time, and still a third, in which recurrent collapse appeared during lysis, and rigors in the postfebrile period without any dis- coverable cause. He believes that ague can be excluded in all of his cases. Herrineham also advances the view that in these cases the heat mechanism of the body is so easily upset that very slight causes provoke febrile movement. We think this view unlikely, and believe that such sudden rigors with fever are due to the 1 Johnston. Medical Chronicle, May, 1892. ^ Carslavr. London Lancet, July 19, 1891. 18S COMPLICATIOXS DUIilXG COXVALESCENCE Ti'jg -- = _^_;__^^ ■ " ^r: r.-i Ivn '-•1 •H"V9 — — ^-~j »• '" |sn ir,-: 'R-jg -^ Tin OC l-l •K-Vfl ^ -J 1 ■KJ9 T " ;tn Oo 91 •KV9 i""- nci to •Ha 9 " -^ ^ ^ Ool 81 51 •KV9 ____ - > roi or •KM 9 "^: :il roi OO 11 •K-v 9 1 ^, "' OSl OO •K-.T •■=i- n SII 00 01 •K-\ ',1 ^ z>^ sni zx. ■KM ;) •-=: =-; _ - = 4^" - - Co azx Oo C •KVfl 1 __ -rr Rol OO •K-• ej 81 -K-.I8 J =^ ji ^ ni f-i 81 E •K-V 8 \ 8S 81 •K-J!) c :^ " ' - " 51 f-8 OJ I -K-V !) -^ > 80 oo -K-J9 ; — ti 001 SS OC It: •K-V ^ ■K-d - Wl OE or: •K-V 9 - ^ t8 OJ •K-.I 9 c =P. 801 oj 02 -K-V 9 1 ^ - ^ a 80 OE -K- 88 OP «; •K-Y n - 00 Of: •K-J 9 \' •" 00 0? io -K-V n /J ■ 90 f-0 -K-J L _ ^ 001 OE rio •K-V 9 ■^ P" 00 0?: •K-J9 ^ ' - - 8 90 0? re -K-V n - - ^ _ - K \l Of: •K-J 9 = -- I JO JJ \z •R-V9 ^ 3 so Oo •M-J9 ¥i ~ - ._ — -- 9 JO oo re •K-V9 - -< »- •i t8 do ■K-J9 •r 00 81 OE •KSI 1 uo ;bu py |"6 " OR ZZ . 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E- -K-ro IT 9G fr -K-J9 i re 6S or- lE -K-V 9 -^^^ HI 0? •K-jg •v : 1 «; GOT ■ OC OE ■K-V9 > i ] ; Sfi ! nc •K-jg *:L — i J Ml GS on t^r i-.I •n-v 9 _i-J — ^" 1 : ' W So -K-jg =Cu j 1 1 1 1 ss KIT r-o SI -K-V 9 J---^^ 1 1 : K OP -K-ag •ef:::;;;^ i 1 1 IS HH K; .!! •K-V 9 _j . — 1-'- ! ! OS I-; •K-ag ^^:i::_ lilt OS sn 1 z-z 91 •WV 9 ^j ! , 1 i-n ; fc- . O o o ^ s s s o o o o -^ • - . ^ o 03 CO r~ S i - ^ C3 C3 CT> 0:1 C3^— ? = 190 COMPLICATIOXS DURIXG COXVALESCENCE entrance into the Mood, or lymph stream, of some pathogenic microorganism previously imprisoned in the gall-bladder, in the kidney, in some of the thoracic or abdominal lymph nodes, or in the floor of a healing ulcer. If the new invasion is virulent the patient succumbs to a post-typhoid bacteremia. Fig. 24 F. 106° 105° 104° 103° 102 = 101° 100° 99° 98° 97° Day cf Dis. Pulse. Rcsp. sj: 5! < T. < S 5J < 5J < 5?! ■J a !! ■^ s? "'a si a -< a o ■i to a sj 5J a a S5 a ■i 00 a < 00 » CO i 1 — — — ' I /t / 1 f 1 1 ^ / r V / Y j 1 J -^ -3- •5" ■f- f^; n ■■ f 1 1 1 1 a 1 O n 1 / 1 / 1 1 1 , 1 1 \ 1 A y^ , 1 f V f V R 1 1 \. 1 1 V \ > * /^ ^ f V \ r — \ / \ \[ CO ^ -■ 'J> - - <^- 2 = 2 3 - :2 3 2 M BS ~ S ?'jS 3 - ^;- O 3 S 3 :-^ s a s r: ?E 5' 3 2'.? 5':^ j^: § ^ s T, -^ P ?, O X -1- 2(2 ill a .^i" "j~ -,^ ?, ?i "1- 5|- 2 2 Case of typhoid fever in which, according to the patient's story, lie liad been sick only three days, but in which the disease ended by a rapid fall in lysis, followed by a severe rigor and rise of temperature. The Widal test was positive, and the rash and enlarged spleen were present. Some years ago the late J. M. Da Costa pointed out that during convalescence from typhoid fever a persistent moderate fever may develop, which is cured by getting the patient out of bed. Shattuck also speaks of such caaes. We have had under our care several RESPfUATORY AFFECrrONS IN CONVALFSCFNT STAr;/-: \')\ instances of lliis cliarac^tor. Tlic [^.'-tlin^^- up ()u<.'lii noi lo l,c i]i;i(lo nntil If, is (>vi(lcnl, (Jiiil (lie IV-vcr is simply ;i, "hcd lc\cr" jiud noi a r('l;i|)S(". Respiratory Affections in the Convalescent Stage of the Disease. — Aside from tlio laryngeal (see e;itliei'eiil(>ii.s infeelif;!!. So, too, Sarda and Vilhird' linve found llie diseases eo-exis(in(:. Zinii^ sliiles lliiil, ]>os(rnor(eni e,\;iniiii;ilioii of llie f;il;d cascs in 190 patients revealed tlie fact that six of tliern showed tiihr-reii- losis of the lung in association with old foci at the apex. Eshner^ in an excellent article iip(;n this subject, states fliat in 2000 fatal cases of typhoid fever, examined after death at Munich, Ilolscher observed 108 (5.4 per cent.) of tuberculosis in various situations. In Gruber's series of 710 fatal cases of tyf>hoid fever, 22 (3.3 per cent.) were complicated by old lesions of liibeieulosis of the lungs. Bettke, in 1420 subjects of tyfjlioid at iiasle, saw 23 (1.6 per cent.) in tuberculous subjects; while Dopfer recorded tuberculosis in 46 (5 per cent.) of 927 cases of typhoid fever. In cases of typhoid fever which are convalescent the presence of irregular and prolonged febrile movement should raise a sus- picion of the presence of tul)erculosis. The Circulation in the Latter Stages of the Disease and in Convalescence. — There are few, if any, diseases, which do not have special predilection for the heart muscle or its valves, which so gravely interfere with normal circulation as does typhoid fever. The length of the febrile movement and its severity, the gravity of the toxfemia, the wasting of the patient, his inability in certain cases to take sufficient nourishment, and the impaired action of various other vital organs than the heart, all tend to produce weak- ness in the heart muscle and actual deg■ene^ati^■e changes in its nerve-supply and muscle fibers. As long ago as 1875, Hayem* made one of his characteristically thorough studies concerning the heart muscle in typhoid fever, in which he showed that a granular parenchymatous degeneration is present in many cases, and that even fatty degeneration may be met with in prolonged severe cases associated with great anaemia. Hyaline changes are not commonly found, but a segmenting myocarditis, in which the intercellular 1 Sarda and Villard. Gazette des Hopitaux, November 30, 1S93. 2 Zinn. Miinchener lued. Wochenschrift ' Eshner. Philadelphia Medical Journal, March 25, 1S99. * Hayem. Legons Clinique sur les Manifestations Cardiaques et le Fievre T\-phoide. Paris, 1875. 13 194 COMPLICATIOXS DURIXG COXVALESCENCE cement substance is softened, may be present, although this is, per- haps, a postmortem change. ]\Iany years ago, Stokes asserted that the heart muscle of patients dead of enteric fever was so softened that if it were held upside down by its great yesscls the muscle would collapse oyer the hand like a nuishroom overspreads its stem. In some cases, on the other hand, the heart seems to escape almost completely. As it is not the intent of this essay to deal with the microscopic alterations which occur, but rather the objectiye symptoms of the disease, little further need be said of these changes themselyes, except that in this connection the researches of Hoffmann are of interest. He found, in an examination of a large number of hearts in typhoid fever patients, 56 instances in which the heart muscle was normal or little changed; 39 in which it was slightly granular, the striations still being visible; 46 in which the muscle was granu- lar; 19 in which it was slightly waxy; 1 in which there was granular degeneration, and 1 in which it was very waxy. More recently, Dewerve^ reports that in 48 cases analyzed by him the heart was found softened, pale, and of a "dead-leaf color" in fifteen instances, had undergone fatty or granular degeneration in sixteen instances, and in three others there was proliferative endarteritis of the small vessels of the heart. It is worthy of note that these changes are responsible in a large proportion of cases for the sudden deaths which occur in the convalescent period of the disease, even more commonly than in the course of the disease itself. So frequent is this condition of sudden cardiac failure an accident of convalescence rather than of the febrile attack, that Graves stated that even if the fever has departed and everything about the patient is favorable, we are not justified in banishing all anxiety or in relaxing vigilance, as a sudden effort on the part of the patient may cause fatal syncope. Instances of this sort have been recorded among the older writers by Bailly, Graves,^ Jaccoud, and Louis. Dewerve also found in analyzing cases of sudden cardiac death that it occurred most frequently in persons between the ages of 1 Dewerve. De la Mort Subite dans le Fitvre TjT>hoide, Arch. G^n. de Mdd., 1887, ii, 385. * Graves Clinical Medicine. THE CllidUr.ATION IN ('A)NV AJ.KSCESCE 105 twenty-two ;iii(l twenty-five ycjirs, prohnhly Ixtiiiisc tlii i. llic w^n- most I'reqnently ad'eeted hy enteric l'ev(;r, and (liat old w^n- un(J infancy rarely sn/lered Ironi it. '^ri)e aecidcul itself is fur more cominon in men than in women, I'or (liis wrih'r foiind il in ilic pro- portion of 114 cases in men to 20 in women. It is interesting to note that this condilion is iu)t a sef|uel of severe cases alone, for Dewerve asserts, on tlic conirary, that it is emphatically a sequel of a moderate form of the fever (forme moy- eiinc). Fnrther, violent effort is not necessary to produce it, for it has occurred after so slight a movement as extending the arm, by emotion, and may develop without any such cause, the patients being found dead in bed in the posture they were in when asleep. Liebermeister records the case of a woman who ate a hearty dinner after convalescence from a mild illness of typhoid fe^•er. She then rose to go to the closet, fell in a faint, and died in ten minutes; and another case of a man who was unable to take the upright posture for many weeks without suffering from nausea, vomiting, collapse, and partial syncope, but who ultimately recov- ered. The autopsy in the case of the woman revealed no lesions save profound cerebral anjemia. (For sudden death due to nervous lesions, see chapter on devel- oped stage of the disease, nervous symptoms.) There are, however, other causes of sudden failure of the heart than myocardial degeneration, namely, embolism or thrombosis of the coronary artery or arteries, heart-clot, thrombosis or embolism of the cavse or pulmonary veins, and pericarditis with effusion, which, pressing on the heart when a change in position is attempted, causes sudden death. In the cases already quoted as having been analyzed by Dewerve (48 cases), there were eight with thrombosis of the coronary arteries. In eight other cases antemortem clots were found in the right ventricle. lyiebermeister reports one case at Tubingen, in which death occurred as a result of embolism of that branch of the pulmonary artery that goes to the lower lobe of the right lung. In this case the embolus arose from thrombosis of the right crural vein, and was accompanied by extensive hemor- rhagic infarction. Clots in the coronary arteries may arise from within the heart cavities from granulations on the endocardium. 198 coMPLiCATinxs nuRixa coxvalescence Beaiunaiioir/ Fritz,- Vallette/ Forgues/ Divwitt,' and others have met with these formations. According to Drcwitt, however, tliese clots are formed in the heart in the acute period of the disease, and then are dislodged when the circulation increases in tone during convalescence. Viti" has found the bacillus of Eberth in the granulations of endo- carditis, and, furthermore, has produced these lesions in rahhits by iiioculaling tiiem with (lie bacillus, and Vincent^ has recorded the case of a previously healthy soldier, who died from enteric fever, and in the vegetations of his mitral valves these specific bacilli were found. Girode^ has made a similar report. Hayem," also, has recorded a case in which endocardial difficulty was recognized in life, and two days later symptoms of plugging of the arteries in both legs ensued. First, pulsation ceased in the dorsales pedes, • then in the popliteals, and finally in the femorals, and gangrene developed. An embolus was found mi the femoral artery, but did not extend below the knee. The autopsy showed antemortem cardiac clots, endocarditis, thrombosis of the aorta, and multiple infarctions in the kidney. On the other hand, it must not be for- gotten that endocarditis complicating typhoid fever is rare. Osier says he has seen but three cases of this complication in his series of 1500 cases, but states that the physical signs were such as to suggest its presence in three other patients. In a series of 793 patients suffering from typhoid fever at von Jaksch's clinic endo- carditis occurred 15 times. Hawkins'" has also reported a case. Only eleven cases occurred in 2000 cases in IMunich. Pericarditis is also very rare — 14 in 2000 cases in Munich and but three times in Osier's 1500 cases, while from von Jaksch's clinic is reported but one case in the series of 793 cases, and Hawkins saw but one case. ' Beaumanoir. La Piogros Medicale, 1891, ix, 364. 2 Fritz. Charitd Annalen, vi, 169. ' Vallette. Contribution il I'Etude de la Gangrene des Membreis Pendant la Cours de Fifevre Typhoide, These de Paris, 1890, Ferrand. ■• Forgues. Rec. de M^m. de M(3d. Militaire, 1880, 3d series, xxxvi, 386 => Drewitt. Lancet, 1890, ii, 1023. " Viti. Atta della Roy. Acad, del Fitjiocritia de Siena, 4th series, vol. ii, fasc. 5 and G, 1890. ' Vincent. Merc. Medicale, February 17, 1892, p 73. 1 Girode. Comptes Rendu Soc. Biol., 1889, p. 622. » Hayem. Progrt's Mddicale, 1875. '" Hawkins. Trans. Clinical Society, London, 1907, xl, 72. 77//'; C/U,(Jl/LAT/(fN IN CONVALh'SC'h'NC'/'J J(j7 Grady iitid (lOiirand' rcporl, lliis (•ondldoii f(jmpli<;i(iiin- ;i mild attack of tyjjiioid i'cvcv. On tlic ciolilli d;iy of I lie disease a diy pericarditis (JcvolojK'd. 'I'licy wen; aMe lo find but thirty iustanees in the literature of the development of this eornj)lication during typhoid fever. Moore^ reports two eases, on<' in a hoy and one in a yonnjy woman, both o('eurriny another cause. Thus, Ilutcln'nsfjii recf>rr|.s it c;ise in whieh ;i j>;i(icijt convalescing from enteric fever suffered from erysi}>elas, then from pleurisy, and finally from pericarditis. Snrely this case was due rather to the streptococcus than (o llie hacilhis of Eherth. Liebermeister only saw foni- e;ises of perienrditis, ;iiid ;dl recovered. Very rarely sudden death ensues without (;ur being able to find any of the causes given. D{\]hrine^ lias recorded two such cases, in which no sign of cardiac degeneration could be found. In such instances an embolism of an artery supplying an important vital spot in the medulla may be the cause. Dieulafoy- asserts that in such cases there may be another cause of death, namely, reflex irritation along the vagus from the abdom- inal cavity, and which, being transmitted along the efferent branches of this nerve, inhibits the heart's action and causes fatal syncope. In other instances he thinks that the respiratory centre is rapidly affected, and that death results. Such reasoning, in view of our knowledge of the functions of the parts of the ner- vous system just named, seems very hypothetical. Death due to the causes enumerated may come on more gradu- ally than has been intimated so far. Thus dyspnoea, irregularity of the pulse, a bruit de souffle, and, rarely, partial syncope, may begin the end. Passing from these changes to those met with in the general bloodvessels, w^e find that marked inflammatory processes often affect these parts in the course of typhoid fever. One of the most important studies made upon this subject is that of Barie,^ who asserts, as a result of his work, that both the large and small ves- sels may be affected by inflammation, although the vessels of the lower extremities are the ones most often and most severely affected. Thus in t^s'enty-two out of twenty-four cases this was true. It takes place generally when the patient first leaves his bed and begins to move about. It is just as apt to follow mild as severe ' Dt^jferine. Comptes Rendu Soci^t^ Biologie, 1885, p. 769. - Dieulafoy. De la Mort Subite dans la Fie\Te Tj-phoide, Paris, 1869. ' Barie. Contribution a I'Histoire de I'Arterite Aigue Consecutif a la Fievre Tj"phoide, Revue de Medecine, 1883, p. 1, and 1884. 200 COMPLICATIOXS DURIXG COXVALESCENCE attacks, and it occurs in two forms, namely, as an acute obliterating arteritis and as an acute parietal arteritis. He describes the change as follows: "The first variety is constituted anatomically by an embryonal infiltration of the three coats, and disappearance of the smooth con- tlition of the intima, which becomes uneven and granular. This leads, as a consequence, to the pioduction of a secondary throm- bosis, which in course of time becomes a dense gray mass adherent to the parietes of the artery. Very often the inflammation of the artery is accompanied by a certain amount of periarteritis. If the lumen of the afi'ected artery is completely obliterated and the col- lateral circulation is not c|uickly established, mortification ensues, and the limb assumes the appearance of dry gangrene. In excep- tional cases, in consequence of the simultaneous occurrence of venous thrombosis or of phlebitis, moist gangrene may follow the mummifying variety, or substitute itself for it. "The principal symptoms of obliterating arteritis are as fol- lows: Acute pain occurring more or less suddenly and seated in the course of the affected artery, sometimes localized in a restricted region, as, for instance, the thigh, calf, or Scarpa's triangle, some- times occupying the whole length of the limb, and increased by pressure upon assuming the erect position and by the movements of walking; diminution of the fulness and, finally, suppression of the pulsations of the artery; swelling of the limb without a-dema or redness; bluish mottling of the skin; sometimes, although rarely, purpura; diminution of the temperature of the limb with or without disturbance of sensibility, such as formication and par- tial ansesthesia, and, finally, the occurrence in the course of the artery of a hard and tender cord. "The parietal arteritis is only a variety of the preceding, and has, consecjuently, the same symptoms but in a less degree of develop- ment, except, of course, that tlie liard, painful cord is absent. It is said, however, that the diminution of the pulsations of the artery is occasionally preceded by an exaggeration of their amplitude, and that in a few cases the temperature of the afi'ected limb^has been observed to be higher than that of the other. "It must be borne in mind that some of the symptoms of the Till': cmcuLA'/'ioN IN (;()NVArj<:s(:HS'(:i': 2i)\ ol)liter;ifMi^ Vfiricty may Jii'i.sc from aJi embolus, hut tijo prosr-rir-r; of a valvular iiujrniur and of other .signs of disease of the heart, and the suddenness of (he seizure, will enaf)le us to recognize without difficulty the eases dependent upon this cause. "The therapeutic indications in the milder forms are best ful- filled by rest in bed, the aj)plication of eniollients or soothing ointments to the limb, and wrapping it in cotton. In easfs in which gangrene has occm-red the [)atient should be suj^jjorterl by tonics and a liberal diet, and appropriate antiseptic dressing should be applied to the part." Other reports on this subject have been made by Ferrand,* Deschamps,^ Mettler,^ Quervain,'* and Haushalter.'' In addition to these interesting researches, there are others of even greater interest, as, for example, those of Rattone," who in four cases found the bacillus of Eberth in the arterial walls and obtained pure cultures from this source. The result of this infec- tion and endarteritis is to aid in the formation of thrombi, and these in turn, by plugging of the vessel, cause rapid dry gangrene of the tributary part. (See lesions in the skin.) The bacilli are supposed to reach the arterial wall by the blood stream rarely, or by the blood stream in the vasa vasorum. The veins are very much more apt to be affected by thrombus than the arteries, as everyone with a large experience with t}^hoid fever well knows. Haushalter and Vaques have found the bacilli in the walls of these vessels, and Rattone and Haushalter have found them in the thrombi themselves, and also that the endothe- lium under the clot was destroyed. As a result of this thrombosis with phlebitis we may have devel- oped phlegmasia alha dolens, but very rarely gangrene, because the collateral circulation is more free in the veins. The clots in the veins may be single or multiple, and may be of very extraordinary size. In De Santi's' case a clot extended from ' Ferrand. These de Paris, 1890. - Deschamps. Ibid., 1886. 3 Mettler. Philadelphia Medical Times, February 19, 1887, p 339, and New York Medical Journal, March, 1S95, p. 289. ■■ Quervain. Centralblatt fiir innere Med., August 17, 1895, p 793. 6 Haushalter. Mercredi M(fdicale, September 20, 1893, p. 453. ^ Rattone Delia Arterit^ Tifosa in Dehu. 7 De Santi. Ree. M(im. de Med. Milit., 1879, series 3, xxxv, 502. 202 COMPLICATIONS DURIXG COXVALESCEXCE the vena cava in the iliac vein down into the femoral vein, and one extraordinarv case is recorded by Beaumanoir/ in which clots were in the arteries of both legs, in the right ventricle, in the pul- monary artery, in tlio femoral veins, and in the aorta. Cases of clots reaching from the femoral vein to the vena cava are recorded by Dumontpalier,- Sorel,^ Bouley,' and Mackintosh.'" A case of thrombosis of the iliac veins and the lower part of the ascending vena cava has been reported by Pansini." Oedema, lividity, pain, and loss of power in the legs were present. Pansini refers to a statistical article of Vimont, who up to 1S90 collected 112 cases from the literature of this character. A curious case of varicosity of the subcutaneous veins of the trunk and extremities is reported by Mackintosh.^ The veins involved were the jugular and internal mammary and external pudic, the superficial epigastric, internal saphenous, and superfi- cial circumflex on both sides. It is supposed by the reporter that a thrombus formed at the junction of the iliac veins and inferior vena cava, which, becoming engorged, necessitated a collateral cir- culation. Curiously enough, the patient survived. Plugging of the veins to a great degree usually results in moist gangrene, as has already been stated. In regard to the vessels most commonly affected by plugging, we gain very interesting information from Keen's classical essay. Out of 90 cases of gangrene, and Keen believes all these cases w^ere due to plugging of vessels, 46 had arterial plugging, of which 8 were bilateral, 19 on the right side, and 19 on the left side. In the veins in 52 cases there was bilateral involvement on both sides in 4 cases; on the right side in 10 cases, and on the left side in 38 cases. Again, in those cases which did not proceed to gangrene, Keen found plugging in the arteries in 15 cases, of which 4 were bilateral, 6 on the right side, and 5 on the left, and in the veins, out of 47 cases, 3 were bilateral, 13 on the right side, and 31 on the left. 1 Beaumanoir. Progrfes M^d., 1891, ix, 364. 2 Dumontpalier. Comptes Rendu Soc. Biol., 1879, 6th series, vol. iv, parts 283. 3 Sorel. L'Union Mddicale, 1882, p. 521. * Bouley. Progrfes Mdd., 1890, viii, 998. ^ Mackintosh. Glasgow Med. Journal, 1892, xxviii, 54. 8 Pansini. Centralblatt fiir innere Med., June 6, 1896. ^ Mackintosh. Glasgow Medical Journal, July, 1893. 77//'; ailiCULATION IN CONVAL/'JSC/'JNC/'J 203 These sljitistics ,siij)|)(»cl, (Ix- ciullcr ones [)re.serite(l to us ])y Liebermeister, who mcl, with -U cases of (lirorribosis in (he veins of the lower extreniilics ainon^ ]71.'> typhoid fever f^atients, the majority of whom were men. In his cases also thiomhosis usually (lid not aj)|)ear until the stage of eonvaleseenee, anrl rarely as early as the third or fourth week. (Jut of 24 cases, 16 of which were in men and 8 in women, the vessels became plugged eighteen times in the criu-al vein, five times in the saphenous vein, and once in the popliteal vein. 'J'hrombosis of the crural vein took place in both sides simultaneously twic;e, four times on the right side, and twelve times on the left. The saphenous vein was affected on the right side once, and on the left side four times, and the throm- bosis in the popliteal vein was also left-sided; in other words, this accident occurred five times on the right side and seventeen times on the left. The frequent occurrence of thrombosis in the left crural vein rather than the right is believed by Liebermeister and by Keen to be due to the slight pressure exercised upon the left common iliac vein by the right common iliac artery, thereby com- pressing the vein. H. C. Jonas^ reports a case of phlebitis of both femorals associated with periostitis of the right tibia. Sometimes phlebitis of the calf of the leg develops in place of thrombosis of the femoral vein. Thus Arnaudet" records three cases, one in a woman aged seventy-five years, another in a woman aged fifty years, and the last in a man aged thirty-eight years. A few years ago one of us (Hare) had under his care a case of this kind occurring in a girl of twenty years, on the left side. In Arnaudet's cases, one was on the left side, the other two on the right. The rarity with which plugging of a vessel in the upper extremi- ties takes place is remarkable. Thus, in 128 cases of phlebitis collected by Keen, only 4 involved the upper extremities alone; 2 involved the arm and leg, and 124 were limited to the legs. Thrombosis of either an iliac or femoral vein is always a serious complication. The immediate dangers — ^gangrene, extension of th ^ thrombus, and pulmonary embolism — are not great, but the remote effects are often grave. In cases of thrombosis of the 1 Jonas. Lancet, October 4, 1903. 2 Arnaudet. La Normandie M^d., Xovember 1, 1S91. 204 COMPLICATIONS DURIXG COXVALESCEXCE tVmoral or iliac vein tlu> aHVcted extremity is always considerably and permanently enlarged, and there is nsnally more or less per- sistent disability. Thayer' has made an exlianstive stntly of the cardiac and vas- cular complications and sequels of typhoid fever, and his conclu- sions are so important and agree so perfectly with onr own observa- tions that we quote freely from his article. That typhoid fever is a disease in which weakness of the heart nuiscle is a (|uite constant contlition is oenerally recognized. ^^'llether this weakening is brought about by the direct action of the toxin of the typhoid bacillus on the heart muscle or by impair- ment of its nutrition, the result is, in a considerable number of cases, a temporary insufficiency of the mitral valve, as indicated by the appearance of a systolic mm-mur at the apex, which not infre- quently is transmitted toward the axilla. These murmurs usually appear during the height of the fever and disappear with con- valescence. There are, however, a certain number that persist. In 12 of Thayer's 188 cases of typhoid fever, which were kept under observation from three months to fourteen years after the attack, he found signs which led him to ])elieve that an organic cardiac lesion was present. In the majority of these cases an apical sys- tolic min-miu" had been discovered dui'ing the attack of typhoid fever. In over one-fifth of the patients in whom during the attack of typhoid fever a cardiac murmur was heard, subsequent examina- tion revealed evidence of organic heart disease. It was also noted that the radial arteries of those cases which had had an attack of typhoid fever were much more readily jjalpable than were those of patients who had not been victims of this disease. That arterial changes take place is indicated by the fact that Thayer found the average systolic blood pressure to be higher among those persons who had previously been ill of typhoid fever than in those patients who had not had this disease. These findings by Thayer of higher systolic blood pressure than normal in patients formerly victims of typhoid fever would seem to indicate that the heart muscle could not have been permanently damaged or the function ' Thayer. American Journal of the Medical Sciences, 1904, p. 137; also Johns Hopkins- Bulletin, 1904, p. 1,5. (IHNITO-dlUNAKY 205 of the valves impjili-cd, l)ii(, on tlic oIIkt IkukI, il may also Ix- (lie case tliat tlic discMsc cjiiiscs iu'lcriiil cliaiiifcs vvliirli, ))y fl('rri;i.riididyrnis, and at last the testicle. Thrombosis of the spermatic veins has been held responsible for this complication in several instances, and in several of these cases the condition has been complicated by phlebitis of the saphenous veins. The theory that phlebitis of the spermatic and testicular veins is accountable for cases of orchitis and epididymitis during typhoid fever has been advanced by Widal and supported by Hutchinson. Gwyn^ has reported a case which apparently supports this theory. Fox" has shown that focal necrosis of the testicle in typhoid fever is not infrequent. Gwyn thinks that many of the cases of orchitis or epididymitis occurring during typhoid fever, in which there is little or no pain, are caused by phlebitis of the veins supplying these parts. In the first edition of this essay we published a table giving a complete record of all cases of this condition which existed in the literature of that time (1898). Eshner, who compiled the table, found but 44 cases, but since his report so many others have been recorded that probably a very small percentage of the cases that occur find their way into medical literature. Alimentary Tract and Associated Organs in Late Stages and in Convalescence. — The affections of the alimentary canal after typhoid fever are not, as a rule, of very great importance nor of great frequency. In the majority of instances they consist in more or less severe signs of indigestion due to three factors, namely, the inordinate appetite of a patient convalescing from typhoid fever, which often leads him to overload his stomach, his inability to deal with ordinary amounts of food is impaired by his ' Gwyn. American Medicine, February, 1907. - Fox. Bull. Ayer Clin. Lab. Pennsylvania Hospital. 1907, Xo. 4, 3S. 14 210 COMPLICATIOXS DUniXC COXVALESCEXCE generally feeble state, and, finally, the disordered condition of the bowels, as represented by the states of diarrhaw or constipation, may be prime factors in interfering with the proper digestion of food. Obstinate and persistent constipation is the condition of the intestine most commonly met with, and it varies from a moderate form readily relieved by proper diet and drugs to a condition in which the fecal mass must be dug out of the rectum with a spoon. This condition is due to two chief causes. In the first place the tissues are so dried by the fever, so to speak, that they eagerly absorb from the alimentary canal all the liquid they can to restore their normal moisture; and, secondly, the prolonged use of a diet leaving but little residue, and lack of exercise, is a causative factor of intestinal atony, even if the ulceration and catarrhal state of the mucous membrane of the bowel in the disease are not con- sidered. Diarrhoea may also be a factor which delays the patient's rapid return to health, and it arises from the use of improper food, from catarrh of the bowels, or from the presence of unhealed ulcers in the colon, or even in the small intestine. This condition of faulty healing of the ulcers in the bowel may be a serious factor in the patient's case. Rarely, serpiginous ulceration of the mucous mem- brane of the bowel is present, and this results in a persistent diar- rhoea of a dysenteric type, with, it may be, loss of blood. This condition has been described by Jaccoud in France, by George B. Wood in America, and by many other clinicians since his time. Perforation. — In other cases perforation of the bowel may take place with death resulting long after the fever has departed. Thus INIorin^ has recorded a case in which perforation occurred as late as the one hundred and tenth day. Sometimes these ulcers, by afford- ing foci for septic infection, cause the maintenance of a low grade of fever for many weeks. They are not true typhoid ulcers, but the result of profound necrosis of the intestinal mucous membrane resultinii' from advanced intestinal catarrh and debilitv. Under the name of diphtheria of the intestinal mucous mem- brane, Liebermeister has described a condition in which the bowel ' Morin. Des Perforations Intestinal clans le Cours de la Fiiivre Typhoide, Paris, 1869. ALIMENTARY TRACT IN CONVALESCENCE 2\\ is affected by (lij)li(licr()i(| sloiiolis. Very ran-ly, if ever, ;u'c iIk-so sloughs truly diplitlieritic. The iilrcintloi) niidcrlying tlH-rii may be severe enough, however, to rcsiill in |)crfor;i(if)ri of flic bf)\vf|, as already pointed out. Gangrene of die bowel in dislinclion IVoni \\\rcr:\\]u\] and \n(u\ necrosis is still more rai-e. It i.s j)r(jl)ably due almost always, if not always, to thrombosis or embolism of the mesenteric vessels, and in Hoffmann's 250 cases at autopsy this lesion was found no less than nine times. In six of these it affected the ileum, in two the vermiform appendix, and in one the sigmoid flexure. Those cases in which there is gangrene of the appendix are probably due to appendicitis, produced by direct infection by the bacillus of Ebertli or by the Bacillus coli communis. (See earlier chapter.; Peritonitis arising from infection from the ulcers in the bowel wall or from perforation may also arise in this period of the dis- ease. Tschudnowsky^ records a case of this character in which, after typhoid fever, perforation occurred with the escape of gas into the peritoneal cavity. Auscultation in this case revealed an exquisite amphoric murmur on inspiration, due, it was thought, to the escape of gas through the opening in the gut. GoodalP reports two cases of obstruction by peritoneal adhesions following typhoid. One was in a boy, aged fourteen years, who was convalescing, when acute abdominal symptoms developed, with vomiting, hiccough, and pain. The symptoms lasted several days, and when operation was finally performed the intestinal obstruction was located some thirty inches above the ileocaecal valve, and was caused by a fibrous band of adhesions, the result of an old peritonitis opposite a deep typhoidal ulcer. Cicatricial contraction of the bowel due to the healing of the ulcers is an exceedingly rare condition, which is a curious fact when we consider how severe the ulcerative process may be. Young^ has recorded a case, however, in which the lower twenty- five inches of the ileum were so greatly contracted that the first joint of the thumb could not be inserted into the bowel. In this 1 Tschudnowsky. Berliner klin. Wochenschrift, 1S69, Xos. 20, 21. - Goodall. American Medicine, May 2, 1902. 2 Young. Medical Press and Circular, 18S6, xlvi, 471. 212 COMPLICATIOXS DURIXG COXVALESCENCE case, too, about two inches above the ileoctvcal valve there was constriction, almost to the ])oint of occlusion, and a similar nar- rowing existed at the upper eml of the ct)ntracted portion of the bowel. AboVe this upper constriction the small bowel w^as so dilated that it resembled a stomach. The patient died as the result of a fall from a horse long after the typhoid attack. Concerning the more infrequent complications affecting the alimentary tract at this period, we find a number of interesting facts. Noma has been recorded in a few cases, notably by Frey- muth and Petruschky/ wdio report a case of noma of the cheek in a case of typhoid fever in which virulent diphtheria bacilli were isolated from the gangrenous tissue, and in which healing follow^ed the use of antitoxic serum. Keen collected nine cases in his 'J'oner I^ecture in 1S76, although some of these were rather those of ulcer- ative stomatitis than true noma, and Hall has reported to Keen a case which, as Keen says, if not one of noma w^as at least akin to it. The patient died of hemorrhage from the area involved on the thirty-eighth day of the general malady. So, too, Littlejohn^ lias recorded two fatal cases of noma following typhoid fever. In one of these both cheeks sloughed; in the other there w^as not only sloughing of one cheek, but gangrene of the skin of the hip. Sailer^ reports two patients, a brother and sister, who during the third week of typhoid fever developed noma. Klebs-Loeffler bacilli were found in the necrotic patches. Walsh, ^ in his analysis of the statistics of Hildebrand and Perthus, notes that noma followed typhoid fever in 26 of 133 cases reported by them. Aphthous inflammations of the mouth may be present in rare cases, and is usually seen only in patients who are in crowded wards or barracks, in which careful attention cannot l)e paid to individual cases. Glossitis may occur in typhoid fever, but is very rare. Osier 1 Freymuth and Petruschky. Deutsche med. Wochenschrift , 1898, No. 15, p. 232, and No. 38, p. .500. 2 Littlejohn. British Medical .Journal, April 30, 1893. 3 Sailer. American .Journal of the Medical Sciences, April, 1902. ^ Walsh. Proceedings of Pathological Society of Philadelphia, 1901, p. 179. A/JM/'JNTAUV TRACT IN CONVA/J-JSC/'JNC/-: 2\'.'> has recorded a case which developed ^los.sitis ten days after his temperature was normal, l)ut recovery ensnfd in ;i fV-w d;iy ;. Frankcl' lias reported seven cases of stonialitis diirin^f lv|)lii)i(| fever, in one of wlildi no .snl)j('('(iv(' syinptoins were foiuid. M(;('rae'' ajso re|)orts three cases of tins coniplicafion (jecnrrin^ in his series of 717 cases of typlu^d fever at the Montreal (^ieneral Hos})ital. I'rullier'' has seen ulceration of the mouth in 220 cases of typhoid fever. Alveolar abscess may also occur, and Jyiehermeister records a case in which tiiere was emphysema of the cheek of the affected side. Franklin* has reported a case in which gangrene began in the upper gum and caused in five days necrosis of the superior maxilla. A case of gangrene of the mouth and partial necrosis of the superior maxillary bone has been reported by WinkouroflP,'' as occurring in a little girl, aged six years. The left cheek was observed to be swollen on the first day of the illness; on the third day a black spot made its appearance in the back of the mouth; on the seventh day the eschar suppurated and perforation of the cheek occurred. The most noteworthy fact in this case is that of recovery. Induration followed by softening and perforation of the cheek, and finally by death, has been reported by Donald" as having occurred in two sisters during the course of typhoid fever. In both cases the right cheek was affected. We once had under our care a woman who, during convalescence from a most grave attack of typhoid fever, developed an abscess in the wall of the right cheek which was not connected with the parotid gland or Steno's duct. Keim^ has reported a fatal case of typhoid fever in a boy, aged nine years, in which gangrene of the left cheek occurred during convalescence. Two other cases are reported in the same journal. 1 Frankel. Deut. med. Woch., March 20, 1901. - McCrae. American iMedicine, September 26, 1903. 3 Trullier. Gaz. des Hop. de Paris, 1908, Ixxxi, 207. ■• Franklin. Quoted by Hutinel. 5 Winkouroff. Bulletin de la Soci^te Anatomique. December, 1SS7. " Donald. London Lancet, February 20. 1893. ' Keini. Lehigh Valley Medical Magazine, October, 1S91. 214 COMPLICATIOXS DURIXG COXVALESCEXCE Another case has been reported by Clark,' in ^vhi(•h a man, aged twenty-eight years, suffered on the thirtieth chiy of typhoid fever with bulging of the right cheek, followed by closure of the right eye and great swelling of the lids, and on the thirty-third day the left eyelids became involved, and on the thirty-fifth day large non-glandular swellings a]i])eared at the angles of the lower jaw. The right upper eyelid sloughed away, and the patient died of exhaustion on the thirty-seventh day of the illness. It is thought that the local condition was the result of a general infection. Sloughing of the face in a child, aged twelve years, ending fatally, is reported by Ewens.- In this case the sloughing really followed an attack of measles and miuiips which occurred during convales- cence in typhoid fever. Gangrene of the tongue has been reported once by Gaston David,^ while Freudenberger^ has seen it involve the uvula. Spill- mann° met with gangrene of the lips with final septicaemia due to a secondary staphylococcus infection, which destroyed life. Liebermeister records one case of melanotic softening of the oesophagus after t^^jhoid fever. (Esophageal ulceration" may lead in some cases to stricture. A case has been reported by Packard and one by Mitchell which occurred in Osier's wards. (See chapter on Well-developed Stage of the Disease.) A case of ulcer of the oesophagus has been reported by Riesman to the Pathological Society of Philadelphia, March 9, 1899. In regard to lesions coming on at the other end of the alimentary canal after enteric fever, we find a case of gangrene of the anus reported to Keen by Betz, of Oakville, Pa., the condition arising in ail probability from general thrombosis of the hemorrhoidal arteries. This patient was a boy, aged ten years, who at the end of the fifth week complained of irritation about the anus, the parts being found slightly discolored. ^Yithin twelve hours the tissues 1 Clark. London Lancet, April 9, 1893. 2 Ewens. London Lancet, August 4, 1889. 3 David. Quelques Considerations sur la GaiiKrene Typhoids, Thbse de Paris, 1887. ■• Freudenberger. Aerztliche Intelligenzblatt, 1880, xxvii, 7. 6 Spillman. Merc. ]M(?dicale, 1895, No. 13, 145. 6 A valuable jiaper, by Russell, on oesophageal ulceration in general is to be found in the Scottish Medical and Surgical Journal for April, 1899. AUM/'JNTA/O' THACT IN CONVALEHCENCl': 2 IT, of the i,sfliior(!(;tal fossti sloiif^licfl out unci the rcftiirn was fVjiind to he gangrenous. It ,s|H'e(lily separafcH, leaving a large opening. Curiously enough, al)sohite recovery Look \)\nrc, the evacuations being finally perfectly controlled. Ceases of gangrene of the perineum and anus may occur from extension of the process from the vulva in women. Keen gives interesting facts concerning these cases which, as they are not medical conditions, are not discussed in this hook. J'arotitis. — Passing on to the lesions found in the cjrgans asso- ciated with the alimentary canal, we find that inflammation of the parotid gland is an unusual complication of typhoifl fever, and is due to extension of infection from a foul mouth through Steno's duct. In many instances, however, the parotitis is due to true typhoid infection. Thus, Janowski' records a case of a man, aged twenty years, who (Hed in "the second or third month" of the fever. The bacillus of Eberth was found to be the infecting organism in the gland. In another case,^ both the bacillus of Eberth and the staphylococcus were found to be present. Sometimes the inflam- matory process goes no farther than swelling and hyperemia; in others suppuration develops, and when it does the destruction of tissue is usually grave, not only in the gland, but in nearby tissues as well. Curiously enough, the other salivary glands are almost never affected. J. Milton INIiller^ has, however, reported a case of typhoid fever in which there was marked swelling of the sub- maxillary glands. Not only may the local necrosis be dangerous in itself, but if the pus is not given free vent it is apt to burrow down between the tissues of the neck and cause septicaemia -or pyaemia by infecting the great vessels and lymphatics. Facial palsy may result either from destruction of the facial nerve, by its section in incising the abscess, or by reason of the pressure exercised upon the nerve as it passes through the stylomastoid foramen, the neighboring bony tissues being involved. In regard to the fre- quency of this condition, we find that Hoffmann met with suppiu'a- tive parotitis in 16 cases out of 1600 patients, and that 7 of these died. 1 Janowski. Centralblatt fiir Bacteriol. und Parasit., 189.5, x^■ii. 685. - Lehman. Centralblatt fiir klin. Med.. August, 1891, 649. 3 Miller. University of Peuna. Medical Magazine, July, 1899. 210 COMPLICATIOXS DURIXG COXVALESCENCE Ordinary parotitis occurred in 3 cases. In 15 cases the attack was liniiteil to one side, 9 times in the right and times in the left. Keen collected 26 cases in his Toner Lecture of 187(5, and .")() more in his recent essay. Thirty per cent, of these died, and 20 of the 28 cases in which the sex was named were males. Twenty-nine of his cases suppurated and only 5 did not. In 12 the trouble was bilateral, and 7 of these suppurated on both sides. Parotitis is a lesion of the third or fourth week, and is of evil omen, since it shows degenerative changes in other important glands. Parotitis was present in 45 of the 2000 Munich cases and in 14 of Osier's 1500. Of Osier's 14 cases, 5 died. Hoffmann noted 16 cases of this complication in 1600 typhoid fever patients during the Ba^el epidemic, while Liebermeister noted it 6 times in 210 fatal cases of this disease. Carpenter^ has recendy reported the case of a boy, aged eleven years, who during a severe case of typhoid fever developed a double suppurative parotitis on the eighteenth day of his illness. On the twenty-first day of the illness both abscesses were incised. From the pus a bacteriological study revealed the presence of the Bacillus typhosus as well as the ]\Iicro- coccus pyogenes aureus. This patient recovered after a prolonged convalescence, the incisions over the parotid glands closing on the fifty-first day of the illness. Osier has recorded a case in which a right parotid abscess com- plicated typhoid fever in a man who was ill in September, 1890. In January, 1896, when Osier saw him, he had profuse sweating over the right side of the face and temple on eating, this condition having lasted more than five years. There was no facial anaes- thesia or paralysis. Hepatic Lesions. — The liver may become affected by various conditions in convalescence. Of these, we find, as most important, abscess, cholangitis, and cholecystitis. Here, again, the exhaustive monograph of Keen may ])e referred to as presenting many of the facts we have concerning this organ. Abscess of the liver is seldom met with, for Keen found only twenty- one cases in literature. Solitary abscess is due to the Bacillus 1 Carpenter. American Medical Association, December 2C, 1908. AUMh'NTAIiV TUACT IN CONV ALESCJICSCK 217 coli coinmiinis, to the .stapliy!oco(;c;u.s, or to tlic fjafilliis of Khfrtli, and is very rare. O.slcr states that this complication occurred in three of his 829 cases, and it was observed to have more fre(|iMiitly followed such complications as [jarotilis or necrosis of Ijonc. J. M. Da Costa collected 22 cases in which the assfjcijilion of iihscess of the liver with ty[)hoid fever seemed heyond doiiiif. Of these cases, only seven were jjiundiecd. In 2()()() jiiitopsics' upon typhoid ffver subjects at Munich abscess of the liver was met with but 12 times, while Dopfer, in 927 cases, found abscess formation present in 10. It is of interest to note that of the 21 cases of solitary abscess collected by Keen, 19 died. Thomas,^ in a recent review f>f the literature, was able to find but 2-or^'anisrri.s, hut his report did not deal with the particiihir \\\\\\\^^\\(^^• of the haeillns typhosus as a causative factor of such iiiflaininatious. The importance of a history of a previous attack of ty}>hoid fever vv^hen making a diagnosis of cholecystitis is always to Ije remembered, for a large numJ)er of cases are now ow rcffjrd in which typhoid bacilli in pure culture have been isohited from gall- bladders which were afiected by cholecystitis a few weeks or as long as twenty-five years after an attack of typhoid fever. Not infrequently other bacteria, particularly the bacillus coli com- munis, are discovered in the gall-bladder with or without the bacillus typhosus. It has also been proved that the bacillus of Eberth may remain for many months in the gall-bladder before it produces grave disorders. Thus, Dupre^ records a case in which, at a chole- cystotomy, the bacilli were found in the gall-bladder six months after the fever ceased, and Chantemesse^ records such an instance eight months after the fever, while von Dungen* recites one remarkable instance of cholecystitis fom*teen and a half years after the fever. In the pus of this case the Eherth bacillus was found. The American writers on this topic have been chiefly Mason, '^ of Boston, and Osier." Pratt,^ Gushing,^ Richardson," Mitchell,^*^ Stockton and Lyte,^^ Burley,^^ Stewart,^^ Kelly," and AYilson^' have all reported cases of this condition. Mason tells us that the ' Naunyn. XI Congress fiir inner. Medicin, Weisbaden, 1891. ^ Dupr^. Les Infections Biliares. Tlifese de Paris, 1891. 3 Chantemesse. Traite de Med., i, 764. ^ Von Dungen. Jliinchener med. Wochenschrift, 1897, No. 26, 699. 5 Mason. Transactions Assoc. American Phys., 1897, xii, 23. 6 Osier. Ibid., p. 378. ^ Pratt. Amer. Journ. of Med. Sciences, November, 1901. s Cushing. Johns Hopkins Hosp. Bull.. 1898, ix. 91. ^ Richardson. Boston Med. and Surg. Journ., December 2, 1897. 10 Mitchell. Maryland Med. Journ., 1901, xliv, 13. " Stockton and Lyte. New York State Journal of Med., 1902, ii, 232. 12 Burley. Am. Med., October, 1903. 13 Stew-art. Am. Med., 190-1, vii. 1019. " Kelly. Am. Jour, of Med. Sci., September, 1906. 15 Wilson. Journ. of Amer. Med. Assoc, May 16, 1908. 222 COMPLICATIOXS DURIXG COXVALESCENCE records of the Boston City Hospital show only three cases of this character other than his own. Two of these died. His own case recovered after the gall-bladder had been tapped. A case has been recorded by Anderson* in a man, aged sixty-seven years, who, two months after typhoid fever, was seized with intense pain in the right hypochondrium, followed by death in ten days. The autopsy revealed peritonitis and perforation of the gall- bladder due to the bacillus of Eberth or the Bacillus coli com- munis. Alexieef" also reports a case in which a child, aged five years, sutt'ered from a pear-shaped tumor in the hepatic area, and great pain. Operation revealed suppurative cholecystitis, with the typhoid bacillus in the pus; recovery occurred. Hawkins' reports a case of this character in which after death there were found typhoid lesions, and Osler^ records four cases, three of which recovered and one died. He also records two cases of hepatic colic, > one of which followed enteric fever, and one which had typhoid bacilli in the gall-bladder without having had typhoid fever. Gushing has also reported in the Johns Hopkins Hospital Bulletin for May, 1898, a case, in which cholecystotomy was performed for a cholecystitis, in which the typhoid bacillus was foimd, although there was no history of typhoid fever. The blood in Cushing's case also gave the typhoid reaction. The diagnosis of gall-bladder infection rests on the following points: Tenderness on pressure a little above and to the right of the umbilicus. There is pain in the gall-bladder and under the scapula, and often a pear-shaped mass can be detected in the ante- rior hypochondrium. This may fluctuate. If perforation occurs peritonitis speedily develops. As Mason well says, in diagnosis we must exclude impacted feces, hydronephrosis, cyst, displaced kidney, and appendicitis, and when rupture of the gall-bladder has occurred, intestinal perforation. Leukocytosis would be indic- ative of acute cholecystitis and appendicitis. The prognosis of cholecystitis is grave. Only one-quarter of the ' Anderson. Canada Lancet, 1896. - .\lexieef. Quoted by Osier, ibid. 3 Hawkins. Lancet, January 30, 1897. ' Ibid. ALIMENTARY TRACT IN COW A LKSCHNCh: 223 cases collected })y Mjison ^ui well. 'V\u- morlalily of \)cy\iiyu- tion of the f^Jill-hliulder is very lii^li. 'i'vveiity-six ca.se.s iioi (.[xi- ated oil died; of four operated on, (liree recovered ancJ (jue died. For further statistics the reader is referred lo Keen's essay. A most iiiterestiuf^ and detailed aceoiint of an extensive investi- gation as to the <'tiologieal factor in a household (-[jirh-inic of typhoid fever was read by George A. Soper hefore (Im- liiolrtgjfjil Society at Washington, D. C, on April 6, 1907. Careful examina- tion excluded Uie water, milk, vegetables, fruit, and shellfish as possible sources. There were no cases in the town iinmcdiately preceding or following those cases studied, and none of the patients had been away for several weeks before they fell sick, so that there could be no question but that the disease had been acquired on the premises, which, however, were in a thoroughly hygienic condition. On August 4 a new cook was received into the family, and had been with them for three weeks before and three after the outbreak. An investigation of her career showed that, although the record for nearly two of the past five years has not yet been completed, twenty-six cases of typhoid, including one death, were associated with her services in seven families, scattered from Maine to New York, during this time. Indirect information indicated that she herself had suffered a mild attack. Examination of the stools revealed the presence of large numbers of typhoid bacilli, and the blood gave a positive reaction to the agglutination test. One of the most important discoveries concerning typhoid fever since the first edition of this essay was published was the discovery of the fact that patients harbored in their gall-bladders the specific organism of the disease long after the original attack of the disease. Lentz* termed those patients from whom the organism could be isolated ten weeks after the onset of the attack or after a relapse, "bacillentrager" or bacillus "carriers." He collected ninety-eight such cases from seven sanitary stations in Germany, and thinks that about 4 per cent, of cases of typhoid become "carriers." In 1 Lentz. Klin. Jahrbuch, 1905, vol. xiv, p. 475. 1 224 COMPLICATIOXS DrRIM; COXVALESCEXCE one case the organism was isolated t'loni the stools twelve years after the attack of typhoid fever. Since the first dis(t)very and reporting of these cases of "car- riers of infection," many cases have been discovered, and withont donbt many household epidemics of the past have l)C('n due to the agency of these "carriers." Dehler^ was the first to report an operation for draining the gall-bladder for the prevention of any fuitlicr dissemination of tvphoid bacilli in the stools. Since his report many other surgeons have performed similar operations. Cholelithiasis. — Bernheim was the first to draw attention to the direct relation between typhoid fever and gallstones, but "Welch- was the first to discover the typhoid bacillus in the nucleus of a gallstone. Fournier,^ in his studies of 100 biliary calculi removed at autopsy, found living or dead bacteria in 3S per cent, of these formations. Pratt^ examined 17 concretions, and found that foiu" contained the bacillus typhosus; and Funke,'"' who examined 102 calculi, found that 31 gave a growth upon media, while 71 inoculations remained sterile. In this series of cases the Bacillus typhosus was found but once, while a pure culture of colon bacillus was found 1 1 times. Dufourt" has recorded nineteen cases of biliary lithiasis w'hich had their first attacks after enteric fever and all of them within ten months of the fever. Gilbert and Fournier^ divide typhoid cholelithiasis into two groups : those which are the more numerous, being due to the colon bacillus, and the less frequent form, due to the bacillus of typhoid fever. Cushing*^ tells us that a prior history of typhoid fever is often met with in gallstone cases in Halsted's clinic at Baltimore: and that it occurs in the proportion of 10 in 31 cases. Hektoen" also tells 1 Dehler. Miinchener medizinische Woclienschrift, April 16, 1907. 2 Welch and Blackstein. Johns Hopkins Hosp. Bull. July, 1891. ' Fournier. Compt. rend, de la. Soc. biol., October 30, 1897. ■• Pratt. Am. Jour. Med. Sciences, 1901, cx.xii, p. 584. ' Funke. Proceedings of the Pathological Society of Philadelphia, 1908, xi. No. 1. 8 Dufourt. Revue de M6d., Paris, 1893, p. 247. ' Gilbert and Fournier. Compte rendus Soc. Biol., March 5, 1897, p. 93G. 8 Gushing. Johns Hopkins Hospital Bulletin, May, 1898, No. 86. * Hektoen. Progressive Medicine, March, 1899. ALIM/'JNTAUr TRACT IN CONVALI::SCJ'JNCE 225 us that he has recently seen a ease in whifli lli'- [>m ; fioni ;i ii|>- purative lithiasis of the gall-blad(Jer gave tlie W i about which the material for the fornuifion of a stone clusters. Abdominal I.ymph Nodes. — The mesenteric and retroperitoneal glands may undergo suppuration and cause sepsis. In other instances a subdiaphragmatic abscess forms because of flK>- lecystitis, of suppuration of these glands, or from perforation of the bowel. A case of this character is recorded by Klein' of left- sided subphrenic abscess due to typhoid fever, in which the pus contained the specific bacillus. Three liters of pus were allowed to escape by incision. The patient recovered. Keen tells us that this is the only case he could find in literature. TungeF reports a very interesting case in which a suppurating mesenteric gland near the caecum caused perforation of the supe- rior mesenteric artery and death from hemorrhage. Lehman^ records a case of suppurating mesenteric gland, the pus of which contained the bacillus of Eberth, and Frankel' reports a case of abscess in the abdomen due to this cause four and a half months after the fever. The specific bacillus was found in this pus also. Other cases have been reported by Michie," Thomson," and Low.^ J. H. Bryant'' reports a case wliich at autopsy showed no intestinal lesions, but the mesenteric glands were engorged \\'ith typhoid bacilli. He was able to find in the literature fifteen similar 1 Fiitterer. Munchener med. Wochenschrift, 1888, No. 19. " Klein. Ueber die Pyogene Wirking des Eberthschen Bacillus bei TjiDliuskomplicationen, Inaug. Dissert., Bonn, 1898. ^ Tungel. Klin. Mittheil. aus der Kaiserlich., Hamburg Allegemeine Krankenliaus, 1864. ^ Lehman. Centralblatt fiir klin. Med., August, 1891, 649. ' Frankel. Verhandl. Kongress fiir inner Med., 1887, 179. 6 Micliie. British Medical Journal, 1888, i, 1388. ' Thomson. Glasgow Medical Journal, 1882, xvii, 244. 8 Low. British Medical Journal, ISSl, ii, 122. 9J. H.Bryant. British Medical Journal, April 1, 1899. 15 226 COMPLICATIOXS DURIXG COXVALESCEXCE cases, wliile Lartigan' adtls to tliis mnnl)er one other case seen by him. Jaundice following tyj)li()i(l fever is exceedingly rare. Of the 2000 cases of typhoid at Munich reported by Holscher, this com- plication occurred 22 times. Liebermeister met with it twenty times in 1420 cases, Griesinger ten times in GOO cases, Osier not once in one series of 500 cases. Murchison saw only three cases, all of which were fatal. It is caused by catarrh of the ducts, toxaemia, abscess, and gallstones with or without cholangitis. Osier," however, records two cases, in one of which the jaundice developetl at the onset of a relapse, in the other at the end of the second week. The first case recovered, the second died of toxamiia. Another case of Jaccoud's, studied by Sabourin,^ was that of a man, aged twenty-nine years, in the third week of the disease, who had intense icterus, great asthenia and delirium. Death ensued, and at the autopsy the lesions of typhoid fever were found associated with a condition of the liver resembling acute yellow atrophy of this organ. Da Costa' made a careful analysis of 52 cases, of which 33 died. As nearly as could be determined, the cause of the jaundice was catarrhal inflammation in 4, pylephlebitis in 3, cholecystitis in 5, abscess in 6, acute yellow atrophy in 5, toxic in 24, and uncertain causes in 5. Dr. Warren Coleman'^ reports a case complicated by jaundice in the prodromal period, while Ogilvie® reports four cases coming on during the course of the disease. It is interesting to note that Hamilton' states, in his excellent account of an epidemic of tj'phoid in an insane asylum in which 27 patients over fifty years of age were studied, that there were three patients with symptoms of cholecystitis, all of whom had jaundice. In the tropics, jaundice seems to be a more frequent complica- 1 Lartigan. Johns Hopkins Bulletin, April, 1899. 2 Osier. Loc. cit. 3 Sabourin. Re^'ue de M6d., 1882, ii, 600. * Da Costa. American .Journal Medical Sciences. July, 1898. ^ Warren Coleman. New York Academy of Medicine, January 10, 1906. Ogilvie. British Medical Journal, January 12, 1901. ' Hamilton. American Journal Medical .Sciences, October, 1907. AfjM/'JNTAR)' TL'Acr IS COS V ALi:s(;i-:x(:r: 997 don of l\|)lioi(| fcvci' lli;iii in (he (cinpctMlc zoiic, for .I;iiiiic^oii' records iiiiie cji.scs, ot" wliicli Umv diod. Si'LKNiC TiKsroNS. Soiiicfimcs l)_v[)f'rlroj)liif (■iil;ir<;cm<-iil r,!' die spleen occurs aflcr (yplioid lexer. VV(; have seen two cases; (lie enlar(^'cmcii( in one case is illiistralcd in \'\ii. 2'). Tlicre were wo Fio. 25 n Splenic enlargement after tjishoid fever. blood changes, and no history of malarial infection was obtained in this case. A number of cases of rupture of the spleen due to the develop- ment of an abscess, and later exposure and traumatism, have been recorded during convalescence in typhoid fever. Harrington" 1 Jamieson. Imperial Maritime Customs Med. Reports, 1S91, 37th issue. - Harrington. Lancet, 1905, p. 1398. 228 COMPLICATIOXS DVBING COXVALESCEXCE reports two cases of abscess of the spleen clurinp; typlioid : one founti post mortem and one operated upon. Federmami^ in the same journal reports an instance of abscess of the spleen wliicli com- plicated convalescence. Biron- reports a similar case. A case of rupture of the spleen, not due to these causes, is, however, reported bv Santi Flavio.' A man, aged twenty years, after having been under observation for ten days, sutt'ering from typhoid fever, devel- oped pleural pneumonia with pleural effusion, which required ta{> ping. Two months later the patient suffered from severe pain in the left hypochondrium, the action of the heart became rapid and feeble, and oedema of the left leg was present. After a brief period of improvement the patient was suddenly seized with peri- tonitis and died, and the autopsy showed that in addition to the peritonitis there had been rupture of the spleen, and that the pus which it contained had been diffused throughout the entire perito- neal cavity. A recent infarction was found in the neighborhood of the rupture, and the intestines showed evidences of an old typhoid fever. It is not certain that this splenic abscess was due to the typhoid fever. Foreign Body ix the Bow^el. — As an illustration of what a patient can recover from during typhoid fever, in the way of an accident extrinsic to his disease, Heath^ cites the case of a man, aged twenty-tliree years, who at the end of the fourth week of his fever swallowed a clinical thermometer. A mustard emetic failed to bring away the thermometer, nor did a castor oil purge cause its discharge from the bowel, but twelve days after it had been swallowed it w'as passed unbroken and registered a temperature of 104.7°. Nervous Symptoms in the Far-advanced Stage of the Disease or following Typhoid Fever. — Paralysis complicating typhoid fever or its convalescence may occur in a number of forms, just as paralysis may occur from lesions due to other causes. It may occur as a local paralysis or monoplegia, as a general ' Federmann. Lancet, 1905, p. 1398. 2 Biron. Vratch. Gaz. St. Petersb.. 1908, xv, 462. 3 Santi Flavio. Gazette degli Ospitali, 1891, No. 43. * Heath. American Lancet, December, 1888. NERVOUS SYMPTOMS FOLLOWING TYI'IIOtl) FEVER 220 paralysis, as a parapl('<;'i;i., or ;i„s ;i, liciiii|)lc;;i;i, ;mhI it iii;i\' \n- <\\u- in the first three instances to peripheral neuritis, in the second instance to a myelitis or neuritis, and in the case of hemiplegia to C(M'ehral lesions, sucii as tiiromhosis, emboh'sm, hemorrliage, jirid meningo-encephalilis. Sometimes llic nionoplcgia, or [jartial p;ir- aplegia, may be due to a poliomyelitis. Neuritis. — 13y far the most common of tlicse ailcclions is the loss of power due to neuritis, a conditifjii which is not com- monly met with as a complication of typhoid fever, yet not so rare as might be supposed. The most exhaustive and interesting monograph concerning this complication of the disease is that given us by Ross and Bury,^ in their essay on "Peripheral Neuritis," first published in the Medical Chronicle and afterward in a separate volume. So complete and thorough is their study of the literature of the subject and of the clinical aspect of the condition that much of the following information is to Ije credited to them. Gubler,^ among several cases of local palsy after typhoid fever, records the case of a boy, aged sixteen years, who developed, a few days after his fever ceased, a nasal voice, which was found to depend upon paralysis of the palate. Shortly after this there was paralysis of accommodation. Tliis latter point is of interest in view of the fact that Gowers states that this condition never arises from typhoid fever. Gubler also cites the case of a boy who, after an attack of forty-seven days, suffered from paresis in his legs and became unable to raise liimself in bed. His lower limbs were feeble, tremulous, and their muscular irritability greatly increased. There was also loss of power in the hands, with some spastic con- traction of the fingers, and the speech was staccato. Surmay^ records two cases of local paralysis due to this cause. In one the loss of power was in the extensor muscles of the hand and fingers and in the extensors of the toes, and in the other case, weakness of the right leg was followed by complete loss of power 1 Ross and Bury. A Treatise on Peripheral Neuritis. Griffin & Co , 1S93. 2 Gubler. Arch. G^ni^rale de Islid., 1860. 3 Surmay. Ibid., 1865, i, 678. 230 COMPLICATIONS DURIXG COXVALESCENCE in the left. So, too, Kraft-Ebing^ speaks of weakness of the adduc- tors of the thigh and hyper?esthesia of the skin suppHed by the saphenous nerve. Bailly- has recorded paraplegia, anaesthesia, and contractions in these cases, and in two instances paralysis of the palate, and NothnageP records four patients in whom the ulnar nerves were paralyzed and the ulnar side of the hand was anaesthetic. In all these cases there was the reaction of degenera- tion, and they also suffered from radiating pains in the upper and lower extremities. In four other cases there was partial paralysis of the lower limbs with partial ana\sthesia, pain, and tingling sen- sations, and in one of these patients the trouble in the lower extremities was followed by weakness in the upper limbs. In still another the patient at the beginning of convalescence first had a feeling of numbness and creeping in the left leg, and after this, paralysis of that limb gradually developed. Later on the exten- sors of the right hand became paralyzed, and four days later some of the muscles of the left hand. Similar cases have been reported by Leyden' and Benedict, and in one recorded by Eisenlolu*,^ a man, aged thirty years, eleven days after his temperature became normal, suffered from numbness and loss of power in the left leg and feet, ^^dth violent pain in these parts and in both knees, followed the next day by effusion into the right knee and a rise of temperature to 104°. There was loss of power in the left peroneal nerve, and fourteen days later the left knee became swollen. On the sixteenth day the right elbow became swollen and painful and the swelling of the left knee subsided. The muscles supplied by the left peroneal nerve showed diminished reaction, and the left foot was cedematous and in the position of equino varus. On the twenty-fourth day the flexors of the feet and the extensors of the toe were completely paralyzed, and gave the reaction of degeneration. This case of Eisenlohr's is of interest, first, because the swelling 1 Kraft-Ebing. Beobachtungen unci Erfahrungen iiber Typlius Abdominalis, 1871. 2 Bailly. These de Paris, 1872. 3 Nothnagel. Deutsch. Arch, fiir klin. Med., Bd. ix, p. 429. ■• Leyden. Klinik de Ruckeimiarkskrankheiten, 1875, Bd. ii, Abth. 1, p. 247. ' Eisenlohr. Arch, fiir Psychiatrie und Nervenkrankheiten, 1876, Bd. vi, p. 543. NERVOUS SVMPTOAfS FOLLOW/XG I'YI'IIOIJ) FEVKR 2'4] passing from joiiil, (o joiiil might have aroused a sus[>icifMi (h;il the cause was septic, and because certain writers in fpiofirig tlie case consider it as an instance of pjiralysis corning on rJiiring relapse. As lioss and Jiury |)oiii( oni, ii is possible th;it iIk- rheu- matic poison was the cause of bolli the joinf fhanges an<] the evidences of neuritis. Additional cases of j)eriph('riii neuritis have also been repojferl by Bernhardt/ Vulpian, and others. Thus a case of deltoid jKir- alysis has been recorded by Vulpian/ which was in all probability due to a peripheral neuritis. A young man, aged eighteen years, after an attack of typhoid fever, suffered from pain in the arm and developed loss of power in the right shoulder, w^ith atrophy of the deltoid muscle. In none of these cases, however, were any studies made, over and above the clinical tests which are ordinarily employed, to prove positively that a true neuritis was present, and it was not until Pitres and Vaillard^ published their paper, in 1885, that the first careful microscopic observations upon typhoid peripheral neuritis were presented. After detailing the cases of two patients who suffered from typhoid neuritis they give the results of the histological examination of nerves removed from the bodies of four patients w4io died during the active period of typhoid infection, but in whom no signs of peripheral neuritis had been noted during life. Cm-iously enough, in tliree out of these four cases changes indicating parenchymatous neuritis were found to be present, and it is interesting to note that one of these patients died as early as the sixteenth day of the disease, wliile two others died on the thirty-sixth and twenty-fourth days respectively. Other instances of postmortem examinations revealing periph- eral neuritis in typhoid fever are those reported by Oppenheim and Siemerling. In one of these instances the patient died in the middle and the other at the end of the second week of the fever, 1 Bernhardt. Deutscli. Arch, fur klin. Med., 1S7S, p. 363. • Vulpian. D'Accident Survenus Pendant la Convalescence de la Fife^Te Tj-phoide, Re^-ue de :Medecine, 1SS3, p. 617. 3 Pitres and Vaillard. Compte Rendu. Soc. de Biol., Paris. 1SS5, S. 8, ii, 661, and Rev. de M^d., Paris, 1SS5, v. 985. 232 COMPLICATIOXS DURIXG COXVALESCEXCE and in both cases, parenchymatous degeneration of the periplieral nerves was found, in one of -wlncli it affected the great saphenous and peripheral nerves, and in the other a branch of the cutaneous nerve supplying the dorsum of the right foot, antl showetl com- plete degeneration of many of its fibers. Since these papers have been published, others tleaiing with the clinical aspect of the subject have been placed upon record by Alexander,' Handford," Archer,^ Humphreys,^ Klumpke-D^jferine,^ and notably two cases reported by Bury in the essay which has been named. One of these was in a girl, aged eighteen years, Avho was seen eight months after an attack of typhoid fever of varied duration and severity. During the fever she was suddenly affected by a condition in which she was unable to straighten out her upper and lower limbs, and this rigidity persisted until she was admitted to the Manchester Royal Infirmary, eight months afterward, when it was found there Avas great wasting of all the muscles of the limbs, particularly in the muscles on the front of the thigh and outer part of the legs. There was drooping of the great toes and the knee- jerks were variable, sometimes being excessive and sometimes being minus. The plantar reflexes were absent, and there was no ankle-clonus. The upper limbs were somewhat flexed, and could not he extended, and there was atrophy of the thenar and hypothe- nar eminences; there were also marked disorders in cutaneous sensibility in the distribution of the radial nerve. The contractions could not be overcome even when the patient was put under chloro- form, and while the paralysis and rigidity remained for many weeks, the patient ultimately made a complete recovery. In still another case, long after typhoid fever, a man, aged forty- two years, suffered from pains in his legs, in which all the muscles below the knees presented a moderate degree of wasting; he had exaggerated knee-jerks. ' Alexander. Deutsche med. Wochenschrift, 1886, xii, 529. * Handford (H.). Peripheral Neuritis in Enteric Fever, Brain, vol. xi, 237. ' Archer. British Medical .Journal, 1887, i, 727. ■• Humphreys (F. R.). A Case of Peripheral Neuritis following Typlioid Fever, Abstr. Tr. Hunterian Society, London, 1889-90, 41. '> Klumpke-D^jt'rine. Des Polyn(5vrites en Gdni^ral et des Paraiysies et Atrophies Satur- nines en Particulier, Paris, 1889, p. 222. NKIiVOUH >S]'MPTOMS FOLLOWINC I'VI'IIOII) /■/■Vhfi 2?>?> DerciJin }i;is reported to us two cases of |)eiipliff;il nciniii-, ;it'l*T typhoid fever, (J lie to the excessive admijiistjalion of alcohol during the ilhiess. Thus a \j(\y\ of fourteen years received on<- anrl a half pints a (hiy for sonic (inic, and (h'\c|()pcd (yjncal alctjlioh'c neuritis. These cases give some ich.-a of tlic cliaractci- of die \ai'ioiis forms of peripheral neuritis which follow typhoid fever. Odici- instance.s might be quoted in which there is doubt as to whether paraplegic symptoms were due to neuritis or to injury to the tracts and cells in the spinal cord. Thus, Mitchell' has recorded a ca.se of paraplegia associated with tremor, in which he thought that the paralysis was due to degeneration of the cells in the anterior cor- nua of the spinal cord, but Ross and Bury consider that the rapid improvement of this patient indicated that she was suffering rather from a peripheral than a spinal disease. So, too, George Ross' has recorded a case in which there was paralysis wath spastic con- traction of the lower extremities, v^dth loss of electrical reaction, but no diminution in the abilities of the sphincters, and in which complete recovery took place. That severe peripheral neuritis may result in tropliic changes in the organs supplied by the nerves which are involved is shown by a case reported by Wedenski,^ of a youth, aged seventeen years, in whom, two years after typhoid fever, symmetrical gangrene devel- oped as a result of degeneration of the peripheral nerves. No lesions w^ere found in the muscles nor in the cerebrospinal nervous system. Closely associated with true paraplegia following enteric fevei' is that partial paraplegia or ataxia of the stage of convalescence in which the patient finds it difficult to use his lower limbs. Tliis lasts in nearly all severe cases for some days after the patient leaves his bed, and is often persistent for some weeks, causing a peculiar waddle or stiff-legged gait, quite commonly met with when the illness has been severe and the patient has been inadequately fed. 1 Mitchell (S. W.). Boston Medical and Surgical Journal, 1S79, c, 245. 2 Ross (G). International Journal of the Medical Sciences, 1SS9, p. 25. ' Wedenski. Wiener medizinischer Presse, 189S, xxxii, p. 421. 234 COMPLICATIOXS DURIXG COXVALESCEXCE In connection A\ith tlie question as to whether these various forms of paralysis are spinal or peripheral, the followino- cpiotation from Ross antl liury is of importance: "While it is probal)le (hat a few cases of muscular atrophy which follow typhoid fever tlepend upon an anterior poliomyelitis, and that a condition similar to that of infantile paralysis is pro- iluced, the presence of sensory disturbances in the vast majority of cases shows that the lesion, if in the cord at all, is not limited to the anterior horns, or involves both the anterior and posterior roots, or the mixed peripheral nerves. The absence of spinal tenderness, of girdle pains, and of disturbances of the sphincters speaks much against an infection of the spinal cord or its roots, while the initial sensory distm-bance, succeeded by a limited paralysis having a slow progressive march up to a certain degree, which varies according to the severity of the case, the paralysis then slowly receding and ultimately, as a rule, completely disap- pearing, are points strongly in favor of an affection of the per- ipheral nerves." An interesting case of peripheral neuritis after typhoid fever has been recorded by Putnam, of Boston. In this the patient suffered from tropliic changes in that small abrasions did not heal. There was marked analgesia, and when seen two years after the attack of the fever, tliis disturbance of sensation extended to the left arm and shoulder, the left side of the neck and trunk as far as the eighth rib. Marked improvement followed treatment. There are tliree other classes of symptoms showing peripheral nerve distm-bances: First, cases in wliich excessive muscular con- tractions are developed in place of paralysis, but associated with pain and hyperaesthesia. Eleven of these cases have been reported by Ai'an in L'Union Medicale, July 18, 1855. The contractions occurred toward the end of the attack of typhoid fever, and never Avere met with at the commencement of the disease. They were preceded by formication, prickings, and numbness in the extremi- ties, and pain in the joints, and the immediate seizure was associated with an intense feeling of anxiety and distress, the contractions affecting both upper and lower limbs, so that many muscles exhib- NERVOUS SYMPTOMS FOLLOW/. \(; TV I'llOII) FLVKR 235 ited almost inccssanl, fihiilhuy rondnfliotis. Jiy graii- lation, artificial cxtensioii ronld he ohiairicd, and thi.s ^avo the patient relief for a short lime. In four ca.s(,'.s the muscles of tlie trunk were affected and opisthotonos was produced, the patient being held immovable by the muscular contraction, which also caused j^rcat pain. These attacks lasted from a quarter of an hour to three hours and recurred from two to ten times a day, and after the cessation of the attacks the fever ran its ordinary course with- out any other synij)toms save an occasional numbness of the affecteri parts. Although three of the patients died, Aran thinks their deaths were due to the severity of the fever and not to the tetanic complication. These cases so closely resemble tetanus that similar ones could be readily taken for tetanus if the symptoms occurred early in the course of typhoid fever. Gubler^ has recorded a case of contraction of the hands, and Dewerve refers to this condition as possible of occurrence in the Nouveau Dictionnaire de Medecine et de Chirurgie. So, too, Xoth- nageP refers to a case of tonic contractions of the interosseous muscles lasting from one-quarter to one-half an hour. Similar contractions ensued when the patient supported himself on his toes. A second class of nervous distiubances is closely associated with the general signs of peripheral neuritis, and is thought by some to have become more frequent since the general introduction of the cold bath in the treatment of typhoid fever. These signs have been particularly described by Handford, and consist of great hyperaesthesia of the toes and heels of patients in the latter part of the disease or, more particularly, diu-ing convalescence. Osier, inwTitingof this subject, states: "Before July, 1S90, when the Brand method of bathing was introduced into my wards, I had never seen an instance. Since then we have had twenty or more cases, all of which have been bathed. Not ha^-ing met vrith. the condition before using the baths, I was inclined to regard it as the effect of the cold water; but in a personal communication from Dr. Handford, I gather that his cases were not treated by the Brand 1 Gubler. Archives Generale de Med., xv, 5th series. - Nothnagel. Deutsche Arch, fur klin. Med., 1872, 9. 236 COMPLICATIOXS Dl'RIXG COXVALESCEXCE method, so that it is evidently one of these coincidences which are so apt to be misleatling in medicine." !Myelitis.^A few cases have been recorded in ^\•hich a ra[)itlly ascending paralysis, usually terminating fatally, has occurred during the course of, or immediately after, an attack of typhoid fever. Cases of myelitis or anterior poliomyelitis as a result of typhoid fever are so rare as to be almost unknown, although Gowers, as already quoted, has stated that poliomyelitis is more frequently secondary to typhoid fever than to any other acute infectious disease. Two cases of ascending myelitis are recorded by 'Raymond in La Science de Mcdecine for 18 Schiff. Arcliiv fur klin. Med., 1899, xlvii, 175. N/'JIiVOUS SYMTTOMS FOLLOWING TYI'IIOID FIALIi 2'M riiiiical Society in LSSO upon tliis sMljjcrl. Ilawkins at tlii.s tinic reported 17 cases which he had cohected from the Hteratiire or had personally observed. Ilolscher, in summarizing the 2000 fatal cases of typhoid fever at Munich, mentions twenty cases as having shown cerebral apoplexy, but a study of 875 fatal cases of typhoid fever in Ik'rlin, in a series of 4703 cases of this disease, did not reveal one instance of hemiplegia. Osier lias recorded a case of a yoinig physician who was taken ill with typhoid fever, on the fourteenth day had a temperature of 104°, which, however, fell the following morning to 100.7°, and in the next three or four days the temperature had not reached 102.5° when the rash developed and the spleen became palpable. Twenty- four hours later, when all the symptoms of the case seemed favor- able, he was suddenly seized witli uneasy feelings in his head, the pupils were dilated, and in a few minutes he suffered from a short, sharp general clonic convulsion, beginning almost simultaneously in both arms; the eyes showed marked conjugate deviation to the left and upward, and tlie head was also turned to the left. The convulsions were severe at short intervals for an hour, then became less intense, and finally ceased altogether for several hours; they were accompanied by profound unconsciousness, and die severer ones occasioned great embarrassment to the respiration. In the interval the patient was conscious, spoke to those about him, and seemed to understand questions. Later in the evening the con- vulsions recurred with great severity, and after five hours the patient died in a severe one. These convulsions were general, but were most marked on the right side of the body. A postmortem examination held by Flexner revealed thrombosis in the ascending parietal and parietotemporal branches of the middle cerebral artery. The meninges over these vessels contained small hemor- rhages, and the brain-matter, while not softened, showed small extravasations of blood. Small but quite extensive punctiform hemorrhages could be seen to occupy the cortex and adjacent white substance in the immediate neighborhood of the tlu'ombosed vessels. Out of the well-known 120 cases collected bv William Osier of 23S COMPLICATIOXS DURIXG COXVALESCEXCE hemiplegia in children, there was no instance of hemiplegia fol- lowing typhoid fever, and in IGO cases collected bv Wallenberg, four only occurred after typhoid fever. Osler,^ however, reports two cases of post-typhoid hemiplegia. One of these occurred in a jrirl, ajjed six vears. Almost two months after the beo-inning of her illness she was seizeil with violent convulsions, which were confined to the head, right arm, and leg; she became unconscious. Later it was noticed that the right side was completely paralyzed, including the face, and that there was total loss of speech and aphasia, lasting for seven weeks. Gradually the patient largely recovered from this paralysis, but complete recoAery did not ensue. The second case was that of a clergyman, aged twenty-five years, who \^as seized ^\itli convulsions fourteen days after going to bed with headache, fever, and diarrhoea. In this case also partial recovery took place, but Osier did not, at the time of making his report, consider that complete recovery would be possible. The paralyzed arm, the left, many months after the attack, was affected by wide irregular choreiform movements on attempting any volun- tary effort, but the mental condition was excellent. Another case of this character was reported to the Johns Hop- kins Medical Society by Blumer:^ that of a little girl, who, one week after convalescence had begun, and who had been eating solid food, was seized ■v\'ith violent convulsions, which were con- fined almost entirely to the right side. These convulsions lasted for eight hours, and were followed by paralysis of the right side; five weeks after the onset of these convulsions she began to recover both the power to move the arm and leg, and also that of speech. She also sufferetl from amnesic aphasia; ultimately almost complete recovery took place, so that there was only slight dragging of the foot, and some pure motor aphasia. The arm, however, did not materially improve, and was affected by rigid paralysis, though no sign of facial paralysis was present, and the tongue was protruded straight. Blumer believed that the case was due to thrombosis. In the same journal Thayer records two other cases of this 1 Osier. Journal of Nervous and Mental Disease, May, 1896. - Blumer. Johns Hopkins Hospital Bulletin, April, 1896, p. 72. NERVOUS SYMPTOMt^ FOLLOWING TYrilOII) l<'l-:VER 2'-;9 cliar{u;i('r seoMi in tlio Mussucbii setts rj(;rH'ral Jl(jspil;il. On (Ik- tenth (lay of the illness in one case the ward onJerly IVmjikJ at I a.m. that the patient was unable to move the right arm and leg; the face was flushed, the eyes half closed, the ))iij)ils ((iikiI, ;ind eyehalls rolled npward. The patient's mental condition wjis very stii[)ifl. Eight days later the patient was distincdy hcttcr, un;d)lc to speak, but evidently understood what was siiid lo liim; Ik- fould noi pio- trude his tongue, but later was able (o read die jjnpcr ;ind U) say a few words. The other case was that of a girl, aged ten years, admitted to the Massachusetts General Hospital on the fifth day of typhoid fever, who was found on the twenty-third day of her disease to lie prin- cipally upon the right side, and failed to answer questions. The next day the patient could not speak, although she apparently understood what was said to her; the tongue was protruded straight; the face was not paralyzed. In other words, these are two cases illustrating the onset of complete right-sided hemiplegia with motor aphasia. A case of hemiplegia has also been recorded by Newbolt,^ in which a locomotive fu'eman, aged twenty-one years, suffered from loss of power in the left arm and leg during the course of a relapse. There was aphasia, and the tongue w^as protruded to the right; there was drooping of the right eyelid, and some dysphagia. Per- fect recovery did not occur. The case was thought to have been due to thrombosis. Still another case of hemiplegia complicating typhoid fever is recorded by Imradi.^ The case had been considered one of influ- enza, and the patient was allowed to go out on the fifteenth day, when he suddenly lost consciousness and remained unconscious for hours; when seen he was suffering from left-sided hemi- plegia. The fever ran a typical characteristic course, and recovery occurred. Imradi asserts that there were only fifteen similar cases to be found in literature at that time. 1 Newbolt. London Lancet, August 27, 1S93. 2 Imradi. Centralblatt fiir med. Wissenschaften, October 25, 1891. 240 COMPLICATIOXS DURIXG COXVALESCEXCE A'iilj)ian' has recorded a case of obstruction of the left Sylvian arterv in the coiu'se of typhoid fever, causing riglit hemiplegia and aphasia in a male of seventy years. Under the title of "A Case of Hemiplegia of Gradual Onset following a Severe Attack of Enteric Fever and Terminating in Insanity" (which was probably hysteria), Stevens" has recorded the histor}- of a man, aged twenty-two years, who three months after recovery from this tlisease found he had difficulty in approxi- mating the fingers of his left hand to one another. Stevens tells us that " the .fingers are flexed upon the palm of the hand more or less. They can passively and slighdy, by voluntary effort, be extended within narrow limits (see figure in Glasgow Medical Journal). Tlie thimib is turned outward and flexed at the interphalangeal joint. Forcible extension of the fingers is accompanied by consid- erable pain, but the thumb is less painful in this respect. The wrist-joint is fixed, evidently largely by muscular spasm, and not bv definite ankvlosis. jNIovement of flexing: the forearm on the arm is perfectly easily accomplished, but it is accompanied by considerable fine tremor of the whole arm. On attempting to raise the left arm above the head it becomes evident that there is little movement at the shoulder-joint. Most of the movement is accomplished by moving the arm and shoulder en masse, and, as a result, the range is much more limited than on the other side. There is no definite wasting of any of the arm muscles. The posi- tion of the thumb in relation to the other fingers is fiu-ther noted. It is turned around in such a way that it rests upon the radial aspect of the first phalanx of the forefinger. As regards the foot, there is noted a spastic condition evidently involving the extensors, so that the toes are all drawn well up upon the dorsum of the foot, the first phalanx in each case being drawn far back upon the meta- tarsal bone. The extensor tendons stand out like cords. Despite this, movement of the ankle-joint is fairly free, although rather jerky. The power of the muscles of the thigh, as tested by making and resisting movements of flexion and extension of the knee, is 1 Vulpian. Re\-ue de Mddecine, 1884, p. 162. - Stevens. Glasgow Medical Journal, January to July, 1897, vol. xlvii. N/|)C('ci;il)lc ^WWi-Yvwcv. is mudc out between tlie two sides. "Sensation is tested in both upper and lower exircnn'tie-,, and found to b(! normal. The reflexes (tendo;ij in I he Kit w^tyvv cxtrenn'ty are abolislied; in the ri^ht, normal. The suj^erfieial abdominal and eremasteric reflexes on th(; ri/^lif sidr- are easily elicited; the former can be I'ainlly brou;^d)l out on llie let! side, but the latter on the left side cannot be elicitfid. 'J"he knee reflex is distinctly exaggerated on the left side, and the ankle-clonus is very marked, while on the right side the knee reflex is normal, and there is no ankle-clonus." Later, the patient became insane and passed into an asylum, and the asylum physicians made the following report on his case, deciding that the condition was male hysteria. "The points that guided us in inclining to a diagnosis of the hysterical nature of the case were as follows : "1. The varying intensity of the symptoms. The flexion of the arm was not constant; at times it admitted of a limited move- ment and a limited power of passive extension, but at other times the spasm of the flexors was intense, and manipulation was almost consciously resisted. The symptoms in the leg varied even more than in the arm. "2. The comparative absence of atrophy of muscles, considering the duration of liis illness (since the middle of 1895). Measure- ments taken last month showed that while there was a degree of atrophy, the greatest difference was between the right and left thighs, which was only one and one-quarter inch. "3. Apparently normal response of the muscles to farad ic irri- tability, "4. The complete disappearance of the symptoms under deep chloroform necrosis. "There were also the peculiar hysterical postm'e of the patient and the difference between the symptoms in the two limbs.'' Still another case of hemiplegia is reported in the Johns Hop- kins Hospital Bulletin for July, 1896, by Haynes, as having pre- sented itself at the Brooklyn Eye and Ear Hospital. A man, aged 16 242 COMPLICATIOXS DUIUXG COXVALESCENCE thirty years, suffered in October, 1S95, from an attack of typlioid fever lasting twenty-one days. On the fourteenth day his left arm became paralyzed, and when able to sit up it was found that both upper and lower cxtrcniitics iVh numb, altliouuii i\]vvv w;is no loss of sensation. Tliis condition persisted for a couple of months, when impro^•ement began, first in the leg; almost completely re- covery ensued, so that only slight loss of motion and inability existed. There was no evidence of facial paralysis or convulsions in this case. As an indication of the possible effects of embolism of the cra- nial vessels, the case recorded by ]\Iensel may be cited, in which necrosis of the skull followed the formation of a clot in the middle meningeal artery. By far the most extensive research into the literature of typhoid hemiplegia has been made by Smithies,^ who has collected 42 cases and added one case which was under his own care. From Smithies' valuable paper we quote freely: Sex. — Of the 33 cases in which the sex is mentioned, 23 are males, 9 are females; in 2 instances the sex was not recorded. Age. — Four cases were five years or younger, 5 were between five and ten years, 8 cases between ten and twenty, 13 cases between twenty and thirty, and 2 cases were more than thirty years of age. As is readily seen, the age at which the majority of the cases of this complication develop is during yoinig adult life, which period is also the one when the patient is most likely to contract the initial disease. Aphasia. — In 32 cases in which disturbances in speech were recorded, aphasia occurred in 26. It was absent in four cases, and in the remainder of the cases there was unconsciousness, with later faltering speech or death before the presence or absence of aphasia could be determined. Time of Onset. — The time of onset varied widely. Of the 30 cases in which a detailed report is given, in but one did the hemiplegia occur in the first week. Eight instances are reported in which the condition appeared during the second week, eight during the third week, two during the fourth, and the remainder during convalescence. In one case, in winch convalescence from ' Smithies. Journal of the American Medical Association, August 3, 1907. NERVOUS SYMPTOMS h'OlJ.OWlNC TYI'IIOIh !■' i:V I'lli, 2^'.', tlic iiiiliiil jilliU'k wjis niiicli prolonn-f'd^ (hi ; coniiili'nlion ocfiirici in the cinlilli iiiotiUi. Mode of Oii.srL — In 10 cjiscs the lictniplc^ia was preceded by convulsions, in foiii- instances tlicse cunu! on sudflcniy and violently. With the convulsions there was usually associated uncon- sciousness, either temporary or lontr continued. In four instances there was delirium. In three there was stupor. In s(;vcral instances a very severe headache preceded tlie onset of the paraly.si.s. In a few instances there was very hio;h tenijxratnrc, with low muttering delirium and nervous symptoms. The Side Affected. — In 21 cases the paralysis was on the right side, in 10 cases on the left. In the remaining cases no note was made of the side affected. In only two cases of right-sirled paralysis was aphasia absent. In three of the left-sided paralyses aphasia was present. Autopsy Findings. — Five of the brains revealed the presence of a clot in the middle cerebral artery or its branches, while in the remaining fatal cases the findings were not recorded. Results. — In 6 of the cases the patients died. Twelve recovered completely. The shortest time to complete recovery was twelve weeks. In the great majority of the remaining cases there was a gradual improvement of the paralysis. This was particularly true of the gross movements, while the finer movements requiring deli- cate coordination were late in returning or entirely lost. In three instances the hemiplegia persisted without any improvement. Recovery from the paralysis w^as usually noted as being more rapid and more complete in the lower limbs, mth the muscles of the feet and lees regaining; their functions earlier than those of the arm and hands. Muscular weakness, more marked than that usually noted in post-typhoid states, was frequently commented upon. In many cases there was moderate atrophy of the parts involved. Contractures both early and late were commonly present. In the patients in whom hemiplegia was associated with aphasia the recovery from the latter disturbance was much slower and less complete than from the former lesion. In some cases there was but slight improvement in the aphasia. In but a few of the patients was there complete recovery. In no instance was the speech as 244 COM FLIC ATIOXS DURIXG CONVALESCENCE perfect as before the illness. In the non-fatal cases the loss of bladder control ■nas but temporary. Athetoid movements on voluntary eft'ort were noted by Osier and ]Jarre(t. The mentality seems to suffer no serious alteration. In a few patients, even without complicating aphasia, slow cerebration has persisted for some time after the febrile state. Confusion and hesitancy of speech is fairly common, sometimes lasting for months. There seems to be, in some instances, more than ordinary tendency towai'd post-typhoid al neuroses, particularly of the psychic nature. Prognosis. — Death occiUTcd in about 15 per cent, of the cases in Avliich hemiplegia developed. In these cases the lesions in the bowel did not appear to have been the most serious factor in causing the fatal termination. In the non-fatal cases the prognosis is for gradual partial recovery. In about 8 per cent, of the cases there was no improvement. Aphasia or other disturbances of speech after enteric fever have also been recorded by a number of observers without simultaneous hemiplegia. Thus, HutineP tells us that aphasia always occurs in children, and more frequently in boys than in girls. In some of these instances the condition arises from embolism, but in other cases recovery has ensued so rapidly that no severe organic cause of this character could have been present, and this has been proved by the failure to find embolism at autopsy. Leyden has expressed the view that such cases may be due to a mild degree of encepha- litis with rapidly absorbed exudation. Mental disturbance following typhoid fever is by no means rare, and varies in degree from slight mental enfeeblement and inability to do mental work to marked insanity. When the patients are violent they are said by some persons to have "asthenic mania." It is not mania, but the insanity of profound mental and physical depression. These variations from the normal are usually fol- lowed by recovery, as is pointed out in the interesting chapter on the mental disorders of the late stage of typhoid fever, wliich has been contributed to this essay by the senior author's friend and colleague, Dr. F. X. Dercum, Professor of Mental and Nervous Diseases in the Jefferson Medical College. > Hutinel. Etude f-ur la Convalescence et les Kechute de la Fievre Tyishoide, Paris, 1883. NERVOUS SYMPTOMS FOIJA)\VIN(l 'rVI'IIOID FEVKU 2'ir> Tremors. ^ — Rathcry' .md Ilnlincl have recorded e;i ,e , of pfj.st- typhoid (i-einor. In one ol" l{;Uh(!ry'.s cases it persisted fit'ieen moiitlis id'ter the fever ee;ised. Siinihir eases have heeii reer,i(|<(| by I^'reiiiid.'' Fry,'' of St. liOiiis, reeords a case of so-eahed paralysis agitans following immediately after typhoid fever. The I rouble began with the ending of the fever in a tremor, which gradually increase*! in violence, and chiefly involved the right arm and later the left. Still later the legs were involved. No definite reasf)n foi' Ix liev- ing the case to be Parkinson's disease and not f>ne of onh'nary tremor is vouchsafed. Amaurosis and Strabismus. — Gubler* has recorded amaurc^sis and strabismus after typhoid fever, and the latter symptom has also been seen by Nothnagel.'' Paralysis of the soft palate has also been recorded by Gubler, and of the vocal cords by Tiirck and Nothnagel. All these symptoms are but evidences of the types of peripheral neuritis, already discussed. Laryngeal Paralysis. — Bouley and Mendel" state that para- lysis of the vocal cords following typhoid fever is, in their opinion, an exceedingly rare condition. They claim they have only found ten other cases in literature which are carefully described and three others briefly mentioned. In some of these cases there was complete paralysis of the recurrent laryngeal nerve with profound paralysis of the adductors. Bernoud^ has also reported cases. Paralysis of the laryngeal muscles is probably more common than is generally thought, arising, as a rule, from neuritis. Thus, Przedlorski found in 100 consecutive cases no less than 25 cases with paralysis. Some years since, at a meeting of the Laryngological Section of the College of Physicians of Philadelpliia, Dr. MacCoy reported ' Rathery. Des Accidents de la Convalescence, Paris, 1875. ''■ Freund. Inaugural Dissertation, Breslau, 18S5. ^ Fry. Journal of Nervous and Mental Disease, 1S97, p. 465. < Gubler. Loc. cit. s Nothnagel. Loc. cit. s Bouley and Mendel. Archives G^n^rales de M^deeine, December, 189-1. ' Bernoud. Lyon M^dicale, March 28, 1897, p 453. 246 COMPLICATIOXS DURING CONVALESCENCE three cases of larvno;eal paralysis c()in})licatinii' typhoid fever. In (Joino; so he well said in his preliminary remarks: "We can most simply classify these paralyses under the various functions performetl by the larynx. Keeping clearly in mind that the chief fimction of sets of laryngeal muscles is to open and close the glottis, we can simplify the clinical facts by grouping them under the two heads of paralysis of adduction and of abduction. Paralysis of adduction in its various forms is of very great interest, and enters largely into our most interesting laryngological experi- ences; but it concerns phonation only — a most wonderful function, but not necessary to life. Abduction, on the other hand, concerns the very existence of Hfe — respiration. A moment's faltering in the function of the openers of the larynx, and we cease to exist. Being then of so vital importance, we must promptly recognize, during the course of a prolonged and wasting acute disease, like typhoid fever, the imminent risk to life when the abductor muscles are paralyzed." Dr. ISIacCoy has been good enough to send us the following reports of his cases for mention in these pages : The first case he saw was one of posterior crico-arytenoid para- lysis. It was double or bilateral, and occm-red in a case of typhoid fever at a suburban hospital. The subject was a young man who had had a severe, prolonged, and complicated attack. The patient had been ill for over two months, was greatly emaciated, and pro- foundly debilitated. One night he was suddenly seized \Wth a suf- focative attack simulating croup, (jetting no relief whatever from remedies applied. Dr. MacCoy was asked to see the case. The patient was greatly distressed in his respiration and cyanosed. Inspiration was performed laboriously, each inspiration being accompanied by stridor, and the patient appeared almost mori- bund. Laryngoscopic examination showed a complete double paralysis of the openers, the vocal bands remaining fixed in the median line. Accompanying paralysis of the arytenoid muscles with loss of tension enabled the patient to get a little air through a small triangular slit at the most posterior portion of the glottis. As promptly as possible an adult intubation tube was inserted into the larynx. This was accomplished without much distress or NERVOUS SYMPTOMS FOfJ/)WIN(! 'lYI'llOII) FEVKU 217 trepidation on the pari of iIk' piilicnt. 'I'Ih- cfrcfi of ihc iiiiul.;itioij was magical; coinj)l(>te relief to Wrejitliitig install tly followed, ;ind in a few minutes tli(^ patient was in a quiet sle(;p. The second subject presented himself fcjr consultatifHi. I le was a young man, aged twenty-three years. lie wore a frnclieofoniy tuhf. The history showed that he had liad a severe attack of typhoid fever in the South a few months previously. During convales- cence he was seized with a grave suffocative attack, and was in such a serious condition as to require tracheotomy, which relieved him completely. Examination of the larynx showed a complete fixation of the vocal hands in the mecJian line. This patient could not do without the tube, and he required it when last under obser- vation. He has a most clever device of a valve and rubber tubing and rubber bulb connected with the cannula, by which air is made to close the valve against the mouth of the cannula, and so he is enabled to carry on conversation with ease and fluency. In this case intubation was attempted but failed of introduction. The subject enjoys good health and is active in business pursuits. The third case was a soldier in one of the city hospitals, who was suffering from great dyspnoea. Laryngoscopic examination showed complete apposition of the vocal bands in the median line, with enough relaxation of tension and arytenoidal paralysis to allow a little air to enter. Intubation was strongly urged, but the visiting physician was reluctant, and the subject died of exhaustion in a short time. In MacCoy's judgment, prompt intubation in this case would have saved the man's life. Chorea. — Cases of chorea have been recorded by Rilliet and Barthez, but these may have been cases of tremor rather than chorea. Myositis. — Sometimes in the convalescence a curious state is developed in which the muscles of the lower extremities become painful, somewhat brawny, and even slight redness may appear in the skin covering them. Usually this is unilateral, but it may be bilateral. INIost commonly it affects the calf of the leg, and pain is developed on pressure or on movement, active or passive. Osier believes tliis to be a myositis. Whatever it may be, the senior author can indorse the statement that the condition is painful, 248 COMPLICATIOXS DURING COXVALKSCENCE from liis own experience, although the condition was not, in his case, well developetl. Typhoid Spine. — In 1889 ^^ P. Gibney, of New York, de- scribed, under the name of "typhoid spine," a condition in which there develops, often some days after the ])atient is uj) and about, and often only after some very slio;ht jar or trauma, great tender- ness of the spine, and pain in the back and in the legs when they are moved. When Gibney introduced the term "typhoid spine" he distinctly stated that the term carried Avith it no pathological commitment, but his suggestion was, that a periosteal lesion, in- flammatory in character and caused by the presence of the typhoid bacillus, would explain the condition. Soon after the original paper was published other reporters publislied notes upon cases having fixed deformity, and the term ''spondylitis" was employed to designate a destructive lesion in the bodies of the vertebrae re- sulting in deformity such as is found in Pott's disease of the spine. There has been much dispute as to the nature of the changes in these cases. Gibney's view of the organic change in the perios- teum was not received with favor by all, and some few men, notably Osier, inclined to the belief that in most cases the condition was a neurosis. Of late years there has been a strong tendency to return to the original view of organic change in and about the vertebrse. As tliis condition is one in which we have no fatalities, although the subjective symptoms seem out of all proportion to the objec- tive symptoms, it w^as not until the common and more skilful use of the x-raj was resorted to, that an attempt to determine the changes that take place in the spine was made. Fluss^ collected 42 cases in 1905, while Silver" has since, by a careful search of the literature, l^een able to find 67 cases reported. In his analysis he reduces this niuiiber to 53, because several of the cases were not fully reported. We quote freely from Silver's extensive report: The time of onset of the first symptoms of the spinal affection occurred as follows : ' Fluss. Centralblatt. f. d. Grenzgeb. d. Med. u. Chin, No. 8, Bd, xvii to xxi. 2 Silver. Amer. Jour. Orthopedic Surgery, October, 1907. NERVOUS SYMPTOMS FOfJ/JW/XO TYI'IIOII) FEVICH 2V.i ()nH(;t (Iiiriii« fovcr ()nH(!t during nouviiU-.Hrjtiir.f OriHct williiii oik; rruuilli after convuloHcence Onact within two irionlliH after (;onvaleHccri<:<; Onwet witl)iri tliree montliH after convalescence Onset within four rnontli.s after convaleHcence 4 .'iO 14 3 1 1 Thus in 00 per cent, the onset occurred before tlie end of the first month foUowin^ convulescence. Some rise in temperature occurred in 28 cases, or in 53 per cent, rracticully all f>f the .severe cases had a rise of tem{)erature at some time. Pain in the back is a constant symptom of the affection. Jt is always increased by, but at times is present only on, movement. The pain is remarkable for its severity, the majority of the patients being completely disabled. The location of the pathological process in Silver's cases was a.s follows : Cervical Dorsal 4 Lumbar 31 Sacral 1 Dorso-lumbar 5 Dorso-lumbar-sacral 1 Lumbo-sacral 7 Not definitely stated 5 Thus in 83 per cent, of the reported cases the lumbar region was affected. Local Changes. — A distinct swelling in the affected region, on either one or both sides of the spine, was present in 14 cases, or 26 per cent.; this was associated with redness in 3, and with increased local temperature in 4 cases. Tenderness was noted in 29 cases, 54 per cent. Kyphosis is stated as present in 15 cases of the series. Scoliosis occurred in 7 cases. The Widal test was made in 14 cases; it was positive in 12 and negative in 2. In one of the two negative cases a blood culture revealed a paratyphoid infection, wliile the other case was not so tested. The evidence is all in favor of the affection being a spondylitis or a perispondylitis, and that periostitis, chondritis, osteitis, and osteomyelitis may occur. In the same periodical that contains this extended analysis of 250 COMPLICATIOXS Dl'RIXG COXVALESCENCE this large series of cases is a verv complete report of two cases by T. Halsted Meyers. Since Silver's article appeared Francis W. White^ has reported a case that came under his care ami added to the list made by Silver several cases recently published. The number of cases collected by Wliite being 74. One of the most recent contributions to the subject is by Thomas McCrae, of the Johns Hopkins Hospital. He presented a most important paper on "Typhoid and Paratyphoid Spondylitis, with Bony Changes in the ^Vrtebra*," at the meeting of the Association of American Physicians in Washington in ]May, 1906, and pub- lished in the December number of the American Journal of the Medical Sciences of that year. He states: "There may be both a spondylitis and a perispondylitis. As Gibney suggested in 1.SS9, it may be an acute inflammation of the periosteum and the fibrous structure which hokl the spine together. Arthritis of the vertebral joints is a possibility, but arthritis of any joint is very rare in typhoid fever." Leonard W. Ely,^ in presenting an elaborate report of a case studied by him, referred to the summary and analysis of 26 cases by F. T. Lord in the Boston Medical and Surgical Journal for June 26, 1902, and to tliis number Dr. Ely added three cases from the literature and the one under his personal care.^ Neuroses. — Sometimes neurotic patients, particularly women, suffer from hysterical attacks of causeless weeping while con- valescence progresses, and in a case under the writer's care, during convalescence, a strong and hearty man, a member of the city fire department, cried like a cliild whenever one of liis fellows came to visit him. Severe hysteria sometimes complicates convalescence in typhoid fever. Thus, Simpson* records the case of a woman who was sud- denly seized with unconsciousness and rigidity during convalescence; she was confined to bed for nine years, but had regular attacks on > White. Journal of tlie American Medical Association, February 13, 1909. ' Ely. New York Academy of Medicine, November 21, 1902. ' .\n elaborate article upon this subject by Fluss will be found in Centralblatt f. die Grenzgebiete der Medizin und Chirurgie, 1905, viii, 645. ■• Simpson. Edinburgh Medical Journal, January, 1896. NERVOUS SYMPTOMS FOLLOWING TYI'IIOIh VKVEU 2:j each succeedini^' Siinduy, Uicdiiy on wliidi (he (ir.sl. ii(f;ick offurrcd. Constant vomiting was also present. A condition of very great rarity after entcrif \i-\i-v is tct;iriy. Janeway has reported cases coming on during the height u'i ty[>hoid fever on the tenth and twenty-fourth days. l^SEUDOHYPERTROPnic MUSCULAR changes have been recorded as occurring after typh(M(l fever l)y Lasage,' The patient, a man, aged twenty-seven years, was seized on the nineteenth day of the attack with acute pain in the left tliigh and with other symptoms, which caused a diagnosis to be made of plilegmasia. Swelh'ng of the Hmb did not, however, disappear, and several months later it was found to be greatly increased, the hypertrophy involving the muscular masses, which were larger and firmer than in the right leg, although the electrical reactions were not impaired, nor were the reflexes. Exercising the muscles on this side produced cramp- hke contractions. At the time the case Avas reported the condition had persisted for two years. The following references to nervous and muscular lesions com- plicating typhoid fever from Ross and Bury's monograph may be of interest in this connection : Meyer. Die Elektricitdt auf Praktische Meclicin, Berlin, 1861, p. 311. Leudet. "Remarques sur les Paralysies Essentielles Consecu- tives a la Fievre Typhoide," Gaz. Med. de Paris, 1861, Imbert-Gourbeyre. "Recherches Historiques sur les Paralysies Cons^cutives aiLX Maladies Aigues," Gaz. Med. de Paris, 1861. Handfield-Jones. "Abstract of a Clinical Lecture on a Case of Paralytic Contracture after Fever," Medical Times and Gazette, 1867, p. 390. Murchison. A Treatise on the Continued Fevers of Great Britain. Second edition, 1873, p. 225. Teale and Morven, quoted by Xothnagel. Deutsche Archiv f. klin. Med., 1872. Rehn. "Ein Fall von Lahmung der Glottiserweiterer nach Typhus Abdominalis," Deutsch. Arch. f. klin. Med.. Bd. x-^'iii. p. 136. 1 Lasage. Revue de Medecine, Xovember 10, 1SS9. 252 COMPLICATIOXS DURIXG CONVALESCENCE 1 ^andouzy. Dcs Parah/slcs (hiii.s lis Maladies . 1 i(jucs, Paris, 1880. Bauinler (C), "Ueber Liihmung des Musculus Serratus Anticus major iiacli Beobaclitungen an Cinem Fall von IMultiplen Atro- pisclien Liimunoen ini Gefolge von Typhus Abdominalis," Deuisch. Archivf. klin. Med., 1880, vol. xxv. p. 305 to 324. Stintzing (R.). "Typhus Abdominalis mit Nachfolgender Atro- pischer Liihrnung," Aeizfl. Lit. BL, ^Mimchen, 1SS3, vol. xxx. p. 4. Bartholow (R.). "Enteric Paraplegia," Medical News, Phila- delphia, 1SS3, vol. xliii, p. 609. Rondot (E.). "Contribution a I'Etude des Paralysies qui Sur- viennent dans la Fievre Typhoide; Paraplegic et Amyotrophia ^Nlyelopathiques d'Origine Typhoidique," Gaz. Hebd. de Sci. Med. de Bordeaux, 1885, vol. vi, p. 446. P^liotis. De la Nevrite Peripherique du Cubital Consecuiif a la Fievre Typhoide, Paris, 1885, These. Raymond. "Deux Cas de INIy^lite Ascendante Observes pen- dant la Convalescence de la Dothidnent^rie," Revue de Medecine, 1885, p. 648. Courtade (D.). "Des Paraplegics Survenant dans le Cours ou pendant la Convalescence de la Fievre Typhoide," L'Encephale, Paris, 1886, vol. vi. p. 431. Wurtz. "Note sur un Cas de Nevrite Tibial Anterieur Siu-venue dans le Cours d'une Fievre Typhoide," L'Encephale, 1886. Buzzard (T.). Paralysis from Puerperal Neuritis, 1886, p. 102. Bassi (U.). "Nevrite Multipla Consecutiva a Febbre Tifoide," Rev. Veneta di Sc. Med., Venezia, 1887, vol. vi, p. 585. Oppenheim and Siemerling. "Beitrage zur Pathologic der Tabes Dorsalis und der Peripherischen Nervenerkrankung," Archiv fiir Psychiatrie, 1887, p. 709. Puybaret (J. A. C). Contribution a V Stride des Paralysies dans la Fievre Typhoide, Bordeaux, 1887, Thesis. Stadelmann. "Ueber einen Eigenthiimlichen jNIikroskopischcn Befund in den Plexus Brachialis bei einer Neuritis in Folge von Typhus Abdominalis," Neurol. Centralb., 1887, p. 285. Gowers. A Manual of Diseases of the Nervous System, vol. ii, p. 824. Stoney (W.). "Paralysis of Extensor Muscles of Thigh fol- THE SKIN IN Till': i^TACK OF COW ALhSCENCE 25,'^ lowinrf Ent(!ric Fo.'vcr," Medical Ptchh mid ('ircuLar, JSSli, X. S., vol. xlvii, p. 502. Kel)lcT (J.J. " J*().st-(.y|>lioi(l Paralyses/' Cincinnati Lanceir Clinic, 1889, N. S., vol. xxiii, p. '4^). Longstreth (M.). "Neuritis after Typhoid; Klicurriatic Neu- ritis/' Phy.rician and Surgeon, Ann Arbor, ]\Iieli., 1887, vol. ix, p. 201. Comte. "Un Cas dc Paralysie G(?n(5ra]isde k la Suite de la Fifevre Typhoide," Poilcau Med., Poitiers, 1887, tome ii, p. ]]'-j. Schmidt (F.). "Ueber Neuritsche I>ahmungen nach Abdomi- naltyphus," Hamberg, 1891. Pal. "ITebcr Multiple Neuritis/' Wicn, 189], p. 37. The Skin in the Stage of Convalescence.— Aside from boils, carbuncles, and gangrene, which may appear at this time, and which have been discussed under the heading of the well-developed stage of the malady, we find as the most common complication to be erysipelas,^ According to Liebermeister, this complication occurs generally during convalescence and seldom at the height of the disease. He believes it may be a dangerous factor, although in 1420 cases of typhoid fever in Basel, erysipelas appeared only ten times, and all of the ten recovered. Eight were cases of facial erysipelas. Two others developed the disease about bed-sores. In other words, erysipelas occurred in less than 1 per cent, of these cases. Griesinger" states that it occurs in about 2 per cent. Taupin (1839) speaks of two cases of erysipelas of the face occurring in children suffering from typhoid fever. The following cases occurred within a period of six weeks of each other in the wards of St. Agnes' Hospital under the care of the senior author. The first case was separated from the second by an interval of five weeks, and the second from the tliird by less than a week. They were all in the same ward, but occupied beds at least twenty feet apart. The fu'st case was as follows: Maggie T., aged twenty-two years, was admitted December 16, 1890, with a history of chi-onic suppuration of the middle ear. 1 See article by Hare and Patek in the Medical News, January, 1S91. ^ Griesinger. Infectionskrankheiten. 254 COMPLICATIOXS DCRIXG CO.WALESCENCE She was treated at the dispensary, and rapidly improved, being discharged on December 23. On January 8, 1891, she was re- admitted with well-defined symptoms of a mild attack of typhoid fever, which ran a short course, the patient being discharged on January 30. On February 2 she entered the house, complain- ing of pain in the abdominal region and in the knees and elbows; the pains were not very severe, but the joints were somewhat swollen; the tongue was brown and dry, and all the symptoms, such as the stools, the rose-colored spots, the characteristic tempera- ture, and appearance of the patient, pointed to a relapse of typhoid fever, although at first the case was treated as one of rheumatism. The temperature did not exceed 103°, and the patient went through a moderately severe attack of typhoid fever without complication, except for very marked enlargement of the glands of the neck, which was relieved very promptly by the use of an ice-collar. On IMarch 5 a well-defined erysipelatous swelling appeared over the left side of the face, about the temples and malar bones, and gradually extended over the entire face and part of the scalp. The eyes were completely closed, and the lips very much swollen. The mouth was very painful, being covered with sores to such an extent that it was impossible for the tongue to be protruded, and it was impossible for food to be taken. The throat was very dry, and a spray was used as a mouth-wash. The ordinary treatment for typhoid fever was at once with- drawn, and the patient was put on thirty drops of the tincture of chloride of iron, three times a day. Under this treatment she improved, and by ]March 16 all inflammation had entirely dis- appeared, leaving only some swelling, which in the course of the next two weeks entirely passed away. The patient during this time continued to manifest symptoms of typhoid fever, and was unable to leave her bed on account of this disease for three weeks after the erysipelas had disappeared. Entire recovery eventually took place. The second case was that of A. E., a female, aged twenty years, who was admitted to my wards with all the early symptoms of enteric fever, which developed into a moderately severe attack, but was without any extraordinarily severe symptoms. It was estimated that at the time the erysipelas developed she was in the 77/ A' -SAViV IN TiiK STAf,'/': OF coNV aij:hcI':nci<: 255 third week of the typhoid fever. At tlie f>n.scf of th(; ery.sijM-la.s there was u cliill followed l)y a rise of teinperatiirf fint- ment, recovery rapidly took place. The mouth was unusually foul and dry, but no delirium was present. It could not be noticed that the complication in any way increasefl the gravity of the case. The third case was as follows : A w^oraan, aged nineteen years, a Swede, was admitted in the early stages of typhoid, which ran a mild course, devoid of delirium or any symptoms of importance, except that on an afternoon, about the middle of the third week of her illness, she developed a sudden rise of temperature to 104°, followed at once, on the use of cold bathing, by a fall to 98°, with loss of the pulse at both wrists. As a precautionary measure, she was treated as if suffering from intestinal hemorrhage, and soon rallied, developing during the next twelve hours a typical patch of erysipelas on the right side of the nose and over the malar bone. There was no further disturbance of the typhoid tempera- ture, and the disease remained limited to that side of the face. The patient was treated ^^^th iron and ichthyol. By far the most exhaustive study which we have found con- cerning erysipelas as a complication of typhoid fever is that of Gerente.^ According to this author, the complication comes on in one of every sixty-one cases, which would give a much higher percentage than that of Liebermeister or Griesinger. Gerente states that females are more commonly affected than males, which is a curious fact, because males are more exposed and more fre- quently have typhoid fever. In regard to the period of the disease at which erysipelas, as a rule, appears, Gerente states that it is generally after the twenty-first day, and he also believes that some epidemics of typhoid are peculiarly liable to this complica- 1 Gerente. Th^se de I'Ecole de M^decine, 1883-84, t. i. 256 COMPLICATIOXS DUIilXG CONVALESCENCE tion. The followino; conclu,sion.s of Gerento, liowever, embody most of his statements: Outside of the question of contagion, it appears to be most fre- quent in the grave, adynamic forms of typhoiil, antl in those of long chn-ation; it appears to be most frequent in lymphatic subjects. While observed at all stages of typhoid fever, erysipelas shows itself especially ami almost exclusively during the last period and during convalescence. Under these circumstances erysipelas produces a marked ameli- oration in the general as well as in the local symptoms. The appearance of facial erysipelas in the course of typhoid fever is of grave prognosis (sixteen deaths out of thirty-six cases); this gravity lies less in the erysipelas, which most frequendy is benign in itself, than in the poor general condition of the patient, the secondary infection being an indication of this condition. The complication consists in a simple coincidence favored by debility, the result of the primary and principal disease. We think the statement that erysipelas seriously influences the prognosis in all cases too sweeping. Thus there are cases on record in wliich the onset of the acute disease has not in any way retarded convalescence. If the disease becomes phlegmonous the prognosis is, of course, very grave; but if the inflammation is capable of undergoing resolution the prognosis is good. Eysipelas of the face is rarely met with dming the course of typhoid fever. We have found it recorded in 64 out of 3910 cases, which is about 1 to 61. These figures are derived from the fol- lowing statistics. Typhoid fever Erysipelas cases. cases. Chomel 130 4 Louis 134 .3 Forget 92 1 Jenner 05 2 De Larroque 105 4 Zuelzer 84 3 Liebermeister 1420 10 Zuccarini 480 18 Griesinger 500 10 Murchisoni 900 9 Total 3910 64 1 The number of Murchison's cases is not strictly correct. 77//'; ,S7\:/yV IN T/f/'J STAdK OF CON V A f. ESC FN CI-: 257 'V\\i\ (jiUisUon ;i,s (o llic j);i-lli \\\ wliidi vt)\\\;\i^\i,\\ find , ciilijinfo has l)een much (h'scnssed, but the opinion of (iri<;.siM^<;r i.s f^fiicr- ally ac(;optc(l. lie believes tliuL IIk; ^- toms set in on September 18, 1881, with pain in the head, vertigo, abdominal tenderness, pain in the right iliac fossa, and an elevated temperature. On October 4 a complication arose in an otorrhoea which by the 22d was growing steadily worse, so that the patient's condition was critical. Now facial erysipelas made its appearance, beginning in the auditory canal. Early in November osteitis of the humerus set in, and the patient died on November 9. Thielman^ reports the case of a man, aged thirty years, brought into the hospital in an unconscious condition. The right ear, eye- lids, nose, greater part of the face, and forehead were covered with an erysipelatous eruption. The tongue was dry and brown, there was pain in the ileocecal region, and the Hver was painful and enlarged. The fever was recognized as typhoid, and the patient put upon calomel. The patient was in a delirious condition, but on the following day there was a slight remission, and he became partly conscious. The erysipelas was seen to be spreading farther over the face, but leaving its original seat. There was delirium the following night and semiconsciousness. Desquamation set in on the right side of the face, the eruption extending on the left. The pulse grew stronger, but the tongue was still brown in the I Armieux. Rev. Med. de Toulouse, 1875, ix. 42. = Thielman. Med. Jahresbuch v. Peter-Paul Hospital in St. Petersburg (1S40. 1841), 142, 147. 17 258 COMPLICATIOXS DURIXC COXYALESCENCE centre. The patient was noticed to ])e troubled with occasional cough, and the respirations were somewhat more frecjuent. Exam- ination showetl a hypostatic congestion of the lungs. The condi- tion became critical, but was relieved, and the patient gradually improved, being dismissed as cured on the thirty-fifth (hiy after admission. Berthoud' re])orts a(juestional)le case of a soldier who had typhoid fever of a nu'niiigeal type. The typhoid fever was declining, but convalescence was tardy, and his general condition was unsatisfac- tory. At this time the scrotum became tumefied and red, the red- ness spreading to the inguinal regions, while the general condition became very poor. The scrotum was triple its natural size, red, moderately warm, tender, not very painful, but oedematous, the redness extending to the right and left inguinal regions as far as the anterior superior spinous process, and also to the internal aspect of the thigh. The skin in these parts was swollen })ut soft, and the color persisted on pressure. On the next day there was no amelioration of the symptoms, but a very small area of necrosis appeared on the scrotum, which was treated by the application of the cautery. On the following day the necrosis seemed to be arrested and the scrotum reduced in size. The general condition, however, remained alarming. Six days later the patient died, after a subdelirium of four hours. The autopsy showed that the iliac and renal veins were involved in a plastic and suppurative inflam- mation, a case of erysipelas in the veins. The conclusion reached was that the redness of the skin and infiltration were due purely to mechanical causes, viz., the stagnation of the blood. Freud enberger" has recorded two cases, in one of which erysip- elas appeared suddenly on both ears in the course of typhoid fever, without unfavorable symptoms. On the following day a chill and rapid advance of the disease took place. The typhoid fever was now considered as declining, but the prognosis grave, because of the erysipelas. In the second case, facial erysipelas suddenly appeared during convalescence from typhoid fever, although the temperature was already quite low. The fever became 1 Berthoud. Gaz. des Hop. de Paris, 1848, v. 29. - Freudenberger. Aerztl. Intelligenzblatt, Miinchen, 1880, xxvii, 37. Till': SKIN IN TIII'J STACH O/-' ('f)N \.\ Li:SC ENC I'] 250 high ii|ji;ii,iii, hiil, was easily iiidiicnccd In Jinlipyrclirs. 'J'lic j^iilse was ]4(). Potaiii' reports a case of erysipehis coining f>n (hiring convales- cence from typiioid fever, which was acconi|)aiiic(l hy a severe rliill and fever. The erysipelas hegan in (lie |)liaiyn.\ and pidaic, ;iud did not affect the tonsils. On the next day die iidhiiiiinwnoji appeared at the corners of the mouth and on the face. Finally, Martinez'^ reports the following cases: A girl, agerl twenty years, belonging to the lower class, of lymphatic teniporfs three cases of abscess of the thyroid in 027 antopsies of ty[>lioid cases. In very rare instances the thyroiditis develojjs with the onset, as set forth by TaveP and Ivaveran.* Finally, it is a noteworthy fact that Chantemesse' has f(jiiiid the bacillus of Eberth in the pus of the thyroid gland and his finding.s have been substantiated since that time by many other observers, among the number being Schadmosky and Valerhos," I>ifhtheim- Tavel,^ Jeanselme,** and Schudmark and Vlachos." A case of suppuration of the right lobe of a goitrous thyroid gland has been recorded by Spirig/" in a woman, agetl twenty-two years. This complication arose after five weeks of typhoid fever, when the disease was on the decline; both the bacillus of Eberth and the staphylococcus were found in the pus. In not a few instances an examination of the pus from the abscess within the thyroid has revealed the ordinary pyogenic micro-organisms, staphylococcus and streptococcus, and it has been noticeable that in this class of cases the condition has been more unfavorable in as much as the condition is a part of a general septicaemia. Joints. — Articular lesions complicating convalescence from typhoid fever may be due to direct infection \di\\ the specific bacillus, which is rare, or to infection by other organisms. This question is ably considered in Dr. Keen's monograph, already quoted, and does not need to be discussed at this point for this reason. 1 Robertson. American Journal of the Medical Sciences, January, 1902, - Topfer. Munch, med. Woch., 1892. 3 Tavel. Ueber die Etiologie der Strumitis, ein Beitrage zur Lehre von den Hemato- genen Infectionen, Bale, 1892. '' Laveran. Revue de Chirurgie, September, 1890, No. 29. 5 Chantemesse. Art. Fi&vre Typhoide in Traitede Med.de Bouchard et Charcot, 1891,768. 6 Schadmosky and Valerhos. W^ien. klin. Woch., July 19. 1900. " Lichtheim-Tavel. Ueber die Aetiologie der Strumitis, Basel, 1892. s Jeanselme. Arch, gen., July, 1893. 9 Schudmark and Vlachos. Wien. klin. Woch., 1900, No. 29. ^'^ Spirig. Correspondenzblatt fiir Schweizer Aerzte. February 1, 1892. 2G4 COMPLICATIOXS DIRIXG CONVALESCENCE Robin and Lereckle* have, however, called attention to the inter- estino- fact that acute articular intlannnation is .sometimes met with in typhoid fever, and believe it to be rheumatic in some cases. On the other hand, in the great majority of instances the joint affection is not due to acute articular rheumatism, but is simply an evidence of the septic process associated with the typhoid fever. Great care should be exercised by the physician that articular inflammation does not mislead him into an erroneous diagnosis. rorter reports two cases of typhoid coxitis, and publishes radio- graphs of the condition. The first sign w^as inability of the patient to lie on the affected side, and there w^as a tendency to keep the thigh flexed; also a tendency to spontaneous dislocation of the hip. As is well known, dislocations have been recorded in consider- able number as having occurred during the progress of typhoid fever and in acute rheumatism. In the first of these diseases the displacement of the bone has occmTed in the earlier days of con- valescence, when the patient has been so feeble that it has seemed as if the accident was due to the relaxation of the coverings of the joint and its associated muscles, with the result that the bone has easily slipped out of place, and in nearly all these cases there has been no evidence whatever of any local difficulty prior to luxation. On the other hand, in acute articular rheumatism where dislocation has taken place there has nearly always been a history of arthritic difficulty prior to the accident, and instead of the dis- location producing pain of a moderate degree, as it has done in convalescence from typhoid fever, the occurrence of the displace- ment has been followed by great relief from pain, owing to the overcoming of the vicious attitude which has been maintained by the limb. The cases of scarlet fever in which this accident has occurred have belonged rather to the typhoid class, in that the dislocation has taken place without much pain, and, therefore, without attracting great attention to its presence. As long ago as 18S2 Rawden reported, in the Liverpool Medico- Chirurgical Journal, an instance of dislocation follo\^^ng typhoid fever, in which, having excised the head of the bone, he found it 1 Robin and Leredde. Archives G<5n^rales de Mddecine, September, 1894. ^ Porter. American Journal Orthopaedic Surgery, 1904-5, ii, 167—172. .lOINTH 265 practically iioniiiil, even llic cartilji^*; bciri^ licaMliy, cxfcptin;.'- \i>r a little ab.soq)tion at lis [X'riplicry; while, on flif oiIkt IkmkI, Adams, in a case of rheumatic (lislocation of ilic lii|>, I'dmikI the capsular ligament ruptured and (lie (orn margins f>l" die r«-nt closely eml)racing the neck of tin; bone. While it is true that unobtrusive monarticular synovitis with effusion may take place in convalescent patients, the literature of the subject does not reveal the fact that post-typhoidal flislocations have usually been due to this condition, and Collier believes that degenerative changes similar to those seen in muscular fibers result in softening of the hgaments and of their attachment (o ihe bones. The possibility of recurrence of the dislocation under such circum- stances is great, and the prognosis as to the correct use of the limb must be made with caution, since some cases seem to become entirely well, while others never get rid of a certain amount of ankylosis or shortening. In this connection it may be a matter of interest to note that the case of typhoid fever with knee involvement under the senior author's care in the wards of the Jefferson Medical College Hos- pital in the early part of 1897, to which reference is made in Keen's essay, page 97, was seen by the senior author again in March, 1899. She was able to walk without the aid of a crutch, but the knee was permanently ankylosed. It will be remembered that aspiration of this knee-joint obtained fluid wliich was perfectly sterile. A much more interesting point in connection with the case, from a prognostic point of view for other cases, is that the ankylosis in marked flexion, wdiich Dr. Keen thought would require operative treatment later on, was gradually overcome, so that shortening in the ankylosed limb was very slight. Prieto^ has reported a case of artliritis involving the tarsal and metatarsal bones, and Laignel, Larastine, and de Jong' have re- ported cases of osteitis and periostitis after typhoid fever. 1 Prieto. Eev. de med. y Cirug. pract., Madrid, 1907, Ixxvii, 96. ^ Laignel, Larastine, and de Jong. Bull, med., Paris, 190S, xxii, 151. CHAPTER Y. THE COXDITIOXS WHICH RESEMBLE TYPHOID FEVER. These conditions are quite numerous. The following is a list of the more common of them: ^Malarial fever, appendicitis, sepsis, pneumonia with great asthenia, tuberculosis, particularly of the abdominal contents; ileocolitis, ulcerative or septic endocarditis, scarlet fever, cerebrospinal meningitis, and paratyphoid infections. Since the first edition of this essay appeared, the continued use of the "Widal test, with a clearer knowledge of its limitations, and the advances made in the methods of studying the blood by means of cultures, particularly by the simplified method of Conradi- Drigalski, to determine its bacteriological contents, have made it possible to separate typhoid infection from the above conditions. It is to be remembered that although comparatively few physicians possess the necessary apparatus, or the bacteriological training, necessary for the successful carrying out these tests, they have at their command full assistance in the many laboratories which have, because of the universal demand, been established throughout the country. With the important question of the diagnosis from malarial fever we have already dealt in the chapter on the Well-developed Stage of the Disease. The important facts for the physician to remember are that the infection by the bacillus of Eberth and that bv the parasite of malarial fever may pursue a course in each case almost identical with one another, and that in such cases a differen- tial diagnosis is to be made chiefly by means of the Widal test on the one hand and a search for the malarial organism on the other. It is also to be recalled that the quinine test is not of great nega- tive value, and that its persistent use in a malarial case may simply make the microscopic diagnosis impossible. For these reasons the use of quinine for several days without result should not be persisted in, since the case under these circumstances is probably TIU<: CONDITIONS WHICH Ji/i>SJwMnJJ'J TYl'IIOllj FEVEii 207 not due to miliaria. Spciikin^ of lliis tlicnipcutif: test, \)uv\. \\c\\ says: "In a case reseiiibliii^ typlioid fever, hut ntally rniihuial, the microscope is essential to ^ofxl [)ractice. Without it, (|uiiu'ne may again he used; hnl if Ihc Icnipcriiliiic iV)v<. not full lo oi- ocar normal, with relief to the other syinj)tonis, il is hcttcr to stop quinine altogether. Only when inicroscopir- evideiife of malaria is present should the di'ug he piislicd ;d'(cr the diiid day. It is necessary to add that while symptoms persist, the jxitient should be treated as though he had typhoid fever. So erroneously is the so-called therapeutic test conceived, that I have known of patients taking quinine in doses of forty grains a day U)y tliice weeks, in order to determine the presence of malaria, each fall of 1° or 2° of temperature being looked on as proof of a s[)ecific efi'ect. I am well aware that some look on massive doses of fjuinine as useful in typhoid fever, but considerable observation has convincwl me of the opposite view." With these views, particularly those of the last sentence, the writers are in entire accord. The facts, already well emphasized in this essay, that severe chills, rigors, and sweats may appear in many cases of typhoid fever entirely devoid of any trace of malaria, proves that all these signs are not proof of malarial infection. In confirmation of these views we find the interesting report of Ewing,^ made after his able studies among soldiers of the Spanish-American war at Montauk Point, in which he says: "The reason why the blood was examined in 159 cases of typhoid fever, was the intermittent character of the fever, wliich was exhibited in patients both with and without malarial antece- dents. In no case of undoubted and established typhoid fever were malarial parasites found in the blood in connection with any of these sudden rises of temperatm-e, but only at the onset of the disease or during the convalescence. "On the other hand, many patients whose blood contained numerous parasites were seen in the 'typhoid state,' but there were always some essential symptoms lacking to confirm the diag- nosis of typhoid fever, wdiile the subsequent course of the disease demonstrated the purely malarial character of the fever. 1 Ewing. New York Medical Journal, February 4, 1S99. 268 THE CO^DITIOXS WlllL'II RESEMBLE TYPHOID FEVER "These patients might suffer from epistaxis, ha-matemesis, bloody stools, tympanites, a few rose spots, though oftener herpes, diarrhoea, and delirium, and in some a partial Widal reaction was obtained. But the intestinal symptoms were inconstant or refer- able to dysentery or simple diarrhoea, from which many of the malarial cases suffered, and these patients never showed sub- sultus or cracked tongues, and they did not die, or, if they did, dysentery and malaria were demonstrated at or before autopsy." Ao-ain, he says: "It is possible that some of these patients suffered from both active malaria and typhoid fever, but there were no positive indications that the latter infection was present. In the cases that came to autopsy there was never any doubt of the natiu-e of the disease. It was either typhoid fever or malaria, but never both, although microscopic evidence of dormant mala- rial infection was found in at least two cases of typhoid fever. "In short, in spite of very painstaking efforts, the attempt to- find a case of typhoid fever and active malaria progressing simul- taneously was unsuccessful." From a study of tliis group of cases Ewing concluded : "1, That typhoid fever is to a large extent incompatible with active malarial fever, and that during the course of the former the latter infection is usually suppressed. "2. That the presence of old malarial infection may alter the course of typhoid fever through the anaemia, but that active sporu- lation of the malarial parasite very rarely occurs during the course of established typhoid fever. "3. On the other hand, since malarial paroxysms often reappear during convalescence, a scanty growth of the parasite must often persist during the course of typhoid fever, and it is possible that some of the irregularities of temperature observed in these cases- are referable to this partly suppressed growth. "4. That the anatomical evidence of a postmortem examination is much needed to demonstrate the existence of typhoid fever in cases showing active malarial paroxysms." A valuable paper upon the relations of typhoid fever to mala- rial infection was published some years ago by Oilman Thomp- riii<: CONDITIONS wiiK'ii i{.h:si':MiiLi': tvi'iioii) i<'i-:vi-:it 200 soil,' ill wliicli lie I'cjiclicd rcsiills i(|('iilic;il willi tlioic jii t liilc'l, namely, that the fever of ty})h(>i(l is iipt to run its course, and that malarial manifestations then sij(:c;c(,"(i il. It is of interest to note that although many (;f (he jj;i(ients siifff-r- ing from typhoid fever at the Johns Hopkins Hospital eonif from malarious regions, only three cases of simultaneous infef;tion by tlie malarial parasite and the Bacillus typhosus are known to have occurred in 1100 cases of typhoid fever admitted to that institution. Lyon, who reported one of these, was able to collect from the litera- ture only 29 undoubted cases, but there were many others in which, although the evidence was not so conclusive, it seemed jjrobable that a mixed infection did exist, and he concludes that in tr(;[;ical countries, where malarial fever is endemic and typhoid fever prev- alent, combined infections are probably common. As already stated, since the more prevalent use of the Ijlood culture and the Widal test, on the one hand, and a more careful search for the malarial parasite in the stained blood smear on the other, the differential diagnosis of the two conditions has been rendered less difficult, and physicians are reaching the conclusion expressed by Dr. Osier some years ago, that "there is no such entity as typhomalarial fever, there being but two forms of con- tinued fevers in the South, the one due to typhoid, the other due to malarial infection." Pysemic and septicsemic affections, such as infective endocarditis, osteomyelitis, puerperal septicaemia, and even appendicitis, or otitis media, may somewhat closely resemble typhoid fever if these affections are insidious and there is pus present which produces a toxaemia. Whatever the cause of the sepsis may be, the loss of flesh, dry tongue, delirium, low^-grade broncliitis, badly nourished skin, and diarrhoea may cause the patient to be most t}^hoid in appear- ance, yet in all such cases we should seek for a possible purulent focus. The absence of a positive cultm-e or of the Widal reacdon and the presence of leul<:ocytosis should arouse om- suspicions greatly, and it is not to be forgotten that the presence of pus deep in the pehis or in the neighborhood of the kidney may not be readily discovered, so that only the development of fluctuation, or the rupture of the 1 Thompson. American Journal of the Medical Sciences, August, 1894. 270 THE COXDITIOXS WHICH RESEMBLE TYPHOID FEVER abscess, will force the physician to revise his diagnosis of typhoid fever. On the other hand, as already pointed out, piu'ulent forma- tions may occur in typhoid fever, the Bacillus typhosus acting as a pyogenic organism, or the sepsis may be due to associated infection by other organisms. Similar symptoms make us suspect and search for signs and causes of ulcerative endocarditis in such cases. The fact that tuberculosis may simulate typhoid fever, and that cerebrospinal meningitis may likewise do so, has already been dis- cussed in the foregoing pages, but it is not out of place to point out that four types of tuberculosis are particularly apt to produce misleading symptoms. In tuberculous meningitis the febrile move- ment is rarely as high as in typhoid fever with associated meningeal symptoms; the abdomen is usually scaphoid instead of tympanitic, and the persistent vomiting of the former disease is comparatively rarely met with in the latter. An ocular examination may reveal optic neuritis in tuberculous meningitis, or paralysis of the muscles of the eyeball, causing squint. An aid never to be forgotten in these cases is afforded by a careful examination of the cerebrospinal fluid removed by limibar puncture, which will many times reveal the presence of tubercle bacilli or an excess of lymphocytes. An additional aid in diagnosis is a careful and persistent examination of the urine and faeces, which may reveal tubercle bacilli, when an examination of the sputum is negative. It is also to be remembered that even in patients who have fever much may be learned by the use of the cutaneous tuberculin test, which is entirely without danger if the necessary precautions are used in performing it. So, too, in acute general miliary tuberculosis, the previous his- tory of the patient as to gradual failure of health, and cough, and the rigors and sweats point to the presence of tuberculosis rather than enteric fever. Further, there AAdll be in some cases marked physical signs of widespread involvement of the lungs in tubercu- losis which will be absent in typhoid fever. It is to be recalled, however, that a roseolar rash may develop in both affections, and that diarrhoea and a dry, brown, tongue may mislead the careless rJlE CONDITION!^ WfffCff R/CSKMBfJ-: TYI'llOlh I'KVEU 271 very readily. Mvcn itilc.s(in;il liciii'>rrli;ii^';(' rii;i\' ocrin' in iiiili;iry tul)er('iil()si,s.' Tubercul(Mi,s jK-ritc^iiiU.s may also cau.sf; tvplioid syniptf^ins, l>ijt as the disease progresses the locahzation of tlic a}>dorr)inal syrn[>- toms and, finally, the development of tumor masses or enlarge- ment of the mesenteric glands, can he felt on deep palpation, or, in other cases, the development of ascites makes the diagnosis clear. Girandau^ has recorded a case in which a young man sufffTcd from enteric fever, and then speedily developeare her .system for operation, slie (lovelo})ed marked lano;uor and malaise and fcijrile movement, which is shown in the accompanying chart (Fig. 20;, and three days later developed typical rose rash of typhoid fever, her blood giving the positive Widal reaction .simultaneou.sly. I'he questions which naturally ari.se in regard to this case are: l-)id the woman suffer primarily from appendicitis, or from tuberculous peritonitis, or did she come under my care at the end of a mild primary attack of typhoid fever after which she harl a relapse, or, again, is it possible that suffering from a mild chronic intestinal catarrh, she received typhoid infection just prior to her entering the ward, thereby superimposing typhoid fever upon the condi- tion present when we first' saw her? Because of her ultimate complete recovery we are inclined to believe that the primary fever could not have been due to tuberculous peritonitis. Another interesting case, illustrating how difficult these differ- ential diagnoses may be, is reported by Dresclifeld in AUbutt's System of Medicine, in which three members of one family that had lived in a cellar which had been under water at the time of an extensive flood were attacked T\-ith a fever. Their symptoms closely resembled those of enteric fever, and one of them pre- sented on the tliird day after admission marked roseolar spots, and had slight intestinal hemorrhage on the fifth day. The tempera- ture showed marked exacerbations, and the patient died from exhaustion on the foiu-teenth day after admission, or about the seventeenth day of the fever. The postmortem examination revealed the intestines apparently healthy. Dresclifeld says he can quote similar cases. He does not state what he believed this illness to be due to, but from the context he evidently regarded it as septic, although the absence of intestinal lesions, as we have already stated, does not exclude enteric fever. Leu^ has reported a case of puerperal septicaemia which was 1 Leu. Charity Annalen, 1891, srv-i, 315. 18 274 THE COXDITIOXS WHICH RFSEMBLE TYPHOID FEVER almost indistino^uishabk' from tyj^hoid fever, for the patient had a rose rash, tympanites, enhirged spleen, intestinal infection, and the pyrexial cm-ve, which is characteristic. The fact that puerperal septicaemia is fatal within a few days, that there is a local focus of the disease, and that such a disease would not present the AYidal reaction nor give blood cultures of typhoid bacillus, would aid us in making; a differential diay-nosis. Another condition which may closely simulate enteric fever is the g'astro-intestinal form of epidemic influenza, for in this con- dition we have enlargement of the spleen, diarrhoea, tympanites, gurgling, slight evidences of bronchial irritation, and very rarely, indeed, a suspicious roseolar rash. It is perfectly possible for enteric fever and influenza to occur simultaneously in the same patient. Under the name of mounfain fever, a febrile disease occurring in the great highlands which occupy the middle portion of the United States has been described by a number of authors. Some of these "VM'iters have been strongly of the opinion that mountain fever is a distinct entity, while others have gone so far as to assert that it is an irregular manifestation of malarial poisoning, and still others that it is a modified form of typhoid fever. As a matter of fact, we may state positively at this time that true "mountain fever" is in all cases nothing more than a greatly modified or altered type of typhoid infection. As has already been pointed out in this essay a number of times, typhoid fever is a disease which varies greatly in its symptomatology and course, and does not, in many instances, follow the classical descriptions of it which we are accustomed to find in the text-books. One of the most conclusive and interesting papers dealing with this matter which is to be found in recent literature, is that of Raymond, who, as post sm'geon at one of the United States Army stations in the West, has contributed to the American Journal of the Medical Sciences, 1898, vol. cxv, an exhaustive paper upon this subject, while Woodruff,^ also of the Army Staff, has reported thirty-five cases at Fort Custer, which he says w^ould certainly have been described as mountain fever, but in which the clinical ' Woodruff. Jour. Amer. Med. Assoc, 1898, xxx, 753. THE CONDITIONS WHICH /^'Hs/'.uii/j-: TYi'iioii) ilioi(l fcvci- is of inlci-csf. If, is ^fciifr.'iily fonsifh-rfd that one attack renders a j)alieiil, al least pailially iiiiiiiiiiir- \i) oilier attacks, but for many years there liave Ixcn duriieroiis reports of second attacks of the disease. '^J'lie aedial oecurrenef; of these attacks, however, have rarely })een proved hy positive blood cultures, \t is impossible, however, to make tlie arbitrary statement that no second or third attacks of ty])li()id I'ever oeeiir. As in other infectious diseases, second and even tiiird attacks sometimes do occur. These repeated attacks probably occur in patients having an unusual susceptibility to the infection, or because the immunity developed by one attack is lost much earlier than by most individuals. Every physician of large experience has seen a number of cases which are said to have had more than one attack of typhoid fever. In a number of these cases one of the supposed attacks is likely to have been due to an infection with the paratyphoid bacillus, the malarial organism, influenza, or to some form of bacteremia developing mthout a discovered point of entrance, or, lastly, from an infection by the tubercle bacillus which the vitality of the patient has speedily overcome. In addition to a careful study as to the possibility of the disease having been other than typhoid fever, it is essential, for a scientifically accurate diagnosis, that the typhoid bacillus be recovered from the patient's blood, as the significance of the reaction by the Widal test is impaired by the fact that the serum reaction may persist for months or even years following the primary attack of typhoid fever. Coville,^ in reporting 1400 cases of typhoid fever in the epidemic at Ithaca, calls attention to the fact that many who had previously been infected again contracted the disease, but in a very mild form. Recurrences of typhoid fever usually take place during epidemics, and seem more frequent among men than women. The second attack is usually milder than the first, although this is not always true; ambulatory and exceedingly mild cases make up a large number of the second attacks, and the cases may be so mild and the symptoms so few and vague that a diagnosis is diflScult. ' Coville. American Medicine, June 9, 1904. 2S0 DURATIOX AXD IMMUXITY TO SECOXD ATTACKS ^Nloore^ lias recordetl a case of a man who suffered from typhoid fever at fifteen years and again at twenty-nine years, and finally from a relapse after this second attack, and Leidy- has reportetl a case of a boy who had an attack of enteric fever at sixteen years, a second attack six months later, a third at the age of thirty-four years, and this followed by four relapses, in the third of wliich he hatl intestinal hemorrhage, but recovery, nevertheless, occurred. Diu-ing the winter of 1897-98 the senior author had under his care a boy who was suffering from his third attack of typhoid fever, his first having occurred at nine years of age, the second at seven- teen years, and the third at nineteen years. Death occurred from hemorrhage of the bowels. In none of these cases, however, was the diagnosis confirmed bv blood cultures. Perochatid^ reported a case which appeared authentic in which one of his patients died during his third severe attack of typhoid fever. In 1626 cases Bey found only one which had a second attack. One of us (Beardsley) saw in consultation with. Dr. B. F. Royer, of the ^Municipal Hospital, a patient supposedly suffering his third attack of typhoid fever. The patient was a young physi- cian, who gave a history of having, during a boarding school epidemic, suffered a mild attack of typhoid fever at the age of fourteen. At twenty-two years he suffered a very severe attack complicated by profuse hemorhages from the Ijowel, and during convalescence from a persistent neuritis as well as troublesome bed- sores. The third attack occurred in 1907 and in the patient's thirty-second year, and was typical as to signs and symptoms, but was milder than either of the previous attacks. One week after the patient was out of bed following this third attack of fever, he suffered from a localized pain along the course of the saphenous vein, which lasted but a day, but was suggestive of a mild phlebitis. During the last attack the Widal reaction was constantly negative and so remained during convalescence, and it is only fair to state that neither of the previous attacks was proved to be typhoid by 1 Moore. Dublin Journal of Medical Science, April, 1893. 2 Leidy. International Medical Magazine, August, 1893. 3 Perochaud. Gaz. M(5dical de Nantes, July 22, 1899. DURATION AND IMMUNITY TO ShCON/J ATTACKS 2S1 the positive l)l()Of] ciiltiire or l)y positive VVidjil reii/tion, hnl I'lom a clinical standpoint tlie patient undoubtedly siiflVicd lioni duce distinct attacks of typhoid fever. We may add dmi diuiiif,' the last attack the agglutination reaction vvidi (he paratyphoid l);i'ilhis was tried and was negative. Although there can he no niing evident until later. It is extremely probable that in such cases there is a markc^fl hererJi- tary tendency to insanity, and that the depression of the prrxlromal period of the fever merely acts as an exciting cause. It siujiild be added that these cases are quite rare. We shoiiUl, hr>\vever, remember that if a given case is obscure in its origin, if the mental depression has developed in a manner more rapidly than that seen in melancholia, and if it is otherwise atypical, the commitment should, if possible, be delayed and the case be kept under observa- tion for some days. The occurrence of this form also shows how important it is to make a thorough 'physical examination of the patient. In the second form of mental disorder of the prodromal or initial period, we have present, as already stated, the symptoms of an acute delirium. This delirium is characterized by profound mental obtusion, confusion, and hallucinations, which are often terrifying in character. There are manifestations of great fear and often impulses to violent acts. In tliis form violent assault upon the person, murder, or suicide may occur. It may, indeed, in rare cases attain the violence of typhomania^ {delirium grave). (See chapter on Onset.) While the delirium is usually accompanied by terrible hallucinations, the patient seeing frightful objects and hearing terrifying sounds, it is under rare circumstances associated with expansive ideas. Kirn" describes a case in which instead of depression there was present delirium of grandeur, only, however, to be followed by depression later on. Deiters^ reports two cases of mental disease of typhoid origin. Both the cases he reports presented a bad nervous heredity. He beheves that this heredity is of importance especially in the appearance of these psychoses of invasion. Both cases presented the symptoms of an initial delirium, and Deiters concludes that in all acute psychoses which accompany a febrile invasion we must always 1 Nasse. AUegemeine Zeitschr. f. Psych., 1870-71, p. 11. ' Kirn. Ibid., vol. xxxix, p. 741. s Deiters. Munch, med. Woch., 1900, No. -47. 2S6 THE MEXTAL COMPLICATIOXS think of a possible typhoid fever. The initial delirium may precede the tlevelopment of the fever for some time. The physical signs may only make their appearance relatively late. The acute delirium of the initial period is to be looked upon as among the unusual mental complications of typhoid fever. It appears to be present especially in certain epidemics, as, for instance, in that recorded by Blanc* as occurring among French troops in Tunis. "Whether the delirium actually antedates the outbreak of fever is uncertain, inasmuch as accurate temperature studies are as yet lacking. It may, however, continue for some time after the fever has been established, and may merge into the ordinary fever delirium. In other cases, again, it disappears altogether as the height of the fever is reached. Many cases, however, die before the fever has fully developed. The existence of acute delirium in the prodromal or the initial period of typhoid fever is always to be looked upon as of ill omen. According to Adler,^ only one-third of the cases presenting this complication recover. The mental complications occurring during the period of fever separate themselves into (1) the ordinary fever delirium, (2) expensive or ambitious delirium, and (3) stupor or coma vigil. The fever delirium is ordinarily quiet in type, and, though at times associated with excitement, does not merit separate consideration here. The expansive or ambitious delirium, a rare form of compli- cation, may be present during the entire course of the fever. INIore frequently it comes on after the fever has passed its height, and persists during the period of decline. In such cases the patient presents the picture of the delirium of grandeur. In a case observed by the writer the patient kept talking about his bags and vaults of gold, about his diamonds, fast horses, and other great worldly possessions. The delirium is not accompanied by marked excitement, and disappears with the defervescence of the fever.^ The stupor of typhoid fever, like the ordinary fever delirium, is ' Blanc. Schmidt's Jahrbucher, cc.xiv. 2 .\dler. Allegemeine Zeitschr. f. Psych., vol. liii, p. 753. 3 Cases have been reported by Delasiauve, Christian, Simon, and Liouville, Diet, of Psycholog. .Med., vol. ii, p. 98G. Till': MKNTAL COMPLICATIONS 287 SO well known as no( (o nicril dcscriplion. I( may onna on as a gradual deepening of the initial aj)atliy and liebctudeof the (Ji.sea,se, or it may be a transition from tlic fever flelirium. .More rarely it is the outcome of an acnic delirinni of the initial jx-iiod. fts oeeur- rence at an early stage is always of grave signifieanee. When arising during the period of decline, it sometimes cfHitinucs long after the fever has subsided. The insanities which arise during or subsefjucnt to convales- cence are those which principally concern us here. They may arise during the subsidence of the fever, anrl may be merely a continuation of the confusion and delirium of the febrile stage; much more frequently they make their appearance after the fever has entirely disappeared. Post-typhoid insanities may make their appearance in one or other of the following forms: 1. Acute delirium. 2. Confusional insanity, stuporous insanity.* 3. Cerebral asthenia, pseudodementia, pseudoparesis. 4. Insanity with systematized delusions resembling paranoia. 5. True mania or true melancholia. 1. Acute Delirium. — The acute delirium following typhoid fever is indistinguishable from the delirium of exhaustion follo\\-ing other infectious fevers, shock, trauma, or other profoundly debili- tating causes. It is characterized by excessive mental confusion, increased rapidity in the flow of ideas, numerous and varied hallu- cinations, obtusion of the perceptive faculties to both internal and external impressions, and marked motor excitement. The onset is usually sudden, and frequently corresponds with, the ter- mination of the fever. It appears to coincide with the collapse wliich follows the disappearance of the fever in some cases. At other times a brief interval of a day or two characterized by in- somnia and ominous restlessness precedes the outbreak. Con- sciousness becomes more obscured; the patient loses the proper recognition of his surroundings, he becomes illusional, everything 1 Kraepelin and Regis are among the few systematic writers to fully appreciate the etiological relation of tMDhoid fever to these disorders. PagUans, Re\Tie de Med., 1S94, xiv, 549 and 656, imfortunately misinterprets, as did the older writers, post-tj-phoid condi- tions attended by excitement or depression as mania or melancholia. 2SS THE MENTAL COMPLICATIONS seems strange and changed, ami in addition he becomes hallueina- torv to an extreme degree. The chairs and other objects of furni- ture are mistaken for strange shapes, persons, or animals. The indivitluals about his bed are no longer properly recognized; the pictiu-es upon the walls, the curtains upon the windows, the rugs upon the floor, all become animate objects. The hallucina- tions rival the illusions in their variety and number. They appear to consist especially of auditory and visual sensations. Voices call to him, strange persons, horrid creatures gesticulate, beckon, terrify him. It is not strange imder these circumstances that he appears to have dreadful and depressive delusions. He believes that horrible punishments are to be meted out to him; that he is to be cut, to be stabbed, to be poisoned, that he has only a short time to live. No wonder that his struggles are often merely the outward expression of a frenzied fear. Very rarely the hallucina- tions and the delusions are of a pleasurable and expansive char- acter, the patient sho\\ing by his demeanor, as well as by his speech, the pleasure that he feels. Sometimes he is distinctly erotic. Occasionally depressive and expansive mental states are present at different; times in the same case. The speech of the patient, in keeping with his disturbed mental condition, is for the most part fragmentary and confused, and the delusive ideas are difficult, if not impossible, to follow. Of course, the delusions themselves are fragmentary and unsystem- atized. The patient cries out or utters merely parts of sentences and phrases, and when the condition is fully established, his words may be entirely incoherent or consist of senseless alliterations. At other times he talks excitedly, loudly, pathetically, or whispers, gesticulates, and makes grimaces. It is generally impossible to obtain a rational answer to a question, though sometimes, during a momentary lull, the patient may comply with a given direction. The well-meant attentions of the nurse and friends are misunder- stood and generally actively resisted. Sleep is almost abolished, indeed, completely so in some cases during the entire attack. Food and medicine are administered with great difficulty. When the food is placed in the mouth the patient may spit it out, though in other cases it may be greedily swallowed. As the delirium 77//'; MHNTAI. (;(>MI'IJ(:A'ri()S'H 2S9 reaches its li('i\\U\s('i\, and the motor excitement miinifesls itself in senseless strn^'j^ling or in purposeless and automatic movements, turning about the ix-d, aimless gestures, pusliing, rubbing, etc. The |)hysieal condition is indicative of great weakness, the color is j)ale, the surlace oi' the body is cohl and often moist, and the emaciation of the typhoid fever is rapidly and greatly aeeent- uated. The pulse is small, sometimes slow, sometimes rapid; it is always weak. As a rule, abrasions and ecchymoses are olxserved on various parts of the body. Generally they are the unavoidable results of the patient's struggles. Acute delirium is a complication of short duration. It may hist only a few hours; it never extends over more than a few days. Recovery is ushered in by the return of consciousness, which is generally quite rapid. The patient begins to recognize his sur- roundings and his hallucinations disappear. He begins to comply with the directions of the nurse, takes his food, and, above all, begins to sleep. As a rule, the recovery is steady and uninterrupted , but at times it is broken in upon by recurrences of the delirium, generally transient in character. Recovery does not, however, always ensue. The exhaustion may proceed so far as to lead to stupor, and the patient may remain in this condition for a prolonged period of time. The final prognosis, however, of even this form of compHcation is relatively good. The great majority of cases of acute delirium following typhoid fever recover. However, emotional irritability and instability, hebetude, and physical weakness persist for several weeks after the delirium has ceased. The memory of the patient for the events of the attack is much obscured. He can seldom, if ever, give any but a vague account of his experiences. A word of caution may not be out of place here in regard to the too free use of alcohol in the treatment of typhoid fever. The \\Titer once saw in consultation a cliild in wliich the delirium proved not to be a sequel of the fever, but was really due to the large quantities of alcohol wliich had been administered. A marked and typical alcoholic multiple neuritis, sthenic in character and exquisitely painful, was also present. 19 290 THE MEXTAL COMPLICATIOXS 2. CoNFUSioxAL Insanity. — The second form of post-typhoid insanity to daim our attention is confusional insanity. Like the acute delirium following typhoid fever, it closely resembles the confusion resulting from other infectious and exhausting disease. It is characterizetl hy obtusion, mental confusion, incoherence of ideas, illusions, hallucinations, and by a prolonged course. It is much more frecjuently met with as a sequel of typhoid fever than acute delirium. Typhoid fever most frecjuently induces exhaustion gradually; it is only in exceptional cases in which this exhaustion comes on suddenly that acute delirium ensues, liegis^ maintains that the psychoses whicli make their appearance in the postfebrile or convalescent periods are more of the type of an asthenic confusion. It is undoubtedly true that in by far the larger number of cases the more slowly acting causes induce the more gradual developing and more prolonged affection we are about to consider. In keeping with these statements the onset is much less rapid than in acute delirium. It does not make its appearance until some days after the fever has subsided; generally, however, M-ithin the first week. The patient becomes nervous, restless and cannot sleep. 5oon he becomes unaccountably afraid and excited, fears impending trouble or death, is obtuse, fails to comprehend readily, often complains that he cannot think, and he readily be- comes confused. After several days the symptoms become so pronounced that the patient begins to lose the correct appreciation of his surroundings, or of the circumstances in which he is placed. He no longer knows where he is, mistakes the people about him for strangers, and often begs piteously to be taken home. To the illusions are soon added hallucinations. He hears threatening voices, shouts, and cries. He sees frightful objects or horrible lookino- men who load him with abuse and curses. As in acute delirium, the patient now believes that he is being injured, that serious bodily harm is about to be done him, that he is to be beaten, crushed, killed. In addition, the illusions also play an important part, even greater than the hallucinations. The patient in his condition of fear is excessively watchful of his surroundings, which he constantly misinterprets. The commonest objects are misun- ' R^gis. Archives de Neurologie, 1905, xx, 268. Till': Ml': NT A I. COMJ'LICAT/OXS 201 derstood — a .sjjoom is taken for a knife, a ilieiinoineicr inspires deadly fear, a Iiypodenrn'c injection is re/^arded a.s a savage on- slaught with a dagger. 'J'he patient also eateh(;s worrls anrl phrases uttered by the bystanders with surprising readiness, always, of course, to inisinter])ret them. l*'or tliis reason it is well not to whisper in the patient's presence, nor to make unnecessary gestures, nor to move about the room mysteriously. Sometimes it is possible, by speaking distinctly and loudly, to attract the patient's attention for a short time. Feeding, when possible, can be accomplished by this means. The food should be urged upon the patient by speech, by the proper presentation of food to vision and to the lips. Frequently, however, it is impossible for many hours at a time to bring the patient to himself or to a realization of his surroundings by any means whatever. Although the hallucinations are most frequently of a terrifying and depressing character, they are not necessarily so. In rare instances they are pleasurable, and the patient may talk in a dis- connected way about his wealth, the beauty and grandeur of his surroundings, and the glorious future that lies before him. Such expansive ideas also are now^ and then found in an intercurrent manner in the ordinary depressive form. In keeping with these facts, the emotional state is usually one of depression and apprehen- sion, infrequendy one of slight exaltation. Laughing and singing are sometimes interspersed with the manifestations of fear, and at times slight eroticism is noticed. The thoughts are disordered and tangled, while, as in the acute delirium, there is almost always some increase in the rapidity of the flow of ideas. Consciousness, as already stated, is much obtunded; frequently it is dream-like. More or less motor excite- ment is always present. It is, however, much less marked than in the delirium. The patient is restless, tries to get out of bed, tries to run about the room, struggles at times to get away, and may exliibit some tendency to ^^olence. In some cases there is relative quiet from muscular weakness or, perhaps, from inhibition. In others the patient holds fast in a senseless sort of manner to siu-- rounding objects or persons, or resists in a semipassive way the attentions of the nurse. In other cases, again, he betrays evidences 292 THE MEXrAL COMPLICATIONS of automatism and tends to remain for some time in the position in whicli lie has been phiced. Symptoms such as these, however,' are rehitively infre(|uent. The speech varies considerably. Sometimes whole sentences are uttered, at other times merely phrases, fragments, or inco- herent and disjointetl words. It is, however, much easier to gain some iilea of the character of the delusions which pass through the patient's mind than in acute delirium; there they are largely a matter of inference, here they are often more or less plainly expressed. As might be expected, sleep is much disturbed. In- somnia is always marked, especially at night. Food is taken badly, partly because it is not properly recognized and partly because of fear and the suspicion of poisoning; the latter idea has its groundwork largelv in illusions and hallucinations of taste and smell. The physical condition of the patient is, as a rule, bad. Molnar^ describes two cases of acute hallucinatory confusion Avhich occiuTed in the convalescent period of typhoid fever. In the first case there were present hereditary factors and in this case severe intestinal bleeding had also occurred. Both cases recovered at the end of several months. Loss of flesh is marked, though rarely as striking as in acute delirium. The surface is cool, the extremities often cold, sometimes moist. The temperature is not infrequently subnormal,^ though it may be normal throughout. The pulse is slow and lacks force. Now and then there is incontinence. The reflexes, when they can be studied, are usually found exaggerated. The symptoms attain a maximum in from two to three weeks after the actual onset. The subsequent course is apt to be irregu- lar, the confusion becoming more or less marked by turns; the periods of temporary improvement often correspond to the taking of increased amounts of food, or follow more or less successful periods of sleep. Convalescence generally sets in very gradually. Generally many weeks elapse before persistent improvement is noted. The patient begins for short periods of time to properly appreciate his surroundings and to understand what is said to him. » Molniir. Wien. klin. Rundschau, 1899, No. 19, p. 307. 2 Wood. University Medical Magazine, December, 1889, ii, 117. Tlll<: M/'JNTAL (:(JMJ'/JCAT/0\S 203 The periods of lucidity gradually Im-couic |>ir,|<)iiu^((| imiil, \'i<,]n being merely of a few hours' duration, (licy hist tlirr>ugli the gifjitr-r part of tlie day. Diu'iug tli(^ eoriv;dc.scenee the pjificnt is ofh-ri irrital)le and luu-d to j)lc;i,s('. Somcliiiics traces of die oM rljstru.st and suspicion are seen; tlie patient makes absurd c;liarges against his nurse, or is obstinate and intractable. Gradually, however, he becomes more sensible, more friendly, and begins to manifest confi- dence in those about him. In many instances, too, diiiin;,^ this period, the patient is mildly excited or depressed, wlu'le in f;thfrs some of the hallucinations persist after lucidity has made its apj>ear- ance, but in such case the latter are no longer made the basis of delu- sions. Rarely, however, fleeting delusions now and then betray themselves. A valuable index as to impending convalescence is the wiUingness of the patient to take food. Partial relapses, it should be added, also occur, especially as the result of emotional excitement, the visits of importunate and mistaken friends, or other imprudent management. The time occupied by the course of the disease varies from six weeks to four months, and sometimes longer. By far the larger number of cases recover, provided, of course, that they receive good care and nursing. Even after recovery appears to have taken place, the patient may betray decided mental weakness and readiness of fatigue. This asthenia is often prolonged, and may persist for months and, exceptionally, even for a year or more. Death as a result of typhoid conf usional insanity, is very infrequent. Death from suicide or accident should not be forgotten as a possibility. Korsakow's psychosis which must be regarded in spite of its memory fabrications and fictions as merely a form of confusional insanity has also been observed as a sequel of typhoid fever. Such a case has been placed on record by Soukhanoff,^ who describes an interesting case of a well-defined Korsakow's psychosis which developed in a man, aged thirty-four years, after a typhoid fever. The man had not been an alcoholic and there were no hereditary factors. The mental symptoms made their appearance simul- taneously with, the symptoms of neuritis. Soukhanoff points out ' Soukhanoff. Journal de NTeurologie, 1902, No, 7, p. 121. 294 THE MEXTAL COMPLICATIONS also that the oldti- tlic patient suffering from a Korsakow's psychosis is, so much more do disorders of memory become apparent. Stuporous Insanity. — Sometimes, though infrequently, cases wliich l)egin as confusional insanity merge into stupor, the nervous exhaustion becoming so profound that the mental faculties are finally completely suspended. However, cases that become stuporous differ from the ordinary confusional cases in the length of the developmental period, and although a stage of confusion is present preceding the onset of stupor, this stage is usually short. The stuporous form is, therefore, well defined clinically, but bears close relations to the form characterized by confusion. Stuporous insanity is characterized chiefly by a more or less marked abeyance of the mental faculties. It is also known as acute dementia or curable dementia. It is of extremely gratlual development. Several weeks usually elapse before stupor is established, and diu'ing this preliminary period the patient is nervous, timid, and fearful, sleeps badly, complains of headache, and is dull of comprehension. Instead of gaining in weight, as does the ordinary case of typhoid during convalescence from the fever, he is either at a standstill or loses. He is worried, feels ill, and loses his appetite. Soon mental confusion makes its appear- ance. As in confusional insanity, the patient loses the proper appreciation of his surroundings. He believes himself to be away from home and fails to recognize the persons about him, and after a time this inability to interpret his sm-roundings gives way to an inability to appreciate them at all. The patient lies motionless in bed, indifferent apparently to everytliing about him. In this condition he cannot be made to answer questions, and does not speak spontaneously. Emotionally he seems placid and indifferent, though in some cases periods are present during which transient emotional movements, excitement, depression, or weeping are observed. The face is relaxed, flaccid, and expressionless. He is utterly helpless. Frequently he betrays a form of automatism; he may remain for some time in the position in which he has been placed without moving. Thus the arm may be kept elevated, the fingers extended, or the head turned to one side. These symptoms are often spoken of as cataleptoid, but they have, of course, no 77/ A' MJ'JNTAL COM I'LICA'I'IOSS 205 relation with tr(ie cjitii,lc[).sy. Auni('f| hy agitation or purposeless movements. The U'vA\\\\r ol" the padf-nt is often difficult. At times he will swallow food that is j^hieefj In his mouth, at other times he will allow it to remain in the mouth, makinp; no effort at swallowing, or will allow it passively to escape upon the pillow. In many cases nasal feeding is the only practi- cable plan of administering nouiisiinient, and, as a rule, this can easily be carried out and answers every possible purpose. Tlie physical condition of the patient reveals great depression of nutrition. There is decided loss of flesh, coolness or coldness of the surface, and at times a subnormal temperature. The features are pale, perhaps slightly cyanosed. The extremities are often bluish and sometimes oedematous. The pulse is small and slow, the respiration shallow. In women the menses cease. Like confusional insanity, stupor is an affection of long duration; several months are always required. Convalescence also is estal> lished very gradually. The patient begins by betraying some consciousness of his surroundings. He may attempt to speak or make movements of expression. He also begins to take his food more readily, brightens up a little toward the latter part of the day, and little by little comes into normal relations with his environ- ment. Readiness of fatigue persists for a long time, and there are frequent recurrences of mental confusion which reveal themselves either in the patient's actions or in his conversation. Great care should be taken to conserve the strength of the patient as much as possible by the avoidance of excitement or of visitors. While by far the greater number of cases end in recovery, tliis is not the invariable rule. A few cases pass into permanent dementia; in others some permanent mental impairment persists, and in a smaller number death results, due either to the gravity of the exhaustion or to some visceral complication. 3. Cerebkal Asthenia, rsEUDODE:MEXTiA, Pseudoparesis. — More frequently, perhaps, than any other complication, we have folloT\ing typhoid fever a condition of general mental enfeeblement. This is generally of short dm'ation, but is sometimes excessively prolonged. There is present in such cases a slight, though unmis- 29G THE MENTAL COMPLICATIONS takable, weakness of the intelligence, together with abnormal excitability and loss or impairment of emotional control. The patient does not comprehend as readily as normally, is incapable of sustained effort, lacks spontaneity of thought, and laughs or cries on relatively slight provocation. He is also very readily fatigued. At times there is in addition a diminution in the facility and readiness of speech. Physical symptoms indicative of weak- ness are also present — e. g., coldness of the extremities, cardiac palpitation, atonic indigestion, and persistent sleep disturbances. This cerebral asthenia for some unexplained reason, occasionally follows comparatively mild attacks of the fever, and may be very marked. In other cases, again, in which the attack has apparently been of great severity, these symptoms may be entirely absent. Instead of a mere mental weakness and anenergia, actual mental obtusion may be present, and this mental obtusion may become so pronounced as to lead to great impairment of all of the mental faculties — a form of dementia. This is not, however, a true dementia, but one in which the mental faculties are merely suspen- ded, not obliterated. It is properly termed a pseudodementia. This pseudodementia lasts many months and at times even one or two years. Recovery follows in the majority of cases, but is very gradual. Sometimes it is incomplete, permanent mental impair- ment resulting. Every now and then there are added to this back- ground of dementia symptoms which closely resemble those of paresis. Thus there may be present great muscular weakness, ataxia of movement, tremor of the lips, face, or extremities,^ and to the condition of obtusion, hebetude, and mental weakness already present, there may be added absurd and ambitious delu- sions. This feeble, expansive state makes the resemblance to paresis appear very striking and often misleading. The pseudo- paresis of typhoid fever may occasion difficulty in diagnosis if the physician be in ignorance of the etiology. However, the detailed history of the case, the presence or absence of the Argyll-Robertson pupil, the condition of the optic nerve as revealed by the ophthal- moscope, are among the factors which should be considered. Pseudoparesis following typhoid fever almost always terminates 1 Christian, Westphal, R^gis. Till': Mh'NTAL COMl'LICATIOXS 207 in recovery; l)osi(]e,s, the course; of tli('(H,sea.se is cJifferent fivMii that of paresis. The mental loss, too, is Jiot as profound or as real. 4. Insanity with Systkmatizkd Delusions IIkskmuling Paranoia. — A very h'milcd nimilx r of cases oi' insaiiify following tyj)hoi(l fever })res('iit a series of nioix* or less well-systcinatized delusions. These delusions are at times remains of the fever de- lirium M^hich have persisted. At other times they arise during convalescence. The patient may give well-connected accounts of frightful persecutions, of murders, hangings, etc. The delusions are almost invariably of a depressive character, and appear to be connected with painful or terrifying hallucinations. Such cases have been described by Miiller,^ Hurd,^ and others. They are distinguished from true paranoia not only by the peculiar etiology, but also by the fact that the delusions are not firmly fixed, but often shifting in character, and also by the fact that sooner or later, as soon as the general condition of the patient improves, the delusions vanish. Recovery may, however, not always ensue, and progressive mental impairment, with final dementia, may be the result. Such an outcome, however, appears to be exceptional. 5. True Mania pr True Melancholia. — In addition to the various forms of mental disorder above described, and which are evidently associated with the excessive nervous weakness and, perhaps, the profound intoxication of the typhoid infection, pure insanities are every now and then observed. In other words, true mania or true melancholia may arise subsequent to typhoid fever. Owing to the loose way in which the terms mania and melancholia are employed by many medical writers, many cases of so-called mania and melancholia have been placed upon record as resulting from typhoid fever. A close examination, however, reveals that they are in most instances cases of an insanity of exhaustion, generally confusional insanity, which have been classed as mania or melancholia, according to the presence of mental excitement on the one hand, or mental depression on the other. Pure mania or pure melancholia, as a result of typical typhoid fever, is excessively rare. For instance, .typical melancholia with excessive psvcliic pain and self-accusatory delusions, as typified by the delusion of 1 Miiller. Loc. cit. - Hurd. .Ajnerican Journal of Insanity, July. 1S92. 298 THE MEXTAL COMPLICATIOXS the unpardonable sin, is almost never met with. This is also true of pure mania as typified bv excessive exaltation, expansion, and increased rapidity in the flow of ideas, without hallucinations or confusion. Further, cases of the pure insanities follo\Aing typhoid fever do not, as a rule, like the insanities of exhaustion, develop iuunodiately after or ^^•ithin a short period of the defervescence of the fever, but at rather later periods — weeks anil months afterward. It is exceedingly probable that when a pure insanity does follow typhoid fever it is an indirect sequel. In other words, the post- tvphoid condition of asthenia merely offers a suitable soil in which true mania or true melancholia may develop in subjects predis- posed to these affections by heredity. We should remember that mania and melancholia are largely determined by heredity, and only need a condition of depraved nervous nutrition in order to make themselves manifest. Prognosis in General. — The prognosis of the various mental complications of typhoid fever depends largely upon the period at wliich the symptoms appear. Prodromal insanity, especially grave prodromal delirium, tends in a large number of cases — one- third according to Adler — to end fatally. The prognosis of the comphcations arising dming the fever is almost uniformly good. The fever-dehrium, the confusion, the expansive and ambitious ideas vanish with the disappearance of the fever. The various forms of mental derangement w'hich occur as sequelre of typhoid fever also offer a favorable prognosis as a wdiole. The great majority of cases of post-typhoid confusional or stuporous insanity make a good recovery, but this is not by any means the constant result. Instead of a continuous progress toward recovery, there may be a series of relapses, follow^ed by incomplete recovery, or cases may pass into hopeless clironicity and dementia. This, how^ever, as has already been pointed out, is the outcome in a small percentage of cases only. Pilgrim^ states that in his opinion only about 50 per cent, of cases due to typhoid fever recover, wliile 20 per cent, die from exhaustion, and 30 per cent, gravitate into clironic insanity. These statements, however, are not borne out 1 Pilgrim. State Hospital Bulletin, Utica, New York, 1896, i, 50. Ph'OCNOS/S IN a EN ERA L 209 by \}h'. ('Xpcriciicc oiil.siMc of (lie ;i,syiiim.s. Tlic jjcrfci]l;i;.'(' ol' favorable rcstiMs is really iiiueli <^i'ea(,er. The EiTECT of Typhoid Fevkii ox J'jik-kxih'J'ing Txhantty. — It may be not uninteresting to add a paragraph as (o the re- markable efFects which follow typhoid fever when attacking those who are already insane. In quite a number of such cases, irre- spective of the special form of insanity, recovery follows typhoid fever. In others, again, long-continued improvement ensues; in a smaller number temporary improvement, and in others still no change whatever is observed. Nasse/ Wise,^ Keay,^ Charon,' and others have placed on record quite a number of cases of recovery.'' Friedlander" has also studied this subject, and has, like others, noted a recovery from mental disease after attacks of typhoid fever. Frequently in such cases the mental recovery does not take place during the period of convalescence, but only some time after convalescence from the latter has been completed; sometimes after many months. Paris^ differentiates between the febrile deliria and the true psychoses, and calls attention to the fact that during an attack of typhoid fever psychic and epileptic disturbances subside; that typhoid fever, when invading insane asylums, attacks only the youtliful cases and cases of recent admission, and, furthermore, typhoid fever is infrequent in insane asylums, and that there is, therefore, really a pronounced antagon- ism between the psychoses and typhoid fever. The author has apparently not taken into account the studies of Fried lander. The interesting fact of recovery from insanity after typhoid fever is comparable to the effects of other infectious processes, such as erysipelas, and also to the results occasionally follo^dng trauma and surgical operations on the insane. Even in so grave a mental disease as paresis, an attack of erysipelas or a trauma is occasion- ally followed by a striking and remarkable remission of symptoms; * Nasse. Loc. cit. 2 Wise. State Hospital Bulletin. I'tica, New York, 1S96, i, 63. ^ Keay. Journal of Mental Sciences, 1S96, xlii, 267. * Charon. Arch, de Neurol., 1S96, i, 330. 5 Hja^ert, Arch, de Neurol., 1895, vi, 103, believes on the other hand, that tj-phoid fever atfects the mental state of the insane to a less degree than do other infections. 8 Friedliinder. Loc. cit. 7 Paris. Le Progr&s medical, 1902. No. 24. 300 THE MEXTAL COMPLICATIONS similar statements may be made with regard to melancholia and other forms of mental disease associated Avith depression and impaired nutrition. In cases in which typhoid fever fails to cure or to improve the mental symptoms, the psychosis already present does not appear to be affected injuriously. At least this is Nasse's^ conclusion. One case under the observation of this writer presented a paroxj'sm of delirium of short duration; in none of the others, five in number, in which the typhoid infection failed to cure the insanity, did any unfavorable result supervene. Nasse further observed a greater percentage of recoveries from typhoid fever in the insane than among the hospital attendants. Wise,^ on the other hand, found the mortality 30 per cent, among the insane and 24 per cent, among the employees. These data evidently do not point to any lessened degree of vulnerability on the part of the insane. 1 Nasse. Hj'^'ert, Arch, de Neurol., 1895, vi, 103. ^ Wise. State Hospital Bulletin, L'tica, New York, i, 69. PART II. COMPLICATIONS AND SEQUELS OF THE ERUI*- TIVE FEVERS OTHER THAN TYPHOII) FEVEll. CHAPTER L VARIOLA. Incidence and Susceptibility. — The practice of vaccination and revaccination has rendered smallpox, as a cause of death in the United States, and in all other countries where vaccination is constantly practised, of comparatively slight incidence. Never- theless, the disease is always interesting because of its periodic outbreaks wherever an unvaccinated community is exposed to the infection. There are three causes for the appearance of sporadic cases of smallpox. The first, and by far the most important cause, is the neglect of successful vaccination of every individual. The second cause is the neglect of the act of revaccination at stated periods through life, particularly during the presence of an epidemic; and the third, and much less important, cause is unusual susceptibility of certain persons to the infection. That there are persons that are unusually susceptible to variola there can be no doubt, but, of cpurse, if such persons were vaccinated with an active vaccine at various times, this susceptibility might readily be done away with. As illustrative of the occurrence of extraordinary susceptibility, a case reported by James^ may be cited. A young mother had variola six months before the birth of her 1 James. Lancet, January 1, 1902. 302 YAEIOLA child, -which showed a few variolous scars at birth. This child was unsuccessfully vaccinated after birth, and again at nine and at fourteen years of age without result, but at the age of eighteen years she contracted hemorrhagic variola and died. It is quite possible that the vaccine used in the attempted vaccinations was not active, but the case is an interesting and unique one. The annual average death-rate of variola in the United States was 3.4 per 100,000 population, from 1901 to 1905, which means that vaccination, revaccination, and quarantine has practically eradicated the tlisease. Prodromal rashes and dermal complications are, as might be expected from the nature of the disease, the most common complications of variola. In the early stages of the infection the prodromal rashes are of immense importance. These rashes vary widely in type and often serve to obscure the true diagnosis for hours, and, it may be, for several days. The frequency of such rashes varies in different epidemics. During the widespread and severe epidemic of 1871-72, in America, they were very common, being observed in 13 per cent, of the cases observed by Osier in iSIontreal. These prodromal rashes are not, however, commonly seen in smallpox hospitals, as they generally disappear before the appearance of the true variolous eruption wliich causes the admis- sion of the patient to such an institution. These initial rashes in variola have recently received deserved attention in an excellent paper by Thomson and Brownlee.^ In this paper, which is a most exhaustive treatise upon the subject, the authors divide the rashes into (1) general erythemata, (2) local erythemata, (3) petechioid eruptions, (4) petechial rashes, (5) vesicular, (6) bullous, and (7) composite prodromal rashes. The general erythemata are as follows: (a) Morbilliform, (6) scarlatiniform, (c) erysipelatous, (d) livid erythemata, (e) urticaria. The local erythemata are as follows : (a) Pale, simple erythemata, (6) capintoid erythemata, (c) erysipelatous erythemata. Prodromal rashes are more often seen in cases of varioloid than in patients suffering from variola. They usually develop upon the second day of the fever, and they commonly disappear in from twenty-four to 1 Thomson and Brownlee. Quarterly Journal of Medicine, January, 1909, vol. ii. No. 6 PROUUOMAL RASJ/J'JS AND DERMAL (JOM J'DKJATIOSS ■/,{)'/, forty-oi;^}it lioiirs. TIk; rashes rri.'iy, however, iv-iiKiin ('.ci;!! (Jays after the appearance of the true variolous rash. The morbilliform rrupiion is llic mosl (•((ininon lypc' <,\' iiiiii;il rash. The eruption is irreguhirly (Hstrihtilcd, hciiif^ al limc^ limited to a, small poriion of the body and at other times generaiizech Jt differs from the ordinary eruption of measles in heing less elevateri above the skin and searcely pereeptible when (he finger is passerJ over it. The scarlalinijorm eruption is next in fre(|ijency to the j-ash whicli resembles measles. It may involve a large part of the cutaneous surface, or may affect certain areas, as the thighs, the iii;^iiinal rcffion, the extensor surfaces of the extremities, and the trunk. Rashes of this variety are not infrequently mistaken for the scar- latinal rash which sometimes accompanies an attack of typhoid fever as well as for the ordinary rash of scarlet fever. The petechial or hemorrhagic initial rash is especially liable to appear in certain well-defined regions of the body. This distri- bution has been carefully studied by Simon, of Hamburg, who pointed out the frequency of this eruption on the lower abdominal, inguinal, and genital regions and on the inner aspects of the thighs. The axillary region as well as the lateral surfaces of the chest and abdomen are also affected. The eruption consists of pin-point to pin-head purplish spots closely aggregated, which gives the skin the appearance of a diffuse redness, and as this redness is due to minute hemorrhages into the skin, the discoloration does not dis- appear upon pressure. The petechial rashes are sometimes seen in cases which prove to be quite mild, but more often they are found in cases which become hemorrhagic in type and malignant in character. Rashes other than those mentioned are rarely seen, and composite prodromal eruptions are only occasionally observed. The conditions of the skin which develop as complications, other than the prodromal rashes, are often of grave importance. Septic eruptions, in distinction from septic infection of the skin during; variola, were first described bv Simon^ in 1S73, and have since received careful attention by JNIeredith Richards,- Welch and 1 Simon. Archiv f. Derniatologie u. Snihilis. 1S96. p. 31. - Meredith Richards. Quarterlj" Journal of Medicine, 1S73. p. 115. 304 VARIOLA Schamberg/ and other writers. During the epidemic of 1901 to 1903, in Phihulelphia, Welch and Schamberg observed septic rashes at the height of the disease in from o to 8 per cent, of the cases admitted to the ^Municipal Hospital. These rashes are undoubtedly due to the action of bacterial toxins. Jn distinction from the rashes that are due to the absorption of toxic material during the disease, we have the secondary pyogenic infections of the skin. Among these are impetiginous lesions, boils, and sulicutaneous abscesses, large and small, carbuncles, erysipelas, and cellulitis, with the occasional occurrence of gangrene of the skin. Durine the stage of incrustation and desiccation in variola it is common to have impetiginous areas develop; in fact, it is unusual to have a patient convalesce from unmodified variola without the occurrence of such skin lesions. Hebra^ called these lesions "impetigo variolosa," and the same term has been used by Welch and Schamberg. In cases where there is a large extent of skin affected with these sores there is often a considerable rise in temperature and other evidences of septic absorption, and this may, very rarely, bring about the death of a patient who is apparently convalescing from the original illness. Welch and Schamberg^ have reported an instance of this kind in a woman, aged sixty years. Boils and Subcutaneous Abscesses. — Boils and subcutaneous abscesses are the next most frequent complications or sequels met Anth in variola. It is very unusual for a patient to pass throuo-h an attack of unmodified variola without suffering from these troublesome complications during the convalescence from the disease. Even patients who have variola which has been modified by early vaccination often suffer from boils. They usually develop during the interval from the twentieth to the thirtieth day of the illness, and are most frequently situated on the extremities, although the face, scalp, and the back are also affected. They vary in size from that of a bean to that of a small orange. They 1 Welch and Schamberg. Acute Contagious Diseases, pp. 196 to 198. 2 Hebra. Diseases of the Skin, p. 231. ' Welch and Schamberg. Acute Contagious Diseases, p. 193. PRODROMAL UASII/'JS AND DERMAL COMJ'L/CA'J/OXS :',{):) are not attended by great pain or by much constitwdonal disfiirh- ance, })ut they are often present in large nuinhcrs. 1 1, is not unusual for a patient during convaleseenef; frf)rn variohi lo fiuve froin five to fifteen boils incised cadi iiioiiiiii;^ for days, and die total number incised often exceeds oik; himdrcd. In rjistinctifjn from boils, large abscesses on the shoulders, hips, limbs, and neck often develop, usually in conjunction with the boils, as well as smaller abscesses in other portions of [lie borly. d'hese abscesses differ from furuncles in that they are extremely jxiinful and are accompanied by septic symptoms, which are sometimes severe enough to cause the death of the patient, who has already been greatly weakened by the primary disease. Moore^ reports a case of variola under his care at the Dublin Fever Hospital, in which forty-two abscesses followed an attack of confluent smallpox, the patient being confined to bed for nine months before recovery took place. The junior author remembers a similar case at the Municipal Hospital of Philadelphia, in the winter of 1903, in which a frail, aneemic, little woman, after passing through an unusually severe attack of variola, developed abscess after abscess, and finally recovered after having had thirty large abscesses drained and scores of smaller abscesses and furuncles opened on all parts of her body. Castellvi^ had the unusual experience of observing a patient develop a psoas abscess while convalescing from variola. True carbuncles are rare complications of variola. Welch and Schamberg,^ in their extensive experience with tliis disease, are only able to recall one instance in which a carbuncle developed. Erysipelas.— Erysipelas also rarely complicates variola, bu,t when it appears it usually develops at the end of the second or in the beginning of the third week of the disease. The face is the region usually aflfected, although the extremities sometimes suffer. When we consider the septic nature of the original disease, the multiple abrasions of the skin, and the weakened condition of the patient, it is surprising that erysipelas is so rarely seen. Welch 1 Moore. Twentieth Century Practice of Medicine.^lSQS. xiii, 428. - Castellvi. Ann. de Obst., Ginecopat., y. Pediat. (Madrid, 189S), pp. 193 201. s Welch and Schamberg. Acute Contagious Diseases, p. 230. 20 306 YAEIOLA and Schamberg^ saw l)ut ten cases of tliis condition in 2000 cases of variola. Cellulitis. — Cellulitis, Avhieh usnally affects the extremities, not infrequently complicates confluent cases of variola during the stage of decrustation. This cellulitis may involve a small area, but more often it is widespread, the condition extending tleeply and often spreading over nearly the entire liinl). The affected part is red, brawny, and hot to the touch and extensive sloughing of the tissues often occurs even when free incisions are made. Not infrecjuently these conditions prove fatal in patients whose resist- ance has been greatly lowered by the primary variolous attack. Gangrene of the Skin. — Gangrene of die skin during variola may be produced in certain cases by the swelling and inflammation, and gangrene of the subcutaneous tissues may result from the undermining of such tissues by the pus from unrelieved abscesses. jNIarson" has noted gangrene of the genitals of women during severe attacks of variola. Gangrene of the scrotiun diu'ing variola occurs only in very severe attacks of the disease, and the majority of the patients thus affected die. The complication usually begins as an oedematous swelling of the scrotum, which is rapidly followed by sloughing, and most commonly this develops at the end of the second or the beginning of the third w^eek of the disease. Gangrene of the skin, other than that of the genitals, affects isolated areas, usually those portions which are subject^ to pressure, and is only seen in severe forms of the disease. Welch and Schamberg saw, during the epidemic of 1901 and 1902, three cases of gangrene of the scrotum and five cases of gangrene of the skin of the thigh. In four cases of the latter complication recovery ensued. Scarring. — Scarring after smallpox occurs in practically every confluent case of the disease. The extent of the scarring depends entirely upon the depth to which the inflammatory lesions extended. After the lapse of several months the scars assume a whitish color, paler than the surrounding skin. The scar may be of any size or shape, according to the shape and the grouping of the lesions which caused it. ' Welch and Schamberg. Loc. cit. 2 Marson. Quoted by Moore Twentieth Century Practice of Medicine. ' Welch and Schamberg. Acute Contagious Diseases, p. 231. oca LA u L/uS/ONS DUinsc vmhoi.a ;^,f)7 Ar>oi'KClA. — Al()j)('ci;i, is ;i vrry i'rc(jiicii( ,sc(|iic| of \;iriol;i. A , in other severe febrile diseases, the hair of \\\c hcnd, heanl, and the eye})rows may he lost after the terinin;i(i(»ii of ;i sl)rile processes as to the local iiifiiiciifc of the cnifi- tion. liestoration of the hair usually occurs and is connnf>rdy complete, exce})t in areas in wiiich the pa|)ill;i' of (he hair have been destroyed by the variolous lesions. The loss of the nails from both fingers and toes is seen in a certain number of severe cases and is usually brought about by injury to the matrix, after which the new nail slowly displaces the old. Ocular Lesions during Variola. — Ocular lesions rluring variola are common, but since Jenner's discovery of tlie protective influence of vaccination the destructive action of smallpox upon the eye has greatly lessened. There are, however, certain compli- cations which still commonly affect these organs. Burton Chance^ analyzed over 2000 cases of variola that were treated at the ]\Iunici- pal Hospital of Philadelphia, and states that among the common complications he found pustulation of the edges of the lid. Con- junctivitis often accompanied this pustulation, but in many cases conjunctivitis appeared independently of the pustulation. In the 2000 cases analyzed there were a very large percentage of cases showing conjunctivitis, which bears out what has been pointed out many times — that it is rare to have a patient suffer a severe attack of variola without there being an associated conjunctivitis. In this large series of cases analyzed by Chance there are men- tioned only 36 instances of corneal ulcer. Of these 36 cases, 17 were follow^ed by perforation of the cornea, with destruction of the eyeball, while 15 recovered without perforation. Ten cases of iritis were seen in this series. Chance found that a common cause of corneal ulceration in variola was the extensive swelling of the eyelids due to the pustular eruption upon them. So great was this swelling that the eyes, in many instances, were opened by the attendant only with great difficulty. 1 Chance. In Welch and Schamberg, loc. cit., p. 231. 308 VARIOLA Notwithstanding the above statistics as to corneal ulceration, we beheve that keratitis is a comparatively common occurrence during variola, especially in confluent cases, and is most commonly seen in badly nourishetl children. It is due, at least in part, to traumatism by the rubbino- of the face and eyes against the pillow and the consequent scratching of the vesicles. Corneal ulcers most commonly occur in the later stages of the disease, and usually affect one eye, or, if both eyes are affected, one is usually less severely involved than the other. Blindness due to smallpox usually arises as the result of corneal ulceration. A rare cause of both conjunctivitis and corneal ulceration din-ing variola is the presence of variolous lesions upon the conjunctiva". These occurred in but tlu*ee of Chance's 2000 cases. Marson^ in reviewing the notes of 15,000 cases of variola, found only 26 cases in which the primary smallpox pustule had been seen on the con- junctiva^. Dufour states that from 10 to 15 per cent, of variolous subjects have ocular lesions, and that in 30 per cent, the cornea is involved. Courmont and Rollet,^ of Lyons, report 45 cases of corneal ulceration as occurring in 641 cases of variola. The statistics of these clinicians, therefore, show a higher percentage of corneal complication than the statistics first quoted. Retinal hemorrhages are frequent occurrences in the type of the malady known as variola hemorrhagica. Iritis, cyclitis, choroiditis and retinitis are very rare, but all have been observed as complications of variola. Orbital cellulitis is occasionally seen during the disease, and particularly in the very severe forms. Ear Complications. — Ear complications are frequent during variola. The external auditory canal is frequently the site of variolous lesions, and the obstruction of the canal often causes impairment of hearing as well as many unpleasant auditory sensa- tions. Among these otic conditions otitis media is frequent in children, but is less commonly observed in adults. In the lattei- ' Marson. Quoted by Moore in Twentieth Century Practice of Medicine. 2 Dufour. Annale? d'Oculistiques, May, 1901. ' Courmont and Rollet. Ibid. UI'ISI'IKATOL'Y COMI'/JCAf/OXS 300 class the otitis nifciy ^ocs on lo .sii[)|)iir;i(ioii, hut llic f((iii|)l;iiiit of earache is a comiiioii one, particularly (liiriii^^ f'Oiivalcsccncc. The condition is iisnally j^roduced l)y extension of the infhinnri;ition from the throat alonfj; the P>u.stachian tnhc, or hy diicrt ini'<-ftif»n through this channel, in some few cases (hroniho.^is ol" the cere- bral sinuses hits followed otitis media, hut tnastoiiii Inir^ (|i|)litlicii;i i^ |)i-;ifii'-;illy iitiknowii ill (mliiiiiiy cases <)!' variohi. An onliiuirv ih-f^'n-c r>j' pliaryii^'itis is very common in all forms of variola, and partir iihirly so in the severe attacks. Postpharyngeal abscess is a rare rjffiir- rence. Thyroid itia durhnj smallpox is not nearly as rare as tfic laf;k oi literature upon the subject would lead one to believe. Roger and Gamier^ have reported several cases, and one of ns u lillc an interne at the Municipal ITos})ital saw this complication several times among the female patients, and once it occurred in a young man, who suffered from a malignant attack of variohi, wliieii proved ra])idly fatal. The Heart during Variola. — The heart during variola suffers the changes that attend any acute febrile infection, and because of the severity of the disease it is but natural that we should expect to find degenerative changes taking place in the heart muscle. It is surprising how little literature there is upon changes in the heart and bloodvessels during variola, and investigations are sadly needed along this line. Myocarditis is certainly present in a very large number of the severe cases of the disease, and deaths from acute dilatation of the heart are occasionally seen. Pericarditis and endocarditis are infrequently reported as having complicated variola. Cardiac murmurs are of frequent occurrence at the height of the disease, especially those which are heard in the region of the apex, but they are apparently due to relaxation of the heart muscle. One of us examined six cases at autopsy which during life had shown murmurs, but no lesion of the valves was discovered. Curschmann" reports having seen a case of ulcerative endocarditis complicating a confluent case of variola, but states that endocarditis during this disease is rare. Welch and Scham- berg' are of the opinion that endocarditis is very rare in this disease. Phlebitis is occasionally met with during the period of con- valescence. 1 Roger and Gamier. Presse Med., Paris, 1903, i, 37.3. - Cursclimann. Nothnagel's System of Medicine. Variola. 5 Welch and Scliamherg. Acute Contagious Diseases, p. 236. 312 VARIOLA Abdominal Complications. — Abdominal complications are rare in variola, and peritonitis is very uncommon. ]MacComl)ie* has reporteil two cases of peritonitis tluring variola; one was asso- ciated with pleurisy, the other a local peritonitis, but in neither instance is any statement made as to the cause of the infection. MacCombie has also reported two cases of peritonitis following abortion during variola. Abscesses in the liver and kidneys have been reported as occurring during the course of the disease, but are very rare, and infarcts have been found in both the spleen and kidney in certain fatal cases. Joint Complications during Variola. — Joint complications during variola are sometimes met with, and are also occasionally observed as sequels of this disease. These complications are most often noted among children, and usually one or more joints are involved. The ell)ow appears to be the joint most commonly affected, although the wrist is also a favorite place for this com- plication to show itself. Chondritis, osteitis, and osteomyelitis are all rare complications, but all may occur as secjuels to variola. Voituriez,^ Debryre,* and Ingelraus^ have all reported bone complications and sequels to this disease. Genito-urinary Complications. — Genito-urinary complications during variola are frequently met with. Phimosis is not infre- quently met with in the pustular stage, and is the result of the sw'elling of the tissues of the prepuce caused by the presence of the rash. This complication is met with among children most fre- quently, in whom it often causes retention of urine. Adult patients often complain of great pain on urination, partly, no doubt, because of the highly acid condition of the urine and partly because of the presence of variolous lesions within the urethra. Albuminuria and nephritis during variola are frequently developed. Albuminuria is frequent in both the mild and the severe form of the disease. Welch and Schamberg" found that 1 MacCombie. In System of Medicine, by Allbutt and Rolleston, Variola, p. 514. 2 Voituriez. Jour, de Sci. Med., Lille. 190.3, xxiii, 93. 3 Debryre. Echo M^d. du Nord., Lille, 1903. * Ingelraus. Ibid. ' Welch and Schamberg. Acute Contagious Diseases, p. 236. PREGNANCY COMPIJCATING VAUfOLA :',]:', 663 per cent, of their cases of variola had antuniiii in lh<- nriiio diirui*!; the course ol" th(! disease, and (iO pci- ccnl. of Hn- cases of variohjid liad albuininiiria. It is siirprisiiin; (o noic (hat in 50 per cent, of the cases of varioloid die urine conlaitied tube casts, but of the cases of variola only 42 per cent, contained casts. The comparative fref(uency of })oth albumin and casts in fatal cases as compared with those that reef)ver('d may be seen froui th<; following figures given by Welch and Scliambcri^-. Of '.'>H cases of fatal variola, 30, or S4.47 per cent., showed albuminuria, and 10, or 50 per cent., showed casts. Of 90 cases that recovered, 45, or 50 per cent., had albumin in the urine, and 41, or 45.55 percent., .showed casts. It was noted in this series of cases that when albumin was found in the urine it usually appeared early, as did also tube casts. ArnamP examined the urine of 400 cases of variola, and found that 95.3 per cent, revealed albuminuria. This same writer states that albuminuria persisted after convalescence in 75 per cent, of his cases. He believes that variolous albuminurias, as in the albu- minurias accompanying other infectious diseases, are not simply functional, but are related to a structural alteration in the kidneys. In proof of this he mentions the results of the histological examina- tion of the kidney, in 15 cases of variola, in each of which he found marked pathological changes. Cystitis is rarely mentioned as a complication or sequel of variola, but it is quite often seen in very sick patients who are unable to void the entire amount of urine in the bladder. This complication usually occurs late in the disease and recovery usually takes place when the patient is well of the attack. Orchitis, single or double, and usually accompanied by an effu- sion of fluid into the tunica vaginalis, is a rare complication of variola, and usually occurs during the pustular stage of severe attacks of the disease. Welch and Schamberg" observed this com- plication but 8 times in' 2000 cases of variola. Pregnancy Complicating Variola.— Pregnancy complicating variola is alwavs extremelv dano-erous for the unborn child and adds greatly to the danger of the mother. The function of the 1 Arnaud. Revue de M^decine, 1S9S. xviii. 392. " Welch and Schamberg. Loc. cit., p. 237. 314 YAJ^IOLA pregnant uterus is greatly disturWcd duriiio- (he coiu'se of variola, and abortions and miscarriages are common. In a series of 113 cases of variola in pregnant women, treated at the iNIunicipal Hospital of Philadelphia, 35 died, giving a mortality rate of about 31 per cent., and in '27 unvaccinated pregnant patients, 20, or 74 per cent., died. Of 85 pregnant women vaccinated at an early period in life, 14, or 16 per cent., died, emphasizing the fact when abortion or miscarriage occurs during variola it is a much more serious complication than when it occurs during an attack of varioloid. The time at which miscarriage most frequently occiu's is during the eruptive stage of the disease, but it may occur at any time, even after complete restoration to health. If the mother goes to term, the child is to some extent protected from the disease, although eases are on record in which children have had smallpox before birth, and, extraordinary to relate, there are instances reported in which the newborn child bore the eruption of variola at birth despite the fact that the mother had not suffered from the disease. The Nervous System. — The nervous system is more often involved in smallpox than in any of the other eruptive diseases. The nervous manifestations may appear during any stage, and may originate in the brain, in the spinal cortl, or in the peripheral nerves. Delirium during the initial stage is common in variola, and is sometimes seen in even mild cases of varioloid. This symptom may abate when the eruption appears, but in some instances it merges into acute mania. MacCombie^ reports an instance of this kind. In some cases of variola which early exhibit marked men- tal disturbances there is a remission diu'ing the vesicular stage, with an exacerbation of the mental symptoms when pustulation begins. In the hemorrhagic form of the disease the delirium is often marked from the beginning and continues until the death of the patient. In children convulsions are common at the onset of the illness and mav occur during its later stages. 1 MacCombie. Loc. cit., p. 51G. 77/ A' N/':inr)(/s systicm :',]r, CoNViTf.SfONS (liii'iiii;' (lie iiiiliiil st;i<^<' ol' ihf iliscjisfr arc alsrj occasioiuilly noted in adult palicnls, l)iil lli<'>c air usually .seen in malignant heinorrlianic cases. Coma of varyin<( intensity may he assoeialcd uidi patalysis niorf; or less generalized. Tlic coma usually disappear^ dniin;: the vesicular stage, hut the j)aralysis may persist foi' a long pcriofl. MKLANCiior>iA is also noted not int're(|ucnfly during convales- cence, hut this symptom is scarcely ever ol' long duration, hut is often a trouhlesome sequel. Strangely enough, acute mania more frequently complicates mild attacks than severe attacks, although it complicates hoth, and may appear at any time, even late in con- valescence. Some patients so affected recover, hut others remain permanendy insane, although it is common to find, in those who remain permanently insane, a family history of mental derangement. Corlett^ reports a case of acute mania which occurred on the fourth day of a discrete form of variola and continued until the death of the patient six days later. Trousseau,^ Seppilli and Mara- gliano,^ Welch and Schamberg,^ and others have recorded similar cases, both in modified and unmodified cases of smallpox. The post-febrile insanities are sometimes associated with par- alyses of various sorts, either local or general. Paralyses may develop during the course of variola without being associated with mental symptoms, but aphasia is a frequent symptom. Of 3000 cases of variola studied by Welch and Scham- berg at the Municipal Hospital of Philadelphia, there were recorded only eight instances of paralysis, but it scarcely seems possible that all the cases that suffered paralysis were recorded. Of the recorded cases, five died and three recovered. Hemiplegia is occasionally seen during smallpox, and has been recorded more often among; children than among adults. This complication may result from a cerebral hemorrhage, which is the most common cause, or may result from a thrombosis of the cerebral vessels. Welch and Schamberg only record having seen one case, and that was in an infant, aged one year and four months. 1 Corlett. The Exanthemata, p. 66. - Trousseau. Clinical Medicine. 1S73. ^ Seppilli and Maragliano. Delia Influenza del Vajuolo .sulla Pazzia, Milan, 1S7S. * Welch and Schamberg. Loc. cit., pp. 237, 23S. 316 VARIOLA Paraplegia is more frequently met with in varit)la than is hemi- plegia, and is a most serious and generally a fatal symptom. Welch and Schambere;^ have seen " half a dozen or more instances." liu- chard" reported 10 instances of paraplegia occurring in 2000 cases of smallpox, and Spiller' has recorded two cases. Westphal'* has reported cases of smallpox during which disease there was marked paralysis of the lower extremities and bladder which he believed were due to myelitis, and Fiessinger^ also saw a case of variola that w^as complicated with an acute myelitis during the eruptive stage of the disease. xVldrich" has recorded 15 instances of dis- seminated encephalomyelitis as complicating variola. He states that these cases improved rapidly following convalescence from the primary disease. ]\Iarinesco and Oettinger^ have seen a case of acute ascending paralysis during variola, and this complication has been noted by a few other observers, all of whom state that the condition is a very fatal one. Sottas^ has reported a case of disseminated sclerosis in a youth, aged eighteen years, following an attack of smallpox. Peripheral neuritis occurs Avith greater frequency than has been thought. Postvariolous paralysis of the soft palate and structures of the pharynx quite similar to those found following diphtheria have been studied by Curschmann,'' Arnaud,^" Saint-Phillippe,^^ Whipham and Meyers,^^ and other observers. In addition to these cases of more or less generalized paralysis, we also find cases of local paralysis, as in the case reported by Putnam,^^ in which there was a paralysis of the serratus magnus muscle, and Cursch- mann reports a similar case of paralysis of the deltoid muscle during this disease. 1 Welch and Schamberg. Loc cit., p. 239. - Huchard. Quoted by Corlett, p. 66. ' Spiller. Brain, London, 1803 (with review of the literature). ■• W^estphal. Berliner klin. Wochensehrift, 1872. 5 Fiessinger. Mt'd. Modern CParis, 1898), No 9, p. 341. " Aldrich. American .Journal of the Medical Sciences, February, 1901. ^ Marinesco and Gettinger. 8 Sottas. Gaz. des. Hop., .\pril 2, 1892, pp. 405 et seq. ' Curschmann. Cong, fiir innere Med., 1886, Weisbaden, p. 469. 1° Arnaud. Marseille Med., 1896, xxxiii, 129 to 140. " Sai.t-Phillippe. Quoted by Combemole, .A.rch de mdd., .June, 1892. 1= Whipham and Meyers. Lancet, March 20, 1886. '^ Putnam. Boston Med. ..nd .Surg. Jour., Ixxxix, 12.5. CHAPTER IT. SCARLET FEVER. ALTHOUGn, as a result of the improvement of tlie laws coneerning sanitation and the general advance toward better hygiene in liomes, schools, and hospitals, there has been a marked decrease in the morbidity as well as the mortality of scarlet fever, nevertheless this disease and its complications and sequels are of great interest and importance. The death-rate of scarlet fever in the United States is slightly higher than that of measles, and averages about the same as the death-rate of scarlet fever in Great Britain. Although the morbidity and mortality have been greatly reduced in recent years, they still are subject to much variation in different periods. The annual average death-rate for the years 1901 to 1905 inclusive was 11.1 per 100,000. Of 26,921 cases of scarlet fever, 3216, or 11.9 per cent., were fatal. Holt states that the average mortality is from 10 to 14 per cent., but that children under five years of age the mortality varies from 20 to 30 per cent. In scarlet fever the complications and sequels are more important and numerous than in any other of the infectious eruptive diseases. It has been well said by William Pepper that this disease "maimed when it did not kill," thus calling attention to the tendency of many of its complications to become chronic, and, when neglected, to lead to loss of the functions of certain organs, or, in some instances, to permanent impairment of health. Scarlet fever, therefore, depends very largely for its gravity, and for the fear it causes in the home and the community, upon the severity and the danger of its complications and sequels. The common comphcations of scarlet fever are: Rliinorrhoea, otitis, ulcerative stomatitis, tonsillitis, adenitis, scarlatinal synovitis (scarlatinal rheumatism), neplu'itis, with ulcerative and gangrenous angina, bronchopneumonia, and ocular complications. 318 SCARLET FKVER Before taking up the various C()inj)Iic'ati()iis, it will be well to consider the initial or premonitory rashes as well as the various skin manifestations ()i)served during the disease. Premonitory Rashes. — Premonitory rashes are fairly frequently seen early in this disease, and they are of great importance from a diagnostic standpoint. Scarlatiniform rashes of varying degrees of intensity are common, and their differentiation from the eruption of other diseases, as well as from the true eruption of scarlet fever, is often not readily made. It is in the mild or atypical cases of scarlet fever that mistakes often take place, and in these cases it is only after a careful study of the history of the illness, the symptoms, and the rash that an opinion of value can be rendered. Unfortunately, despite the greatest care, in c|uite a large propor- tion of cases the true diagnosis is only revealed when desquama- tion appears or when some typical complication develops, which proves that the primary disease w^as true scarlet fever. Helpful points in determining that the eruption is that of scarlet fever have been pointed out by WhitfiekP as follow^s: (1) The rash in scarlet fever always appears first at the root of the neck; (2) when not absolutely universal the edge of the eruption gradu- ally fades off into normal skin and the tip of the nose and the circumorbitaal region is never affected ; (3) a yellowish stain appears w^hen the hypersemia is displaced by pressure on the skin, and browning of the flexures of the elbow's is almost invariably present; (4) the backs of the hands and the sides of the fingers are generally affected when the rash is fully developed. Miliary vesicles are seen in nearly all pronounced cases of scarlet fever, but in the skin of some persons this variety of eruption is much more in evidence than in that of others. Griffith^ has reported several marked instances of this eruption, and gives it the name of "scarlatina miliaris." Febrile herpes is an unusual complication of scarlet fever, but is more frequent in this disease than in smallpox or measles. Urticaria is occasionally seen during an attack of scarlet fever, and this rash is usually in evidence before the true scarlet rash ' W'hit field. The Practitioner, January, 1909, p. 69. - Griffith. Scarlatina Miliaris, Jacobi's Festschrift, 1900, pp. 182 to 186, uiiiNOiaaKi'iA 319 appears, ("onion' rcporls ;i, r'ji.sc in wliicli nitifji il;i f (ini|ili';in-(| tlic ousel, of sciirlcl, fever, iUid was in evidence for several days. Blebs and Bullae. IJlehs and hnlla- may develf>fj (\\\v\u[r the course of llie disease, l)ii( aic nnnsnal. When llie\ oecni- llievare usually seen in very severe eases, and sonielimes le;id Wi ;ian;.Tene of tlic skin. Gangrene of the Skin. — Gangrene of die skin is sometimps seen during scarlet fever in eliildren wlio are li\in;^' in erovMJefl quarters, and the term "derniatitis gaiigra-nosa," or "scarlatina gangra^iosa," has been aj)plied to such cases, '^l^his complication usually appears at the height of the disease, hnl i( may aj)j)ear, as in a case reported by ITeubner,^ as late as one month after convales- cence. Gangrene of other portions of the body are observed during scarlet fever in rare instances. This condition usually develops during the second or third week of the disease in severe cases, and usually attacks the extremities. The condition is usually attributed to embolism of the dermal vessels. Cases of this kind have been reported by many observers, among them Blandpain,^ Hudson,^ Kuster,^ Chapin," Eichhorst,^ Pearson and Littlewood,* Buchan,^ and Welch and Schamberg,^" Wood and Arrigone" have reported cases of gangrene affecting the genitals, and Wilson'^ a case of gangrene of the face three weeks after convalescence from scarlet fever. Rhinorrhoea. — Rhinorrhoea is a very frequent symptom of all attacks of scarlet fever, but it is particularly in evidence in the severe forms. It appears in two forms. In the first the dis- charge from the nose is purely mucous in character, similar to the discharge seen in a case suffering from a catarrhal cold. In the second form the discharge is mucopurulent, and, especially if thin 1 Coulton. La M^decine Infantile, Paris, February 15, 1894. 2 Heubner. Medical Press, September 30, 190S. 3 Blandpain. Arch. Med. Beiges, Brux., 1S69, ii, 324 to 331. 1 Hudson. Trans, of the Ohio Med. Soc, 1858- 6 Kuster. Tod Kassel, 1876-1878. 15 Chapin. Medical Age, Detroit, 1884. ' Eichhorst. Deut. Arcliiv fur klinische Med., Band Ixx, Heft 5. s Pearson and Littlewood. Dry Gangrene of both Legs, Lancet, 1897, ii, 84 8 Buchan. Lancet, October 5, 1901, p. 915. 10 Welch and Scbamberg. Acute Contagious Diseases, p. 423. 11 Wood and Arrigone. Quoted by Thomas, Ziemssen's Encycloptedia, p. 190. 1= Wilson. _ Article reviewed in Arehiv f. Kinderheilk, 1898, p. 418. 320 SCARLET FEVER anil straw-colored, is the result of a destructive ulceration of the posterior nasal mucous membrane. French writers assert that early purulent corvza is of evil significance in scarlet fever. Thus ill one epidemic in the Arbervillier Hospital the mortality of these cases was over 50 per cent. Not only is a purulent rhinorrhoea dangerous in the acute stage, but in the cases which recover the rhinorrhoea is apt to become clironic and does not yield readily to medical treatment. In many of these cases the continued discharge is the result of the presence of adenoids. This complication is of great importance, as it bears a very definite relationship to protracted infectivity and the spreading of the scarlatinal infection. Otitis Media. — Inflammation of the middle ear is the most common, if not the most dangerous, complication of scarlet fever. It may arise at any stage of the scarlatinal attack. The frequency of this complication varies with the character of the epidemic and the age of the patient. In the severe anginose attacks of the disease middle-ear complications follow nearly every case. Infants seem more liable to develop otitis media than do children who are a little older. This is possibly accounted for by the relatively large Eustachian tube in infancy. The otitis may occur either in the form of a simple inflammation of the external auditory canal, with possibly a slight involvement of the membrana tympani, in wliich case it is a trivial aflfection of short duration, or, as is much more common, in the form of an otitis media followed by more or less profuse mucopurulent discharge. Caiger^ states that 15 per cent, of 10,983 cases of scarlet fever developed otitis media. Bader and Geuinon" report 33 per cent, involvement in the mild catarrhal form, and purulent otitis media in but 4 or 5 per cent, of scarlet fever cases. Sprague^ states that from 3 to 9 per cent, of children suffering from scarlet fever develop ear complications, and in 50 per cent, of these both ears are involved. Bezold,^ of Munich, found that 37.5 per cent, of 1787 cases of 1 Caiger. In System of Medicine by Allbutt and Rolleston, vol. iii, p. 150. 2 Bader and Geuinon. See Moizart in Traitu.'> h;i(l chronif; sii|)piir;ifif)ri hislinrr ff)r over eight years. The annual report of tiie Metropolitan Asylum's lioard ff>r KiOG states that 2355 eases of searlet fever fiiul r)fi(is in ]7,'S20 eases (13.21 per eent.). ill Ihe 1007 rej)()rl of the same hojinl the percentage of ear (•ompiieations is given at 11.4 per eent. Biirekhanlt-Merian' found that of 4309 cases of otitis media, 445, or lO:} per cent., were due to scarlet fever. At the Willard Parker Hospital, in 1898, of 386 cases of scarlet fever, otitis occurred in 77 eases, 33 of which were affected in both ears. Le Marc'hadour" foimd 30 instances of otitis in 339 cases of scarlet fever (10.65 per cent.). MacCrae^ stated that of 325 cases of scarlet fever under his care, 83, or 25.5 per cent., developed otitis media. Fifty-seven of this last series were suppurative cases (17.5 per cent.). Purulent otitis media usually pursues a protracted course, and frequently lasting for years, often for a lifetime. The dangers, immediate and remote, from this condition are many, the chief one being the danger of extension of the purulent process to the mastoid cells or to the coverings of the brain, while the less frequent but more immediately fatal complications are the erosions of large bloodvessels and the development of septicaemia and pyaemia. Baader, Hynes,^ Hessler," Huber,' and others^ have reported fatal instances of hemorrhage due to the erosion of the carotid artery as a result of the septic processes connected with otitis media. The hemorrhage in these cases may pour from the ear or cause hcTmatoraa in the tissues of the neck. Mastoiditis. — Not infrequently, within a few weeks after the appearance of an otorrhoea, an inflammatory swelling appears in the mastoid region attended by severe pain and acute tenderness 1 Burckhardt-Merian. (Volkman's) Sammlung klin. Yortr., 18S0, Chirurgie, Xo. 54. - Le Marc'hadour Gaz. des Maladies Infantiles, Xovember 5, 1903. 3 MacCrae. Montreal Medical Journal. September. 1908. * Baader. Corresbl. f. Schweiz Aerzte, 18~5. Band v. * Hynes. Quoted by Forchheimer. Twentieth Century Practice of Medicine. 8 Hessler. Quoted by Forchheimer, loc. eit. ' Huber. Deutsche Archiv f. klin. Med., Bd. viii, p. 422. 8 Kennedy, Moller, and West. Quoted by Welch and Schamberg. 21 322 SCARLET FEVER in this region. Of the 1650 cases of otitis medio quoted hy Caiger, 0.6 per cent, developeil a mastoid abscess. Of the 17,829 cases of scarlet fever re})()rt('d In tlic Metropolitan Asylum's Board for 1006, 2355 were complii-ated with otitis media (13.21 per cent.), 122 of which developed mastoid abscess (0.68 per cent.). The usual history in a case of mastoiditis during scarlet fever is that the patient has a discharging ear, but with the establish- ment of communication between the tympanic cavity and the cells of the mastoid there is usually a decrease in the amount of discharge from the ear. and the temperature at once rises. There is pain over the mastoid region and tenderness more or less marked. It is not unusual for the patient to feel chilly or even to have a chill, and there is commonly great discomfort and restlessness. Meningitis and Tempore sphenoidal Abscess. — It has long been known that these complications, as well as other intracranial abscesses, are all liable to occur in cases of chronic middle ear disease, and are particularly prone to occur in scarlatinal cases. Purulent meningitis is a very serious complication, which may arise from a suppurative otitis media. Welch and Schamberg^ report such a case in which a child, aged three years, developed this condition on the fifty-fourth day of the attack of scarlet fever, and died ten days later. Autopsy revealed a pm-ulent exudate covering the entire base of the brain. Roger^ saw a case in which meningitis followed a severe purulent rhinitis complicating scarlet fever. At the autopsy the left frontal lobe was covered with purulent material and the left sphenoidal sinus contained pus. Sinus thrombosis is a rare complication which occurs as a sequel to otitis media. Facial Paralysis. — Facial paralysis is a relatively infre(juent complication of scarlatinal otitis, although it has been repeatedly observed by those seeing a large number of suppurative otitis cases complicating scarlet fever. The conflition is due to an extension of the inflammation from the tympanum to the facial nerve where it passes through the roof of the cavity. ' Welch and Sehamberg. Acute Contagious Diseases, pp. 403,404. - Roger. La Maladies Infectieuses (Meningitis in Scarlet Fever). ADI'INITIS 323 Deaf Mutism. — Nol, only is otitis mcdiit (Vau^cvow . \u life, \,\\t this coiiipliciilioii is rcsfKJiisihIc for many fuses of (|(;iF imiii m. Na^cr' liiis ("illcd |);irlicnl;ir ;ilfcn(ion to the f;isii;il rchitioii liip of j)nriilt'nt otitis media, iiiid deaf mutism, and states that one ease of deaf irnitism occurs in (;ach S(JO cases of srvirlet fever, and May^ states that 10 per cent, of 5000 cases of dcjif mutism, whose his- tories he investigated, owed tiieii" deafness to the aural eom|)li';i- tions of scarlet fever. Wilde,"' wliose statistics coneerninn- (h-jif mutism in Ih rchition to scarlet fever are tlie earliest known, states that 7 [xr ccuf. f>f the cases of accpiired deaf mutism in Ireland in ISol were due to scarlet fever. In (iermany, Ilartmann* investigated this subject, and found that 11.3 per cent, of the cases of deaf mutism were due to scarlet fever. Other statistics state that in Italy 1.5 per cent., Austria 10.8, Ireland 10.8, United States 26.4, Norway 27.5, Saxony 42.6, and Denmark 20.8 per cent, were due to scarlet fever. From these figures it can be seen that scarlet fever gives rise to acquired deaf mutism in from 1.5 to 27. 5 per cent, of cases. The cause of deafness lies in the partial or entire destruction of the labyrinth from middle ear suppuration. It is seldom that serious deafness, resulting in deaf mutism, appears at an early stage of scarlet fever. Burckhardt-Merian' has shown that the majority of all cases occur during the stage of desquamation. Adenitis, or a generalized enlargement of the lymph glands, constitutes a part of the normal symptomatology of scarlet fever. It is only when the lymph glands become excessively enlarged or undergo suppuration that a complication is added that increases the danger of the disease. Adenitis of a marked degree is verv common in this disease, is quite distinct from the glandular swelling of onset, and may vary from a slight glandular fulness to a very severe glandular infiltration with enormous swelling of the neck, the so-called "collar of bra'uni" or "tippet neck." The J Nager. Corresbl. f. Schweiz Aerzte, September 15, p. 592. - May. Archives of Pediatrics, July, 1S99. ' Wilde. Quoted by Yearsley, Practitioner, January, 1909, p. 36. ■* Hartmann. Taubstummheit und Taubstuninienbildung, Stuttgart, 18S0 ^ Burckhardt-Merian. (Volkman's) Sammlung klin. Vortr., ISSC, Chirurgie, Xo. 54. 324 SCARLET FEVER glaiulular inflainniatioii is jiractically always accompanied l)v fever. Ludwig's angina is ilu' naine given to the most aggravated cases of lymphadenitis which occur in association with the anginose variety of scarlet fever. The connective tissue of the neck may become the seat of a diffuse cellulitis during the first and second week of the disease. This condition is fortunately rare, for it is almost invariably fatal. Scarlatinal synovitis or scarlatinal rheumatism is of sufficient intensity to give rise to temperature, pain, tenderness, and distinct effusion into the joints, and is a fairly frecjuent complication of scarlet fever. It usually affects the smaller, rather than the larger joints. The metacarpophalangeal, the fingers, the wrist, and the elbows are the most frequently affected. This condition tlevelops more commonly in adults and older children than in the younger ones, and seems to affect females in a larger proportion than males. This complication more frecpiently complicates severe cases than mild ones, although even mild attacks are often associated with very troublesome pain in the joints. In a series of 500 cases of scarlet fever reported by Ashby^ there were but ten cases of mild rheumatic symptoms and only two cases in wdiich the symptoms were severe. In 3000 cases of scarlet fever studied by Hodger,^ only 117 cases, or 3.2 per cent., were complicated by synovitis. Hunter's^ experience at the London Fever Hospital ^vas that the great majority of the cases of scarlet fever that had articular pain suffered a very short time, and that the pain w^as not severe. He states that 95 per cent, of his cases suffered little pain, and the pain was evanescent in character. McCrae* states that arthritis compli- cated 17 of his series of 325 cases of scarlet fever (5.2 per cent.). The order of frequency in which the joints were affected in this last series of cases was knee, shoulder, wrist, ankles, elbows, and fingers. The vertebral joints in the cervical region w^re affected twice and in the lumbar region once. Carslaw^ (Glasgow) states that 60 of a > Ashby. Brit. Med. Jour., 1883, ii, 514. - Hodger. See Eichhorst, Specieile Pathol()(>:ie uud Therapie (Leipzig, 1897\ ~ Hunter. Tiie Practitioner, January, 1909 p. 3. * McCrae. M.jntreal Medical Journal, September, 1908. ^Carslaw. Kdinburgh Medit-al Journal, 1906, 24, 280. hcarIjAtinal HYNOviris. on. nil i:iM.\TisM :\2') series olT).'}.') (;iise,s of scarlet !"<• vet- uiidcr liis f;iic(|(\(|()[>((| synovitis. Ilotno/ in re})or(in<^ r)0() cases of sfiirld. U-^-cs, states (l];il I 1, or 1^.^ per cent., developed arthritis. Roberts^ has reported the case of a ^n'rl, ag(.-d fifteen years, who during an attack of scarlet fever developed pain and sweliiiifr in ;dl the joints of her horly, and later developed effusion into the joints, but in a few days this coinJition disappeared. Detnme, of Berne, has reported a similar case. Stockman^ tried an interesting experiment in five cases which developed symptoms of arthritis during scarlet fever. He gave them no treatment, and found that the symptoms disappeared in two, three, four, seven, and eight days respectively. This writer also found that only a very small percentage of the cases of arthritis appearing during scarlet fever were relieved by the salicylates, and drew the conclusion, which is now generally held, that scarla- tinal arthritis and synovitis is essentially a septic process and has no relation to true articular rheumatism. A few of the cases of arthritis develop suppurative joints. When this occurs the elbow, wrist, knee, and sternoclavicular joints seem to be the earliest involved and most frequently affected. Dr. Burvill Holmes informs us that in all the cases of suppurative synovitis coming under his observation at the Municipal Hospital of Philadelphia, the Streptococcus pyogenes was isolated from the purulent exudate. Henoch^ pointed out that the suppuration of the joints might be the result of two processes: the first and most frequent form being that of local development of suppuration in the involved joint, or as the result of emboli following septicaemia involving a number of joints. The most common source of septicsemia in these cases is the ulcerative and necrotic processes in the pharynx. Bokai^ has seen the local process following a scarlatinal arthritis become chronic, and instances of ankylosis and even deformity of the joints have been reported in the literatme.*^ 1 Homo. Wien. klin. Woch., 1901, xiv, 281. - Roberts. Journal of the American Medical Association. July 20, 1907, p. 246. ' Stockman. Edinburgh Medical Journal, 1906, xx, 244. ■* Henoch. Mittheilungs ueber das Scharlashfieber und Vorlesung. p. S60. ^ Bokai. Ueber die Scarlatinossen Gelenkentzundungen. Jahr. f. Kind., 1885. xxiii, 304. * Eichardier et Peron. Soc. proceed. Gaz. des Hop., December 5, 1S93, p. 1318. 326 SCARLET FEVER The prognosis in thr usual case of artluitic trouble complicating scarlet fever is good, although it is to he remembered that the presence of synovitis or arthritis durino- scarlet fever involves the possible development of endocarditis and pericarditis, as these lesions are more Hkclv to occur in cases complicated In- joint affections, owing to the septicivmia. (See latter part of this chapter.) Vomiting is a frequent symptom, and death often results, although this is by no means invariable. Welch and Schamberg^ report a case of this complication occurring in a boy, aged thirteen years, who was extremely ill for ten days with daily chills and repeated vomiting, but who recovered seventeen days from the onset of the complication. Nephritis and Albuminuria Complicating Scarlet Fever. — During the febrile period of scarlet fever, albuminuria is a very common occurrence. Roger' found, in his analysis of 2157 cases of scarlet fever in adults and children, that 816 cases show^ed albu- minuria. Of these cases, 38.9 per cent, were men, 33.1 per cent, women, and 24.8 per cent, were children. It will be seen from these figures that albuminuria during the disease is less frequent among children than in adults. In some cases the only evidence that the kidneys are affected is the presence of albumin in the urine, although in others the general symptoms, such as the a?dema and the presence of casts in the urine, render it plain that a true nephritis is present. Hunter^ found that albumin occurred during the first week in scarlet fever in from 36 to 62 per cent, of the cases. Of these, 16 to 27 per cent, showed albumin in the second w^eek and the remainder in the third and fourth weeks. The average of his cases for the years 1905, 1906, and 1907 in the London Fever Hospital shows that 43 per cent, showed albumin during the first week, 18.8 per cent, during the second, 11.5 during the third, 9.7 during the fourth, and 8.7 after the fourth w-eek of the disease. Febrile albuminuria is usually slight in degree and lasts but a short time. Of Hunter's 149 cases, in which he records the dura- ' Welch and .Scliamberg. Acute Contagious Disease, pp. 401, 402. - Roger. La Maladies Infectieuses. ' Hunter. Tlie Practitioner, .January, 1909, p. 3. NI<:i'IIIUTI.H AND ALIiUMlNUUIA IN SCAU/J:'/' I'HVICH :>,21 tion of this syiiiploin, (iO sliowcd ;ill)imiiii I'lom oik- Io tlii'(-(; <|;iys; 20 froin Tour to six diiys, niid 20 from .seven Io nine rlays. 'Jlie reiruiindcr ol" the series showed itihiiniiri from ten duys to two and one-half months. No separate line of distinction can be drawn between albnrninnria of a severe degree and a true nephritis. In the patient .suffering from a nephritis, however, not only does the urine show consider- able quantities of albumin with many tube casts, but there are usually distinct symptoms and signs that r(;veal the ne[jhritis. Not only is there usually present cHstinct pufHness of the eyeh'ds and fjedema of the extremities, but there is often present a general anasarca. The patient may suffer from pressure symptoms be- cause of the presence of fluid within the pleural sacs and peri- toneum. Ura^mic symptoms are common, and not infrequently cause death. In many cases of nephritis, however, recovery follows with the subsidence of the primary disease, l)ut unfortunately the patient is prone to suffer from recurrences of the nephritis throughout life. It has long been noted by many observers that the frequency of nephritis during scarlet fever varies markedly in different epidemics. VogP reports as high a percentage in one epidemic as 34. Cadet de Grassicourt^ has observed late nephritis in 30 per cent, of all his cases. It v^^as present in 18 per cent, of a series of . cases studied by Friedlander.^ Baginski^ has reported 88 cases of nephritis in a series of 918 cases of scarlet fever, or 9.57 per cent. Caiger,^ in reporting 10,983 cases of scarlet fever, states that nephritis was present in 11.9 per cent of the cases. McCrae^ found albumin present in 18 per cent, of his 325 cases of scarlet fever, blood was found 39 times, and casts 21 times. He states that in this series of cases only 2.5 per cent, showed nephritis which could \^'ith truth be said to have resulted from the scarlet fever. Hunter's experi- ence in the London Fever Hospital was that nephritis was a very 1 Vogl. Jlunch. med. Wocliens , 1S95. p. 949. - Cadet de Grassicourt. Quoted by Moizard. 3 Friedlander. Fortsch. der Med., 1SS3. i, 381. ^ Baginski. Kinderkrankh., Berlin. 1899, p. 117. ° Caiger. In System of Medicine, Allbutt's, New York, 1897. ^ McCrae. Montreal Medical Journal, September, 1908. 328 SCARLET FEVER variable complication both as to degree and in frequency. It occurred in but 2.7 per cent, of his G4S cases. Hunter^ found that the complication usually occurred between the eighteenth and thirty-eighth days of the scarlet fever. Acufc ucpJirifis is one of the forms of nephritis that sometimes attacks a scarlet fever patient, and suppression of urine may be the first symptom of this disorder. In certain eases of scarlet fever the infection seems so virulent that the kidneys may be completely suppressed in their function very early in the disease, or a great diminution in the urinary flow takes place, with the presence in the urine of large quantities of albumin, many casts, and sometimes blood. In these cases death may ensue in a very short time, but more often the function of the kidneys is partially restored and the patient recovers after a prolonged convalescence. The renal changes of scarlet fever are, therefore, to be carefully watched, for the condition is an unusually treacherous one. The greatest care must be exercised that the kidneys are not allowed to become congested as the result of exposure, for any additional congestion may change a mild renal condition into a desperate one. Postscarlatinal nephritis usually develops after the acute symp- toms of scarlet fever have disappeared. As already stated, most of the cases are found to occur during the third week of the disease, but albuminuria and casts may appear as late as several months subsequent to an attack of scarlet fever. The importance of making repeated examinations of the urine after either a mild or a severe attack of scarlet fever cannot be too strongly emphasized. Respiratory System. — Perichondritis of the larynx is a rare and usually a fatal complication. Krause^ states that this affection occurs once in 200 to 250 cases of scarlet fever, but this statement is not borne out by statistics in American hospitals. Rauchfuss' saw 4 cases among 903 patients suffering from scarlet fever, and Leichtenstern^ 2 cases among 4G7 patients suffering ■ Hunter. Tlie Practitioner, January, 1909, p. 3. -' Krause. Prag. med. Wochensclirift, 1899, pp. 29, 30. ' Rauchfuss. Quoted by Welch and .Schamberg, .\cute Contagious Diseases, p. 427. * Leichtenstern. Deutsche med. Wochenschrift, 1882, p, 3173. ciitcuLATOiiY hvsti-:m 329 from lli(^ .sjunc disease. The (l<'\'cl(ipiiicii( of llii. '■oiii|)li';iti(,i) often iiecessiliiU'S llu; jx'rfoniiJiiicc of iiidiUiilion of li'aclicotoiiiv. Bkon(.'iioi'Ni<;um()Nia is a fju'rly rrc(|iiciif. coiiiplicjilion of sfarlet fever, partieuliirly in iiilniils. Ho/j;er' sfjifcs lli;i(, in oil eases of scarlet fever in infants, 0, or 10.7 per cent., were eoni|)lif;itc(l )>y bronchopneumonia. Of 4,30 cases of scarlet fever in diildren, (), or 1.3 per cent., developed this complication, while of 1727 cases of scarlet fever affecting adults, 4, or 0.2 jxt cent., dcvclf>j)((l bronchopneumonia. In the series of 08 fatal cases of scarlet fever reported by McColluni,^ 15 were due to l)ronchopneumonia. In McCrae's' series of 325, 3 developcfl this complication and all three died; and Henoch'* remarks: "We found bronchitis and bronchopneumonia in nearly all severe cases." Pearce,'' in a series of 23 autopsies upon scarlet fever subjects, found broncho- pneumonia in eight. Lobar Pneumonia.^ — Lobar pneumonia is a rare complication of scarlet fever, and when seen usually complicates this disease in an adult. Leichtenstern" states that acute lobar pneumonia, sometimes bilateral, appears at the height of the primary disease, but it has been noted but few times, and more often in association with the nephritis caused by the scarlet fever. Pleurisy and Empyema. — Pleurisy and empyema are infre- quent complications of this malady. Pleurisy is most likely to complicate severe forms of the disease, especially those that are complicated by gangrenous processes in the throat, and in these particular cases the pleuritic effusions often become purulent. McCrae^ found two cases of pleurisy among his 325 cases of scarlet fever, and Pearce^ discovered one in 29 autopsies upon scarlet fever subjects. Empyema is usually a late complication, often being discovered long after the initial illness. Circulatory System.— Cardiac changes caused by the toxins of scarlet fever or by the toxins of the secondary infections during the 1 Roger. La Maladies Infectieuses. 2 McCollum. Boston City Hospital Reports, Series 10, 1S99. ^ McCrae. Montreal Medical Journal, September, 1908. ■• Henoch. Charitt? Annalen III, Jahrgang, 1S76, p. 553. ^ Pearce. Medical and Surgical Reports of the Boston City Hospital, 1899. ^ Leichtenstern. Deutsche med. Woch., 1882. pp. 246 et seq. McCrae. Montreal Medical Journal, September, 1908. Pearce. Report of Boston City Hospital, 1899. 330 SCARLET FEVER disease are among the most important complications of this disease, and rank second in importance to the kiihiey comphcations. Mi/ocardiiis is the condition of the heart which is most frequently calleil into existence hv the scarlatinal toxin and the secondary toxivmias. Everv severe attack of scarlet fever probably produces some degree of myocarditis. This makes it ])articularly necessary that great care should be exercised not only during the illness, but throughout the convalescence, that no undue strain be placed upon the weakened and diseased heart muscle. Endocarditis is a relatively infrequent complication of scarlet fever, but a very important one. There has long existed a differ- ence of opinion among clinicians as to the frequency of this complica- tion during scarlet fever. Ashljv^ found endocarditis not uncom- mon during the disease, particularly when the scarlet fever was complicated by synovitis and arthritis. Roger," on the other hand, considered endocarditis an uncommon complication. In a series of 2213 cases of scarlet fever he saw only two cases of true endo- carditis, but noted murmurs not due to actual valvular lesions 692 times. ]McCollum,^ in an analysis of 1000 cases of scarlet fever, states that a mitral systolic murmur was detected in 187 cases; bruit de gallop in 5 cases; irregular action of the heart in 54 cases; endo- carditis in 3 cases. Many of the murmurs referred to were thought to be due to a relaxation of the heart muscle as a result of the action of the scarlatinal toxin. Daniel,^ in studying 304 cases of scarlet fever, found that although in 66 murmurs were to be heard, in only 3 cases did the murmurs remain permanently. Eddy^ observed but 3 cases of endocarditis among 225 cases of scarlet fever, and Cheadle" states that he observed 15 cases of endocarditis during scarlet fever. Henoch^ observed two cases of endocarditis (luring scarlet fever which were followed bv chorea, and Schmoltz,^ of Dresden, in 30 autopsies upon scarlet fever patients, found " Ashby. Medical Chronicle, January, 1894, p. 161. - Roger. Les Maladies Infeetieuses. ' McColluni. Boston City Hospital Reports, loc. cit. * Daniel. Journal American Medical Association, 1900, xxxiv, 536. ^ Eddy. American Journal of Obstetrics. 1907, Ivi, 493. » Cheadle. Lancet, 1885, ii, 705. ' Henoch. Charit(5 Annalen, 1876, iii, 538. 8 Schmoltz. Miinch. med. Woch., 1894, li, 1417. ciucuLATOiiY svsy /■:.]/ '/,:>,] 3 cases of ciKlocjinlilis. lie concliKlcd rinin lii : ,111'lics tt);it. the majority of tlic hc'iil s\ mpioiiis (lniin;^- ^ciirld i'cver were due. to the varyiii;;' <;rii(lcs oF iiiyociirf>;inl for 1007 we find that in 220() cases of scarlet fever erulocarditis occurred in 120, or 0.58 per cent. In the statistics of the J^ondon Fever Hospital for the last five years the percentage of cases showing endocarditis was 1.8 per cent. Hunter^ states that he met witli hut one fatal case of endocarditis in 1000 cases of scarlet fever. Jn this case the patient, a young child, died after five days' illness, and at the autopsy the mitral valve was found to be covered with enormous masses of soft vegetations. Pericarditis is a less common complication of scarlet fever than is endocarditis, but like the latter lesion usually occurs in severe septic cases of scarlet fever which are so often complicated by septicaemia or arthritic symptoms. This complication is also occasionally found in cases of scarlet fever that are complicated by nephritis. Roger^ has observed several cases of plastic pericarditis, both at the height of the primary disease and during convalescence. Hodger,^ Pospischill,^ Beatty,'' Spencer," and Barbier' have all reported instances of this complication, but ^Yelch and Schamberg^ state that it has been a very rare complication in the large number of cases that have been under their care at the ^Municipal Hospital of Philadelphia. In the experience of the ^letropolitan Asylum's Board of London the percentage of incidence of pericarditis was O.S per cent., and the percentage in the London Fever Hospital was 0.15 per cent. When we consider how large a number of scarlet fever patients pass through these hospitals in a year it is evident that pericarditis is a comparatively rare complication during scarlet fever. 1 Hunter. The Practitioner, January, 1909. - Roger. Les Maladies Infectieuses. 5 Hodger. See Eichhorst, Specielle Pathologie und Therapie (Leipzig. 1S97). 1 Pospischill. Wien. klin. Woclienschrift. September 12. 1907. p. 10S9. ^ Beatty. Dublin Journal of the Medical Sciences, 1907, Ixxx, 11 to 29. s Spencer. Lancet, 1905, i, 420 to 422. " Barbier. Journal de Med. de Paris, 1907. ii, xix, p. 310. s Welch and Schamberg. Acute Contagious Diseases, p. 407. 332 SCARLET FEVER Phlebitis is a rare complication of scarlet fever. The veins of the neck, upper extremities, and cranial cavity are those most likely to be ali'ected. As would be expected, this complication occurs in the very severe forms of the disease, particularly in those affected with gangrenous, ulcerative, or suppurative processes about the mouth and neck. Cases have been reported by Rees,^ Hofnagels,^ von Jurgensen,^ and Moizard and Ulmann.^ The latter writers were able to collect from the literature only four cases of phlebitis following scarlet fever. Roger' reported the case of a woman, aged forty-nine years, who died on the eleventh day of a severe scarlet fever infection. For three days before her death she suffered from phlebitis of the crural vein, and at autopsy vegetations were foimd on the auricular surfaces of the mitral valves. In all the cases of phlebitis tluring scarlet fever that have been studied bacteriologically the condition has been found to be due to the streptococcus." The Alimentary Canal. — The alimentary canal during scarlet fever is the subject of many complications, many mild and without danger, and several severe in their course. Siomafitis is often a troublesome early complication, particularly in voung and poorly nourished children, and varies in severity from very mild manifestations to the gangrenous cases considered under the term of Noma (see below). The mucous membrane of the lips is commonly swollen and reddened, and their epithelial covering is often lost, which leads to superficial ulcerations and may cause fissures about the mouth which not only cause pain, but often seriously interfere with the administration of food. Tonsillitis and Angina Pseudomemhranosa or Gangranosa. — Tonsillitis occurs much more frequendy in adults and older chil- dren than it does in infants. A predisposition, moreover, is seen in those patients who are already subjects of throat affections. Although tonsillitis during scarlet fever often proves a mild dis- order, it may readily become a very severe one when associated with ' Rees. Lancet, 1862, ii, 63. = Hofnagels. Ann. Soc. de M^d. des Enfants, 1899, vol. ii. No. 10. p. 001. 3 Von .Jurgensen. Archives de Mdd. des Enfants, 1899, vol. ii. No. 10, i>. 001. * Moizard and Ulmann. Archives de Mdd. des Enfants, vol. ii, p. 601. ' Roger. Les Maladies Infectieu.ses. " Moizard and Ulmann. Loc. cit., p. 601. 77//'; AUMh'NTAnV CANAL \\'.>;.\ an iiifhimcd and confi^'cslcd pliary/ix. 'llic tonsils ol"(cn iK-fornf covered wiUi ifrennlar piilclies of exudate, wliieh is usually diM- to the sti'eptoeoeeus, idflioii^li occasionally the k'lcl)-,-i.of(ilcr hnciNns is found. Jn severe cases the tonsils are greatly swollen and f:ovcrcd by grayish white membrane, which spreads raf)idly, covering the posterior pharyngeal wall, the hard |>ala(e, and the mucous mem- brane of the posterior surface of the cheeks. With the extension of the membrane, which varies in color from gray to almost black, there follows a severe necrosis, ulceration and sloughing f>f the tissues, and the clinical picture becomes one of prot'outid s«'ptica'mia. In a small percentage of the cases the local process in the pharynx early assumes a gangrenous type and gives rise to numerous ulcera- tions affecting not only the tonsils, but the pillars of the pharynx, the uvula, and, in rare instances, the deeper cellular tissues of the neck. Guindesse,^ Mery and Halle,^ De Brehler,^ and Gindes* have all reported such cases under the name of "primary per- forating angina during scarlet fever." Closelv allied to these gangrenous processes is the condition known as noma, which is occasionally seen during scarlet fever, although it occurs much less frequently than in measles. Tourdes,^ who analyzed 98 cases of noma, found that only 5 complicated scarlet fever, while Woronichin'' found that 4 of 22 cases of noma complicated severe cases of scarlet fever. It is fortunately a rare condition, for it is extremely fatal, although during the last year Dr. W. J. Roe, of the Jefferson Medical College Hospital Staff, has had most gratifying success in several cases of noma complicating measles by the administration of diphtheria antitoxin. Retropharyngeal abscess may occur as the result of the burrowing of pus from suppurating glands or from direct infection from the ulcerating surface in the tlu"oat. Bokai^ observed this complica- tion seven times in 664 cases of scarlet fever in children. In six 1 Guindesse. Semaine M^d., 1906, p. 13S. - Mery and Halle. Ann. de M^d. et Cliir. Inf., Paris, 1903, \-ii, -403. 3 De Breliler. Arch, de med. d. enf., 1907,x. 22-1. ^ Gindes. Yratcli. Gaz. St. Petersb., 1905, xii, 1323 to 1355. 5 Tourdes. Tli^se de Strassburg, 1S9S. s Woroniehin. Jahrbueh f. Kinderlieilk., 1SS7, xxvi. 161. 7 Bokai. Jahrbueh f. Kinderlieilk., X. F., Band x. p. 108. 334 SCARLET FEVER of these cases this author attributed this compHcatiou to the break- ing down of the retropharyngeal glands. In one of Bokai's cases, that ended fatally, llie rctrophai-yugeid abscess was seen as early as the fifth day of the primary illness. We have seen three cases of very severe scarlet fever which developed retropharyngeal abscess during the second week of the disease, but all tlu-ee recovered after a somewhat prolonged convalescence. Gastritis is a common complication of scarlet fever, and may be very severe, although our knowledge of this condition is largely based upon the findings in fatal cases. Crooke* found catarrhal gastritis in each of six cases examined, and several of these also showed interstitial as well as follicular gastritis. Hesselwarth" found 21 cases of severe gastro-enteritis among 81 autopsies upon scarlet fever subjects, and Pearce's^ findings in 6 cases showed similar changes. Vomiting, which is so common as an initial symptom, is seldom troublesome enough to unfavorably influence the course of the disease, although in the severely toxic cases it may become danger- ous. In the hemorrhagic cases of scarlet fever, the material vomited often contains blood, and in some instances in which the hemorrhage is very free the blood is ejected, looking as if it had just come from a freelv bleedino- vessel. During the later stages of scarlet fever, vomiting may be an expression of the toxaemia of a complicating nephritis. Diarrhcca is a frequent symptom during the period of invasion in severe cases of scarlet fever, and is not at all rare in ordinary cases, although the frequency of this symptom varies greatly in different epidemics. It is due to a catarrhal enteritis, which usually yields to simple treatment. A severe attack of scarlet fever in a young child is nearly always complicated by enteritis accompanied by many loose movements, with green stools, fre- quently with mucus, and occasionally with bloody stools. JoeP reports a case in which severe gastro-intestinal symptoms and high fever were the most conspicuous symptoms of the illness. Slight ' Crooke. Quoted by Welch and Scliamberg, loc. cit., p. 443. 2 Hesselwartli. Quoted by Welch and Schamberg, loc. cit., p. 443. ' Pearce. Bo.ston City Hospital's Medical and Surgical Reports, 1899. ■* Joel. Quoted by Thomas in von Ziemssen's Cyclopaedia of Medicine. 77//'; A/JMJ'JNTA/fV CANAL WVy-y arifi'iiiii., followed hy .siibscfjiiciii (lcs((ii;iiii;ili<)n <»!' iIk- I. in, ;iiiil ;iii attiick ol" scarlet fever in anollicr iiicnihcr of the r;iiiiil\ , rciiflcrcl iIk- (liiig'iiosis clenr. in (lie l;ii(^r slii^cs of (he (|i,sc;isc tlicic i, ouk- tiiiie.s eiicomitered ;i (ly.senl,erie coiKJilioii, eli;ir;i(tcii-/.e(| Ity fre(|iici)t •siiiiill cniiirrlial or Moody slools, with tenesiiiiis. Litteii' refers to the oeciirrence of diarrhci'as of a ty})lioid;d (iijiritclcr. in diese cases there is marked distention of tlie ahdoinen and in scenic of them hemorrhages from the bowel. At autopsy there is found enhxrgement of the spleen, swelling of Peyer's patches and of the solitary follicles, the latter at times exhihidni; erosions. A re[)ort as to the Widal reaction is not given with these cases, mid the possibility must be l)()rne in mind that these may have been in- stances of true typhoidal infection, in which scarlalinifonn rashes obscured the true diagnosis. Pearce,^ Crooke,"' and Hesselwarth, ' in their autopsies of scarlet fever subjects, all noted hyperplasia and necrosis of the lymph follicles, and Crooke states that in these cases Peyer's patches not infrequently resemble those found in typhoid fever in the early stage of the disease. The liver in scarlet fever has been reported by many observers as being increased in size, the inferior border being palpable below the false ribs. Welch and Schamberg,' Corlett," and others state that although, in their experience, the liver is gen- erally enlarged during this disease, this finding is not a constant one, and the organ may in severe cases be much diminished in size as the result of degeneration. Histologically the changes in the liver are those found in all the acute infectious fevers. Pearce^ examined 22 cases, and found that 4 showed distinct fatty degeneration and 7 fatty infiltration, while focal necrosis was found in 4 cases. The findings of Roger and Garnier in their examination of 12 cases at autopsy were practically the same as those of Pearce. Cirrhosis of the liver as a sequel to scarlet fever has been 1 Litten. Charite Annalen, vol. vii, pp. 12S et seq. - Pearce. Medical and Surgical Reports of Boston City Hospital, 1899. ' Crooke. Quoted by Welch and Schamberg, loc. cit., p. 443. ^ Hesselwarth. Quoted by Welch and Schamberg, loc. cit., p. 443. 5 W^elch and Schamberg. Acute Contagious Diseases, p. 442. ^ Corlett. Acute Infectious Exanthemata, p. 211. ' Pearce. Medical and Surgical Reports of the Boston City Hospital, 1S99. 336 SCARLET FEVER reported bv Rinoie/ who saw this coiitlitlon several times among chil.lreii. Postmortem examination in S of his cases revealed nnmistakable degeneration of the liver cells. Jaundice in scarlet fever is not a frequent complication of the disease, but is met with in certain epidemics, particularly among severe cases. McCollunr states that jaundice appeared 15 times in a total of oOOO cases of scarlet fever collected bv him at the Boston City Hospital, and Barlow'* found that this symptom was notetl in 15 of the 10,000 cases of scarlet fever treated at the London Fever Hospital. Kaupe,^ Shostak,'' Gross," and Byalokur^ have noted jaundice during, and Phillips,* Barlow,^ and Klingmuller'" following, attacks of severe scarlet fever. Mild jaundice has no particular signifi- cance during an attack of scarlet fever, but severe jaundice may indicate degeneration of the liver. Roger" is of the opinion that delirium and great variations of the temperature during scarlet fever are often to be explained by the pathological changes in the liver cells, and Baginski'- states that he considers the appearance of jainidice in a case of scarlet fever that is complicated by nephritis to be of grave import, as in liis experience this ushers in a very severe urpemic condition. Possibly some of these cases are in reality instances not of hepatogenous but hematogenous jaundice. Peritonitis is an exceedingly rare complication of scarlet fever, and is due in the majority of cases to streptococcus infection of the peritoneum. McCollum and Blake" have reported two cases of this complication. It is to be remembered that ascites developing during scarlet fever is a fairly frequent occurrence, being due either to a compli- ' Single. Jahrbuch f. Kinderheilkunde, Ixv, No. 4. ■ McCollum. Boston City Hospital Reports, 1899, Series 10. ' Barlow. British Medical Journal, August 4, 1906. * Kaupe. Miinch. med. Wochenschrift, 1906, liii, 314. 5 Shostak. Vratch. Gaz. St. Petersb., 1903, x, 1168. ' Grcss. Miinch. med. Wochensciirift, 1905, Hi, 2326. 7 Byalokur. Prakt. Vratch. St. Petersb., 1907, vi, 211 to 213. 8 Phillip.?. Lancet, March 21, 1908. ^ Barlow. Loc. cit. "> Klingmuller. Aerztl. Prax., Berlin, 1906, xix, 182. " Roger. Les Maladies Infect ieuses. '2 Baginski. Die Kinderkrankheiten, 1889, p. 117. '' McCollum and Blake. Boston Medical and Surgical Journal, December 10, 1903. Till': Ni'jiivous ^YHTi'hM ;j;i7 oatiiifi; ncpln'ili's or ii, fnilinj^- licncl, or in sonic in.slMiif^c.s to hotli C'iinscs. The Nervous System. 'V\u- hcinous syslcm ->iifrci^ iiunkcfJIy during scarlet fever. Tlic onsd ol' the disease is atteruK-d in many oases by marked ji(>rvons symf)toms, siieli as headaelie, drowsiness, delirium^ convulsions, and occasionally hy coma. Tliese symf>- toms usually abate if the course of the disease be r;i\-or;d»lf, ;ind do not necessarily add to the gravity of the disease. Tiie early cere- bral manifestations are due to the effects of the scarlatinal poison as v^ell as to the high temperature present, and in some cases the delirium of onset persists for days and not infrecjuently until die death of the jiatient. Insanity during or following scarlet fever is rare and the mental condition is usually temporary, but may in some cases persist after convalescence. Mitchell,^ Rabuske,^ and Wagner^ have each reported cases of acute mania during an attack of scarlet fever. Mania during: scarlet fever has been noted to have followed ursemic convulsions, and Carrieu* and Brille'^ have each reported cases of insanity occurring as sequels of scarlet fever. ^Melancholia is a rare sequel, and usually is short in duration. Meningitis during scarlet fever is a rare complication, and when seen is usually due to the extension of the infective process from the middle ear or from the nasal sinuses, or, more rarely, is caused by infective emboli which infect the meninges at the height of the disease. When meningitis develops, it is an extremely serious affec- tion, and death usually occurs within a week of the onset of the symptoms. Welch and Schamberg," Roger,' and Baudelocque^ report instances of this complication during the acute stage of the disease. Meningo-encephalitis and cerebrospinal meningitis are both rare ■complications of scarlet fever, but the former has been reported 1 Mitchell. Edinburgh Medical Journal, February, 1S82. - Rabuske. Deutsche med. Wochenschrift, October S, 1881. 3 Wagner. Quoted by von Jurgensen (Nothnagel's Encylopadia of Practical Medicine). •> Carrieu. New England Medical Monthly, 1882-1883, ii, 55 to 58. 5 Brille. Quoted by Welch and Schamberg, loc. cit., p. -429. 8 Welch and Schamberg. Acute Contagious Diseases, p. 403. ^ Roger. Les Maladies Infectieuses. « Baudelocque. Gaz. des hop. de Paris, 1837, ii, 197 to 199. 22 33S SCARLET FEVER by Baudelocque/ Avhose patient suffered from headache, vomiting, and convulsions, followed by coma, loss of speech, loss of hearing, and blindness. Cerebrospinal meningitis has been reported by Althaus,- ^NIcKenzie,^ Leroux,^ and Leichtenstern.'^ Althaus states that his patient not only hatl spinal meningitis, but also developed consecutive lateral and posterior sclerosis. Hemiplegia is also a rare complication of scarlet fever. It may occur early in the course of the disease as the result of a cerebral hemorrhage or may come on at a later date as the result of embo- lism or thrombosis. Taylor" has reported a right-sided hemiplegia resulting from embolism of the middle cerebral artery. Sufrin^ has reported a similar case seen by him, and Osier* states that scarlet fever was the cause of seven of his series of 120 cases of infantile hemiplegia, Addy*^ reports a case of what he calls "partial hemi- plegia with amnesia," which appeared as a complication during the convalescence of one of his scarlet fever patients. Rolleston^** has summarized the literature upon this subject when reporting three cases of hemiplegia during scarlet fever. These three cases were found in a series of 10,781 cases of scarlet fever. Rolleston found 63 cases in the literature, this making GG in all. Of 58 of these cases, the right side was affected in 43, the left in 15. This complication occurred at any time during the disease from the first week to the sixth. Of the G6 cases, 49 recovered, and in 17 the recovery was complete. In the majority of the cases, however, contractures and atrophy took place. In 28 cases of right-sided hemiplegia there was associated aphasia. Cherepnin" reports a case of scarlet fever which was complicated by aphasia, but does not mention that there was hemiplegia associated with this symptom. 1 Baudelocque. Gaz. des hop. de Paris, 1837, ii, 197 to 199. 2 Althaus. British Medical Journal, 1881, i, p. 50. 3 McKenzie. Glasgow Medical Journal, 1905, Lxiii, 326. * Leroux. Bull. Soc. de P(5diat., Paris, 1905, vii, 277. ^ Leichtenstern. Deutsche med. Wochenschrift, 1882. 8 Taylor. Medical Times and Gazette, London, 1880, ii, 686. ^ Sufrin. Spitalul. Bucuresci, 1903, pp. 23 to 25. * Osier. Practice of Medicine, p. 985. ' Addy. Glasgow Med. Jour., 1880, bcxxv, 13, 463 to 465. '" Rolleston. Medical Review, January, 1909, p. 24. " Cherepnin. Prakt. Vratch. St. Petersb., 1903, ii, 803. TJIK N/':iiVOI/S SYSTEM :>;.',() Paraplegia (liiriii Strom. Era Gothenburg, 1887, ii, 132. ■' Dercum. Medical and Surgical Reports, 1892, Ixvii, 836. '2 Lund. Norsk, mag. f. Laegeuv., 1871, 219. " Wilson. Arch. Pediat., 1895, xii, p. 679. " Heubner. Berl. klin. Wochen, 1908, p. 1345. »' Miller. Lancet, April 8, 1905. '0 CuUen. Brit. Med. .Jour., 1903, i, 197. " Elliot. Arch, of Internat. Medicine, April 15, 1909. PA HOT IT IS AM) oik: urns ;^4I reported inst.'inccs of tliis fondilioii. In Klliot's patient, agwl ei^lit and one-half years, the syinptoins of the original diseji-se were very severe, and seventeen (hiys after the onset of the searlet fever the patient cornphiined of a, reditu of llic soic ilnoni, ;iiid two days later a purpuric s[)ot on the ankle aJid a litth; later ^an^renous areas of the skin were seen. Tlie patient died sixty-eight liours after the onset of the purpura and twenty-two days after onset of the scarlet fever. Elliot found in the literature 10 cases of purpura fulminans that were sef|uel.s to an attack of scarlet fever. Abscesses.^ — Abscesses of different portions of the bfxJy, more often on the extremities and particularly on the fingers, are infrequently noted during convalescence from scarlet fever. Onychia. — Onychia is a troublesome complication which often affects the nails of children who are convalescent from scarlet fever. Its frequency among children is explained, at least in great part, by the tendency of such patients to pick at the desquamating skin in the region of the nail matrix, thereby causing a focus of infection in the injury done to the new skin. Ridging of the nails is a frequent occurence in this disease, as in all severe febrile affections. Swelling of the Thyroid Gland. — Swelling of the thyroid gland is one of the very infrequent complications of scarlet fever. It is occasionally seen during this disease, as it is in nearly all the acute infectious fevers. Roger and Garnier^ have reported several instances which occurred during epidemics of unusual virulence. One of us (Beardsley) saw a well-marked instance of fills complication during the first week of a severe attack of scarlet fever in a girl, aged thirteen years, and he has several times noted slight puffiness of the gland during the height of the fever in female patients. Parotitis and Orchitis. — Parotitis and orchitis are both rare complications of the disease, but they have been observed, usually being associated with severe attacks of the disease. Phillips" has reported an instance of acute parotitis which appeared in the early stage of a severe attack of scarlet fever. 1 Roger and Garnier. Virchow's Archiv, clxxiv, 1. - Phillips. Lancet, March 21, 1908. 342 SCARLET FEVER Myositis. — ^Myositis durinii' or following scarlet fever is a soiiiewimt unusual occurrence, but is prol)al)ly not as rare as the dearth of literature upon the subject would indicate, l^ruck' has reported several cases, and is inclined to think the conilition a not uncommon one. Somerset" has reported an instance of this condi- tion which developed during the height of an attack of scarlet fever imder his care. The condition is characterized by local tenderness, fever, and stiffness in muscles in vaiious portions of the body. The junior author remembers having seen a number of such cases during his interneship at the Municipal Hospital of Philadelphia, and was inclined at that time to ascribe the symptoms to slight injuries, such as bumps against the cribs when the children were being lifted, but no history of injury could be ascertained. Very rarely these painful areas suppurate and discharge a thick bloody, grumous fluid. Necrosis of Bones. — Necrosis of bones during or following scarlet fever is rare. It is well known that necrosis of the ear ossicles and even the petrous portion of the temporal bone follows scarlet fever in not a few instances. (See Otitis.) Brown^ has seen a case in which the lower maxilla was involved in a suppurative process, and Weickert* reports a case in which both jaws were thus affected. Suppurative artlu'itis has already been considered in another section of this work, while osteitis and periostitis are rare complications which occasionally attack the nasal bones (Henoch), the temporal bone, as above mentioned, and infrequently the cervical vertebrae. Neumark,^ who reported 30 cases of acute infectious osteomyelitis, stated that 5 of them followed attacks of scarlet fever. Ocular Complications. — Ocular complications are not un- common during attacks of scarlet fever, although a study of the literature does not give one a correct idea of their frequency. In severe forms of the disease, particularly in forms complicated by piu-ulent rhinitis, a severe conjunctivitis is often developed. In > Bruck. Petersb. Med. Presse, 1896, No. 18. - Somerset. New York Medical Journal, Ixxii, No. 23. 3 Brown. Lancet, 1844, i, 220. * Weickert. Deutsche Klinik, Berlin, 1854, vi, 22. ' Neumark. Archiv f. Kinderheilk., Band xxii. OC (J LA R COM I'LICA TIONS 'M 'A ran; cases a pscudorncinbrarioiis conjiuK-fiviUs occrurs. 'J'liis is most commonly due to str('[)tococcic inf'ectiorj, less ofteu to the Klebs-Loeffler bacillus. When streptococcic conjunctivitis occurs it is a serious complication, as corneal ulceration of a vinil' nt nature ensues and the eye in many instances is lost. Frimary keratitis is frequently observed in scarlet fever wards, but few cases are to be found reported in the lifcr.'idire of scarlet fever. One of us remembers having seen tlircf; cases of well-marked corneal ulceration in a series of less than fifty cases of scarlet fever, and Dr. Burvill-IIolmes informs us that while a resident physician at the Municipal Hospital of Philadelphia, he observed this complication repeatedly in scarlet fever patients, in all at least twenty-five times. The complication is prone to occur in scrofulous subjects, although children who have been in previous good health occasionally develop this complication during even mild attacks of scarlet fever. Leichtenstern^ reported two cases of corneal ulceration and one of hypopyon keratitis dm-ing an epidemic of scarlet fever at Cologne. Schrotter^ states that the cornea may be primarily affected, usually in the way of rapidly progressing ulcerative processes. Choroiditis may in rare instances complicate scarlet fever. Leichtenstern^ saw such a case, but it is noteworthy that the more important ocular complications are usually secondary to scarlatinal nephi'itis. Of these, ursemic amaurosis is the most frequent. Albuminuric retinitis is rare in all forms of acute nephritis, and the scarlatinal type is not an exception. It may, however, result from the subsequent chronic nephritis. Amblyopia may complicate the kidney condition, but after some days complete restoration of vision usually occurs. Welch and Schamberg,* Porter,^ and DuvalP all report such cases. Orbital cellulitis is a rare complication. Burton Chance' has reported two cases, and Sidney Phillips* tliree cases, while Porter^ 1 Leichtenstern. Deutsche med. Wochenschrift, 1882, p. 3173. ^ Schrotter. Ziemssen's Encyclopsedia of Medicine, p. ISO. 5 Leichtenstern. Deutsche med. Wochenschrift, 18S2, p. 3173. * Welch and Schamberg. Acute Infectious Diseases, p. 405. ^ Porter. Quoted by Thomas in Ziemssen's Encyclopsedia. ^ Duvall. Ibid. ' Burton Chance. American Medicine, Jime 13, 1903, p. 960. * Sidney Phillips. Ophthalmoscope, ilay, 1905. ' Porter. Loc. cit. 344 6C ABLET FEVEli Diivall,* Werner,- Gregory/ and Nettlesh'p^ have all reported single instances. Werner's case was a bov, aged six vears, who at the height of h's scarlet fever developetl unilateral proptosis and oedema of the lids, probably due to thrombosis of the cavernous sinus. In Nettleship's case there was also unilateral optic atrophy. Both the cases leported by Porter and that of Duvall developed exophthalmos caused by infiltration of the cellular tissues of the orbit (see below). Opiic neuritis is another rare complication during scarlet fever. Uhthoff^ studied 253 cases of optic neuritis due to various infec- tious diseases, and found that only three were due to scarlet fever. Groenouw" was able to find in the literature five cases of scarla- tinal optic neuritis, one with albuminuria (Barlow's case), and three without this symptom (Betke, Vance, Pfluger). Other ocular comphcations are rare, but Hodges^ has reported a case in which there developed embolism of the central artery of the retina during a severe attack of scarlet fever. Kendall' has reported a case of dacryocystitis, lyinder^ one of dacryo-adenitis, and Lenhartz^ has seen paralysis of the extrinsic ocular muscles. Surgical Scarlet Fever. — Surgical scarlet fever has been a mucli discussed subject since Sir James Paget called attention to the fact that patients who had undergone surgical operations were particularly susceptible to scarlet fever infection. Paget s first paper* was published in 1804, and Paley and Goodhart* reported 25 cases of this condition in 1879. House^° also reported an epidemic of surgical scailet fever in a hospital for children. From the time of these early reports there has been frequently seen in the literatiu'e accounts of surgical scarlet fever, and there seems no manner of doubt that solutions of continuity of the skin render a patient more susceptible to the disease. Patients with 1 Duvall. Loc. cit. - Werner. Ophthalmoscope, May, 1905. 'Gregory. Quoted by Parsons, Practitioner: January, 1909. < Nettleship. Ibid. ' Uhthoff. Ibid. " Groenouw. Ibid. ' These authors are quoted by Parsons in his article on Ocular Complications of Scarlet Fever, in the Practitioner, January, 1909. * Paget. Clinical Lectures and Essays, 1874. 9 Paley and Goodhart. Guy's Hospital Reports, 1879. >" House. Guy's Hospital Reports, 1879. lU'lLAI'SK 'Mr> extensive surface burns are piuiiciihnly prone fo develop sfjirlr-t fever. It must never he for^ollcn, li()W(-vci', iIimI, lli(Te are many cases that (leveh)p toxic rashes (hie I** sepsis without having true scarlet fever. Relapse. — l{('la|)se occurs, hut is an infrcrjufnt sef|Ufl to scarlet fever, it is well known that the rash in scarl(;t fever may, in certain cases, disappear and recur in a few days. Sueh eruj>- uons should not be interpreted as a true relapse, for io he called a relapse the patient must have a recurrence of all the prominent symptoms of the original diseaseas well as the rash, and these should appear shortly after the beginning convalescence from the original attack. In the majority of the cases of true relapse the recurrence is quite as severe in every way as was the original attack. Korner^ has reported 8 cases in which the relapse proved fatal, and Welch and Schamberg^ quote Richardson, who gives an interesting account of a large number of relapses following scarlet fever on board the frigate "Agamemnon," in which epidemic 300 of the 800 men suffered from the disease. Among these 300 men second attacks were frequent, some of these attacks being mild but others were very severe. Sloan^ reports 154 cases of scarlet fever that had a relapse among 14,143 scarlet fever cases. Trujowsky^ states that among 300 cases of scarlet fever there were 18 which had relapses. Hose^ mentions that among 2453 cases of scarlet fever there were 15 cases of reinfection which occurred between the third and sixth week of convalescence. Lettre^ states that 1.5 per cent, of scarlet fever cases relapse, and Seitz^ states that in his experi- ence it is common to see recurrence of the rash and development a second time of the primary symptoms after eight or ten days of convalescence. Slade-King^ reports two cases of relapse, one occm'ring on the twenty-ninth and the other on the thirty-fourth day of the original attack. 1 Korner. Ziemssen's Encyclopsedia, p. 190. - Welch and Schamberg. Acute Infectious Diseases, p. 394. 3 Sloan. Lancet, February 14, 1903. * Trujowsky. Dorpat Med. Zeitschrift, 1873, 3. 5 Hose. Jahrbuch f. I-underlieilk, Band xxxix, p. S58. 6 Lettre. These de Paris, 1906-1907, Xo. 2. ' Seitz. Munch, med. Wochensehrift, 1S9S, No. 3. ' Slade-King. British Medical Journal, December 2. 1905. 346 SCARLET FEVER In very rare instances a second relapse may occur in scarlet fever, and tliree and four relapses have been reported. Welch and Schamberg^ report in detail a case that had an undoubted second relapse. It was interesting to note that desquamation followed each attack. Second Attacks. — Second attacks of scarlet fever are rare, for one attack protects the majority of individuals for life from this disease. There are, however, many cases on record of second and a few of third and even fourth attacks of this disease. It is without doubt true that many of these reputed second attacks should be classed as relapses or are cases of mistaken diagnosis, but there can be no doubt, on the other hand, that a second or even a third attack of scarlet fever does rarely occur. Mycelius, quoted by Sternberg, states that he was able to find in the literature 29 cases of second attacks of scarlet fever and four cases in which third attacks took place, but no authentic cases of foiu- attacks of the disease were recorded. Willan' never encountered an instance of a second attack of scarlet fever in 2000 cases of the disease that he attended, but, on the other hand, Trojanowsky^ states that 6 per cent, of his cases consisted of patients who were ill of a second attack of scarlet fever. Thomas,^ in his large experience, was only sure of having seen one true second attack, and Henoch^ saw but one. Kinnicutt" had under his care a boy, aged five years, w4io had two attacks of the disease within eight months, and Seitz,^ in an experience of 833 cases, saw two second attacks, one occurring after one year and one two years after the primary attack Sequels. — Sequels of scarlet fever, other than those mentioned, usually represent a continuation of the complications resulting from the infectious nature of the disease. The mucous mem- brane of the throat and nose shows the most persistent patho- logical alteration. The ears, however, as already stated, are the organs which chiefly suffer. Next in importance is the danger 1 Welch and Scliamberg. Acute Contagious Diseases, p. 394. 2 Willan. Quoted in Zieinssen's Encyclopaedia. ' Trojanowsky. Dorpat Med. Zeitschrift, iii, 1873. * Tliomas. Ziemssen's Encyclopedia. ^ Henoch. Ibid. ^ Kinnicutt. Arch, of Pediatrics, .January, 1908. ' Seitz. Munch, med. Woch., 1898, No. 8. that following scarlet fever the kidneys will Ix- \cU in a state of subacute or chronic inflammation. Various cutaneous (Jiseases, such as eczema, furunculosis, sclero- derma, and even (uberculosis of tlicskin, have been noted as sequels to an attack. Certain psychic disturbances, such as melancholia and even mania, may persist for days, weeks, or even months after an attack of scarlet fever. CHAPTER III. MEASLES. Although measles is usually looked upon as a comparatively harmless disease of infancy and childhood, its complications make it a serious malady. The mortality of measles varies from year to year, hut the disease is one of constant importance. The annual average of deaths per 100,000 due to measles,from 1901 to 1905, was 9.1 in the registration area of the United States. In many countries, notably Austria, Belgium, Hungary, Spain, England, and Prussia, the mortality rate is much higher than in America. The mortality rate for the registration area of the United States census for 1900 dispels any idea that measles is a trivial affection, for we find that it caused 12,866 deaths during that year, whereas the mortality rate for scarlet fever was less than half that of measles for the same period. This difference is, of course, chiefly due to the greater frequency of measles, but it emphasizes the fact that the number of deaths due to measles and its complications is by no means small. Nearly every severe case of measles is accompanied by one or more complications, and sometimes after the patient recovers from the initial illness he is left with a sequel of the disease which may trouble him for months or years. In this respect cases seen in private practice differ greatly from those met with in public institutions for children. Barthez and Sannee^ found, in their study of 1521 cases of measles, that complications or sequels were present in 1044, and Haig Brown' reports 60 cases of this disease, in 48 of which there were present complications or sequels. Such percentages as these are far in excess of those met with in general practice. The complications may appear at any stage of the dis- 1 Barthez and Sannee. Traite cliniq. et pratiq. des mal. des enfants, Paris, 1891, tome iii, p. 38. 2 Haig Brown. British Medical Journal, April 10, 1887, p. 826. PJiODUOMAL RASI/h'S 340 ease, und iml iiifrcriiictidy llic syinploins of the (■<>i]\\)\]c;iiin^ stiite may c-omplclcly iii;isk (Jiosc of tlic or-i^inul Jifrcclion. Prodromal Rashes.— As in jiciuly iill (lie cxMritliciiKitoiis fcvens, the typiciil cniplioii of iiicmsIcs is at limes prcccf led hy ;ifr'i(|cnt;il or |)ro(h'oiii;i,l rashes. Tlicse rashes are not coinmoii, hut f^ecnr with SLilIieient fretjueney to deserve attention, paitieularly as they are often responsible for mistakes in diagnosis. lioger* reeords 5 cases of prodromal rash of the erythematous type in 1917 eases of measles. One rash appeared In an infant, another in a fhiM aged tliree years, and the remaining three eases oeenrred in aduh.s. Gerhardt,^ Coniby,^ and Welch and Sehamberg'' all i* port instances of pro(h-omal rashes, and Meredith Richards'' and Kolleston" call particular attention to the danger of mistaking these early rashes for the rash which accompanies typhoid or scarlet fever. The pro- dromal rashes of measles usually appear for one to three days before the ordinary rash, sometimes fading before the appearance of the true rash, and at other times for a day or two exist in associa- tion with the characteristic blotchy rash of the disease itself. Rolleston divides these prodromal rashes into: (1) Isolated macules. (2) Blotchy erythemata. (3) Isolated papules. (4j Urticarias. (5) Circinate erythemata. In addition to these rashes, miliary vesicles or sudamina are sometimes seen in young children before the true eruption appears, but more often when the eruption is at its acme. Chairou^ has reported several epidemics during which miliary vesicles frequently occmredjand he proposed the name of "sweating measles" for this class of cases. Thomas^ is of the opinion that the prodromal rash is an expression of an abortive attempt to produce the ordinary rash. In considering the complications of measles it is important to remember that in many instances it is difficult to distinguish the ' Roger. Revue de Med., April, 1900. Les Maladies Infectieuses, Paris, 1902. 2 Gerhardt. Quoted by Thomas in Ziemssen's Cj'clopasdia of Medicine, 1897. 3 Comby. Traits des Maladies d'Enfance, Paris, 1S97 ■* Welch and Schamberg. Acute Contagious Diseases, p. 492. ^ Meredith Richards. Quarterly Medical Journal, 1898, v, 31. " Rolleston. British Medical Journal, February 8, 1905. ' Chairou. Quoted by Trousseau. * Thomas. Ziemssen's Cyclopaedia of Medicine, 1897, ii. 350 MEASLES visceral lesions due directly to the infection of measles from those prodiicci] by secondary infections. Complications.^ — "^llie most common complications of measles are as follows: Disorders of tlie respiratory tract; tlisorders of the digestive tract; skin complications. Although bronchopneumonia is the most important of the respira- tory complications, it is appropriate, before discussing its character- istics as such, to speak of the lesions often met with in tlie upper respiratory passages. As the catarrhal symptoms are so prominent,, it is to be expected that the mucous membranes of the respiratory tract would suffer during or after the disease. Thus, we find that catarrhal laryngitis is so constantly present in measles that it can scarcely be looked upon as a complication. Holt^ states that severe catarrhal laryngitis is present in over 10 per cent, of all cases of measles. Ulcerative laryngitis appears in a certain limited number of severe cases. The inflammation leads to necrosis of the mucous and submucous tissues and the vocal cords in these cases are commonly involved in the destructive process. Barthez and Rilliet^ found ulceration of the larynx in nearly 50 per cent, of the cases of measles which came to autopsy, and Gerhard t,* who studied these ulcerations of the larynx during life, came to the conclusion that they occurred very much more commonly than is usually thought. The superficial ulceration gives rise to a dry cough, accompanied by severe pain, which is made worse by swallowing or speaking. Membranous laryngitis is a very fatal form of the disease which) is produced by the action of the streptococcus, the diphtheria bacillus, and possibly other organisms. Holt found that 35 cases of membranous laryngitis occurred in 283 cases of measles, but is confident that the complication occurs much more frequently than this in epidemics in institutions. Granlou* found in his work at I'Hospice des Enfants Assistis that in 1633 cases of measles,, membranous laryngitis occurred 235 times, and of these cases, 218 were fatal, while among the remaining 1398 cases only 388 died. 1 Holt. Infancy and Childhood, p. 967. - Barthez and Killiet. Traitd cliniq. de prat. d. mal. d. enfants, Paris, 1891, t. iii,p.38_ ' Gerhardt. Lehrbuch der Kinderkrankheiten, p. 63. * Granlou. La rougeole I'hospice des enfants, Paris, 1892. P ULMONA It V CO M/'/J (J A 770 A'-S' .'jo J These statistics show what jui cxirciix-ly (lan^rcroiis coinijlif ation m('inl)raiioiis laryiioilis is. AIth()ii|j;li th(T(! has cxislcd, in (he past, a (|in'crf':if(r ol' o^Ainon as to the cause of incinhraiioiis laryngitis, it is prohahly true that in the great majority ol' cases pyogenic cocci are responsihle for tli<; condition, bnt it is to be remembered that the diagnosis Ix-tween true laryngciil diphtheria and membranous laryngitis com}>h'cating measles can only be made by a bacteriological examination. When di[)htheria complicates measles it is likely to make its appearance late in the disease, while membranous laryngitis usually apj>ear.s early or at the height of the malady, De Cerlant^ records a case of obstructive dyspnoea which ap- peared before the rash of measles developed. In this instance the symptoms of obstruction were in evidence throughout the disease. Sevestre and Burmus^ have reported a similar case in which the obstructive symptoms were so intense that it was found necessary to intubate. Welch and Schamberg^ state that a number of such cases have been seen by them, many of which it was found necessary to intubate, and they add the significant statement that, in their experience, all the patients intubated for this condition died. True diphtheria occasionally complicates measles, but many of the cases reported are undoubtedly instances of membranous laryngitis due to pyogenic organisms. Adriance,^ however, has reported an epidemic of 96 cases of measles in the Nursery and Child's Hospital of New York, 36 cases of which were complicated by diphtheria. Four of these 36 cases proved fatal. Necrosis of the laryngeal cartilages and oedema of the glottis are rare complications, and are usually seen dm-ing epidemics of the disease occurring in ill-nourished children such as are found in asylums and charity hospitals. Pulmonary Complications. — The trachea and bronchial tubes are always involved in the catarrhal process of measles, and during the extension of the inflammation tlii'ough the air passages the complication may assume a serious aspect. The most frequent 1 De Cerlant. Gaz. Hebdomadaire des Sciences Medicales de Bordeaux, Maj" 8, 1904. 2 Sevestre and Burmus. Archives de M^decine des Enfants, 1S99, No. 2, p. 65. 5 Welch and Schamberg. Log. cit., p. 502. * Adriance. Archives of Pediatrics, February, 1900. 352 MEASLES and by far the most important C()iiij)lication of measles is broncho- pnenmonia. BRONCHOPNErMONiA. — This is not only the most frequent but also the most fatal (•t)ni])lieation of measles. Its frequency varies very much in different epidemics, and it is far more common in foundling asylums and similar institutions than in private piactice. Holt* states that during two epidemics of measles in the Nursery and Child's Hospital, affecting about 300 cases, bronchopneumonia occurred in about 40 per cent. These children were nearly all under three years of age, and therefore more susceptible than older children. Seventy per cent, of those affected with pneumonia died. Holt agrees with Henoch, who believes that a certain amount of pneumonia is fountl in every fatal case of measles. Bartels^ saw 68 cases of bronchopneumonia among 573 cases of measles, that is, 11.9 per cent. Ziemssen and Kabler^ reported 50 attacks of this complication in 311 cases of measles, or 16.1 per cent., while Embden^ found only 27 cases of pneumonia in 4(51 cases, or 5.9 per cent. Landis,^ in his analysis of 457 cases of measles at the Philadelphia Hospital, found 54 complicated with broncho- pneumonia, and of this number 43 proved fatal (79 per cent.). It is a noteworthy fact that bronchopneumonia usually manifests itself when the eruption begins to fade rather than during the course of the malady, and it may be delayed for some days after the dis- appearance of the eruption. When measles is complicated by a pneumonia, particularly of the bronchopneumonic type, the tem- perature does not fall after the disappearance of the rash, but instead usually rises to a point higher than before, and with the increase in temperature there is noted a rapidity of pulse and in the respiratory rate, with cough. Percussion will reveal impairment of resonance over areas of the lung, the breath sounds are of the bronchovesicular type, and fine and coarse moist rales are often clearly heard. Lobar pneumonia is a much less frequent complication of measles than the catarrhal form, and when it occurs is usually met 1 Holt. Loc. cit., p. 966. * Bartelg. Quoted by Welch and Schamberg, loc. cit., p. 503. ^ Ziemssen and Kabler. Griefswalder med. Beitriige, 1861, Band ii, S. 117. * Embden. Quoted by Welch and Schamberg, loc. cit., p. 503. ' Landis. American Medicine, 1908, viii, 234. rULMONAUY COM I' Lie AT IONS :j53 wli;li as a complication in an ;ulult or in cliildicn iic;ir- pnltcrty. Stcdcrns* lias r(!j)ortc(] 5 cases of this coiiiplicatioii in a scries of 322 cases of measles. Bernardy^ reports his very unusual experience in caring for 12 cases of lobar pneumonia in a series of 160 cases of measles, and Bottomley' states that he has met with 13 cases of this complica- tion in treating a large number of cases of this disease. Pleurisy, with or without effusion, is a rare complication of measles. When encountered this complication is more likely to prove to be tuberculous than to be a simple pleurisy. Fiirbringer^ has called attention to the occasional development of a primary pleurisy, usually followed by effusion purulent in character, early in the course of measles. He has observefl a number of sucli cases, and believes that the effusion is purulent from its onset. Mery and Lorrain^ report a fatal case of measles complicated by a large pleural effusion. Roger" had under his care a child, aged five years, who developed a purulent pleurisy during measles, and Guttceit^ has recorded an unusual epidemic of measles in which hydrothorax was a frequent complication, and states that nearly all the patients who developed this complication died. Cornil and Babes* and SteibeF have also seen cases of measles in which the pleura was involved. Ballico^" reports a case in which a hemorrhagic pleurisy occurred during measles. Empyema during and following measles is almost as frequent as pleurisy, for, as above stated, the purulent effusions are prone to become purulent. Roger and Fiirbinger have both reported instances of this complication. Pulmonary tuberculosis so frequently follows an attack of measles that in a certain proportion of cases tuberculosis may be looked upon as a direct sequel. Whether there has been present a 1 Stefferns. Deutsche Arcliiv f. klin. 1899, Ixii. 2 Bernardy. Ann. Gynecology and Pediatrics, July, 1S99, p. 618. 8 Bottomley. British Medical Journal, February 4, 1905. ^ Fiirbringer. Quoted by von Jurgensen in Eulenberg's Encyclopedia, xii, 559. ' Mery and Lorrain. Anat. de Paris, March, 1897. * Roger. Les Maladies Infectieuses. ^ Guttceit. Quoted by Houl, Wiener klin. Rund., 1S97, ii, 833. 8 Cornil and Babes. Quoted by Dawson WiUiams, Glasgow, 1896. ^ Steibel. Quoted by Thomas in Ziemssen's Cyclopedia. 1° Ballico. Rendic. d. Assn. Med. Chir. de Parma, 1905, vi, 139. 23 354 MEASLES latent focus of tuberculosis in the lung before the attack of measles is often tlilHcult to deternn'ne, but in many cases (his is undoubtedly the case, and following the exhaustion of the j)a(iciit from the acute disease the tuberculous jirocess finds little resistance in the pulmonary tissues. Tuberculosis may develop in an area of bronchopneumonia which remains unresolved. Gangrene of the lungs following measles was met with by Barthez and Rilliet^ in four instances. Steiner and Neureutter" have also met with this complication twice in their experience. Aleiy and Lorrain^ report the case of a three-year-old child who died on (lie seventh day of a severe attack of measles, and at autopsy the entire lower lobe of the lung was gangrenous. Ruhrah^ observed four cases of gangrene of the lung in one epidemic of measles, but this is a very unusual experience. In all cases the gangrene of the lung is secondary to a severe l)ronchopneumonia. Disorders of the Digestive Tract. — The mucous membrane of the gastro-intestinal tract is always involved to a greater or less degree during measles, and the complications may become, particu- larly among badly nourishetl children, second in importance only to the pulmonary complications. Catarrhal stomatitis is always present in severe cases of measles and in a great number of the mild cases. Ulcerative stomatitis is by no means infrequent, particularly during epidemics of the disease among children in crowded insti- tutions. The usual location is in the buccogingival furrow. The condition is characterized by the formation of small patches covered with necrotic epithelium. Gangrenous stomatitis or noma is fortunately a rare complica- tion or sequel, but more often follows measles than any other disease. It usually occurs during the course of a severe type of the disease in a badly nourished child, particularly in those children living in crowded institutions or with bad surroundings. The condition is a most distressing one to treat, and is fatal in the great majority of cases. The most frequent site for noma is in the furrow between ' Barthez and Rilliet. Traits cliniq. et pratiq. des mal. des enfants, Paris, 1891. 2 Steiner and Neureutter. Quoted by Welch and Schamberg, loc. cit., p. 505. ' Mery and Lorrain. Anat. de Paris, March, 1897. * Ruhrah. In Nothnagel's System, Measles. j)JS()UJji:h's ()!<' 77//'; i)i<:h:s'i'i\ I': tuact wr^'i the cheek und teeth, next hi imjijeney in tlie nf>s, |);iiti(iil;irly the h)wer hp, und rarely the arcli of the soft pjihilc In I Ik- Ki cases rep()rt(!(l hy Hhnner and MaeKarhmd' llic nioiilli nlonc \\;i^ ;i fleeted in 4, tlie inondi and e;ir in W, tlic nioiilli, e;ir, iind vul\;i. in '■'>, (Ik- vnlva alone in .'5, iind the reetnrn in '.'>. Ilolt^ lias rej>orU'd 7 instances in whicii noma, attacked the external e;ir. Wejiver and 'rniniiclid"' liiive reviewed tite litcriitnrc of lliis siihjcci mo :( (Iioi- onjijiily in re[)ortino- a case ol" noma complicatiiif^ scarh't fever. ToLirdes,* who analyzed 98 cases of noma, found that in 39 of this number the condition comphcated an attack of measles, and Krahm""' found that 55 of 133 cases of noma also occurred during measles. Hildehrandt and Perthes" have collected 133 cases of noma, and of these cases, 53 accompanied an attack of measles. Blumer and MacFarland have reported an interesting epidemic of measles that occurred among the inmates of an orphan asylum, in which, of the 173 children suffering from the disease, 16 devel- oped noma. Crowdon, Place, and Brown'' report a similar epidemic of measles, in which there were 46 cases of ulcerative stomatitis but only 6 of gangrenous stomatitis or noma. Landis,^ who studied the records of 457 cases of measles at the Philadelphia Hospital, found that there were only records of 6 cases having developed noma, and that of these 6, 5 died. We find that among the 6364 children admitted to the East London Hospital, only 5 had noma, and among 13,000 children admitted to the Great Ormond Street Hospital for children, only 6 cases were seen, which gives one some idea as to its rarity. Noma is not infrequently accompanied by gangrenous processes elsewhere in the body, as gangrene of the lung, larynx, oesophagus, and stomach. In four cases of noma reported by Barthez and Rilliet" in their study of 20 cases of this condition, they found gangrene of the lung. 1 Blumer and MacFarland. American Journal of the Medical Sciences, 1901, cxxii, 527. - Holt. Diseases of Infancy and Childhood, p. 968. 3 Weaver and Tunnicliff. Journal of the Infectious Diseases, January, 1907. ^ Tourdes. These de Strassburg. ' Krahm. Quoted by Crowdon, Place, and Brovm, loc. cit. ^ Hildebrandt and Perthes. Dissertation, Berlin, 1873. ' Crowdon, Place, and Brown. Boston Medical and Surgical Journal. April 15, 1909. ' Landis. American Medicine, 1908, viii, 23-1. ^ Barthez and Rilliet. Loc. cit. 35G MEASLES Move than one attack of noma is a verv unusual condition, but Berthe/ writing in 1754, stated that he saw a child afflicted with this condition twice, and ZiegkM'- reports two cases of noma that rehipsed. Noma has a particuhuly liigh deatli rate for several reasons: (1) The condition only develops in poorly nourished children that do not have sufiicient food and are deprived of fresh air. (2) The condition usually develops during or after severe attacks of the primary disease, and is in many cases accompanied by a severe bronchopneumonia. Tourdes^ states that of 00 cases of noma seen by l^aron and Taupin, everyone died. Tourdes also collected information concerning 239 other cases of noma, and found that of this number, 176 died, giving a mortality of 73 per cent. Nine of the 14 cases seen by Mayr^ died, as did 10 of the IS cases collected by Gierke. Springer^ reports 23 cases with 2 recoveries, giving a mortality rate of 90.5 per cent. Of this last series of cases, 10 were operated upon and 14 died, a mortality of 87.5 per cent., while of the 7 not operated upon, all died. Of the entire number (970) of cases of noma collected by Weaver and TunniclifT" from the literature of the subject and their own experience, 7()0 died and 210 recovered, giving a mortality rate of 77,8 per cent. As already stated, when death occurs during the course of noma the fatal termination is often actually caused by an accompanying bronchopneumonia. Thus it was found in one series of 03 fatal cases of noma that bronchopneumonia was present in 58, and in 21 cases of noma reported by Barthez and Rilliet,^ pneumonia was absent in but two. Tonsillitis during measles is occasionally noted, and when the tonsils are affected membranous patches not infrequently are pres- ent which are due to infection of the inflamed mucous membrane by pyogenic bacteria which are usually streptococcic or staphylo- coccic in their nature. The Klebs-Loeffler bacillus is rarely met with as a cause of this condition. ' Berthe. Quoted by Weaver and Tuiinicliff, loc. cit. ^ Ziegler. Miinch. med. Woch., 1892, xxxix, 10". ' Tourdes. Loc. cit. ■• Mayr. Ztsch. kais. kou. Gesellsch. der Aerzte zu Wien, 1852, p. 201. * Springer. .Tahrbuch f. Kinderheilk, 1904, Ix. 613. * Weaver and Tunnicliff. Loc. cit. ' Barthez and Rilliet. Loc. cit. DfSORDfJRS OF T/ff'J DldlC^TIV E THACT y^TyJ RetROPHARYNGKaf. aijsckss ofnurinf^^ ;i.s u cornpliojitioii ur sequel is extremely nire, and wlicii it, flcvclop.s i.s nearly always a sequel of pyogenic infection of the [)l)aryn^('al wall. Parotitis is another rare eornplieation or sequel. I'ucfi' has reported a case, and there have been occasionally seen cases in which mumps com[)Iicated mea.sles. Thomas^ states that Ficht- bauer, Thore, Kismann, Biifalini, and Battersey have all .seen cases of parotitis accompanying measles, and that Scidl, Schultze, and Kellner have met with this condition as a scfjuel to this disease. The stomach and intestines are rarely affected In the sense that they develop definite or characteristic lesions, but vomiting and diarrhoea during the course of measles are commonly met with. Obstinate vomiting due to an acute catarrhal gastritis is not com- mon, but when it occurs it is often a dangerous .symptom. Diarrha.-a is a frequent and in many cases a severe symptom, being caused by a catarrhal conditionof thebowel. This symptom may vary in severity from a slight catari hal enteritis, which is common, to a severe and, at times, fatal enterocolitis, which is rare. This symptom, when it develops in an infant or young child during an attack of measles, and particularly during the summer months, is likely to be a serious complication. Welch and Schamberg^ state that cases are on record in which diarrhoea during an attack of measles in adult life has proved fatal. One of us (Beardsley) had under his care a young man, aged twenty-six years, who suffered from a very severe attack of measles, at the height of which diarrhoea appeared as a prominent and most troublesome symptom. The prostration in this case was very marked, although the temperature after the appearance of the rash was at no time high. On the second day of the diarrhoea a small quantity of blood was passed by the bowel with a quantity of foul-smelling mucus. Convalescence in this case was much delayed, and the patient was unable to resume his work for four weeks after he left his bed. Diarrhoea is much more frequent in certain epidemics than in others. "Willischanin* studied and reported an epidemic of measles m a school for girls, 1 Pucci. Gazz. d. osp. del. clin., 1896, x^-ii, 291. - Thomas. In von Ziemssen's Cyclopaedia. 3 Welch and Schamberg. Acute Contagious Diseases, p. 506. ^ Willischanin. St. Petersburger med. Wochen., December 4, 1893. 358 MEASLES in which 10 of tho '^0 patients had a scvciv diarrhoea chn-jni^ convalescence. Appendicitis occurs with no greater frequency durino; an attack of measles than in ordinary life. This is illustrated by the fact that tlie only case we have been able to find in the literature of the suljject is oiu- rc})ortcd bv ]\ren(i;us.^ Skin complications durino- measles are of importance. We have already mentioned the prodromal and complicating rashes (p. 349). Facial herpes is sometimes seen during the early stages of measles, and may persist until convalescence. Rarely herpetic spots appear late in the disease. This eiuption ^vas noted in five of Landis'' 457 cases. Urticarial eruptions are rare, but are sometimes seen dining the prodromal stage of measles or even in the well-developed stage of the disease. Claus^ has reported two cases which appeared during the stage of incubation. Bullous eruptions during measles have been reported by many observers, but the condition is infrequent. Among those reporting cases which showed bulLi? are Krieg,^ Loschner,'' Henoch," Steiner/ Du Castel,*^ Baginski," and Romberg.^" Steiner saw four cases in the same family. The blebs, which appeared in crops, varied in size from that of a pea to that of a pigeon's egg, attacked both the skin and mucous membranes, and w'ere frequently accompanied by fever. Impetigo is occasionally observed during the convalescing period of measles. Eczema sometimes occurs after an attack of measles, and ery- thema nodosum is rarely seen. Disseminated tuberculosis of the skin following this disease has ' Mengus. Arch. M^d. de Angen., 1905, ii, 756. 2 Landis. American Medicine, loc. cit. ' Claus. Jahrbuch f. Kinderheilk. u. Phys. Erzieh., June, 1894. * Krieg. Cst. Jahrbuch, 184.3, p. 219. ^ Loschner. Quoted by Welch and Schamberg, loc. cit. p. .508. " Henoch. Berliner klin. Wochenschrift., 1882, p. 19.3. ' Steiner. Jalirbuch f. Kinderh., new series, vii, 346. 8 Du Castel. Rev. gdn. de clin. et de thdra., Paris, 1897, ii, 609. ' Baginski. Archiv f. Kinderh., 1901, Band xxviii, Heft 1 and 2. "I Romberg. Quoted by Henoch, loc. cit. >S'A7yV COMI'LICATIOSS •/,:><) Ix'cii iiolcd hy iiiiiny vvrllcr'.'-:, iiiiioii<^- llicin M;i(l(i)(|,' II;ill,^ Wliitiikcr,'' l^>,sclicricli,' I)ii ( 'iisld,'' IIjiiisIiuIUt,'' jmkI Afliiinvjii.'' 'J'liis condition is usually widely distributed over Uu; surfiiec of dir- patient, and affects the face of the extremities as well as Uh- (ruul.. Psoriasis has also been known to make its first aj^fjearunce shortly after an attack of measles, the primary disease in this instance probably actin^^ as the exeitiiif^ cause in a predisposed subject Miliary vesicles are rarely seen durinr, 1 Richter/ and Blumcrand MacFarlurid.'' AnfoniHfi^ has reported pjangrene of the skin of tlic gciiiUil region jissociatcd witli tli.'if (jf (lie gluteal and ioi^iiinal rcnion, ;iiid M;ijiiiia,'' I'crriri,' Wiiridfr," Tlioiiias/ Kiclilioi'st,*^ I Icllcnrii," ;iihI rdliccs liavc r<-\>(>rU:(\ siinihir cases. lite lymphalJc glaiuLs arc always slif^htly (-nlar^cd. Jn some cases this enlargement may become very marked, particularly in the cervical and submaxillary regions. Abscesses are partifiihirly frequent in the lymphtitic glands and other tissues of the sul>- maxillary region. The suppurative process does not cause trouble, as a rule, until some weeks after convalescence (see sequels, p. 372) from the acute disease, and is therefore rarely recorded as a com- plication or even as a sequel of measles. One of us (Beardsley) has seen sixteen such cases at the out-patient department of the Starr Centre Dispensary during the last six months. In some cases the glandular enlargement may persist for a long time, and may terminate in a tuberculous infection, while in other cases the glands break down and suppurate, as described by Gregory and Rilliet.^** Genito-urinary Complications. — The genito-urinary complica- tions of measles, although, as a rule, not severe, are neverthe- less of some importance. Albuminuria during the febrile period is as common as it is in all the acute febrile diseases. The junior author examined the urine of 20 cases of measles daily, and found that of this number 16 showed albumin at some time during the course of the disease, and m 4 cases the urine contained casts. In none of the cases was albumin present ten days after convales- cence, but in one case casts were found for a period of six weeks after the disease itself had ceased to exist, but after this time no casts were found. Loeb" reports propeptonuria present in 9 out of 12 cases examined at the height of the malady. 1 Richter. Monographie, Berlin, 1828. - Blumer and MacFarland. Loc. cit. 3 Antonucoi. Gaz. degli Ospedali/No. 69, 1908. ^ Majima. Jahrbuch f. Kinderheilk., 64, No. 5, p. 651. ' Perriu. Ann. de m^d. et cliir. inf., Paris, 1903, ^•ii, 109 to 114. ' Wunder. Munch, med. Wochenschrift, Jlay 18, 1897. ' Thomas. Von Ziemssen's Cyclopaedia. 8 Eichhorst. Deutsch. Archiv f. klinische Med., Band Ixx, Heft 5. 9 Helleneu. Jahrbuch f. Kinderh., 1908, Ixvii, 294. 1" Gregory and Rilliet. Quoted by Welch and Schamberg, loc. cit., p. 512. " Loeb. Trans. Med.-Chir. Soc, Ixxii, 57. (Quoted by Dawson Williams.) 362 MEASLES Thomas' ([iu)tt\s 1.") autlioi's as having' iiu't with nephritis chirino- measles and is of the opinion that it" the urine was examined as carefully and over as lon^' a period as it is in scarlet fever, we would liiul nephritis a miuh more common complication of measles than is generally believed. Fatal cases of measles complicated by urjemia have been reported by several writers, among them Miiller,^ Demme,^ Browning/ and Zichy-AVoinarski." \Vhen the kidneys are seriously in\ olved there may be general anasarca present, as in the cases reportetl by Abeille," Denizet,^ and Comby^ (2 cases). One of us (Beardsley) saw a case of this kind which appeared during convalescence in an Italian girl, aged sixteen years. There was marked oedema of the extremities and the abdomen was distinctly distended with fluid, but the patient recovered, although there were still many casts in the urine and a trace of albumin present when tlie girl last attended tiie dispensary at the Starr Centre Dispensary. Hsematuria is an unusual hnding in the ordinary variety of measles, but in the malignant forms of the disease, hsematuria is a frequent complication. Bambace" reports an epidemic in which hsematuria was a frequent finding, and in all the descriptions of "black measles" hsematuria is almost constantly referred to. Urethritis during measles must be an infrequent symptom in male children, as we have been unable to find any reference to it in the literature, although one of us saw three cases during the past winter. All the cases were in young boys, their ages being respec- tively five, six, and nine years. In one boy there was evidence that there had been introduced into the urethra some foreign body, but in the other cases the boys denied any knowledge of the discharge until it was discovered by routine examination of the body. The discharge was examined microscopically, but although there was much pus present, no bacteria were found. Injections of salt ' Tliomas. In Von Ziemssen's Cyclopsedia. 2 Miiller. Quoted by Welch and Schamberg, Acute Contagious Diseases, p. 512. ' Demme. Ibid. * Browning. Ibid. ' Zichy-Woinarski. Australian Medical Gazette, October 1.5, 1893. 6 Abeille. Quoted by Welch and Schamberg, loc. cit., p. 512. ' Denizet. Ibid. 8 Comby. Ibid. ' Bambace. Gazette degli Osped., Milan, April 5, 29, No. 41. 77//-; iii<:art and jn.oo/jv/'Jssf'JLS :>,(;?, solution WiiS the only (rcjilinciil, used, ;ui(| (lie coiMlil inn di ;i|)[)<;i rcl in tlircc diiys. Vulvitis is ii rclalivcly roniinon coinplicnlion of severe iittacks of measles, and is by no ineiuis nncoiimioiily seen in oi(lin;iry attacks of measles. (>)ml)y' observed vulvitis in 27) eases among 715 eases of measles treated in isolation pavilions. Tt must be remembered, however, that vulvitis is by no means an nncommon eoniplieation in ehildren's homes and lios|)ilaIs even when no aente cruplive ilisease is pi-esent. Vulvitis din-ing measles begins early, as a rule, and has a tendency to persist. The parts are red, swollen, covered with a mucopurulent discharge, and are extremely tender. Micturition is accomplished only with difficulty, and causes much pain. In a few cases vulvar ulceration occurs, and occasionally gangrene. Gangrene of the genital regions in both sexes has been mentioned under noma and under gangrene of the skin (loc. cit., p. 355). The Heart and Bloodvessels. — The heart and bloodvessels are not, as a rule, subject to complicating lesions during measles, although it is by no means rare for the heart muscle to be weakened in the course of a very severe attack, and death may occur from what is commonly termed "heart failure," wh'ch is probably an infectious myocarditis. Welch and Schamberg^ report the case of a young child who fell back upon the pillow dead after the effort of sitting up in bed durine; convalescence, and two other children in the same familv died during the same epidemic of profound toxaemia. Williams^ states that fatty degeneration has been found post mortem in cases of measles in which during life the first cardiac sound had been in- distinct, and in some cases there have been noted systolic murmurs. Most writers, however, agree with MacKenzie,* I>ee,' Sturges,** and Corlett,^ that the few cases on record do not show any evidence that measles, per se, induces disease of the cardiac muscle. 1 Comby. Traite des Maladies de I'Enfance, 1902, i, 190. 2 Welch and Scliamberg. Acute Contagious Diseases, p. 511. ' Williams. Trans. Med-Chir. Soc, Ixxvii, 57. * MaeKenzie. British Medical Journal, February 26, 1SS7, p. 425 et seq. s Lee. Trans. Medico-Chir. Soc, 1S91, Ixxiv. 229 et seq. « Sturges. Trans. Medico-Chir. Soc, 1891, Ixxiv, 229 et seq. 7 Corlett. The Acute Exanthemata, p. 306. 364 MEASLES Endocarditis diiring measles is even more rare than is myocarditis. Cases have been reported bv Hutchison,* Cheadle," Martineau,^ West/ Kobler,^ Comby;" and Sansom/ but the majority of these cases were based upon the presence of cardiac miumurs during life rather thaii upon the finding of endocarditis at autopsy. Pericarditis chuing measles is also a rare complication, and when seen usually complicates a maligjiant case of the disease. Auten- rieth, Berndt, Majer, Espinouse, Braun, Siegel, Mettenheimer, and He\-felder are all quoted by Thomas^ as having met with cases of pericarditis during the course of measles. It is stated by several of these writers that pericarditis is particular likely to occur in cases of measles that are complicated by pulmonary affections. Phlebitis as a complication of measles is extremely rare. Zam- boni^ and Mackey"' have each reported a case. In each patient the condition was bilateral and both patients died. The Ears. — ^The ears during an attack of measles are more often affected than is usually thought by those who do not see a large number of cases. Bezold^^ examined the ears of sixteen subjects who had died as the result of measles, and found in each case inflammatory changes, and in addition the tympanic cavity contained either mucopus or pus. Tobietz^^ examined the ears of twenty-two subjects and confirmed the findings of Bezold. Both of the above writers are in accord as to the presence of early aural catarrh. The catarrhal inflammation is not looked upon as a secondary infection, but rather as the result of the localization of the exanthem. Catarrhal otitis media may develop very early in the disease. In one case studied by Tobietz the child died twenty-four hours after the appearance of the eruption, but there was already present otitis media. ' Hutchison. Trans. Med.-Chir. Soc, 1891, vol. xxiv. * Cheadle. Quoted by Welch and Schamberg, loc. cit., p. 511. 3 Martineau. Ibid. * West. Ibid. ' Kobler. Ibid. 8 Coniby. Quoted by Williams in Trans. Med.-Chir. Soc, Ixxvii, 57. ' Sansom. Quoted by Williams, loc. cit. * Thomas. In Von Ziemssen's Encyclopaedia. ' Zamboni. Bull, de Sc. Mdd. de Bologne, 1808, vii, S. 8, p. 548. "> Mackey. British Medical Journal, December 19, 189G. " Bezold. Munch, med. Woch., 1896, Nos. 10 and 11. 1' Tobietz. British Medical Journal, 1894, viii, 1163. 77//'; i<:yI':s .'ifio Severe purulent otitis media is more often s(!en in eertain epi- demies than in otliers. Downie' found that elu'ldren that suffe-red from adenoid growths were particularly likely to develoj) otitis media during an attack of measles. It has heen noted by many f>hsen'ers, that the early otitis is, as a rule, mild, but the secondary infections from the nasopharynx is much more prone to result in suppuration. In severe cases of middle ear disease neerfxsis of the ossicles or of the surrounding bony walls may take; place. T'urknei^ reports such cases and states that they are frequent. Downie, in 501 cases of tympanic involvement, found tli;it lol, or 26.1 per cent., were due to measles. Deaf mutism is not frequently due to an attack of measles in which there has been serious labyrinthian necrosis. Kerr, Love, and Addison^ have collected statistics from institu- tions in Great Britain which show that of 1140 deaf mutes, 138, or 9.8 per cent., attributed their misfortune to an attack of measles. In American institutions, of 1673 acquired cases of deaf mutism, 52, or 3.1 per cent., were due to measles. Among 1989 acquired cases on the continent of Europe, 84 cases, or 4.2 per cent., were ascribed to this disease. Of 487 children admitted to the Ohio Institute for the education of the Deaf and Dumb, 14 gave a history of a previous attack of measles as the cause of their deafness. Mastoid suppuration may occur as a sequel, or even as a com- plication, of measles, but this occurrence is rare. In general, the pathological changes that occur in the ear as the result of measles are less serious than are those which appear during or subsequent to an attack of scarlet fever. Intracranial abscesses, meningitis, and thrombosis of the lateral sinus are all accidents which have occurred during convalescence, but the conditions are very rare as sequels to an attack of measles. The Eyes. — ^The eyes are always affected w'ith some degree of conjunctivitis, but, as a rule, this condition is not dangerous, although corneal ulcers are by no means rare in the wards where children are 1 Downie. British Medical Journal, 1894, ii, 1163. 2 Burkner. Behandlung der bei Infectionskrankheiten Vorkommenden Ohraffectionen, loc. cit., p. 581. 3 Kerr, Love, and Addison. A Clinical and Pathological Study of Deaf Mutism, Glas- gow. 1S96. 366 MEASLES suffering from measles. In addidoii to corneal nlceratlon, we see cases of blepharitis, granular lids, and occasionally cases of specific conjunctivitis. By far the most serious complication that attacks the eye is the corneal ulceration, which unfortunately at times results in total blindness as the result of the perforation of the cornea. Rollet^ has reported such a case. Di])htheritic conjunctivitis is occasionally seen during measles^ and the condition is a dangerous one, for it usually occurs inana?niic, scrofulous children whose resistance is already at a low ebb. The corneal ulcers that complicate the condition fail to respond to any treatment, and not infrequently the cornea perforates and the eye is lost. Lougier has collected 22 cases of diphtheritic conjunctivitis during measles, in 10 cases of which death resulted, and in 5 there was the loss of one or both eyes. Empyema of the frontal sinus during an attack of measles has been repoi'ted by Belin,^ and is probably more frequent than the dearth of literature upon the subject would indicate. The Nervous System. — The nervous system during an attack of measles may suffer a variety of disturbances from the effect of the specific toxin of the disease, but when we consider how frequent a disease is measles, we realize that seiious complications of the nervous system are rare. Convulsions sometimes usher in an attack of measles, especially in young children. INIcTlrath'* found that of 250 children with convulsions, in 7 an attack of measles was the etiological factor. The appearance of convulsions during the disease, as a rule, indi- cates the onset of grave nervous complications. Cerebral paralysis as the result of an attack of measles is unusual,, but Allyn^ was able to collect 35 instances in which this complica- tion occurred. In Wallenberg's'* series of 160 cases of cerebral paralysis 8 cases occurred during an attack of measles. Gowers^ 1 Rollet. Ann. Med.-Chir., Tours, 1903, iii, 90. ^ Lougier. Revue Mensuelle des Maladies des Enfants, June, 189G, p. 294. 3 Belin. Soc. M(5d. des Hopitaux, May 30, 1902. * Mcllrath. Medical Chronicle, November and December, 1906, and January, 1907. ' Allyn. Medical News, November 28, 1891. 8 Wallenberg. Jahrbueh f. Kinderheilkunde, 1886, xxiv, 384 to 439. ' Gowers. Manual of Diseases of the Nervous System, 1888, ii, 423. 77/ A' NI':iiV()(IS SVST/m 367 has socn 7 instances, Osier' I, Alieicidinl.ic' !, ;iiiy severe toxaemia, may bring about the patient's death. The usual attack of varicella is easily recognized, and the initial symptoms are slight, in fact, are often unnoticed, particularly in young children. A child is sometimes fretful for a few hours before the appearance of the rash, and there may be headache or vague body pains, with a complaint of chilliness or even an actual chill, while vomiting is occasionally seen about the time the rash appears. In rare cases the initial symptoms are severe and are accompanied by drowsiness, less often by delirium and convulsions, and rarely by coma. Thomas^ has reported a case with an initial temperature of 106°, and MacCombie^ has on several occasions noted delirium as an initial symptom, while Henoch,^ Jennings,* Tham,'' and other clini- cians have reported convulsions which complicated the disease at its onset. The severity of the symptoms and the duration of the acute stage of the illness depend upon several things: First, upon the health of the patient immediately preceding the attack and the amount of resistance the body tissues oflfer to the toxins of the disease, and second, upon the abundance of the eruption and the number of crops of vesicles that appear, the degree of suppuration in the vesicles, and upon the number of lesions in which inflammation, ulceration, and gangrene take place following the rupture of the vesicles. 1 Thomas. In Von Ziemssen's Cyclopaedia of Medicine (Varicella). 2 MacCombie. In System of Medicine by Allbutt and Rolleston (Varicella), p. 477. ' Henoch. Vorlesungen ilber Kinderkrankheiten, Wien, 1S90, p. 211. * Jennings. Keating's Cyclopaedia of Medicine (Varicella), i, 762. * Tham. Jahrbuch f. Kinderheilkunde, Neue Folge, Band xxv, 5, 155, 156. 374 VARICELLA Prodromal Rashes.— These are by no means uncommon, and occur froui twx) tt) twenty-four hours before the varicellous eruption. The scnrhitiniform initial rash is the most common, ahhough urticarial as well as morbilliform rashes have been infrequently reporteil. MacCombie' reported the case of a o'irl, aged seven years, whose skin was covered by a very marked erythema, accompanied by many urticarial wheals, twenty-four hours before the appear- ance of the vesicular eruption. Rolleston^ has recently called attention to the accidental rashes which occur preceding and during the attacks of varicella. He thinks that the initial erytiiemas are sometimes mistaken for the rasii of scarlet fever. Cerf^ was able to collect 45 cases in which there had been seen prodromal rashes. Skin Lesions. — Gangrene of the Skin. — This occasionally follows the rupturing of the vesicles, and is caused by secondary pyogenic infections. It is most likely to attack very young children who live in unhygienic surroundings, particularly those whose nutrition and general health are poor. In mild cases of this com- plication but few of the many varicellous lesions undergo necrosis and gangrene; in some cases, however, large numbers of the vesicles are involved. Hutchison^ has referred to these cases as examples of "varicella gangra?nosa," but it is to be remembered that the gangrenous condi- tion is not to be regarded as a variety of varicella, or even as a com- plication peculiar to this disease, as it may occur in vaccinia, variola, scarlatina, erysipelas, typhoid fever, and other diseases; but it is true that this complication most commonly complicates varicella. Crocker^ has written an excellent description of this affection, w^hile many men in various countries have repoi-ted experiences with it. Impetigo Varicellosa. — It is very common in varicella for the infection of the drying lesions to take place, and in many cases blebs and pustules form which may become of considerable size. These have been appropriately designated by Welch and Scham- • MacCombie. Loc. cit., p. 477. - Rolleston. British Journal of Children's Diseases, January, 1906. ' Cerf. Quoted by Crocker, loc. cit. * Hutchinson. Clinical Lectures, i, 15. ° Crocker. Diseases of the Skin. iii'LMouuiiAdia \ A Hie 1:1.1. A 'm:, berf^* as cases of "impo^ti^o vuriccllosii." In m;iiiy of the sfvore attacks of vjiricclla certain vesicles become tlic site of iiii|jetigiiiou.s sores, and (he patient recovers after somewhat prolonged convales- cence. In some instances it has been found dinl these lesions of the skin cause infcclioii cnoufi^h to [)njduc(; fever f(jr many days. As a result of the infection of the skin lesions by pyogenic cocci the neighboi-inn; glands often enlarge, but they infrecjuently su[j[jurate. In connection with this sul)ject of impetigitujus lesions it is well to remember that although this complication is usually simply troublesome, it may, when neglected and when the lesions are irritated by scratching, become serious and even bring about the death of die patient. Dr. Burvill-Holmes informs us that he once saw, in the infirmarj' of the Girard College, a boy ill of varicella who, although he had but few varicellous lesions, was extremely ill as the result of the toxaemia resulting from several large areas of impetiginous ulceration. I'he constitutional symptoms of such a case may be very severe and the fever remain high for several days. Trousseau^ and Kaupe'' have reported epidemics of varicella during which pemphigoid blebs appeared on various portions of the skin in several patients and left ulcerating surfaces not to be dis- tinguished from the ulcerations of true pemphigus. These ulcera- tions persisted for many weeks. Pye-Smith^ and Freeth' have reported cases of varicella in w^hich bullse appeared and persisted much as the above-mentioned pemphigoid cases. Boils and subcutaneous abscesses often occur during con- valescence from varicella, and are particularly prone to occur in the region of the scalp, although any portion of the body surface may become involved. Hemorrhagic Varicella. — This type of varicella is fortimately rare, although hemorrhages not infi-equently take place in a small number of the vesicles. In the more severe forms, large and small, 1 Welch and Schamberg. Acute Contagious Diseases, p. 325. 2 Trousseau. Lectures on Clinical ^Medicine. Philadelphia, 1SS2. 5 Kaupe. Vierordt, Penzoldt-Stintzing's Handbuch der speciellen Therapie innere Krankheiteu, Band i, S. 187. ■• Pye-Sniith. British Journal of Dermatology, 1S97, xix, 148. 5 Freeth. British Medical Journal, March 24, 1906. 376 VARICELLA ecchymoses appear under the skin with petechial hemorrhages into or about the vesicle. These hemorrhages may be accompanied by marked constitutional synij)toms, with luvmatemesis and some- times witii mehvna. The symptoms of tiiesc cases may be very severe, but recovery usually takes place. Rundle' has reported a case of hemorrhagic varicella in a child, aged two years, in wliic h the petechia and ecchymotic spots were scattered over many areas of the body, while there was also present se\eral large ecchymotic hemorrhages. This child developed sub- conjunctival hemorrhages and died on the fourth day of the illness. Porter,- Beniouilli and Baadei,^ Gallianl,' ('oml)y,'^ Rollcston," Ploc,' Andrews,** and others have reported similar cases, although in the majority of them the symptoms were not severe and recovery took place. Erysipelas. — Erysipelas does not complicate varicella nearly so fret|ucntly as would seem natural when we consider the oppor- tunities for infection. Fre^'er' mentions a case of eiysipelas migrans complicatijig varicella, and Holt^" mentions three fatal eases in which varicella was complicated by erysipelas. Fatal Cases of Varicella. — Deaths as a result of uncom- plicated varicella are rare, but Fiirbringer'^ and Nisbet^" have each reported an instance, while Aviragnet and Apert^^ report two deaths from this disease in a total of 10 cases in a family epidemic. MacCombie" had under his care a child, aged thirteen months, in which large areas of the skin were involved, and following the rup- ture of the vesicles, the epidermis peeled off extensively and the skin became inflamed and swollen. There was high temperature from ' Rundle. Lancet, January 16, 190G. 2 Porter. Lancet, May 18, 1907. 3 Bernouilli and Baader. Corr. f. Schweizer Aerzte, No. 11, p. 1880. * Galliard. In Brouardel and Gilbert's Traitd de M(!-d., art. Varicelle. ' Comby. TraitfS des Maladies de I'Enfance, 1905. * Rolleston. Loc. cit. ' Ploc. Casop. lek. cesk. (v. Praze, 1898), 37, pp. 84 to 86. * Andrews. Clinical Societies Tran.sactions, London, 1890, xxiii, 79. » Freyer. Deutsche med. Wochenschrift, 1878, iv., Ill tO 113. >o Holt. Diseases of Infancy and Childhood, p. 978. " Furbringer. Quoted by Gee in Reynolds' System of Med., original, v. Ziemssen's Handbuch, a. a. a., S. 22. '= Nisbet. Australian Medical Magazine, 1894, xiii. I' Aviragnet and Apert. In Cheini.sse's article, Semaine Mddicale, 20, No. 52. '* MacCombie. Loc. cit., p. 480. 1' A HOT IT IS 377 the second (lay of ilic disease, and (lie ehild died on \\\'- \\\\\ da\- of tli(! illness. It is to l)e reinenilxTed, liovvever, dial eondiieni \aiiee||;i I> rate, particularly a,inonati(tnt i.s seen late, that is, after the ruj)tiire and partial drying of the vesicles. Generalized (Edema. — Generalized fx^dema of die horly diirinj( varicella has been reported by Starck,' bnl (Ids, as in several other cases not(>d, was probably due to a nephritic conditi(Mi. Lymphadenitis. Siif^-ht enlargement of the lymph glands occurs in nearly all cases of varicella. Jyympliadenili^ eoi]i|)li- cating this disease has been particularly referred (>) by Lamae(|- Dormoy,^ who reported his observations during an ej>idemic, and concludes that general enlargement of the lymphatic glands is the rule; but he lays particular emphasis upon preauricular and mastoid adenitis, stating that they were present in every case of the disease. Pyaemia as a complication of varicella is a rare occurrence, but this apparent infrecjuence may be due to the fact that the cases are not reported. Brunner^ has reported an interesting case of this complication during a severe attack of varicella. The child devel- oped a suppurating lesion of the elbow-joint, followed by a double parotitis and otitis media of the left ear. The case ended fatally on the ninth day of the illness. Autopsy revealed the presence of pus in the anterior mediastinum, the pericardium, and in the spleen and kidneys. The staphylococcus pyogenes was recovered from the blood, pus, and urine during life. Parotitis. — Parotitis has been reported but few times as a complication of varicella. Brunner^ saw a case in which both parotids were involved in a case that ended fatally, while one of us (Beardsley) saw a case of unilateral parotitis in the dispensary at the Starr Centre, in an Italian child, aged four years, whose body was still covered with numerous drying lesions of varicella. In this 1 Von Starck. Deutsches Archiv f. klin Med., Leipzig, 1S96, Ivii, 448. - Lamacq-Dormoy. Gaz. Hebdomadaire des Sciences Medicales de Bordeaux, March 6, 1904. 3 Brunner. Quoted by Brown, art. on Varicella, Twentieth Century Practice. * Brunner. Loc. cit. 37S VARICELLA case the parotid became enlarged dh the fourth day of the illness and coincidentally with the appearance of a bright red ervthema which had faded in part before the child was brought to the dis- pensary. The parotitis persisted for three days. The erythema, which was not accompanied by any other symptoms, disappeared twelve hours after its appearance, and the child became perfectly well. Thyroiditis. — Thyroiditis is a very rare complication of varicella, but Allaria^ has reported an instance in which the thyroid became inflauied and suppurated. Laryngitis. — Laryngitis is another rare complication of varicella, but probably not as rare in severe cases of the disease as the lack of references to the complication would indicate. Marfan and Halle" have reported two cases. In the first case the dyspncea was so urgent that it was necessary to perform trache- otomy, the child making a good recovery. In the second case, which resulted fatally, there was found at autopsy a small ulcer on the posterior surface of the right vocal chord, probably the result of an ordinary varicellous vesicle. Fiirbringer^ has also reported a fatal instance of involvement of the larynx during varicella. Otitis Media. — Otitis media is a rare complication of varicella, but has been reported by Dournel,* Brunner,^ Lamois," and others. I\Ioy^ reports 17 cases of otitis complicating varicella in an epidemic of 875 cases of the disease. Mucous Membranes. — These are quite frequently the site of varicellous lesions. ^Yelch and Schamberg,^ Henoch," and Coste^" all assert this fact and state that lesions upon the buccopharyn- geal mucous membrane, hard and soft palate, gums and tongue, are frequently found and often cause difficulty in feeding the patients. Thomas^^ has noted lesions upon the nasal mucous 1 AUaria. Monats. f. Kinderheilk, December, 1903. 2 Marfan and Hall6. Quoted by Brown, loc. cit. ^ Fiirbringer. Von Ziemssen's Handbuch, a. a. o., 3, 22. * Dournel. Paris Thfeses, 1906. ' Brunner. Loc. cit. » Lamois. Rev. Hebd. de Laryngol., Paris, 1904, i, 105 to 109. ' Moy. Theses de Lyon, 1906-1907, No. 53. * Welch and Schamberg. Loc. cit., p. 327. ' Henoch. Berliner klin. W'ochenschrift, January 14, 1884, No. 2. •o Coste. Marseille M^d., January, 1908. " Thomas. Loc. cit., vol. ii. BRONCHITIS AND JiUOSCIiOi'S ICII MOM A ;J70 memhnincs, while lesions iirc somcfinics seen upon llic nin'ous inenibnine of tlic vaninii iiiid \)vv\n\vv jind in these situations soine- tinies eaiise (lidiciiity and pain on nrinalion. Cofjmhs' has re- ported a case in which variccllons lesions npon tlif [)r(f)uce caused such sweliinfif that retention of urine resulted. Jn this ease there seemed to be one or more lesions within the urethra about one inch from the orifice. There was pain on urination for several days and slight swelling- and induration about tiiis porlion of the urethra. Bones and Joints. Synovitis and arthritis have been reported as rare complications of this disease. Laudon^ and Perret' have both reported examj)les of these complication. Laudon's patient was a boy, aged four years, who developed high fever early in the course of the disease and later there developed a marked swelling of the left elbow-joint. Recovery followed. Semtschenke'' saw two patients who suffered from purulent arthritis during the course of varicella. Hogyes" reports the case of a girl, aged seven years, who after an attack of varicella devel- oped nephritis and subsequently a polyarticular arthritis accom- panied by high fever. This patient recovered. Braquehaye" saw^ a case of arthritis complicating varicella, which developed on the ninth day of the illness and which resulted in death despite incision and drainage. At autopsy a septic endocarditis was discovered. Periostitis of the femur as a complication of varicella has been reported by Steiner,^ and the same complication affecting the humerus was reported by Brunner.^ Bronchitis and Bronchopneumonia. — These conditions are rare complications of varicella. PowelP and Partridge^'^ have both reported instances of bronchopneumonia fatal in the course of varicella, while MacCombie" has seen both bronchitis and broncho- 1 Coombs. British Medical Journal, March 18, 1905. ^ Laudon. Deutsche med. Wochenschrift, Leipzig. 1890, xvi, 576. ^ Perret. Province med., Lyon, 1899, iii, 256 to 261. ^ Semtschenke. Wiener klin. Wochenschrift. 18S9. quoted by Rille. ' Hogyes. Jahrbuch f. Kinderheilk., X. F., Band xxiii, S. 337. ^ Braquehaye. Quoted by Welch and Schamberg. loc. cit., p. 231. ^ Steiner. W^ien. med. Wochenschrift, 1875. 5 Brunner. Loc. cit. ' Powell. International Clinics, January, 1S97. 1° Partridge. Exhibited patient at New York Pathological Society, 18S7. " MacCombie. Loc. cit., p. 482. 3S0 VARICELLA pneumonia coniplic-ate the disease in ^veakly infants. Rille' has notetl a case of varicelhi complicated bv "pleuropneumonia" wliicli resulted fatally on the nineteenth day after the onset of vari- cella. Marfan and Hall^,' as well as Ilogyes'' and Eustace Smith,' have all met with cases of varicella complicated hy pneumonia. Pleurisy. — This com[)lication has been noted by but few observers. Rille'" and Semtschenke" have both observed cases of varicella, complicated by pleurisy, during epidemics of the former disease. Nervous Complications. — These complications during the course of, and during the convalescence from, varicella are rare, but are exceedingly interesting. Encephalitis, meningitis, paraplegia, monoplegias, and various paralyses of the muscles of the eye have been reported by various observers. Caccia^ has reported a case which developed encephalitis second- ary to a severe attack of varicella, Rossi* has made mention of a right bronchial monoplegia which developed during convalescence from varicella. MacComl)ie^ states that one of the children under his care had an attack of varicella which was complicated by paraplegia. This condition became gradually improved some weeks after convales- cence from the original disease. Gay, in 1894, also reported this complication. It is to be remembered that those cases of varicella developing otitis media are prone to also develop mastoiditis, meningitis, cerebral abscess. Nephritis. — Although albuminuria and nephritis are both rare complications of varicella, it is quite likely that if the urine of the patients suffering from the disease was carefully examined albumin would be discovered much more frequently than is usually thought. When nephritis does develop it is one of the most dangerous complications of varicella. ' Rille. Deutsche med. Wochenschrift, 1891. 2 Marfan and Hallf?. Loc. cit. ' Hogyes. Loc. cit. ■* Eustace Smith. Diseases in Children, p. 49. ^ Rille. Loc. cit. ^ Semtschenke. Loc. cit. ^ Caccia. Riv. de Clin. Pediat., November, 1904. 8 Rossi. Gaz. degli Osped., 1903, N. 43. » MacCombie. Loc. cit., p. 482. ' VAJi/CJ'JLLA IN ADIII/r LIFE v,Sl ITcnocli' Wiis one of llur first to cnll iiltciilioii (o flic rir-j;liriti.s following vuricella, and lie reported four eases of this eoii)j>l)e;iiif>ri. Other writers, notahly voii Jurf^enseii,'' linmncc,' iJillr-,' ;ind Dillon Brown/' have also reported this eomjilieafioii, ;iiid fidlffj attention to the necessity of watchful care as to th(; slate of ihe kidney both during and following the attack of vai'icella. The inflammation of the kidney usually occurs during tlu first or second week of the disease, and varies in severity witli (Ik- degree of toxa3mia and the resistance of the tissues of the patient. As a rule, the nephritis is mild, recoveiy taking place promptly; but without doubt, some of the cases are prolonged and may cause death months after the primary disease. Dillon Brown" has reported such a case in wliich the kidney involvement following a mild attack of varicella ran a chronic course, ending fatally some ten years later. Hogyes^ has recorded a case of varicella which was complicated by pneumonia and nephritis, and also terminated fatally, while Rille reports a case of varicella complicated only by nephritis, which ended in death, and at the autopsy parenchymatous changes were found in both kidneys. One of us (Beardsley) has recently studied a case of varicella, in a child six years of age, that devel- oped albuminuria and casts on the third day of the eruption. The casts disappeared after six days, but albuminuria persisted for two weeks. Varicella in Adult Life, — Varicella is considered by many physicians to be a disease of childhood only, and many writers of experience state that they have never observed a case of the disease in an adult. Thomas, whose experience was extensive, states that he had never seen the disease in an adult, while von Jurgensen^ remarked that varicella was a disease peculiar to childhood. On the other hand, Lys" has seen three cases in the same family, all in adults, and 1 Henoch. Loc. cit. - Von Jurgensen. In Nothnagel's Encyclopaedia of Medicine (Varicella). 3 Brunner. Loc. cit. < Rille. Loc. cit. ^ Dillon Brown. Loc. cit. s Dillon Brown. Loc. cit. "^ Hogyes. Loc. cit. s Von Jurgensen. Loc. cit. « Lys. Lancet, May 12, 1S83. 382 VARICELLA Bohn' lias also reported a case, while Tripolcp has observed 34 cases in adults during a large epidemic of the disease, Wanklyn^ reports 33 cases in patients over eighteen years of age, seen in two years at the diagnosticating station in London. Welch and Schanibei'g"' also, whose experience and whose oppor- tunities iov (^l)servation have been second to none, state tiiat within a period of eighteen months they had observed no less than IG cases of varicella in adults, while in the last thirty-two years there had been admitted to the Municipal Hospital of Philadelphia 35 cases of varicella in adults. One of us (Beardsley) had under his care a few years ago a physi(>ian, aged about forty years, who came from the West to attend the meeting of the American Medical Associa- tion in Atlantic City. During the convention he developed a rash so universal and symptoms so unusually severe that although the junior author had recently enjoyed eight months' observation of smallpox at the Municipal Hospital, he was very glad to shift the responsibility of confirming the diagnosis of varicella upon Dr. Welch, of the Board of Health of Philadelphia. Dr. Welch, after a careful study of the case, decided that it was a case of true varicella, but one of the most marked cases that he had ever seen. Second Attacks. — Second attacks of varicella are of gieat rarity. Neale' reports a second attack after a period of ten days, and Vetter** also states that he has seen a similar case in which the eruption appeared fourteen days after the first eruption had disappeared. Many physicians whose interest lies particularly in contairious diseases have never seen a second attack of the disease. The two cases quoted above might more truthfully be termed relapses. Scarring after Varicella. — It is usual to find some slight scar- ring after a severe attack of varicella, and after a severe attack the scarring is usually more marked than in a case of modified variola. > Bohn. Quoted in von Ziem?«en's Cyclopaedia of Medicine. STripold. Med. Klinik. 1908, No. 34. ' Wanklyn. British Medical Journal, July 5, 1902. * Welch and Schamberg. Loc. cit., p. 327. ' Neale. Lancet, 1891, No. 2. 6 Vetter. Quoted by Welcli and Schamberg, loc. cit., p. 319. S(JAkh'/N(J Ah'TICh'. V auk: ELLA p^^^ Occa,yi(>iially keloid growUis an; ohscrvwJ al. the .si((; f^f tlic scarring. Scleroderma following vjiricella has fx^eri j'e|;orted by Bouvy/ and scroriiloliilxTciilosis of (lie skin hy J''oiil;iid.'"' 1 Boiivy. .IdNnijil ill' din. ct, (\c IhrTiip. inf., IHOH, vi, 480 to 4Hi). ^ Foiilanl. Ann. dc ilciiri. (;l do l;i .Hypli., 1890, vii, :',l,2. CHAPTER V. RUBELLA. Rubella, or German inea:sles, sometimes called epidemic roseola, is the mildest of the acute exanthemata and least likely to have troublesome complications or sequels. When these occur they are usually characterized by catarrhal processes. Bronchitis and pneumonia, which are such common complications of true measles, are rarely met with in rubella, and when they occur usually develop in children who are primarily of low vitality. In conse- quence, we find that the complications and sequels of rubella are much more frequently met with in orphan asylums and institu- tions for poor children than they are in private practice. In the latter class of cases complications arise almost solely as the result of unnecessary exposure, and rarely in children that are properly cared for. In other words, the disease by slightly impair- ing the patient's vital resistance lays him open to conditions which arise from exposure. Even in institutions, however, pneumonia rarely occurs, either in the course of or as a sequel to rubella. In 166 cases, Edwards* met with only three which were complicated by pneumonia, and Griffith^ met with only two cases of pneiunonia in 150 cases of rubella. So, too, Cheadle,^ Smith,^ Earle,'^ and Park,® although they all met with bronchitis and pneumonia complicating severe cases of rubella, note its infrequency. Klaatsch^ quotes Kronenberg, who states that bronchitis, pneu- monia, and cerebral congestion caused four deaths in patients under his care. 1 Edwards. Keating's Cyclopaedia of Diseases of Children, p. 687. 2 Griffith. New York Medical Record, July 9, 1887, p. 39. ' Cheadle. International Med. Cong., 1881, iv, 4. * Smith. Diseases of Children, 1879, p. 191. ' Earle. St. Louis Medical and Surgical Journal, 1881, xli. 392. ° Park. Chicago Medical Journal and Examiner, 1881, xliii, 130. " Klaatsch. Zeitsch. f. klin. Med., Band x. Heft 1, S. 1. RUBELLA 385 Pleurisj/ juul emjyjjema arc exticiricly rare (■ornplications, but Ryle* and J^'.dwaTds'' each saw a case which developed empyema during the course of a severe attack of rubella. NasopJiari/iK/rdl ralarr/i willi priuuiry and secoiKhuy son; throat are very troublesome coinpiications during e[)ideniirs of a severe type. Tonge-Smith,'' P^mminghaus/ ?]usta(;e Smifh,'' and other observers have re|)oi-ted cases of secondary s(jre thi-oat as compli- cations of rubella, while Cheadle," Lublinski/ Atkinson," and Mettenheiraer have reported tonsillitis occurring as a complica- tion or sequel to an attack. Throat Comjilkaiions. — Sore throat of a mild character is a very common symptom of rubella, and we have already spcjken of the primary and secondary sore throats which may occur and which may be very severe. Hoarseness, usually mild in character, but occasionally severe, has been noted by many observers during the early stage of the disease, and may pei-sist for several days, although it commonly disappears with the disappearance of the eruption. Stomatitis is a frequent complication during epidemics of rubella, and varies in intensity from a mild catarrhal inflammation to the rare ulcerative form. Edwards^ noted stomatitis, of varying grades of severity, thirty times in his series of 166 cases. Hatfield'" and Earle'^ have both reported instances of this complication. Parotitis is a very rare complication of rubella, but has been reported by Roth.^^ Thyroid enlargement occurs in this disease, as it does in neaj-ly all the acute infectious diseases, but much more rarely than in any of the others. SlageP^ has reported a painful enlargement of this gland in six cases of rubella under his care. ' Ryle. British Medical Journal, 1886, ii, 160. " Edwards. American Journal of the Medical Sciences, 1884, p. 484. 3 Tonge-Smith. Lancet, 1883, i, 994, 1036. * Emminghaus. Loc. cit. ^ Eustace Smith. Diseases of Children, p. 31. ^ Cheadle. International Medical Congress, 1881, iv, 4. 7 Lublinski. Med. Klinik., 1907, No. 52. 8 Atkinson. American Journal of the Medical Sciences, Januarj', 1887. ^ Edwards. Loc. cit. '" Hatfield. Chicago Medical Examiner, August. 1881. n Earle. St. Louis Medical and Surgical Journal, 1881, xli, 392. 12 Roth. Quoted by Welch and Schamberg. Acute Contagious Diseases. 13 Slagel. Trans. Minnesota Med. Cong., 1881, p. 204. 25 3S6 RUBELLA Gasiro-inlcsiinal Disturbances. — Altboiioh the usual case of lubella does not show signs of gastro-inlestinal irritation, in severe epidemics these disturbances may cause great difficulty. In 40 per cent, of Edwards'^ cases symptoms of gastro-intestinal irritation were presejit, and in five of this series vomiting was a persistent and troublesome feature. Welch and Schamberg' report a case under their care, at the Municipal Hospital of Philadelphia, in which vomiting persisted for several days before the appearance of the rash. Griffith^ states that vomiting occurred in several of his severe cases. Diarrhoea is a not infrequent symptom of the more severe attacks of rubella, but the milder attacks seldom show this symptom. Cuomo,* Earle,^ and Balfour" found enterocolitis a common symptom in some severe cases of rubella, but most writers upon rubella consider enterocolitis a rare complication. General lymphatic enlargement has long been regarded as a sign of much importance in the diagnosis of rubella, and particularly has this been true of the glands behind the ears and those lying posterior to the sternocleidomastoid muscle. Maton,'' as long ago as 1815, pointed out the importance of these enlarged glands, and Thierfelder^ and Atkinson,® as well as other WTiters, point out that the enlargement of the glands of the neck is a constant prodromal symptom, and may attract attention several days before the appear- ance of the rash. Emminghaus,^" on the other hand, states that the glandular enlargement may be slight and subside before the appear- ance of the rash. Corlett" states that 96 per cent, of his cases showed the glandular enlargement. The maxillary and superficial cervical glands were most commonly involved; next the occipital, posterior and anterior auricular, and sometimes the inguinal, axillary, and epitrochlear glands. Corlett also states that the swelling from the inflammation ' Edwards. Loc. cit. ^ W^elch and Schamberg. Loc. cit. ' Griffith. Medical Record, July 9, 1887, p. 39. ■• Cuomo. Gior. internaz. d. sc. med., Napoli, 1884, vi, 529. * Earle. Loc. cit. 6 Balfour. Edin. Med. Jour., 1856-57, p. 717. ' Maton. Med. Trans. College of Physicians, London, 1815, v, 149. * Thierfelder. Greifsw. med. Beitr., 1864, Band ii, Berlin, p. 14. * Atkinson. Loc. cit. " Emminghaus. Loc. cit. " Corlett. A Treatise on the Acute Infectious Exanthemata, p. 356. CUTANJ'JOUS LJ'JSIONS 387 of tlic gliuids of the neck may ho siifriciciit to liinit Uic motion of the nock, and in a lew cases it has cansed a;dema of tlie tissues, Musser' noted tumefaction of the inguinal glands in several of his cases, and also saw the same state of the axillary glands less often, Golson' has reported a unicjuc complication of rubella in reporting a case of abscess of the su))ma.\illary glancJ during convalescence from this disease. Eustace Smith' and Kassowitz* are of the opinion that in certain epidemics of rubella the glandular enlargement is not seen, or at least occurs in only a small percentage of the cases Park'' met with glandular enlargement in but 50 per cent, of his cases, but Klaatsch" declares that this sign is so constant that the diagnosis may be made from this alone. Cutaneous Lesions. — Urticaria has been observed to complicate the onset of rubella by Musser,^ Slagle,® Earle,'' and Cullingworth.*^ Griffith" noted among his cases an eruption, which gave a shotty feel to the palpating finger, and Davis reports a case of rubella with a purple rash. There have been reported by various writers instances in which the rash of rubella closely resembled that of scarlet fever, and these cases have been designated as the "scarla- tiniform variety" of rubella. Griffith, ^^ who has studied a large number of cases, concludes that there are two easily recognized types of variation from the normal character of the rash in rubella : 1, "An eruption in which the spots are for the most part nearly or fully the size of a split pea, more or less grouped and having a great resemblance to measles. 2. "A rash which is confluent in patches or universally not elevated, and which produces a uniform redness closely simulating that of scarlatina, but a very careful examination will often reveal a few papules amid the general diffuse redness." ^ Musser. Quoted by Griffith, loc. cit. * Golson. Transactions of the Medical Association of Alabama, 1SS3. ' Eustace Smith. Loc. cit. * Kassowitz. Transactions of the International Congress, ISSl, iv, 10. ^ Park. Chicago Medical Journal and Examiner, 1881, xliii, 130. 6 Klaatsch. Zeitschr. f. khn. Med., Band x, Heft 1, S. 1. ^ Musser. Loc. cit. ' Slagle. Loc. cit. ' Earle. Loc. cit. 10 Cullingworth. British Medical Journal, 18S3, ii, 1234. 11 Griffith. Loc cit. 12 Griffith. Loc. cit. 388 RUBELLA Dunlop' and Chcadle" have each reported an instance of petechial hemoirliaije into the cutaneous lesions, but this comph'cation is exceedingly rare. Ei'skine^ noted })etefhial lesions upon the uvula and soft palate of one case, and Glaiser^ mentions that he saw a case of rubella with a purpuric rash. Miliary vesicles during the course of the disease and furunculosis during convalescence have been noted by various observers, but are rare. Pemphigus has also been seen during convalescence. Douglas^ and Griffith® and Thier- felder^ both noted oedema of the face, concurrent with the appear- ance of the eruption in several cases. Emminghaus^ noted a*dema of the extremities in one of his cases. Eri/sipclas. — This is a rare complication, but has been reported as a se(|uel to the disease by Alexander." Jaundice is a unique symptom of rubella, but was noted in one of the cases seen by Musser. Roughness of the skin during rubella has been noted by Golson,^" Shoemaker,^^ Musser,^^ and Griffith.'^ This condition resembling cutis anserina may precede, accompany, or even persist for a few days after the rash of rubella has disappeared. Eye complications are rare in rubella, but conjunctivitis, bleph- aritis, and keratitis have been infrequently reported. Hardaway" has reported ciliary blepharitis during a severe attack of the disease, and de Schweinitz^'' has seen two cases of phlyctenular keratitis. Ear complications are also uncommon, but Hardaway" has reported a case of otitis media. Cheadle" states that "earache" often developed among his patients as the rash subsided. 1 Dunlop. Lancet, 1871, ii, 464. - Cheadle. Loc. cit. ' Erskine. Lancet, 1880, ii, 452. * Glaiser. Transactions of tlie International Medical Congress, 1881, iv, 31. <> Douglas. Lancet, 1877, i, 784. ' Griffith. Loc. cit. ^ Thierfelder. Loc. cit. ' Emminghaus. Loc. cit. ' Ale.xander. Canada .Journal of the Medical Sciences, 1882, p. 297. '" Golson. Loc. cit. " Shoemaker. Quoted by Griffith, loc. cit. '- Musser. Loc. cit. '3 Griffith. Loc. cit. '< Hardaway. St. Louis Courier of Medicine, 1881, p. 83. '5 de Schweinitz. Quoted by Griffith, loc. cit. '^ Hardaway. Loc. cit. 1' Cheadle. Loc. cit. ALBUMINURIA 380 Arthritis or, synovitis, or, us more coiiinioiily .shifcd, " rlHiiiri;i- tism," (liiriiif^ nihelhi is a very unusual (•oiu}>lication — so ran;, in fact, that its occirronce may woll \n\ taken for a coincidt^nce. SlageP observed tliis eomj)lieation once during the disease, and Edwards^ twice, but p]arle^ observed several cases. Convulsions and delirium in the course; of rubella .'ii-e altn(tal life, 35 mortality in, 18, 38 and morbiditv in later life, 38 mountain fe\cr, 274 myelitis, 230 myocarditis in, 193, 204 myositis in, 247 n(>crosis of bone in, 34, 213 of cartilages in, 95 IND/'JX 397 Entoric lover, iicpliril.iH in, fjO, 1 I (i norvouH HyHUsin in, (il, 159, 227 ncuritiH in, 171, 229 neuroHCH in, 250 noiTiii in, 212 aHlotrui of iliorux jind ;il)(io- incn ui'ter, 2(12 ocHopliugoul IcsioriH in, 123, 214 orcliifis (luriiif:;, 205 osteitis roUowing, 2()r) ostcoinyolitis n!K(Mnl)linf^, 269 pain in iibdoinen in, llif) paralysis duriiif!;, 171, 245 parotitis during, 212 perforation in children, 33, 138 during, 140 following, 210 of the gall-bladder in, 152 pericarditis following, 196 perichondritis during, 97, 99 periostitis after, 265 " pharyngo typhoid," 55 pharynx in, 57, 124 phlebitis in, 201 phlegmasia alba dolens, 201 pleurisy in, 55, 106 " pleurotyphoid," 55 pneumonia in, 51, 54, 102 pneumothorax, 108 "pneumotyphoid," 51, 105 poliomyelitis during, 234 polyuria in, 123 pregnancy in, 35 prognosis in, 89 of mental complications, 298 prodromal rashes in, 66 pseudodementia in, 295 pseudoparal.ysis in, 295 puerperal septicaemia resem- bling, 274 pulmonary complications in, 54, 102, 104 oedema in, 104 pulse in, 108 pus containing specific organ- isms in, 177 in urine during, 118 pyjemia in, 269 pylephlebitis in, 219 pj'onephrosis, 122 pyuria in, 119 rash of, 66, 175 recent epidemics of, 28 recrudescences of, 182 recurrences in, 279 relapses in, 182, 186 JMitcric fever, respiratory cf)rri[>licu- tioiiH in, 51, 94, 191 reHtleHsnoHH in, 173 retention of urine in, 57 rigors in, 47, SO, 187 sanitutirm in, 18 scarlet fever in, 180, 275 second attacks of, 279 septicaemia resembling, 269, 274 short duration, 77 incubation, 39 skin in, 66, 174, 178, 253, 261 spine in, 248 spleen in, 114, 227 splenotyjilioid, 1 15 spondylosis in, 250 stomach in, 125 stomatitis in, 212 strabismus in, 212 stuporous insanity in, 294 subcutaneous emphysema in, 99 sudamina in, 177 sudden death in, 194 sudoral typlioid fever, 48 suppuration of the thyroid gland, 262 suppurati\e pylephlebitis, 219 sweating in, 48, 259 synoyitis in, 177, 265 temperature during, 44, 68, 205 yariations from usual in onset, 44 testicle in, 205 tetany in, 251 third attacks of, 280 thrombosis in, 170, 195, 203 thyroid gland in, 262 tonsils in, 57 tremors in, 245 tuberculosis during, 104, 191, 270 miliary, resembling, 270, 271" tuberculous peritonitis re- sembling, 271 typhoid cholangitis in, 218 coxitis, 264 feyer, 17 spine, 248 "typhus leyissimus." 77 ulceratiye endocarditis re- sembling, 270 stomatitis. 212 urethritis during, 206 urinary- casts in, 56. 116 yarieties of onset in. 41 398 INDEX Enteric fever, vascular lesions in, 109 veins in, 201 vomiting in, 59, 125 water supply as cause of, 19 without intestinal lesions, 129, 169 Enteritis in measles, 357 Epidemic roseola or Gennan measles, 3S4 Epididymitis in enteric fever, 206 Epilepsy during enteric fever, 174 in scarlet ievev, 340 Epistaxis during enteric fever, 94 in smallpox, 305 Eruptions during enteric fever, 66, 175, 179 hemorrhagic, in enteric fever, 179 in measles, 349, 358, 359 septic, in smallpox, 303 in smallpox, 302 EruptiAC diseases during enteric fever, 179 Erysipelas in chickenpox, 376 in enteric fever, 253 in German measles, 388 Eve complications in German measles, 388,389 in smallpox, 307 in measles, 365 Facial paralysis in scarlet fever, 322 in smallpox, 309 "Fever, catarrhal," or enteric fever, 29 enteric, 17. 5ee Enteric fever, mountain, or enteric fever, 274 scarlet, in enteric fever, 180, 275 tvphoid, sudoral, in enteric fever, ■ 48 Filtration of water, effect of, upon enteric fever, 21, 22, 23 Foetal life and enteric fever, 35 Furunculosis in enteric fever, 177 in scarlet fever, 347 in smallpox, 304 G Gall-bladder, infection of, in enteric fever, 45, 152 Gangrene of genitals in enteric fever, 107,212,215 in measles, 3G0, 363 in smallpox, 306 of intestines in enteric fever, 211 of limbs in enteric fever, 202 of lung in enteric fever, 107, 191 Gangrene of lung in measles, 354 of mouth in enteric fever, 212 in scarlet fever, 319 of skin in chickenpox, 374 in enteric fever, 178, 212, 253 in measles, 360 in scarlet fever, 319 in smallpox, 306 Gangrenous stomatits in enteric fever, 212 in measles, 354 in smallpox, 310 Gastric ulcer in enteric fever, 126 Gastritis in scarlet fcAcr, 324 Gastro-intestinal tract in enteric fever, 58, 212 in German measles, 386 Genitals, gangrene of, in enteric fever, 212, 215 in measles, 360, 363 in smallpox, 306 Genito-urinary complications in measles, 361 in smallpox, 312 tract in enteric fever, 56, 115, 205 Gemian measles, 382. See Measles, German. Glands, lymphatic, in measles, 361,372 mesenteric, in enteric fever, 225 suppuration of, in enteric fever, 225 thyroid, in enteric fever, 262 in German measles, 385 in smallpox, 311 Glandular abscesses in measles, 361 swelling in enteric fever, 124, 225 Glossitis in enteric fever, 212 in smallpox, 310 Glottis, oedema of, in measles, 351 in smallpox, 309 H.EMATEMESis in cntcric fever, 126 Ha-maturia in enteric fever, 56, 57, 116 in measles, 362 Haemoptysis in smallpox, 309 Hair, loss of, following enteric fever, 262 following smallpox, 307 Headache during enteric fever, 41, 162 Heart, acute dilatation of, in small pox, 309 in enteric fever, lOS, 111, 196 in German measles, 389 in measles, 363 in .scarlet fever, 329 in smallpox, 311 Hemiplegia in enteric fever, 236 INDEX y/.i'.} Hemi|)li^fi;i.'i, in hcuxU-A, fever, '.',2'.> ill ,siii!i.ll|)o,\, '.ilT) Hem()i'rli;i,f;;e (luring!; seiulet fever, 321 reliiiiil, in sin.'illpox, '.iOX from siroiii.'icli in eiii.eric fever, 126 llemorrliiif^ic ei U|)l,i()iiH in enteric fever, 17.S form of ni(!;isle,s, lidO infarction in eiiUsric fever, lOG IcHioiiH in (J(!rnuin nieaHles, '.iHH Hepatic abscess in enteric fever, 216 lesions in enteric fever, 216 Herpes in enteric fever, 178 in measles, 358 in scarlet fever, .318 Hip, dislocation of, in enteric fever, 264 Hydrocele in smallpox, 313 Hydrothorax in measles, 353 in smallpox, 310 Hypostatic congesiton of lungs in enteric fever, 104 Hysterical convulsions in enteric fever, 161 Immunity to enteric fever, 278 Impetigo in measles, 358 in smallpox, 304 varicellosa in chickenpox, 374 Incubation period in enteric period, 39 short, of enteric fever, 39 Infarction, hemorrhagic, in enteric fever, 106 of lungs in enteric fever, 106 Influenza compared with enteric fever, 106 Insanity during enteric fever, 61, 161 scarlet fever, 337 following smallpox, 315 stuporous, in enteric fever, 294 Insomnia during enteric fever, 173 Intestinal lesions, enteric fever with- out, 129, 169 ulcers in enteric fever, 128 Intestine, cicatricial contraction of, after enteric fever, 211 in enteric fever, 128 gangrene of, in enteric fever, 211 in measles, 358 Intracranial abscess in measles, 365 Iritis following smallpox, 308 Jaundice in enteric fever. 226 in Gennan measles, 388 in scarlet fe^•er, 336 Joints in eliifkcn|)0\, 379 complications of, in -inall)>ox, 312 in enteric fever, 263 in measles, 370 Kkhatjti.s in (icnnuri measles, 'JS8 in scarlet fever, 343 in smallpox, 308 Kidnciv, abscess of, in smallpox, 312 in chickenpox, 380 in enteric lever, 56, 116 in Gennan measles, 389 in measles, 362 in scarlet fever, 326 in smallpox, 313 Knee-jerks in enteric fever, 1 73 Knee-joints in enteric fever, 173 Laryngeal lesions in enteric fever, 55, 95, 245 Laryngitis in chickenpox, 378 in measles, 350 membranous, in measles, 350 in smallpox, 309 ulcerative, in measles, 350 " Larvngotyphoid" in enteric fever, 55 Lar3-nx, necrosis of, in measles, 351 ulceration of, in smallpox, 309 Leukocytosis in enteric fever, 112 Limbs, gangrene of, in enteric fever, 202 Liver, abscess of, in enteric fever, 216, 219 in smallpox, 312 cirrhosis of, after scarlet fever, 335 in enteric fever, 152, 216 in scarlet fever, 335 Lobar pneumonia in enteric fever, 51, 54, 102, 105 in measles, 352 in scarlet fever, 32S in smallpox, 309 Ludwig's angina in scarlet fever, 324 Lumbar puncture in enteric fever, 169, 270 Lungs, abscess of, in enteric fever, 191 gangrene of, in enteric fever. 107, 191 in measles, 354 hypostatic congestion of, in en- teric fever, 104 infarction of, in enteric fever, 106 400 INDEX Lungs, tuberculosis of, following measles, ,'^53, 371 Lj mphailenitis in chickenpox, 377 Lymphatic enlargement in Ciemian measles, 380 glands in measles, 301, 372 M Malaria during enteric fe\er, 61, 101, 244, 282 Malignant forms of enteric fe\-er, 43 Mania in scarlet {e\er, 337, 347 during smallpox, 315 Mastoid suppuration in measles, 305 in snaallpox, 309 Mastoiditis in scarlet fever, 321 Measles, 348 albuminuria in, 301 aphasia in, 308 appendicitis in, 358 artnritis in, 370 ataxia in, 308 atrophy in, 308 bones in, 370 brain abscess in, 305 Ijronchopneumonia in, 302, 371 casts, urinary in, 301 cerebral paralj-sis in, 360 chorea in, 309 complications of, 348, 350 conjunctivitis in, 305 convulsions in, 360 corneal ulcers in, 305 deaf mutism in, 305 diarrha?a in, 357 digestive tract in, 354 dementia in, 309 diphtheria in, 351 diphtheritic conjunctivitis in, 366 disseminated sclerosis in, 367, 368 dyspnoea in, 351 ears in, 304 eczema in, 358 emphvsema subcutaneous durine, 359 empyema in, 352 of frontal sinus in, 366 endocarditis in, 364 in enteric fever, 181 enteritis in, 357 eruptions in, 349, 358, 359 eyes in, 365 gangrene of, genitals in, 360, 363 of lung in, 354 of skin in, 360 gangrenous stomatitis in, 354 geni to-urinary complications in, 361 Measles, Cierman, ;W4 age of patients in, 391 albununuria in, 389 arthritis in, 389 bronchitis in, 384 bronchopneumonia in, 384 cerebral congestion in, 382 complications in, 384 con\ ulsions in, 391 cutaneous lesions in, 387 deaths in, 39!) delirium in, ;iS9 tliarrluea in, 386 ear comjilications in, 388, 389 empyema in, 385 endocarilitis in, 389 epidemic roseola or, 382 erysipelas in, 388 eve complications in, 388, ' 389 gastro-intestinal tract in, 386 heart in, 389 hemorrhagic lesions in, 388 jaundice in, 388 keratitis in, 388 kidneys in, 389 Ivmphatic enlargement in, ' 380 mortality in, 390 nasopharyngeal catarrh, 385 nephritis in, 389 oedema in, 388 otitis media in, 388 parotitis in, 385 pericarditis in, 389 pleurisy in, 385 rashes in, 387 relapse in, 380 rubella or, 384 skin in, 388 stomatitis in, 385 svnovitis in, 389 throat comjjlications in, 385 thyroid gland in, 385 Aomiting in, 380 glands in, 30l glandular abscesses following, 301 ha?maturia in, 362 heart in, 363 hemorrhagic form of, 360 herpes in, 358 hydrothorax in, 353 impetigo in, 358 intestines in, 35S intracranial abscess in, 305 joints in, 370 kidneys in, 302 laryngitis in, 350 lobar pneumonia in, 352 lymphatic glands in, 301, 372 7 INDEX 401 Measles, nuislioid sii|)pur;i,Lio[i in, l}(;5 mcnibnuioiiH iiiryii^ilis in, I'.fiO inoiiiiif^il.is in, Hdf), /ifiS, '.',1\ mon(,iil (ii.shiii),'i,nc;(;s in, :i(i!) miliary vesicios in, '.'yh\) mortality of, .'fl8 muscular atrophy in, 'M\H myocarditis in, 'MV.\ necrosis (jj' larynx, Ilfjl nephritis in, '.M\2 nervous system, 3(j() neuritis in, ^(i!) noma in, '^M oedema of the j^lottis in, 351 osteitis in, 370 otitis media in, 304, 371 paraplegia in, 307 pericarditis in, 36-1 phlebitis in, 304 pleurisy in, 353 polio-encephalitis in, 368 paralysis in, 3(i(j paraplegia in, 3(37 parotitis in, 357 pulmonary complications in, 351, 371 tuberculosis following, 353 pregnancy in, 370 prodromal rashes in, 349 psoriasis in, 359 purpura in, 359 rashes in, 349, 358, 359 relapse in, 370 respiratory tract in, 350 retropharyngeal abscess in, 357 second attaclvs of, 371 sequels of, 371 skin complications, 358 spinal meningitis in, 369 paralysis in, 367 statistics of, 348 stomach in, 354 stomatitis in, 354 subcutaneous emphysema in, 359 suppurative adenitis in, 361 "sweating measles," 349 third attacks of, 371 thrombosis in, 365 tonsils in, 356 tuberculosis of the lungs follow- ing, 353, 371 of the skin in, 358 ulcerative laryngitis in, 350 stomatitis in, 354 urethritis during, 362 urticaria in, 35S vulva, ulcers of, in, 363 vuhitis during, 363 MehT?na in chickenpox, 376 Melancholia in enteric fever, 297 26 Mobuicljolia in scarlet fever, 337, .'347 during smallpox, 315 Membru/ies, mucous, in chickenpox, 378 Mem'ngitis in chickenpox, 380 in enteric U-ycr, I(i2 in measles, 365, 368, 371 in scarlet fever, 322, 337 spinal, in measles, 369 Mental affections after smallpox, 315 complications, prognosis of, in enteric fever, 298 disturbances in measles, 369 state in enteric fever, 61, 159, 244, 282 Mesenteric glanfis in enteric fe\er, 225 suppuration of, in enteric fever, 225 Miliary tuberculosis resemliling enteric fever, 270, 271 vesicles in measles, 359 Miscarriage fluring smallpox, 314 Morbidity in children in enteric fe\-er, 29, 38 in enteric fever, 18 and mortality, diminution of, of enteric fever, 18 in pregnancy and foetal life in enteric fever, 35 Mortality in enteric fever, 18, 38 in German measles, 390 and morbidity in later life in enteric fever, 38 Mountain fever or enteric fe-\er, 274 Mouth, gangrene of, in enteric fever, 212 Movements, choreiform, in scarlet fever, 340 Mucous membranes in chickenpox, 378 Muscular atrophy in measles, 368 Myelitis in enteric fever, 236 in smallpox, 316 Mj'ocarditis during smallpox, 311 in enteric fever, 193, 204 in measles, 363 in scarlet fe-ver, 328 Myositis in enteric fe^•er, 247 in scarlet fever, 342 N Nails, loss of, following; smallpox, 307 Nasopharyngeal catarrh in Gennan measles, 385 Necrosis of bone in enteric fever. 34, 213 in scarlet fever, 342 402 INDEX Necrosis ol" cartilage in enteric fever, 95 of larynx in measles, 8"il Nephritis, acute, in scarlet fever, 341 in chickenpox. 379, 3S() in enteric fever, oii, 115 in German measles, 389 in measles, 302 postscarlatinal, 32S in scarlet fever, 32G in smallpox, 312 Nervous svstem in enteric fever, Gl, ■ 159, 22S in measles, 3(36 in scarlet fever, 337 in smallpox, 314 Neuritis in chickenpox, 3S0 in enteric fe^er, 174, 229 in measles, 369 optic, in scarlet fever, 344 in scarlet fever, 339 in smallpox, 316 Neuroses in enteric fever, 250 Noma in enteric fever, 212 in measles, 354 in scarlet fever, 333 in smallpox, 310 Ocular lesions in scarlet fever, 342 in smallpox, 307 CEdema in chickenpox, 377 in Geniian measles, 388 of glottis in measles, 351 in smallpox, 309 of thorax and abdomen after enteric fever, 262 OEsophageal lesions in enteric fever, 124, 214 Onset, varieties of, in enteric fever, 41 Onychia in scarlet fever, 341 Optic neuritis in scarlet fever, 344 Orchitis in enteric fever, 205 in scarlet fever, 341 in smallpox, 313 Osteitis following enteric fever, 265 in measles, 370 in scarlet fever, 342 in smallpox, 312 Osteomvelitis resembling enteric fever, 269 in scarlet fever, 342 in smallpox, 312 Otitis media, in chickenpox, 378 in German measles, 388 in measles, 364, 371 in scarlet fever, 320 in smallpox, 308 Pain in alulonien in enteric fever, 136 Palate, ulceration of, in smallpox, 310 Paralysis, acute ascentling, in small pox, 316 bulbar, in enteric fever, 172 cerebral, in measles, 366 during enteric fever, 174, 245 smallpox, 315, 316 facial, in scarlet fever, 322 in smallpox, 309 in measles, 366 spinal, in measles, 367 Paraplegia in chickenpox, 380 following smallpox, 316 in measles, 367 in scarlet fe\er, 339 Parotitis during smallpox, 310 in chickeniiox, 375 in enteric fever, 212 in German measles, 388 in measles, 357 in scarlet fever, 341 Pemphigus in chickenpox, 375 Perforation in children during enteric fever, 33, 139 during enteric fe\er, 140 foUoAving enteric fe\er, 210 of gall-bladder in enteric fever, 152 Pericarditis during smallpox, 331 following enteric fever, 389 in German measles, 389 in measles, 364 in scarlet fever, 331 Perichondritis during enteric fever, 97, 99 in scarlet fever, 328 Periostitis in chickenpox, 379 after enteric fever, 265 in scarlet fever, 342 Peritonitis during .smallpox, 312 in scarlet fever, 336 tuberculous, resembling enteric fever, 271 Pharyngitis in smallpox, 310 " Pharyngotyphoid" in enteric fever, 55 Pharj'nx in enteric fever, 57, 124 in scarlet fever, 325, 333 Phimosis in smallpox, 312 Phlebitis in enteric fever, 201 in measles, 364 in scarlet fever, 332 in smallpox, 311 Phlegmasia alba dolens in enteric fever, 201 Pleuri.sy in chickenpox, 380 in enteric fever, 55, 106 INDEX 403 PleuriHy in (Icnniin iiio;i„sIoh, .'J8.5 in riK!iisl(!K, '.\^h\ in HCiU'lct lever, ."52!) in sni.'illpox-, ;{1() " Pleurotypiioid" in cnlciie IcA'er, .55 Pneunioniu in enteric lever, ."jl, .54, 102 lobiir, in enteric fever, 51, .54, 102, 105 in ni('iisl(!s, ;{52 in .scai-let lever, .'52S in .snijillpox, .SOO in scarlet lexer, ;i29 in .smallpox, 310 Pneumotlun-ax in enteric lever, 108 "Pneumotyphoid" in enteric lever, 51, 105 Polio-encephaliti.s in measles, .368 Poliomyelitis, anterior, following en- teric lever, 234 durinji; enteric lever, 234 Polyuria in enteric lever, 123 Postpharyngeal abscess in smallpox, 311 Postscarlatinal nephritis, 328 Pregnancy complicating smallpox, 313 in enteric fever, 35 in measles, 370 Pseudoclementia in enteric fe\-er, 203 Pseudoparalysis in enteric fever, 295 Psoriasis in measles, 359 Puerperal septica?mia resembling en- teric fever, 274 Pulmonary complications in enteric ' fever, 54, 102, 104 in measles, 351, 371 oedema in enteric fe\-er, 104 tuberculosis following measles, 353 Pulse in enteric fever, 108 Puncture, lumbar, in enteric fever, 169 270 Purpura ha-morrhagica, 340 in measles, 359 Pus containing specific organisms in enteric fever, 177 in vu'ine during enteric fever, 119 Pyaemia in chickenpox, 377 in enteric fever, 269 Pylephlebitis in enteric fever, 219 suppurative, in enteric fever, 219 Pyoneplirosis in enteric fever, 122 Pvuria in enteric fever, 119 Rash of enteric fever, 66, 175 in German measles, 387 initial, in smallpox, 302 in measles, 349, 358, 359 prodromal, in enteric fever, 66 liasl), prodromal, in inc'ihles, .319 in HC'irlci fever, 3IS in .smallpox, -302 Respiratory cornplication.s in enteric fever, 51, 94, 191 in Htnallpox, •3f)9 system in scarh-t friver, ,328 tract in rneaHlrj.s, .3.50 Piestle.ssnesH in entf;ric fever, 173 Retention of urine in smallpox, 312 in enteric fever, 57 Retinitis in smalljirix, 308 Hct nij)li;irvngeal abscess in measles, ' 357 in .scarlet fe\'er, 333 Rhinorrhrra in scarlet fevf;r, 319 Rigors in enteric fever, 47, 80, 187 Roseola, epidemic, or German measles, 384 Rubella or German measles, 384 S Sanitation, effect of, upon enteric fever, 18 in enteric fever, 18 Scarlatinal rheumatism in scarlet fever, 324 syno^•itis in scarlet fever, 324 Scarlet fever, 317 ab.scesses in, 341 acute nephritis in, 328 adenitis in, 323 albuminuria in, 319 alimentary canal in, 332 angina in, 3.32 ankj-losis in, .325 aphasia in, 338 arthritis in, .325 ascites, 336 blebs and bulhe in. 319 bronchopneumonia in. -329 cardiac changes in. 329 chorea in. .329 choreifonn movements in, 340 choroiditis in, .343 cirrhosis of the liver after, 335 complications of. 319 conjunctivitis in. 342 deaf mutism after, 323 dennatitis gangra?uosa in. 319 diarrhoea in, 334 ears in, 320. 323 eczema in, 347 empyema in, 329 endocarditis in, 330 in enteric fever. ISO. 275 404 IXDEX Scarlet lever, epilepsy in. 340 facial paralysis in, 322 I'urunculosis in, 347 gangrene in. 319 of skin in, 319 gastritis in, 324 heart in, 329 hemiplegia in, 33S hemorrhage during, 321 herpes in, 31S insanity tiuring, 337 jaimdice in. 33(j keratitis in, 343 kidneys in, 32(5 liver in, 335 lobar pneumonia in, 329 Ludwig's angina in, 324 mania in, 337. 347 mastoiditis in, 321 melancholia in, 337, 347 meningitis in. 322, 337 mortality in, 317. 322, 337 myocarditis in, 330 myositis in, 342 necrosis of bone in, 342 nephritis in, 326 nervous .system in, 337 neuritis in. 339 noma in, 333 ocular lesions in, 342 onychia in. 341 optic neuritis in, 344 orbital cellulitis in, 343 orcliitis in, 341 osteitis in, 342 osteomj-elitis, 342 otitis media in, 320 paraplegia in, 339 parotitis in, 341 pericarditis in, 331 perichondritis, 328 periostitis, 342 peritonitis in, 336 phar\-nx in, 325, 333 phlebitis in, 332 pleurisy in, 329 pneumonia in, 329 postscarlatinal nephritis, 328 premonitory- rashes in, 318 purpura ha>morrhagica, 340 relapse in, 345 respiratory system in, 328 retropharyngeal abscess in, 333 rhinorrhor'a in, 319 scarlatinal rheumatism in, 324 synovitis in, 324 second attacks of, 346 sequels of, 346 Scarlet fever, sinus thrombosis in, 322 skin lesions in. 340 stomatitis in, 332 surgical scarlet fe\er in, 344 temporosphenoitlal abscess in, 322 tetany in, 340 tonsillitis in, 332 unemia in, 327 urticaria in, 31S vomiting in, 334 Scarring in chickenpox, 382 in smallpox, 306 Sclerosis, disseminated, in measles, 367, 368 in smallpox, 316 Septiccpmia, puerperal, resembling en- teric fe\er, 274 resembling enteric fever, 269, 274 Sinus thrombosis in scarlet fever, 322 Skin com])lications in measles, 358 in enteric fe\er, {j6, 174, 178, 253, 261 gangrene of, in chickenpox, 374 in enteric fever, 178, 212, 253 in measles, 360 in smalljiox, 30<) in German measles, 388 lesions of, in chickenpox, 374, 382 in scarlet fe\-er, 340 tuberculosis of, in measles, 358 Smallpox, 301 abdominal complications during, 312 abscess in, 304 of kidney in, 312 of Uver in, 312 acute ascending paralysis in, 316 dilatation of the heart in, 311 albuminuria during, 312 alopecia following, 307 arthritis during, 312 boils in, 304 bone complications in, 312 bronchitis during, 304 bronchopneumonia during, 309 carbuncles, 305 casts urinary in, 313 causes of outbreaks of, 301 cellulitis during, 306- chondritis during, 312 choroiditis in, 308 coma in, 315 conjunctivitis during, 312 convulsions during, 314, 315 corneal ulceration in, 307 INDEX 405 Small |)()x, cycliii.s diiriiig, ,308 0VH(il.iH 'luriiif^, '.'>\'.'> (l'(\'iJ,h-r!iU; in, :'M2 clcliriiiiti (lun'iif^, .'■{! 1 (loriiial coriiplioations during, .'i02 digestive HyHtcm in, .'J 10 di.s.s(!tninatod sclerosis in, 310 ear O(jni[)lications in, '.M)\) eiTipyetna in, 1510 endocarditis in, lUl cpistaxis in, iiO.") eruptions in, 'MY2 eye complications in, 307 racial paralysis in, 309 i'urunculosis in, 304 gangrene of genitals in, 30G ol' skin in, 30(i gangrenous stomatitis in, 310 genito-urinarv complications in, 312 glossitis in, 310 haemoptysis in, 309 heart in, 311 hemiplegia in, 315 hemoptysis in, 309 hydrocele in, 313 hydrothorax in, 310 impetigo in, 304 incidence of, 301 initial rashes of, 302 insanity following, 315 iritis in, 308 joint compHcations in, 312 keratitis in, 308 kidneys in, 313 laryngitis in, 309 lobar pneumonia in, 309 loss of hair following, 307 of nails following, 307 mania during, 315 mastoid suppuration in, 309 melancholia during, 315 mental affections after, 315 miscarriage during, 314 myelitis in, 316 myocarditis in, 311 nephritis in, 312 neuritis in, 316 nervous system in, 314 noma in, 310 ocular lesions in, 307 oedema of the glottis in, 309 orbital cellulitis in, 308 orchitis in, 313 osteitis in, 312 osteomyelitis in, 312 otitis media in, 308 paralysis during, 315, 316 paraplegia following, 316 parotitis during, 310 Smallpox, p<.Tif;!ir'lilis ill, 31 I pcritonids during, 312 pharyngitis in, 310 pliiiiiosis in, 312 phlebitis in, 31 1 pleurisy in, 310 jineuinonia in, 309 postph/iryngeal abscess in, 311 jiregnancy implicating, 313 prodromal rashes in, 302 j'ashes in, 302 respiratory complications in, 309 retention of urine in, 312 retinal liemorrliage in, 308 retinitis in, 308 scarring in, 306 septic eruptions in, 303 stomatitis in, 310 susceptibility to, 301 thrombosis of cerebral sinuses in, 309, 315 thyroid gland in, 311 tongue in, 310 ulceration of larynx in, 309 of palate in, 310 ulcerative endocarditis in, 311 stomatitis in, 310 variola, 301 Spinal meningitis in measles, 369 parah'sis in measles, 367 Spine in enteric fever, 248 Spleen in enteric fever 114, 227 " Splenotyphoid" in enteric fever, 115 Spondylosis in enteric fever, 250 Stomach in enteric fever, 125 hemorrhage from, in enteric fever, 126 in measles, 354 Stomatitis in enteric fever, 212 in German measles, 385 in measles, 354 in scarlet fever, 332 in smallpox, 310 gangrenous, in enteric fever, 212 in measles, 354 in smallpox, 310 ulce^ati^■e, in enteric fever, 212 in measles, 350 in smallpox, 310 Strabismus in enteric fever, 212 Stuporous insanitv in enteric fever, 294 Subcutaneous emphvsema in enteric fever. 99' during measles, 359 Sudamina in enteric fever, 177 Sudden death in enteric fever, 194 Sudoral typhoid fever, 48 Suppuration, mastoid, in smallpox, 309 406 IXDEX Suppuration of thyroid gland in enteric lever, 202 Suppurative pvlephlebitis in enteric lever, 221 Surgical scarlet lever, 344 Sweating in enteric fever, 48, 259 measles,, 349 Swelling, glandular, in enteric fever, 124, 223 Sj-novitis in chicken pox. 379 in enteric fever, 177, 2(j5 in German measles, 3S9 Temperature during enteric fever, 44, (38, 205 variations from usual in onset, 44 Temporosphenoidal abscess in scarlet fe\er, 322 Testicle in enteric fever, 205 Tetany in enteric fe\-er, 251 in scarlet fever, 340 Thorax and abdomen, oedema of, after enteric fever, 262 Throat complications in German measles, 385 Thrombosis of cerebral sinuses in smallpox, 309, 315 and embolism, cerebral, in enteric fever, 170 in enteric fever, 170, 195, 203 in measles, 365 Thyroid glantl in enteric fever, 262 in German measles, 385 in smallpox, 311 suppuration of, in enteric fever, 262 Thyroiditis in chickenpox, 378 Tongue in smallpox, 310 Tonsillitis in scarlet fever, 332 Tonsils in enteric fever, 57 in. measles, 356 Tremors in enteric fever, 245 Tuberculosis during enteric fever, 104, 191, 270 of lungs following measles, 353, 371 miliarv, resembling enteric fever, 270," 271 of skin in measles, 358 Tuberculous peritonitis resembling enteric fever, 271 Typhoid cholangitis in enteric fever, 218 coxitis in enteric fever, 264 Typhoid fe\er or enteric fe\er, 17 "sudoral," in enteric fever, 48 spine in enteric fever, 246 Typhus levissimus or short duration enteric fever, 78 U Ulcer, corneal, in measles, 365 gastric, in enteric fever, 126 intestinal, in enteric fever, 128 of ^•ul\•a in measles, 3(53 Ulceration, corneal, in smallpox, 307 of larynx in smallpox, 309 of palate in smallpox, 310 Ulcerative endocarditis resembling enteric lexer, 270 in smallpox, 311 laryngitis in measles, 350 stomatitis in enteric fever, 212 in measles, 354 in smallpox, 310 Unpmia in scarlet fever, .327 Urethritis during enteric fe\-er, 206 measles, 302 Urinary casts in enteric fever, 56, 116 in measles, 361 in smaU]TOx, 313 Urine, casts in, during enteric fe^er, 116 pus in, during enteric fever, 119 retention of, in chickenpox, 379 in enteric iexer, 57 in smallpox, 312 Urticaria in measles, 358 in scarlet fever, 318 "\'aricella or chickenpox, 373 ^'ariola, 301 Vascular lesions in enteric fever, 199 "N'eins in enteric fever, 201 "\'esicles, miliary, in measles, 359 "N'omiting in chickenpox, 373 in enteric fever, 59, 125 in German measles, 386 in scarlet fever, 334 Vulva, ulcers of, in measles, 363 "N'ulvitis during measles, 363 W Water supply as cause of enteric fever, 19 COLUMBIA UNIVERSITY LIBRARY 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