Columbia WLnibtx&ity in tfie dtp of Jfceto gorfe College of ^yaitiuni anb burgeon* Ht. lalter $. Barnes; / Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/medicalcomplicatOOhare THE MEDICAL COMPLICATIONS, ACCIDENTS AND SEQUELS OF TYPHOID OR ENTERIC FEYER. BY HOBART AMORY HARE, M.D., B.Sc., PROFESSOR OF THERAPEUTICS IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA ; PHYSICIAN TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL ; LAUREATE OF THE MEDICAL SOCIETY OF LONDON, OF THE ACADEMIE ROYALE DE MEDICINE DE BELGIQUE, ETC. WITH A SPECIAL CHAPTER ON THE MENTAL DISTURBANCES FOLLOWING TYPHOID FEVER BY F. X. DERCUM, M.D., CLINICAL PROFESSOR OF DISEASES OF THE NERVOUS SYSTEM IN THE JEFFERSON MEDICAL COLLEGE. LEA BROTHERS & CO., PHILADELPHIA AND NEW YORK. 18 9 9. Entered according to the Act of Congress, in the year 1S99, by LEA BROTHERS & CO. In the Office of the Librarian of Congress. All rights reserved. DORSAK, PRINTER. PHILADELPHIA. THIS ESSAY .IS DEDICATED TO MY HONORED COLLEAGUE, W. W. KEEX, M.D., LL.D., PROFESSOR OF THE PRINCIPLES OF SURGERY AND OF CLINICAL SURGERY IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA. PREFACE. At the present time there are few diseases so widespread as typhoid fever, and the literature 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 sequela?. Anyone who has had even a limited experience with typhoid fever has met with cases in which the manifestations wandered so far from the clas- sical 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 phy- sician. The following pages deal with these aberrant forms of the disease and the courses which they pursue. As mental disorders sometimes complicate typhoid fever, I have asked my colleague, Dr. Dereum, to add a chapter on this phase of the subject, which is of great interest. Finally, I desire to acknowledge my great indebtedness i" the several authors who have enriched medical literature by special contributions to this subject, and from whose writings and bibliographical researches I have gained much valuable material. The first of these is the essay of my honored col- league, Dr. W. W. Keen, on the Surgical < bmplicaMons and Sequelae, of Typhoid Fever. In many instances I>r. Keen, in com- pleting his statistics, steps into the bound- of medicine, in distinc- vi PREFACE. tion from surgery, and in this way our studies sometimes overlap. Another writer to whom all subsequent authors on typhoid fever are indebted is Liebermeister, whose classic article in Ziemssen's Encyclopaedia is well known. I am also anxious to acknowledge my indebtedness to the writings of Osier, Mason, and Fitz. 222 South Fifteenth St., Philadelphia, Apeil, 1899. CONTEXTS. < NAPTER I. General Considerations 17 CHAPTER II. Varieties of Onset 37 CHAPTER HI. The Aberrant Symptoms, States, ob Complications of the Well- developed Stage of the Disease 63 CHAPTER IV. The Complications of the Period of Convalescence . . .174 CHAPTER V. The Conditions which Ape Typhoid Fever 253 CHAPTER VI. Duration and Immunity to Second Attacks 262 CHAPTER VII. The Mental Complications 265 THE MEDICAL COMPLICATIONS AND SEQUELE OF TYPHOID OR ENTERIC FEVER. CHAPTER I. GENERAL CONSIDERATIONS. It may be said by those who are disposed to be critical, that an essay dealing with the medical complications and seqnelse 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 presents 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 indis- position ; 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 cer- tain. A febrile course, characterized by malaise, headache, fever, drowsiness, intestinal disorder, enlargement of the spleen and liver, the eruption of rose spots, and the confirmatory Widal test, may be considered to represent true uncomplicated typhoid fever ; and with cases presenting these general symptoms this essay will not deal. On the other hand, the object in view is to di-eiiss three classes of 2 18 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. the manifestations of typhoid infection, namely, (a) those ordinary symptoms of onset and complete development which, by reason of moderation or modification or exaggeration, become interesting 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 complicating 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 rapid and normal return of the patient to perfect health. I am well aware that at certain points it will seem that the dividing line between the ordinary symptoms and those considered in these pages is overstepped, and while it is not my intention to avoid this overstepping when the complete discussion of the con- dition is necessary to a thorough study of the process under con- sideration, these ordinary symptoms will not, as a rule, be gen- erally considered. Before proceeding to a clinical study of the disease, it is inter- esting to note that its frequency, severity, and mortality are dis- tinctly 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 mortality is now much less than this, and 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. 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 has fallen from 10 per 10,000 to 2.4, and finally to 1.5 per 10,000. In Stockholm it fell from GENERAL CONSIDERATIONS. 19 5.1 in 1877 to 1.7 in 1887. So, too, in Boston from 17.4 in 1846-49 to 5.6 in 1870-84. The following table is of interest in this connection : Mortality in Munich from 1851 to 1896. Year. Inhabitants. Annual. Per 100,000 inhabit' nts. Year. Inhabitants. Annual. Per 100.000 inhabit'nts. 1851, 123,957 123 99.0 1874, 181,300 289 159.0 1852, 125,588 152 121.0 1875, 187,200 227 121.0 1853, 127,219 235 184.0 1876, 193,024 130 67.0 1854, 128,850 293 227.0 1877, 205,000 173 84.0 1855, 130,481 253 193.0 1878, 211,300 116 55.0 1856, 132,112 384 291.0 1879, 217,400 236 109.0 1857, 133,847 390 291.0 1880, 223,700 160 72.0 1858, 135,733 453 334.0 1881, 230,028 41 18.0 1859, 137,005 240 175.0 1882, 236,400 42 18.0 1860, 140,624 153 109.0 1883, 242,800 45 19.0 1861, 144,334 172 119.0 1884, 249,200 34 14.0 1862, 148,200 300 202.0 1885, 255,600 45 18.0 1863, 154,602 252 163.0 1886, 262,000 55 21.0 1864, 160,828 397 247.0 1887, 268,400 28 10.0 1865, 167,054 338 202.0 1888, l 292,800 31 10.5 1866, 168,265 342 203.0 1889, 306,000 31 10.1 1867, 169,476 88 52.0 1890, 331,000 28 8.5 1868, 170,688 136 80.0 1891, 357,000 24 6.4 1869, 170,000 190 111.0 1892, 372,000 11 3.0 1870, 170,000 254 149.0 1893, 385,000 57 14.8 1871, 170,000 220 129.0 1894, 393,000 10 2.5 1872, 169,693 407 240.0 1895, 400,000 15 3.7 1873, 175,500 230 131.1 1896, 412,000 14 3.4 The effect of improved sanitation is to decrease the virulency of infection, and for this reason there follows a decreased severity of illness and a decreased percentage of mortality. X<>t only are these facts true of the cities just named, but it is also true that the frequency, severity, and mortality of typhoid fever arc steadily decreasing all over the world, as is shown by the following inter- esting tables of Dreschfeld in regard to England in general and London and Manchester in particular : 1 This table is taken from Pettenkofer's "Munich a Healthy City," up to 1887 inclusive ; after 1887 from returns obtained from the Statistical Bureau. 20 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. Annual Mortality, Period. per Million Persons Living, from Fever in England. Enteric Period. Enteric eases. cases. 1838 . 1228 1866 . . .986 1839 . 1010 1867 . 778 1840 . 1089 1868 . 895 1841 932 1869 390 1842 1004 1870 388 1843 1871 . 371 1844 1872 377 1845 1873 376 1846 1874 . 374 1847 1807 1875 . 371 1848 1266 1876 . 309 1849 1044 1877 . 279 1850 865 1878 306 1851 997 1879 231 1852 1022 1880 261 1853 1008 1881 212 1854 1015 1882 229 1855 875 1883 228 1856 847 1884 236 1857 988 1885 175 1858 918 1886 184 1859 806 1887 185 1860 652 1888 172 1861 767 1889 176 1862 919 1890 179 1863 874 1891 168 1864 960 1892 137 1865 1089 EATH-RATE EROJI J Enteric Fever in London and Manchester per Million. Year. Londo n. Manchester. Year. London. Manchester 1871 . . 267 450 1883 . . 247 200 1872 . . 242 400 1884 . 234 190 1873 . . 269 460 1885 . 150 170 1874 . . 256 390 1886 . 154 290 1875 . . 235 440 1887 . 151 310 1876 . . 217 420 18S8 . 169 330 1877 . . 251 290 1889 . 130 310 1878 . . 283 310 1890 . 146 270 1879 . . 229 180 1891 . 132 370 1880 . . 186 260 1892 . 102 240 1881 . . 254 170 1893 . 161 250 1882 . 252 250 GENERAL CONSIDERATIONS. 21 These figures are exhibited graphically in the following chart : Fig. 1. CD z -a: C3 z UJ CD CD CD 1 OD UJ DZ CD z ce H 00 H 01 X H XX H H 10 00 t. X H £ H X N X H is X H X X H H X X H :> X X H CO X X H 4 X X H X X H CO X X H X 00 H X X X H a X X H X rl H X H X H M r. i. H 3 SO 280 4GO J A 370 270 -4SO A 360 260 -4-4 O V i / y \ HI i 330 250 43 O 1 v i s X V / r \ r -♦-■ A 340 240 -42 O *l H] 1 / \ / \ V 330 230 -410 \ I \ 1 ', / u/ I / 320 220 400 i \i \ v ' \ j I 310 210 390 I f! 1 / 1 1 300 200 380 < A \/ 1 290 XOO 370 J V T sso 180 360 V 1 | !l 270 170 350 i A I j 260 160 340 A \ i /' \ l| r 250 150 330 ! 1 A L ■*- J \ A 1 ! J 240 140 320 ■ / \ A f \ y 1 \ i • / 230 130 UIO 1 .* \ r V \ *' V. \ 220 ISO 300 i - 'i \/ 1 \ / t • / 210 HO 200 * ■ V ) 4 . | y 200 lOO 280 i i \ ! v 190 270 i i i ii ISO 260 i t +* -\ | 170 250 (1 I i > ,• 160 240 h \ ;- 150 230 i i \ 140 220 i | i \ i \ 210 i ; 1 1 ■ 200 \l ■\ — lOO if '. / "1 180 i 1 j ! 1 170 i i Chart showing decreasing mortality of typhoid fever per million persona livim in England, London and Manchester. Solid line, England. Broken line, London. Dotted line, Manchester. Xot only is the decrease in mortality seen in England, bul in Philadelphia and New York, as follows. The decrease in eases and in mortality in Philadelphia is shown in the following chart in broken and complete lines ( Fig. '2) : 22 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. Fig. 2. NUMBER OF CASES > < S c o 2 ' CO 30 CO CO CO o 33 1-1 33 30 CO C3 CO 3S id 33 oo o - . oo 05 00 CO ao BETWEEN 21 ♦ n f 4500-4200 20 \ / 4200-3900 19 \ 1 / -■«. 3900-3600 18 \ i \ 1 ' 3600-3300 17 \ 1 \ 1 \ A 3300-3000 16 V V 3000-2700 15 \ 2700-2400 14 \ 2400-2100 13 \ 2100-1800 12 1800-1500 11 V ' Chart showing the morbidity and mortality of typhoid fever in Philadelphia. Notwithstanding the present epidemic which in 1898 raised the morbidity from between 2700 and 3000 to over 4500, it will be seen from the dotted line that the mortality per cent, still decreased. Solid line, morbidity. Dotted line, mortality. Year. 1888 1889 1890 1891 1892 1893 1894 1895 1886 1897 1898 Philadelphia. Cases. Deaths. . 3573 785 4631 736 3182 566 3531 683 2304 440 2519 456 2357 370 2748 469 2490 402 2994 401 4749 566 Per cent, of mortality. 21.9 15.8 20.9 19.3 19.1 18.1 15.7 17.0 16.1 13.3 11.91 These statistics go back as far as the comparative 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 GENERAL CONSIDERATIONS. 23 make the total percentage 10.47 in 6097 cases. The low mor- tality 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 neces- sary to the safe conduct of a typhoid case. Again, while the frequency of the disease has risen from 2994 cases in 1897 to 4749 cases in 1898, the mortality is only 11.91 for 1898, or, if the soldiers are included, making 6097 cases, 10.47 per cent. Fig. 3. NUMBER OF CASES i-t- ^ z < ^1 1; y DC < HI >- oo oo r> o GO CO oo OS C5 00 OS oo O OS oo OS CO 'JO 23 t 85 22 f\ . SO 21 ; 75 20 i I 70 l'.l 1 / r° ldB ith I legu a in 1S'J2 05 IS i.- 1 GO 17 \ / I 1 ,* 55 16 1 1 I / / ' \ 50 i:> V / / f \ 45 M >i / \ 1 1 V 40 13 1 1 I 35 12 \ 30 11 \ 1 \ 1 25 10 1/ 20 9 i Chart showing morbidity and mortality per cent, at the Philadelphia Hospital for ten years (1888-1897 inclusive). Both the morbidity and mortality are de- creased. Solid line, morbidity. Dotted line, mortality. As only a little over two months of 1899 have elapsed the statis- tics for this year cannot be included in Fig. 2 ; but it is inter- esting to note that, while this wide-spread epidemic, due to bad water, has persisted and increased, the mortality j>cr cent, has not increased. Thus in 1899, up to March 13th, no less than 3424 cases of typhoid fever occurred of which 360 cases died, or 10.51 per cent. 24 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER Fig. 4. NUMBER OF CASES 00 CO CO H © CO CO H © CO H H o en © CO H w © CO H CO H © CO H CO H © CO H 1400 13SO 1300 1350 / 13 OO / 1150 / llOO 1 1050 lOOO 9oO 900 8oO soo Chart showing decreasing number of cases annually in New York. 1 Fig. 5. ANNUAL DEATH RATE OF NEW YORK CO 00 H N 00 CO H 00 00 00 H © 00 00 H © CO H H © X H 01 © H CO I H © I H © 00 n 30 H O CO H O.2o A 0.2-I / \ 0.23 N y / \ • ,J 0.2S V V 0.21 0.20 0.19 O.IS 0.17 0.16 0.15 Chart showing decreasing death-rate from typhoid fever in New York City. 1 A comparative chart of the number of cases and of mortality per cent, from these figures is not given, as Dr. Biggs, of the New York Health Office, writes that only recently have the cases been generally reported, and even now many are not reported. GENERAL CONSIDERATIONS. 25 New York. Year. Cases. Deaths. Year. Cases. Deaths 1888 . . 1108 364 1893 . . 1008 381 1889 . . 1414 397 1894 . . 792 326 1890 . . 1100 352 1895 . . 965 322 1891 . . 1342 384 1896 . . 1002 297 1892 . . 1140 400 1897 . . 1004 299 The chart on preceding page from the New York Health Report shows a decrease in death-rate from typhoid fever (Fig. 5) : When we consider that the population of these cities has in- creased enormously, the great decrease in the frequency of the disease and in its mortality is very notable. These tables are supported by the statement of Billings, that in Norway from 1888 to 1891 the mortality from typhoid fever was 755 in 7467 cases, or less than 10 per cent. In the recent Maidstone 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 1000 cases was 13 per cent. Bryant 1 states that out of 608 cases treated in Guy's Hospital from 1879 to 1893 14 per cent. died. Again, hi the Gazette Medicate des Hopitaux of July 10,1890, we learn that a collective investigation showed that, whereas in the period from 1866 to 1881 the mortality from typhoid was 21.5 percent. ; from 1882 to 1888 it was 14.1 per cent., and in 1889, 13.5 per cent. We may assume then that the ordinary mortality of typhoid fever is at present less than 15 per cent, in the general run of cases, and that in good hospitals and private practice with good nursing, that it varies from 1 to 10 per cent., the more so as many years ago, before the disease had become modified, Mur- chison placed 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 similar doorcase in mortality is evident : 1 Guy's Hospital Reports, 1893. 26 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. Basel ( Liebermeister ) Basel (Liebermeister) Maidstone, England .... Boston (Mason) ...... Homerton (Collie) . . . . Glasgow (Collie) . . . . Societe Medicale des Hopitaux (1879) 1 Jaccoud ...... Riess ....... Boston (Shattuck) . Germany (?) Brand has collected Cases. Per cent, of mortality. Treatment. 223 11.7 Calomel. 239 14.6 Iodide. 1885 7.5 General. 676 10.4 General. 677 9.5 General. 618 8.2 General. 1979 12.47 665 10.8 General. 900 7.5 Tepid baths. 237 9.8 Expectantly and cold sponging. 19,017 7.8 All kinds of cold baths. 27,116 10.0: 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 about 10 per cent. The wide distribution of these cases and the large number of clinicians give us a standard average. At Basel in 1873, 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 1874 at Basel the water cases were 200, with a mortality of 10.5 per cent. ; at Homerton 372, with a mortality of 9.6 per cent. ; at Glasgow 343, with a mortality of 7 per cent. Basel (1873) Glasgow " Homerton " Basel (1874) Glasgow " Homerton " No. of cases. Treatment. Mortality per ct . 163 Bath 10.4 . 275 General 9.4 . 305 General 9.5 . 200 Bath 10.5 . 343 General 7.0 . 372 General 9.6 1 These statistics are based upon the fact that twenty-one chiefs of hospital service reported to the Societe Medicale 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. GENERAL CONSIDERATIONS. 27 Of the fact that a change in type has taken place in enteric fever, I do not think there can be any doubt, and no one who has watched the disease during the last fifteen or twenty years, or even for a shorter period than this, can fail to note the difference in its character. Particular attention has been called to this fact by Sidney Phillips 1 and James F. Goodhart. 2 The latter writer says : " I agree in toto with what Dr. Sidney Phillips 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 pro- duce a considerable modification of the original disease. There is considerable difference in the symptoms described fifty or even twenty-five years ago and those occurring to-day. 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 pro- nounced ; probably also hemorrhage and perforation are less com- mon ; tremors and dilatation of the pupils are now uncommon ; and, instead of noisy, active delirium, the mind is often clear throughout even fatal cases. The typhoid state with the patient sunk deep in bed, unable to move himself and unconscious or semi-conscious for days, is now quite exceptional. Dr. Phillips attributes this ' to a lessened tendency to ulceration of the intestines,' and argues that if so much variation of type has taken place in a quarter of a century, much more has gone on in fifty years, and that where conditions existed such as made typhus rife the distinctive features of typhoid may well have been affected, and that in this is pos- sibly to be found the explanation that the separate diseases were regarded as one." In this connection the question of the frequency of typhoid fever in children may be considered. At first sight it would appear that in this class of patients it is a more common disease than formerly, but this is only because it was not recognized and recorded. 1 British Medical Journal, November, 12, 1898. 2 Ibid., January 28, 1899. 28 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. Typhoid fever in children is by no means as rare as has been supposed. While the earlier years of life seem to be blessed with a relative immunity to the disease, there is no doubt that it often occurs in a mild form and is not correctly diagnosed. A young child sickens, has fever, is wretched, has moderate diarrhoea or constipation, and a coated tongue. Debility is rapidly developed, the stomach becomes irritable, and the fever is persistent, even though it is not high. After an illness lasting for from a few days to several weeks, the child gradually recovers, and the diagnosis originally made is adhered to, namely, that the case has been one of " simple catarrhal fever." The longer one practices medicine the more strongly the idea develops that such a thing as " simple catarrhal fever," does not exist as an entity, and that this term covers a multitude of diagnostic sins. As was pointed by Lieber- meister years ago, typhoid fever may occur even in adults with these mild symptoms, and be called " catarrhal fever." It may be laid down, however, as a rule, that the younger the child the less likely is it to have enteric fever, and that the prog- nosis is usually favorable if the child be young. In other words, the older the child, the more grave the prognosis. On the other hand, it is only fair to state that Rocaz 1 believes that while the duration of the fever in children is shorter than in adults, the fever itself is apt to be excessive ; that the prognosis is grave under three years, less grave at four years, and only less grave than in adults when the child is above five years of age. This question of how frequently typhoid fever does occur in children is of great importance. At the head of those who advo- cate the view that it is common we have Ashley and Wright, 2 who assert that " children and young people are more susceptible to typhoid fever than are adults, though it is not common in children under three years of age." This is certainly an excessive state- ment, although Pepper 3 states that typhoid fever is far more com- mon in early life than is generally recognized. Henoch records 1 Annales de la Polyclinique de Bordeaux, 1897. 2 Diseases of Children. 3 American System of Medicine, vol. ii. GENERAL CONSIDERATIONS. 29 376 cases and 2, lS'.io. 4 Journal des Practiciens, January 2 1 KMfi < t* II ■K-\ i; _ --^. >« 1 •KM C. "= 01 •K-v 6 ~K.dC, r< c •K-v 6 __ -^. s» •km i; 8 •K-v 6 r •KM S 4- i 1 1 1 I,' "+ CO OJ i — C3 CO CO r— •£ l-l- O O CD CD o CO CO CO C Q O D C 'U ci a a ** So bC 8 -a a, c ° ^ to a> ^3 a> o o .2 £ O QQ COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. goes. The temperature of typhoid fever is, as is well known, rarely as high as in many other of the grave infectious maladies, yet at times it may become in itself dangerous by reason of its height. Sometimes, though rarely, as in the days of onset, we meet during the fastigium, without the presence of an additional exciting cause over and above the ordinary typhoid infection, with cases in which there is developed a distinct hyperpyrexia amounting to 105°, or even, very rarely, to 110°. Such high temperatures are sometimes seen for long periods of the attack as the result of nervous excitement, or of unusual sus- ceptibility to the infection in the sense that the heat mechanism is easily disturbed by the disease. These cases, as a rule, however, do not persist in hyperpyrexia, but soon fall to the usual level. When the fever is persistently high there can be no doubt that, as a rule, the attack is one of a severe character. Conversely, a low range of fever is indicative of a mild attack, although by no means proof of it, for moderate fever is sometimes seen in cases charac- terized by very severe infection. Rarely the disease, pursuing a fatal course, is accompanied by progressively rising fever until toward the end of the second or third week it may reach 107° or even 110°, as has been recorded by Wunderlich. When a severe and prolonged attack of typhoid fever is present the period of " steep curves " may be postponed from the end of the third or beginning of the fourth week, or even to the fifth or sixth week, and in these cases there is usually wide-spread ulceration of the small and large intestine. Additional evidence of this condition is adduced by the fact that the abdomen is still tender on pressure, and the so-called meteorism or active peris- taltic movement is persistent. Care must be taken in these cases that other causes than uncomplicated typhoid fever are not actively engaged in the continuance of the fever, either in the form of other infections or as secondary infections by the bacillus of Eberth of such parts, for example, as the gall-bladder, the kidney, or the bones. Or, again, the fever may be continuous as the result of a tubercu- lous infection superimposed on the typhoid trouble or antedating that disease in time of entrance into the body, but only active WELL-DEVELOPED STAGE OF THE DISEASE. 67 when vital resistance is decreased by the exhaustion of typhoid fever. (See further on.) Among the particularly noteworthy causes of sudden rises of fever during the fastigium, or in the period of ambiguity, or during lysis, we find the development of some acute complication, such as pneumonia, catarrhal or croupous, abscess in some part of the body, and what has been called " intercurrent relapse." The pneumonia at this period is often of the croupous type (8 per cent.), and pleurisy may also develop (8 per cent.), but their onset may not noticeably disturb the temperature curves, so that while the presence of a rise may be indicative of another source of diffi- culty, its absence does not indicate that no secondary pulmonary trouble has arisen ; more rarely still catarrhal pneumonia elevates the temperature, and its very insidious onset makes it readily over- looked, while the development of hypostatic congestion may make no change at all. The temperature under some circumstances rises quite suddenly, and, after maintaining a generally higher course for a few days, begins to drop back to its former level, or at once the whole temperature course passes into the stage of lysis. So, too, an otic abscess may produce such results, and, finally, should an intercurrent relapse ensue, the fever, gaining new force, may mount to a point as high or higher than any previously reached, and last from ten days to two weeks or more, falling again as a tendency to lysis is developed. The presence of a mild primary attack followed by a relapse after several days of no fever, and finally complicated by phlebitis, with fever secondary to it, and then a second relapse, is shown in this chart. It is important that a secondary exacerbation of the fever be not regarded as indicative of true relapse unless it persists, un- less it is followed by a renewal of many or all of the earlier symptoms of the disease, and unless the eruption and enlarge- ment of the spleen a second time indicate true secondary infec- tion. Not only is the physician to avoid a diagnosis of relapse until it is proved to be present, for the sake of accuracy, but in addition he must avoid it, because it is an easy way to ex- plain temperature irregularities, which should cause him to care- 68 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. "KM 9 -*—-__ _LL GS fSl 8S CI •irv 9 MI " 'KM 9 SS 8SI OS II ■K'Y 9 9SI !-,- ■K'jg <- IS 9SI os CI •K-v g 981 t- ■KM 9 ■*-. 9S OSI 81 ST •K-y g __ "ill " ■KM 9' £2 SOI " II ■K-V OSI SE 'KM 9 ft MI SE 01 •K-v 9 80T SE 'KM 9 EE OSI or G ■K-v 9 8SI SE "KM 9 * 1 ZT- 911 f,~ 8 •K'Y 9 OSI SE •km 9 is 88 OS I •K'Y 9 nnt Yb "KM 9 < «= ^r OS 081 98 fi ■K - Y 8 __ _- =• ss t-s 'KM f, 6t hi H i-- g •K'Y g Jz » os ■km 8 .. St S6 S8 OS \ ■K'Y 8 OS "km s 1\ 81 OS S •K'Y 8 I Zl 81 •K-ag 9T n 81 s •K - Y 8 « 81 •km 9 kC et *8 OS I •K - Y 9 V > 80 ss "KM 9 4 <\ fl 0OT 8S If: ■K-YG > SG OS ■km 9 1 SI H)I OS OS •K'Y 9 : :> 1-8 OS •km 9 4 s SI 801 ss 68 •K'v 9 =f" 86 OS "KM 9 n- 88 OS 8E •K-y 9 00 OS •KM 9 S - 01 m: OS « 'K'v 9 i 9G \z ■KM 9 t. - _ G fin I OS 98 •K'Y 9 7 in; OS •KM 9 ' S 0G MS '.',- ■K-v 9 U II- ■KM 9 =n I SO SE 1- •K'Y 9 ^ ?* 86 II,- •KM 9 9 S6 SE 88 ■K-Y 9 __ is OS •KM 9 ^ " s m; SI SE 'MSI ■* \ OISS III PA a6 0s ss O o o ° o ° 'JS q 0) "3 rfl Ph — S~, O) — fl -*- 1 c £ & 5 ~ — >, wl > -C 01 -H *~ bo iD t- c. c a e* & 53 o WELL-DEVELOPED STAGE OF THE DISEASE. 69 ss 01 •K-V9 s: 81 •KM g < " K oe OZ G •K-Vfl / » OS u- ■km g 1 es Ofl ss - •K-vg 0E SI 'K'J |l '•: 01 IT -' •IfV G 06 8S •KM |l = K Mll| III: •K'V , — ,-r, s<- •KM 9 " oc rn 9<" £ •K-V9 911 1- •KM 9 01 rn is i •K-V9 801 92 •KM 9 < St Ml 96 : ■K'V i; • (i,-| I- •KM 9 K fl ssi 1- ,- •K"\ 9 » » HI ns •KM (; Of il- 1 ES i ■K-vg f-Sl I.- •KM 9 fff- r-I 9S re •K-V9 - — ' 0OT ii,- •KM 9 tt m ir. 08 •K'V 9 911 81 ■KM 9 El SSI 9Z ez ■K-vg HI SS •KM 9 Zf- HJ SS ■■- •K-v 9 "11 OS •KM 9 If SIX ir. a •K'V 9 '.'II -- •KM 9 -U_ _ Of mil r-r. 03 K'V 9 _L_ __ " :::::,, 08 ii,- •KM 9 =c. 4-k sL 68 001 n- .,- •K-v 9 | 1 88 w •KM 9 i r+= = SS osi nr ir. •K-v 9 ] 88 ts •KM 9 is SI I i-s :.,- •rev 9 rn 81 •KM 9 ns :>J ii,- " •K'V 9 96 !-,- ■KM 9 —— '.-.: ss OS r ■K"\ [1 ■-- := * , I.; nr •KM 9 I:: mil si; OS ni 08 'K-v 9 •KM 9 SS nil IS •n-v 9 '-r. gj; ■KM 9 JS inl ,-s '■I ■K \ 9 91! ni: ■KM 9 IS HH I:: -'i •M-V 9 iiv I," ■KM 9 n:. -11 ,".,- ni ■W l| * — . ll 1 1! ir • O o o o o o o a U_-*co cm r— o cd co r— Q a - C3 CD CD CD CD Cft C5 CO _ ri ^ rj - ^ - - => ? tf Q 70 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. fully search for complicating affections. To sum up this matter with brevity, it should be the rule to consider any sudden and considerable rise of fever above the ordinary lines previously fol- lowed, an indication of some other factor than the ordinary typhoid infection. These various complicating states which are productive of febrile movement will be discussed later on when studving the lesions found in various organs. Of the cases in which the temperature is of low degree and mild, much may be said. In the first place, in very rare instances cases occur in which there is not only no fever, but actually a con- dition of subnormal temperature from the beginning to the end of the attack. Thus in several cases under the writer's care, some years since, there was a characteristic temperature curve in form but not in degree, the morning temperature being distinctly sub- normal and the evening temperature normal, and in which the return 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 what- ever 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. Strabe 1 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 1 Berliner klin. Wochenschrift, 1871, No. 30. WELL-DEVELOPED STAGE OF THE DISEASE. 71 no less than 14.1 percent. So, too, Fraentzel 1 has recorded forty- one cases treated in a field-hospital during the Franco-Prussian war, in three of which the fever did not exceed 99.1°, and in the rest did not arise above 102.2°, and yet in which the mortality was 89 per cent, for the forty-one patients. Guiteras 2 records a case in which he diagnosed the condition as intestinal obstruction, in which the patient died of peritonitis, and at the autopsy the lesions of typhoid fever was found, although no fever had been present. Tallin 3 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 writer 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 further on.) In La Province Jledicale, November 26, 1897, Weill and Piery report a case of apyretic typhoid fever, which they considered in other ways entirely typical. Two cases of apyretic typhoid fever have also been recorded by \Yendland. 4 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 had true typhus fever at ten years. On admission he had a tem- perature of 98.4°; pulse, 84 ; respirations, 26 ; the tongue was coated, showing distinct red tip and edge ; he had an apathetic appearance, and complained of headache ; the pupils were dilated, there were tenderness and gurgling in the right iliac fossa. He still had constipation, but when by medication the bowels were acted upon, the fecal matter was of pea-soup color and liquid. 1 Zeitschrift fur klinische Medizin. 1881, p. 226. 2 Transactions of the Association of American Physicians, 1887. 3 Archives Generale cle Med., November, 1873; see also Liebermeistcr and Hagenbach A us der med. klin. zu Basel, 1869, \>. 9. 4 Deutsche Medizinal Zeitung, August •_'!>. 1SU3. r ~ Sf w •K T ? tr 00, 55 cmana TC i i N If 05 55 ■ Of •K T s ; 58 5S ■K ■a 8 w -? o5 f 98 ■K v - "? 55 •H J Q < BS 91 fZ m K v 5 \ 81 f-5 Of ■H a r k 88 81 55 ■ ttraang K v 8 > 01 53 8? •K .1 Q ■^ XS f: ZZ I *mra a OK v X \ o: 55 SS ■" a s t 98 n: 55 IE •H T a f! 1 o: 53 nt ■n j 8 1 1 es o: 55 00 sman'j ■» T 8 ^ o: 55 K a 8 , fE 89 35 r-. Of K T - / 00 55 IP Fk J Q 88 fo 53 9T- ™ M 3 ■» v : > 00 35 fo ■K a c S8 t9 53 -- SOiatl^ ■K T = B9 33 if: •K •I 0, IS 90 35 05 turana ■K v G 00 33 08 ■K J : 00 01 35 05 unrana; ■K t r, > 01 55 SS K .i 6 95 t5 G* •K k r. , j i 85 o: 55 05 ™™I ■K v r, ) 01 33 no •K j a s. Zo r9 33 T.Z ^msnj •K y r, oo 55 08 'IV a r, I | 95 fO 35 15 ^manu ■K v ■ 99 33 ■B j 6 C" 59 35 05 18 •K » 6 > 59 35 OS •K J i- (ft w f9 55 61 •cmanj K v 0, v fo 55 or: ■H «6 / 65 09 33 BI vmrnig •K » 6 y no 33 or ■K .1 6 4 " 09 33 II ™™j ■K y 6 L. 00 33 95 •K -i r, 5 N 15 85 33 91 ™™j •M '6 _^. 90 33 -- ■K .i r, •c 05 90 f3 01 crasnj •K » 6 iH 90 f5 or: ■K i GI 00 f3 fl rnran-i •K v 6 90 t5 25 ■K '6 8t 09 f5 01 umanjj ■K v r, s 85 f3 58 •K -i 6 II 09 r3 51 unran a ■K v r, / 05 *8 00 ■B ^ 6 / 91 r9 t5 II Btnana K ▼ 6 59 t5 IS ■K 'i r, SI f9 f3 01 umaug ■H v c SO f5 10 ■H t! M 53 G urnaug ■K v e fO 53 00 ■K a 6 > 81 no 33 ? ■nang •rc-y 6 <~ fo 53 [8 T16 51 Og 35 - Tiraaua ■K v fO 33 IE K .1 i- II "0 55 9 uraanj ■K " 6 < fo 33 •K •i r, > 01 B9 55 - CO It y 6 < fO 53 Binaiig •K i i-. > G 00 55 f 00 •K y 6 > 00 55 'K i .-, ■ V ; 99 f5 mmng ■H » e <- 09 55 •K i ., - 89 55 - ™™S ■K y n o: " 'K i 6 1 1 9 00 K I ■K » r, j / no f5 ■jg •i 6 » }J 55 10 ■K y g OS f5 •K a G T 92 05 OS turanjf K v r, so T.7. ■H ■i G 8 09 f5 65 'K v 0, 90 f5 K l fi 3 5! f5 35 •re v r, 08 85 ■re -i n I 00, 05 1- COISEIU1 I'Vno ^> M 95 5 i| 11 g m JO £-.j£ » i « Q WELL-DEVELOPED STAGE OF THE DISEASE. 73 There was an eruption of "rose spots;" the spleen was normal. Upon the patient's abdomen and back were found numerous pale- blue spots — tache bleudtre. ('lose inspection also showed evi- dences 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, 10*20; acid, no sugar, no albumin. Later the headache nearly disappeared, but stupor still con- tinued. The diagnosis was afebrile typhoid. The accompanying temperature-chart is an interesting confir- mation of this history : Dreschfeld also mentions this form of apyrexial typhoid fever. Under the name of typhus levissvmus, 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. In that condition known as " abortive typhoid fever," the severe onset and high fever may so soon be followed by modera- tions and signs of convalescence, with a falling temperature, that the course of the temperature may be most aberrant and the chart misleading. Here, again, however, as in all the variations of temperature just described, the physician must not be readily led into a diag- nosis of an aberrant form of typhoid fever by the knowledge that such aberrant forms occur, for these forms are so infrequent as to be curiosities, and are so rare that the probabilities in an obscure case are against their presence. Only the clear and undoubted development of a sufficient number of pathognomonic 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 74 COMPLICATIONS AND SEQUEL M OF TYPHOID FEVER. curves, and the characteristic febrile movement is so irregular and distorted as to be devoid of much diagnostic value. 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 a reverse type in which the morn- ing temperature is highest. Such an occurrence took place in the case reported to me by Krusen, which is quoted in Chapter I. Fig. 12. F 104° 103° 102° 101° 100° 99 a 98° 97° Day of Dis. 1 1 * i 1 i 1 / 1 / h / f 1 \ i / \ i I -.j I \ , ! \ 1 / \ \ s — \ \ - "O ^ ~"^ \ - \ \ S^ s s, ^ l\ V / s /*< 1 \ \ \ I L_ \ \ CO -* » « t- en C5 o Abortive typhoid fever ending by the seventh day, and by crisis instead of lysis. 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, this form of the fever is by no means rare in this class of patients. Again, as this week or the third week ends, the febrile movement may even be distinctly like that of a malarial intermittent with- out there being any malarial infection of the patient whatever. Striimpel speaks of such cases in which distinct remittance occurred, and of others in which the fever was completely inter- mittent, the afternoon temperature for two or three weeks being as WELL-DEVELOPED STAGE OF THE DISEASE. 75 high has 104°, yet followed by morning temperatures at the norma] point, and Pepper has expressed the belief that these great varia- tions are in part the result of marked sepsis and intestinal ulcera- tion. Tims he has seen as much as 7 degrees variation occur for several days in succession. Such variations should never be con- sidered curiosities in typhoid fever, but should stimulate the med- ical attendant to increased endeavor to discover a septic source other than the intestinal lesions as, for example, a septic kidney. They may occur, however, in cases without complicating diseases or lesions, as is shown in Fig. 12. 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 Her- ringham, who discusses these temperature variations in St. Barthol- crmew's Hospital Reports for 1896. In one of these a woman of 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, which amounted to a crisis, and speedy convales- cence ensued. In still another case chills and fever occurred on the thirty-first, thirty-fifth, and thirty-sixth day of the illness, followed 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 occurred in acme and severe rigors in lysis, probably due to thrombosis. Osier has also reported a case of this type. 1 Church 2 has recorded a case in which a girl had twenty-two rigors in a primary attack in fourteen days, twenty-five in fifteen days in a first relapse, and six in eleven days in a second relapse. It is well to recall the fact insisted upon by no less an authority than Janeway, 3 that the use of the coal-tar products in the course 1 Johns Hopkins Hospital Reports, L895, No. 5. 2 St. Bartholomew's Hospital Reports, L896. 5 Transactions of the Association of American Physicians, 1894. 76 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. •TC-JR 821 K •" ST < 831 01 R-V 01 1!:I 21 0F6 isi 21 OS'O rn.i 11 1"t 01- 1 01 •H'V J 281 8t #'9 ra 21 OS'9 081 21 Try g OCT 8S -rc-vt 0S1 88 OFS 881 88 OS'S 21:1 98 •K-vg 921 OS OS'BI n K 1 3 J 1 v r 81 Oil OS '""SI 1 \ i.: •Hd 6 l!:l ST I 82 82 •rc-dg •H-dg ? * 021 S2 ■n ST CJJ "3 ffi H IS a ^13 !=) £ B Sat of * 3 bC cp -G O £ t> # ac £ ~ -d ^ ja « "3 5 .5 e3 2 .22 >d £ ei -43 >-> 0) a t * j= IKS r£ G jg ° T3 a -§ 5 a WELL-DEVELOPED STAGE OE THE DISEASE. 77 •K T f, / > - ; 02 •H'TQ ^ / zo B1 ■K'C < n 0G Bl K K 51 / > flfi 81 •km r, < mi 02 •KMO s nil 1- ■"'•IE f r, -1 •K5I till ,-r •K-y r, no 11,- Tl« inn n- •K'T £ s? 001 or ■«;i \ mn -,- ■KM fi \ \ -l\ t' "KM 9 < on 1- •KM £ <* ') ' on 1,- •KJl < sot 82 •K-Y G zn 1- •KTtl -III h- *K'T g 32 06 ir ■'• ■'■ "I on tr •KM 6 S >^ ■^ JOT or •KMO * wii 0- •KM 8 mi 0,- •k ri tin " •K-r (j S -hi 11- •K-'O > tni 22 •K»c IS 811 1- •KK5I 001 f," •KM G K\ 81 ■km n 11 2? a r V 091 00 KMC "KM E 11 [ > "fll 1 n< 1 801 I- •K-I 801 n 011 1,- •H-TO :>n -- KY £ I'll "," '« K Z\ 07. -11 ,-:: •km r, on n •KM 9 :>ii 82 •KM £ - 1 1 28 •KZt t-i 1.- •KV r, n::l f" *K-v ,, 1 IP [! ■ ■11 n 081 !.- •K"T Q 1 1 [i i u u m xij CI Ii,-1 1: >K K ;t o-l r:; KM 6 or.] -:: •KM . : ci 01 WO or 1 0: 05'9 o::i 0: ■WM 9 4_ i["ir)j'i.i\- III 28 •KMC III'l. -11 rTTtr- ii"«o *r> -*»• m cn > — o o> oo r^-« 41 « 78 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. of enteric fever may have a chill-producing effect. It is well known that the external use of guaiacol will produce severe rigors. In other cases presenting such rigors there is present a true double infection of typhoid and malarial fever. (See further on.) There are a number of conditions which result in producing a marked and sudden fall of temperature during the periods of the fastigium 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 effect of powerful antipyretic drugs. Often great falls in temperature take place when the typhoid infection is associated with malarial infection, as already inti- mated. (See further on.) In the case of a complicating disease a few hours' delay 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 gastrointes- 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 expression and color of the tongue closely watched. If the patient is conscious and capable of giving expression to his sensa- tions he may complain of a sensation of faintness or of sinking, or if the hemorrhage is very profuse the patient may pass rapidly into a state of collapse or shock, owing to the extravasation of blood into the small and large bowel, dying almost simultaneously WELL-DEVELOPED STAGE OF THE DLSEASE. 79 with the gush of blood from the rectum. Thus I 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 half-clotted blood, which extended from the anus to the heels, at the same moment developing gasping respiration, profound syncope, and seeming to be in articulo mortis. So, too, I have seen actively employed hypodermoclysis result in the recovery of patients so greatly exsanguinated that death seemed inevitable. Sometimes, however, even profuse intestinal hemorrhage recur- ring again and again, fails to cause a very great fall in the tem- perature, or does not keep it low but 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 1 asserts that these symptoms have no effect 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. 2 (See circulatory changes in the well- developed and convalescing stages of the disease.) How far constant fever occurring day after day and associated with manifestations of general loss of strength and debility can be relied upon in the diagnosis of typhoid fever is hard to deter- mine. Certain it is that if a physician makes a diagnosis of enteric fever upon these symptoms alone, without bearing in mind the fact that similar conditions are equally well developed under other forms of infection, he will find himself in error in not a few instances. Chief among these may be mentioned tuberculosis of the lungs or peritoneum, that form of influenza in which the chief 1 St. Bartholomew's Hospital Reports, 1SH<>. 2 Revue de Medicine, 1887, p. 804. 80 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. symptoms are abdominal, cases of ulcerative endocarditis, septi- caemia and pyaemia, and those of cholecystitis with ulceration, as from impacted gallstones. It must not be forgotten, too, that syph- ilitic fever may in very susceptible persons resemble typhoid infec- tion. 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 syphilis pro- longed, low septic fever may be present. Finally, let it not be forgotten that trichiniasis 1 may resemble typhoid 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 leucocytosis (particularly in eosinophils), and its absence in typhoid fever, and puffiness of the bridge of the nose. 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 difficul- ties in differential diagnosis in cases of suspected gall-bladder dis- ease 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. Further 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 will be considered later on. Reference has already been made to the possibility of the febrile movement resembling that of malarial fever. In some cases this infection is truly present, but in others the temperature-chart is that of an irregular typhoid fever. These facts bring us face to face with a discussion of a subject 1 As the most recent paper on this subject, see Osier, American Journal of the Medical Sciences, March, 1899. WELL-DEVELOPED STAGE OF THE DISEASE. 81 about which great diversity of opinion exists, and has existed for years, namely, the question of that condition which has been called " typho-malarial fever." At the present time it may be asserted as a fact that a separate disease entity of this character does not exist, and this is done on the basis that recent discoveries in the natural history of these diseases, particularly the recognition of the malarial germ on the one hand and the use of the Widal test on the other has enabled us to make an absolute diagnosis in cases in which so positive a statement has heretofore been im- possible. There is no doubt whatever that pure typhoid infection may result in the production of a fever which closely follows the remittent and intermittent malarial types, and which is often associated with so much gastric disturbance and vomiting and so lacking in the more prominent typhoid symptoms usually seen that the picture of remittent malarial fever is clear, while the true picture of typhoid fever is clouded. (See also chapter on diseases which ape 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 diag- nosis is almost impossible, particularly if an epidemic of typhoid fever is in full swing at the time. 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 termination. To this mixed infection the term typho-malarial fever may be correctly 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 profound debility, the patient was in a typhoid state — that is, in a condition of which typhoid fever is a type. Practically, however, it should be discarded or limited in its use to the double infection just described. Johnston has well said, "As at the present employed the term typho-malarial fever has no determined meaning, leads to 6 82 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. confusion and misunderstanding, is a cover for uncertainty and, ignorance, and should be discouraged and abandoned." As already shown, there can be no doubt that mild grades of typhoid infection take place in which the only symptom of this disease is fever which runs a moderate course, and is accompanied by a certain degree of general debility. Often they begin rather abruptly, with a slight chill, or gradually the patient feels less and less well till he takes to his bed. These 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, and the diagnosis arrived at will depend largely upon whether the physician is practising in the North or the South, is treating many cases of enteric fever or many of remittent fever, unless he is skilful with his microscope, in which case the Widal reaction for typhoid fever in a majority of cases will at some time settle the diagnosis for him, or an autopsy will show typhoid lesions. Or, on the 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 with 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 WELL-DEVELOPED STAGE OF THE DISEASE. 83 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 anti-periodic treatment and the gradual appearance of typhoid symptoms excite suspicions of the incorrectness of the original diagnosis." (For a description of infectious processes complicating typhoid fever, see further on.) The Course of the Fever in Relation to Prognosis. It has 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 an 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 between the two being but slight, possesses an evil significance, while, on the other hand, marked differences between these points are considered of good omen. This is so because remissions indicate that the fever is not violent 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 ways 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 temperatures 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 105.8°, more than half died. Fiedler 1 found that when the temperature reached 106° more than half died, and Wuuderlich states that at 106.1° the danger is considerable, at 107° the deaths are almost twice as numerous as the recoveries, and at 107.2° and over recovery is rare. Concerning the influence 1 Deutsches Arch, fur klin. Medicin, Bd. i. p. 534. 84 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. of high morning temperatures, Fiedler says that practically all patients died whose morning fever rose to 106.2°, and that more than half died if their morning fever reached, if only once, 105.4°. In the Maidstone 1 epidemic only one death occurred in 81 cases, the temperature of which reached less than 104°, whereas nine deaths occurred in patients who had fever at some time above 104°, but a case is recorded of recovery after a temperature of 110°. 2 While acute hyperpyrexia is an evil omen in enteric fever, long-continued, moderately high fever is, perhaps, more harmful. In the Boylston Prize Essay of Harvard University for 1890 the writer 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 106° or 107° F. ; but in reality the figures have little to do, except in an indirect way, with what student or physician wishes to know. A temperature of 106° F. in a young healthy man suffering from an acute attack of some short-lived disease does not mean very great danger ; but a tem- perature of 103°, day after day in typhoid fever, does mean danger, and must be carefully attended to. In simple, continued fever 106° F. is a hyperpyrexia; in typhoid, or other low fever, 103° F. is a hyperpyrexia. The question is not one of actual de- grees Fahrenheit, 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 high 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, 1 Poole. Guy's Hospital Reports, 1898. Wrongly labelled on cover, 1896. 2 St. Thomas's Hospital Reports, 1895, p. 248. WELL-DEVELOPED STAGE OF THE DISEASE. 85 reference may be had to the following chart (Fig. 14), in which it is seen that as great a fall as 8° F. occurred. One is tempted to inquire how low it would have fallen had the routine method of plunging every patient sick with typhoid fever been instituted. Yet the patient was an unusually heavily built, stalwart lad of twenty years, well nourished, and in good condition for bathing. Further, he came under care by the third day of his illness. Respiratory System in the Developed Stage of the Disease. The respiratory functions of patients suffering from typhoid fever are not materially disturbed unless some complicating affection of the lungs or nearby organs develop. Beyond a slight quickening 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 this 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. 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 1 pre- sented in a recent 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 bleeding was violent, lasting half an hour, and several ounces of blood were lost. Cerebral 1 Medical Fortnightly, February 1, 1899. ofo 7 RS f" OS'O BO 0F ■K-V6 Be Yb •k-t i / 001 SB wo 4 - 1 80 SB 0S'9 « 001 OS ■K-y 9 t--- *01 OS •H-vg \ Ofi 93 •r-t I *6 fB Of 'SI V 06 rS OS 51 ^ ss f- •kkji 8 RS ob ■»■' (IX \ 06 0B 0*'6 L 06 0B OSG \ fR 0B ■it-.! r, l„~~~ -Z" \ SR rB ;K-a o --^ B6 fr •K-J» B6 f- Of'S B6 BB OS'S RR BB ■K-ag J"E 1 96 BB 'KSt --I 1 RR B? •k-t 6 '3 O 06 BB K-T C, 2E-- 98 n •KT g /l- 08 RI •K It SI 51 06 BB •Hi 01 K 00 0? 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KIT 08 •KM C( 001 f5 •KM* \ SR 05 WE ~* > ^ >in ^ 56 55 OS'S J -A — K -^ •KMS 001 i-p •KM I \ 06 f?. 0*'ol \ pi; 95 05 SI \ 56 95 •K EI JL_ on OP •K-v 6 \, 001 95 ■K-T9 i >s so fp •KTf, / s >- no f-p we SR 05 05'E 88 ii- •K-r R OT TOT t- •B-Y I "OT TP WZT t« I-" o-'-t _ — / IS I-p F. 105° 104° 103° 102° 101° 100° 99° 98° 97° Day of Dis. Pulse Resp. WELL DEVELOPED STAGE OF THE DISEASE. 89 symptoms were relieved, and the man made good progress after- ward. The second patient had profuse bleeding 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, which 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 the symptom excessive enough to require active interference, and still more rarely does it cause death. Thus out of 1420 cases seen by Liebermeister, epistaxis took place in 107 cases, but death occurred from this cause in only two, and this is probably a high percentage. Perichondritis of the larynx complicating typhoid fever, occurs in less than 1 per cent, of all fatal cases, and Trousseau has pointed out that it is most apt to occur when the patient suffers from pro- found exhaustion, particularly if his attack has been a prolonged one. Schultz, who analyzed 4094 cases of typhoid fever which occurred in Hamburg in 1886 and 1887, does not record any cases of perichondritis, and Jacob does not mention this compli- cation. That this accident may be due to the local action of the bacillus of Eberth seems to be vers- probable, and Luca- tello 1 believes that he has proof that it is the cause of the affec- tion. On the other hand, Dittrich 2 asserts that the process is due to the dorsal position of the patient, and is more directly the result of the pressure of the laryngeal cartilages, particularly the cricoid rings on the vertebral column. By this means their vitality is impaired and their invasion by pyogenic micro-organisms is rendered easy. Lemcke 3 records a case of this affection occur- ring in a Swede aged twenty-four years. A similar case has been reported by Tooth, 1 in which a boy of five years suffered from typhoid fever and developed on the eighteenth day of his illness 1 Beitrag ziir Pathogenese der Kehlkopaffectionen Beim Typhus. Berliner klin. Woch., 1894, vol. xxxi. p. 379. - Ilandbuch diir Spec. Path, und Ther., Bd. i. p. 311. 3 Chicago Medical Recorder for 1897, vol. ii. p. 114. 4 London Lancet, April 2, 1893. 90 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. laryngeal cough and aphonia. Tracheotomy was performed with- out relief. The cervical glands were enlarged and death finally occurred. At the autopsy the larynx and trachea were found lined with diphtheritic membrane. Whether this was due to the bacillus of Loeffler or to the bacillus of Eberth is not stated. Finally, Eppinger 1 believes that the ulcers which form in the larynx in typhoid fever are slightly analogous to the ulcers which form in the intestines, since he has discovered the bacillus of typhoid fever in these ulcers. In an inaugural thesis upon ulcerations of the larynx in typhoid fever, Grader 2 describes three types of this disease. In one of these there are specific ulcers occurring simultaneously with those in the bowel, although the bacteriological examinations failed to show the presence of the specific bacillus in these ulcers. Iu the second class there are simple catarrhal manifestations with a ten- dency to ulceration. Both of these classes involve the posterior wall of the larynx on the ary-epiglottic fold. The third class is that in which ulcers formed at the margin of the epiglottis. These usually occur singly. Laryngeal ulceration occurs in a fairly large proportion of the severe cases, and is usually due to secondary infiltration of the laryngeal mucous membrane, apart from true typhoid infection, arising from the general debility of the patient. Usually these ulcers form at the posterior part of the larynx, and often involve the insertion of the vocal bands. Under these circumstances they may cause hoarseness and aphonia, but often they exist if in mod- erate degree, with but little discomfort to the patient. Rarely a painful laryngeal cough develops, and if they extend to the epi- glottis they may cause pain in swallowing. Contrary to what might be supposed, they rarely lead to serious difficulty, nor do they materially affect the course of the disease. Very rarely they produce perichondritis of the larynx or oedema of the glottis. Hoffmann found laryngeal ulcers in twenty-eight cases out of 250 1 Ziegler. Path. Anatomie, Bd. ii. p. 626. 2 Centralblatt f. Bacter. und Parasit., February 17, 1891. WELL-DEVELOPED STAGE OF THE DISEASE. 91 typhoid autopsies, and from his studies it is evident that tins lesion may occur in the second week of the disease. Gricsinger found them in 26 per cent, of the cases that died, and that the lesion is more common in men than in women. These statistics show that in severe cases of typhoid fever resulting in death the laryngeal lesions are more commonly present than is generally thought, and illustrate the fact already pointed out that unless the ulceration is widespread and the ulcers involve the epiglottis and vocal bands, no marked symptoms of laryngeal trouble may present themselves. On the other hand, in 166 cases of typhoid fever Landgraf 1 found laryngeal complications to be rarely pres- ent ; in some instances they had apparently been present during the early stages of the disease, but had healed before death occurred. Only three cases of perichondritis and two cases of muscular paralysis were met with, the latter during convalescence. (For a discussion of laryngeal paralysis see the chapter on the stage of convalescence.) An interesting case of so-called laryngo-typhus has, however, been recorded by Lewy 2 as occurring in a child of one year ; death occurred on the eighth day, and the autopsy, in addition to revealing the intestinal lesions of typhoid fever, also showed fibrin- ous laryngitis and croupous pneumonia. A case of necrosis of the two arytenoid cartilages has also been reported as occurring in a man, aged eighteen years, by Souques. 3 When severe laryngeal disease asserts itself the condition of the patient is apt to become at least pitiable, and it may be alarming. The largest number of cases collected of this affection are those of Liming, 4 who, in 1884 collected 213, although Keen, in 1876, had collected 169 cases. Westcott, in collecting statistics for Keen's well-known monograph on the Sun/teal ( 'amplications of Typhoid Fever, collected thirty-eight others. Basing his views upon his statistics, and in particular upon fourteen original 1 Deutscher Medicmischer Wochenschrift, January 6, 1890. 2 Archiv fur Kinderheilkunde, Bd. lx., heft. 3, 1888. :i Bulletin de la Societe Anatomique. 1 Archiv fur klin. Chirurgie, 1884, vol. xxx. \>. 225. 92 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. cases, Liming gives the following graphic word-picture of the conditon : "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 painful. The picture now quickly alters. Soon, often within a few hours, come dyspnoea and suffocating attacks. Sometimes even during the very first 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 with 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- tive is only a finally fatal attack of suffocation, or a late palliative tracheotomy with all its uncertainties. ... If one will read the cases of death from suffocation without operation (52 cases, 49 deaths), he will find that, almost without exception, suffocation occurred early arid quickly, before either physician or patient had even thought of tracheotomy. " This is the picture in cases of perichondritis. If the patient is in the stage of typhoid stupor, when the ulceration is accompa- WELL-DEVELOPED STAGE OF THE DISEASE. 93 nied with acute suppuration and swelling which may lead to destruction of the cartilages, the initial symptoms of the threat- ening danger may escape us entirely in spite of careful observa- tion. ... In these cases the objective signs of laryngeal stenosis, on which we usually depend, are much less marked ; stridor, movements of the larynx, inspiratory depression, action of the auxiliary inspiratory muscles — in short, everything by which, in the healthy, we make the diagnosis of narrowing of the air-passages is, in the vita minima of the weakened patient, far less outspoken, and easily deceives us as to the degree of the danger of suffocation. The striking suffocative attacks, with arrest of respiration, so alarming even to the lay observer, are less noticeable, since the struggle of the patient with the mechan- ical obstruction quickly fails or is quickly abandoned. The con- dition passes into a death agony with oedema of the lungs, with- out the stenosis seeming to have reached a threatening degree. And thus one sees, often with astonishment, in the reports of the necropsies, how often the stenosis and destruction of the cartilages occur, as it were, ' without even any symptoms.' ' Liming' s statistics seem to show that severe laryngeal ulceration is far more frequent in Germany than in England or America, and in the latter country it must be very rare. Keen's essay points out that emphysema and suppuration of the mediastinum may follow perforative ulceration of the larynx, and Wilks 1 records the case of a patient of twelve years, who on the twelfth day of the disease developed general emphysema due to this cause. Denhanr records a similar case in a boy of ten years, and Chomel 3 another in a man of twenty years, from a perforation of the thyroid cartilage. One instance is recorded by Luning in which an abscess had destroyed the arytenoids and rendered the cricoid necrotic, so that the anterior mediastinum was filled with pus, and Retslay 4 records another in which a 1 Medical Times and Gazette, 1862, vol. ii. p. 276. 2 Holmes' System of Surgery, 2d, ed., vol. iv. p. 571. 15 These de Paris, 1877. 4 Retslay, Ueber Perichrondritis Laryngva Berlin, Dissert. 1870, No. 10. 94 COMPLICATIONS AND SEQUELJE OF TYPHOID FEVER. perichondral abscess about the thyroid cartilage caused secondary involvement of the anterior and posterior mediastinum. Keen's table shows that in 146 cases of severe laryngeal dis- ease 12 occurred under fifteen years, 87 between fifteen and twenty-five years, and 47 over twenty-five years. The marked exemption of children is evidently associated with the mild character of the disease in this class of patients. Lim- ing' s table of 165 cases showed 18 under fifteen years, 109 between fifteen and twenty-five years, and 28 between twenty-five and thirty years, and 10 between thirty and thirty-five years or over, giving results of a similar character. The far greater fre- quency of the malady in men than in women is interesting, for in the female the general disease is as severe as in males, as a rule, yet in Keen's table there were 119 males to 29 females, and in Liming' s table 129 males to 36 females. Keen tells us in regard to the date of onset that 7 cases occurred in the first week, 23 in the second, 30 in the third, and 82 in the fourth week to two months. Keen states that necrosis of the cartilages is by far the most common and also by far the most dangerous form of laryngeal affection, but adduces no evidence in support of its being the most common lesion. Opposed to this view we have that of Liebermeister, who tells us that "laryngeal ulcers do not in any way affect the ordinary course of the disease, and in favor- able cases heal without leaving any evil consequences." " Occa- sionally," he tells us, "they may lead to death by producing perichondritis laryngea or glottic oedema." This difference of opinion rests upon a difference in the severity of the lesions. Surgeons only meet with cases which are severe enough to demand operative relief, whereas physicians comparatively commonly see the milder forms. When necrosis of the cartilage does take place there can be no doubt that Keen's statement as to the danger being great is correct, for in this condition his statistics show that the mortality approximates 95 per cent. In 197 cases of laryngeal stenosis in enteric fever Keen records a mortality of 67 per cent., which if the cases are divided into those operated WELL-DEVELOPED STAGE OF THE DISEASE. 95 on by tracheotomy equals 55.5 per cent., and not operated on, 78.6 per cent. That operation is imperative as soon as suffoca- tive attacks are threatened, is evident. The bronchitis of advanced typhoid fever is a very constant symptom, so constant that it really forms part of the symptom- complex of the regular disease. It is only when it becomes severe and passes into a broncho-pneumonia that it possesses any consid- erable interest, for if at all well developed it becomes a grave menace to the patient's life. This lobular pneumonia depends upon four separate causes for its existence. First, the bronchial irritation characteristic of the disease ; second, the feeble respira- tory movements of the patient, and the dorsal decubitus whereby dependent portions of the lung collapse ; third, the feeble circu- lation which permits stasis in the pulmonary vessels ; and, finally, and very important, the inspiration into the lungs of particles of food or foreign bodies in the mouth or nose which are septic, or which decompose, and produce pneumonia in this manner. The physical signs of this form of the diesase are identical with those of ordinary lobular pneumonia, and the prognosis is bad in direct proportion to the feebleness of the heart and general system, the extent of the lesion, and the slowness with which the heart and general system responds to stimulation. Hoffmann tells us that this complication was found 38 times in 250 autopsies ; so it is evident that its influence in producing a fatal result is probablv not very great, as a rule. It is emphatically a symptom pertain- ing to feeble and debilitated patients, and most often comes on in the latter part of the second or third week. As is often the case lobular pneumonia may afford a favorable field for the growth of the bacillus tuberculosis, and, therefore, in those cases in which resolution does not take place, pulmonary phthisis not infre- quently follows this form of the disease. Mettcnheimer 1 saw thirteen cases of this character out of thirty-eight deaths from typhoid fever or its sequela?. 1 Beobacbtungen ueber die typhoiden Erkrankungen der franzosischen Konigs- gefangenen in Scbwerin, Berlin, 1879. 96 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. Very much more rarely acute miliary tuberculosis develops in typhoid fever, probably because the focus of some earlier and dormant tubercular infection breaks down and sets free tubercle bacilli in a system the vitality of which is depressed. Hoffmann found it four times in 250 typhoid fever autopsies. Hypostatic congestion of the lungs, a condition closely allied in causation and prognosis to lobular pneumonia, occurred in 100 out of 1420 cases recorded by Liebermeister, and pulmonary oedenia is the usual immediate cause of death in cases which die of failure of the cardiac muscle, as Hoffmann has proved. True croupous pneumonia occurring in the later stages of typhoid fever, either as a result of an infection with the micrococcus lan- ceolatus or by the bacillus of Eberth, is a very rare affection, much more rare than it is in the stage of onset as already pointed out. Hoffmann found it present only eighteen times in 250 typhoid autopsies. Again, in 1420 cases quoted by Liebermeister, 52 cases had " extensive consolidation " of the lung not dependent on hypostatic congestion. A " good many " of these, however, were probably cases of true lobular pneumonia and were not croupous. In this connection it is interesting to note that as long ago as 1839 Becquerel wrote an article on pneumonia complicating typhoid fever when making an analysis of eighteen cases in the service of Jadelot in 1837. Hemorrhagic infarction of the lungs arises in typhoid fever from several causes, and is usually met with in cases with greatly impaired circulation. It is due to emboli arising in the right side of the heart or, very rarely, to emboli arising from a phlebitis. (See circulation in convalscence.) It has been suggested that it may arise, when septic, from the intestinal ulcers, but no case of this kind has come to my notice. Sometimes it may arise from a bed-sore, a parotid abscess, or or from an abscess elsewhere. In many cases the presence of small infarctions is unsuspected, either because they cause little difficulty or because they are not differentiated from lobular pneumonia, the physical signs in each case being; nearlv identical. "When the infarction is large we have WELL-DEVELOPED STAGE OF THE DISEASE. 97 a rise of temperature, pain in the chest, currant- jelly Mood in the sputum and, if the embolus is septie and the patient survives signs of pulmonary abscess or gangrene. Sometimes the infarc- tion is due to thrombosis. The presence of a focus which can supply an embolus and of a feeble heart, increase the probability of the pulmonary difficulty being infarction, and an infarction severe enough to be recognized is of evil prognostic omen. Out of 250 typhoid autopsies Hoffmann found fifteen cases of hemor- rhagic pulmonary infarction. Haemoptysis complicating typhoid fever in a patient free from tuberculosis may occur. Creagh 1 has reported such an instance in a man of thirty-five years ; the accident resulted in death. Unfor- tunately, no autopsy was made in this case to prove that there was no local tubercular lesion ; but it is possible that such hemor- rhages may occur without tuberculosis. Primary pleurisy complicating typhoid fever is very rare. Nearly always it is secondary to infarction, pneumonia, or gan- grene. Rarely it may be due to direct typhoid infection, and when this is the case the effusion is usually purulent. As early as 1885 Rendu and de Gennes, 2 and in 1887 A. Fraenkel 3 obtained the bacillus of Eberth from the pus of an empyema. In Keen's essay Westcott has collected nine instances of typhoid pleural effusion, in five of which this specific organism was found. As a rule, this state comes on as a late symptom, not earlier than the third week, or sometimes not until two months after the fever. Further, in support of the statement as to the secondary char- acter of pleurisy, out of these nine cases it succeeded pneumo- thorax once,' pulmonary abscess once, 5 gangrene of the lung once, G and suppurative mediastinitis once. 7 1 London Lancet, November 30, 1895. 2 La France Med., 1885, vol. ii. p. 1821. 3 Verhandlungen Sechste Kongress fur Inner. Med., 1887, p. 179. * Rendu. La France Mddicale, 1885, vol. ii. p. 1809. 5 Ramsey. Annals of Surgery, .January, 1890, p. 39. 6 Griesinger. Infectionskrankheiten, 7 Barr. Liverpool Medico-Chirurgical Journal, L893, vol. xiii. p. 346. 98 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. The prognosis is apparently very good, as six of these nine cases recovered after aspiration or drainage, including that with pus in the mediastinum. Empyema due to the streptococcus, occurring in the course of typhoid fever, is also reported by Hanquet. 1 A case of empyema complicating relapse in typhoid fever, in the pus of which typhoid bacilli were found in large numbers, has been recorded by Valentine. 2 A case of gangrene of the lung in a boy of eight years, occur- ring as a sequel to typoid fever has been recorded by Acker. 3 Death occurred. Circulation in the Developed Stage of the Disease. The development of fever in enteric infection is accompanied by an acceleration of the pulse-rate, as it is in all maladies. With the onset of the disease the heart, not yet weakened by illness, may not only greatly quicken its beat, but also cause the pulse to be more strong than normal. As the disease progresses, how- ever, the pulse becomes weaker and weaker in severe cases, and the heart-sounds more and more feeble till they may be inaudible even with the most careful auscultation. With the ordinary quickening of the pulse and its common alterations we have little to do at this point. The points that interest us are the unusual variations, which consist chiefly in dicrotism, tachy- cardia, bradycardia, and intermittence, relaxation of the vascu- lar pathways on the one hand, and aberrant action of the heart as to force and sounds on the other. Dicrotism may be present for days at a time in feeble cases, and is an unfavorable sign of not great gravity unless associated with other grave symptoms. Ordinarily pulse-rates varying between 80 to 120 can be regarded by the physician with equanimity, although much depends upon the character of the pulse, and. still more upon the quality of the heart-sounds, which should always be studied in connection with the pulse. With each ten additional beats the gravity of the 1 Archives Medicale Beiges, June, 1892. 2 Berliner klin. Wochenschrift, 1889, No. 15. 3 Archives of Pediatrics, September, 1896. WELL-DEVELOPED STAGE OF THE DISEASE. 99 condition greatly increases, and if a pulse rises to 140 or 150 per minute without some momentary exciting cause, and remains so rapid, the condition is indicative of doubtful recovery. If at the same time there is coldness of the extremities, independent of contact with ice-bags or other extraneous causes, dissolution may be imminent. Much depends, however, upon the quality of the pulse- wave. If it is full and possesses an approximately normal tension, the danger is less grave than if it is gaseous and relaxed and easily extinguished. Sometimes auscultation of the heart will show that it is acting strongly yet pumping futilely in an attempt to fill relaxed and dilated vessels. It has been asserted by some clinicians that much prognostic information can be gained from the heart-sounds in typhoid fever. Thus Landouzy, Picot, Huchard, and others have formulated this conclusion, namely, that the disappearance of the first sound of the heart at the apex or at the base in the course of typhoid fever constitutes an evil sign if the pulse goes as high as 110, and that if the sound be absent and the pulse-rate increases in excess of this number per minute, the prognosis is fatal. Of course, any condition of profound depression in the heart or general strength which can extinguish the first sound is more or less grave, but the association of this disappearance with high pulse-rate they consider a very evil omen. Mongour 1 has recently written a con- firmatory paper on this theme. In still other instances the heart-sounds are like those of a foetus, the loug pause being absent. This is called " embryocar- dia," and indicates distinct cardiac feebleness. These circulatory changes have been chief! v discussed bv French clinicians. Bernheim 2 has described a variety of typhoid fever that lie calls "forme eardiaque," the chief signs of which are a eonditioD of asystole and cardiac feeblenees. Demange 3 has also written on this topic, and Potain is quoted by Homolle in his 1 La Presse Medieule, April 21, 1897. - Association pour 1' A vancement des Sciences ; Conures de hi Rochelle, 1 V ^'J. ■ Revue de Me'decin, 1885, p. 1025. 100 COMPLICATIONS AND SEQUELJE OF TYPHOID FEVER. article on typhoid fever, in Jaeeoud's Dictionnaire, as having found a constant decrease of arterial pressure by means of the sphygmomanometer of Basch. This reduction of pressure is an almost constant symptom, as every one knows who has studied the pulse of patients suffering with this disease. In other cases, which are rare, comparatively speaking, the pulse-rate remains at or below the normal all through the attack. This is without any particular import, and was thought by the older writers, such as Hufeland, Sauvages, and Berndt, to be quite pathognomonic of this disease. Liebermeister states that a good pulse in typhoid fever rarely rises above 110. If the circulation distinctly fails, congestion of the veins may develope, but the surface of the body instead of becoming cyanotic or congested in appearance, often becomes pallid and relaxed, a profuse sweat often being present, even though the temperature may be as high as 104°. Over and above these gradual signs of circulatory failure, sud- den collapse from hemorrhage or perforation may develop. (See article on alimentary canal.) A sudden diarrhoea or an attack of vomiting may, however, cause a syncopal attack, and a sud- den fall of high temperature due to some complicating state may also do so. Liebermeister, though an ardent advocate of the cold bath, says : " Sometimes a condition resembling collapse is seen to follow a cold bath." So far as prognosis is concerned, care should be taken to separate the collapse of defervescence from that due to grave cardiac degeneration. (For circulatory acci- dents see chapter on the circulatory system in the stage of con- valescence.) Acute endocarditis complicating typhoid fever has been reported by Carbone. 1 The patient was a young women avIio had the classi- cal symptoms and lesions of typhoid fever, and from whose endo- cardium typhoid bacilli were obtained. These bacilli were injected intravenously in various animals, producing the same lesion. ConnelP has also recorded a case of infectious endocarditis in 1 Gazette Medica di Torino, No. 23, 1892. 2 Montreal Medical Journal, August, 1896. WELL-DEVELOPED STAGE OF THE DISEASE. 101 typhoid fever, due to the staphylococcus and involving the mitral and tricuspid valves. In connection with this subject, it may be proper to call atten- tion to the profound exhaustion and depression, chiefly manifested at the close of severe typhoid fever, having a tendency to cause death from asthenia. This state was far more frequently met with some years ago, when the infection seemed more virulent than it does to-day, and when the treatment was not so well understood. The condition of the patient has been described by Huxham in his Essay on Fevers, 17 •">(), p. 78, in the following words : " Now Nature sinks apace, the extremities grow cold, the nails pale and livid, the pulse may be said to tremble and flutter rather than to beat, the vibrations being so exceedingly weak and quick that they can scarce be distinguished, though sometimes they creep on surpisingly slow, and very frequently intermit. The sick become quite insensible and stupid, scarce affected with the loud- est noise or the strongest light, though at the beginning strangely susceptive of the impressions of either. The delirium now ends in a profound coma, and that soon in eternal sleep. The stools, urine, and tears run off involuntarily, and announce a speedy dis- solution, as the vast tremblings and twitchings of the nerves and tendons are preludes to a general convulsion, which at once snaps off the thread of life. In one or other of these ways are the sick carried off, after having languished on for fourteen, eighteen, or twenty days, nay, sometimes for much longer." 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 diarrhoea be present, in which case there may be concentration < >f the blood- cells. In the third week the red cells begin to decrease, and may get as low as in eases of pernicious anamiia. The lowest point is reached about the end of the first week of convalescence, when they gradually begin to increase. The haemoglobin follows the red cells, as might be expected, and the degree of the anaemia is in direct proportion to the severity of the ease in most instances. The most noteworthy fact about the blood in this fever is that, 102 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. as rule,. there is no constant increase in the leucocytes unless some intercurrent inflammation is set up. Cabot asserts, however, that sometimes leucocytosis does occur without any complication that can be found. On the other hand, in patients profoundly asthenic from this disease complications may not cause leucocytosis. As an illustration of the manner in which these accidents may produce blood changes, the following table of Cabot is of interest : Perforation. Phlebitis. Otitis media. Leucocytes Case I (a). Five days before perforation 8,300 (6). At time of perforation . 24,000 Case II. At time of perforation 18,500 Case I (a). 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 Case I (a). At entrance . 5,300 (b). Mastoid abscess 16,400 Case II (a). At entrance . 8,400 (6). Two weeks later, after opening drur a membrane (sero-purulent disc large ) 11,200 Caselll (a). At entrance . . 7,320 (b). Otitis . 14,000 A freely discharging otitis soon ceases to cause leucocytosis — e. g., a case of serous otitis media seven days after puncture, but still dis- charging freely, showed but 5320 white cells per cubic millimetre. An abscess of the buttock raised the count from 8000 to 11,200, and a hemorrhage from 8000 to 11,300. As with all inflammations, it is the increase in the polymorpho- nuclear cells which is chiefly indicative. The real value of discovering alterations in the blood in typhoid fever is very great for diagnostic purposes. Increased leucocytosis will give us reason to believe that there is present, and make us search for, some complicating inflammatory focus, such as pneu- monia, perforation, cholecystitis, phlebitis, or abscess in any part of the body, as in the liver. Further, it niay render a case of suspected typhoid fever clearly one of appendicitis or some other inflammatory affection. WELL-DEVELOPED STAGE OF THE DISEASE. 103 The study of leucocytosis 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 leucocytosis may be present. 1 The blood in typhoid fever should not be examined after a bath, as this may cause a temporary leucocytosis in the peripheral vessels. The bacillus of Eberth is very rarely found in the blood, but a recent case of interest lias been reported by De Grandmaison and Cartier. 2 They report the case of a woman who was admitted to the hospital suffering from the results of an abortion, who pre- sented typical typhoid symptoms, and whose blood gave the posi- tive Widal reaction, and from whose blood they obtained pure cultures of the bacillus of Eberth. The Spleen. The changes produced in the spleen are usually developed during the fourth week of the disease. Hoffmann found nine cases of infarction of this organ in 250 autopsies, and seven of these died in the fourth week. Griesinger believed infarction of the spleen to be found in 7 per cent, of fatal cases, and Liebermeister believed these lesions to be responsible for the production of peri- tonitis 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 which after death from general peritonitis the spleen, which was three times its natural size, was found trans- formed into a huge abscess, making seven-eighths of its bulk. Xo perforation of the abscess wall had occurred. Under the name spleno-typhoid, Eiselt 3 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. 1 Valuable studies of these questions are those of Cabot, from whose l.mok on the blood I have quoted, and those of Thayer, Johns Hopkins Hospital Reports, vol. iv. p. 83. Also Ouskow and Aporti and Radaeli, Eleventh Congress for Medical Science, Rome, March, IS',14. 2 La Presse Medicale, February 1, 1899. 3 La Semaine Mgdicale, August 27, 1891. 104 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. 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 third 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 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. 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 such an occurrence is very uncommon, and the development of a nephritis in the later stages of the disease is almost as rare. In such a case the presence of albumin, casts, blood-cells, and, per- haps, pure blood may make a diagonsis easy. Curiously 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 which there is marked hserna- turia, the autopsy fails to reveal marked renal change, or instead of nephritis an infarction. Such cases have been reported by Hom- burger and by Duckworth, by Sorel, and by other writers. In cases in which there are tube casts and other signs of acute diffuse nephritis, the prognosis may be grave. Osier reports two cases which died. Amat had ten deaths in twelve cases, while Wagner had five consecutive recoveries. Hemorrhagic nephritis has been recorded by Stevens 1 in associ- ation with ursemic symptoms. Relief came by a profuse hemor- rhage from the bowels, and recovery occurred. A very excellent paper on the important subject of albuminuria in typhoid fever has been published by Hewetson, in which he 1 University Medical Magazine, May, 1896. WELL-DEVELOPED STAGE OF THE DISEASE. 105 has exhausted the literature. He quotes Guiniet as having met with albuminuria in children 21 times in 45 cases, and Mason as having met with it in 60 out of 676 cases, of which 45 recovered and 15 died. At the Johns Hopkins Hospital Hewetson found it in 164 out of 229 cases, but tube casts were found in only 103 of these. He also found that the period in which albumin ap- peared in the urine, so far as he could tell, was in the first week in 6(5 per cent, of the cases ; in the second week in 75 per cent. ; in the third week in 41.6 per cent. ; while in the fourth week it occurred in 35 per cent. A very interesting thing in this connec- tion is the fact that in none of these cases were there any objective signs of renal disease, any uraemia, or oedema. Hanford 1 has also shown that albuminuria may occur in typhoid fever without possessing any grave prognostic import, but the quantity of the albumin is in direct ratio, as a rule, to the gravity of the case. Among patients with large amounts of albumin the mortality is usually very high. Albuminuria occurred in 31 per cent, of 190 cases in Nurem- berg, according to Zinn, 2 and epithelium and hyaline casts in 21 per cent. The urine in typhoid fever is nearly always decreased in amount in the acute stage, and is usually darker in hue than normal, con- taining a high percentage of solids. Small amounts of albumin may be in it without indicating nephritis, but if casts are present much albumin is usually found, and the diagnosis of nephritis is justified. About 20 per cent, of all cases of this fever show albuminuria at times, but even if mild nephritis develops the prognosis is not, as a rule, grave. Thus in the Johns Hopkins Hospital albuminuria occurred in 164 out of 229 eases, and tube casts in 103; altogether 21 out of these 229 eases had definite nephritis, and 10 had red cells in the urine ; 2 suffered from hemorrhagic nephritis, but only 5 of these cases died, and nunc of them from the renal difficulty. 1 London Lancet, April 28, 1889. 2 Munchener Medicinische Wochenschrift, February 14, 1899. 106 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER. Rostoski 1 found albumin present in the urine 205 times in 346 cases, or in 59.2 per cent. In 37 of these 205 cases the albumi- nuria was marked and hyaline and epithelial casts were found, proving the presence of an infectious nephritis. Rostoski 2 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 disease. A woman, aged twenty-six years, was admitted with urine con- taining blood and albumin, and subsequently epithelial casts. About three weeks 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. A little later an impaired percussion note was made out over the ileo-csecal region, due, as it was thought, to a localized serous peri- tonitis. The patient gradually improved, and subsequently made a good recovery. The case was very obscure at first. The pres- ence of an acute nephritis was only recognized thirteen days after the onset of the disease. The diagnosis from tuberculosis, malig- nant endocarditis, and sepsis was very difficult. It was only when Widal's reaction was found in the fourth week of the disease that the nature of the case became obvious. The temperature was not characteristic, but the spleen was enlarged. The signs of perito- nitis appeared about the fiftieth day, shortly after the administra- tion of a clyster ; previously there had been no intestinal symp- toms. The patient also recovered from this complication. Rostoski 1 Miinchener Medicinische Wochenschrift, February 14, 1899. This is the most recent paper on this topic, and contains references to the literature of the subject. The title of the paper "Zur Kenntniss die Typhus Eenalis," refers to nephritis complicating typhoid fever, and not that of the form of onset called "nephro- typhus." 2 These cases are also to be found in an abstract in the British Medical Journal of April, 1899. WELL-JDEVELOPED STAGE OF THE DISEASE. 107 expresses the opinion that in every case of nephritis which might be classed as idiopathic, but which has a high temperature, the urine should be examined for typhoid bacilli, and the blood tested for Widal's reaction. In 147 cases admitted to the German Hospital of Philadelphia 1 in 1898 from the United States Army, albuminuria was present in 57.1 per cent., and true nephritis in 25.2 per cent. Late in the disease or in convalescence a transient nephritis may develop, associated with pretibial oedema. Aside from diffuse nephritis due to enteric fever we find that the kidneys may be the seat of suppurative processes, developing, as a rule, in the form of multiple or miliary abscesses. These abscesses are due usually to infection of the organ by the ordinary pyogenic cocci and rarely to infection by the bacillus of Eberth. The latter condition has, however, been recorded by Flexner, who has studied two cases of focal abscesses in the kidney, and found by careful differentiation that this bacillus was the sole cause of the lesion. The urine in these cases was albuminous and contained blood-cells, and at times casts covered with leucocytes. There are few clinical symptoms which can be used to diagnosticate such lesions other than those shown by the urine. Pyuria arises in typhoid fever either from the kidneys (very rarely) or from the bladder. It varies in severity from the pres- ence of a few pus cells, which are found with difficulty by the microscope, to marked pyuria with quantities of pus. The best study of this subject is probably that of Blumer. 2 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 day ; in 3 between the twenty-second and twenty-eighth day, 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 1 Philadelphia Medical Journal, February 25, 1899. 2 Johns Hopkins Hospital Reports, 1895, vol. v. 108 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. 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 dif- ferentiation between the colon bacillus and that of the typhoid was not properly carried out. No case of pyelitis due to the bacillus of Eberth alone has as yet been reported, which is interesting in view of the well-known fact that this bacillus has frequently been found in the kidney after death, and is always found in the renal lyniphoniata of this disease. Konjajeff 1 asserts that the discovery of this bacillus in the urine indicates the development of these formations 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 has recently shown 2 that typhoid bacilli were pres- ent in the urine of nine out of twenty -eight case&of typhoid fever ; that they were always in large numbers and in practically pure cultures, and that they appear in the later stages of the disease and persist in most cases far into convalescence. Their presence is nearly always associated with albuminuria and casts. In a still later report Richardson 3 reports sixty-six further cases, of which fourteen showed the presence of bacilli in the urine. Petruschky 4 has estimated that in one case a single cubic centi- metre of urine contained 170,000,000 typhoid bacilli. Horton Smith 3 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. 1 Central blatt fur Bakteriologie, 1889. 2 Journal of Experimental Medicine, 1898, vol. iii. 3 Journal of Experimental Medicine, 1899, vol. iv. 4 Centralblatt fur Bakteriologie, 1898, xxiii. 5 Transactions of Medical aud Surgical Society, London, 1897. WELL-DEVELOPED STAGE OF THE DISEASE. 109 Petruschky 1 lias 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, we find that pyuria in typhoid fever is not a grave sign, hut that if the specific bacillus is found in the uriue the patient must he kept under observation till it disappears, since it may lead to serious mischief. Pyonephrosis has been recorded by Kernel. 2 The patient, who had previous to typhoid fever suffered from intermittent hydrone- phrosis, developed a fluctuating abdominal tumor, which proved to be a pyonephrosis containing a pure culture of the bacillus of Eberth. A case of typhoid cystitis has been recorded by Houston. 4 A woman, aged thirty-five years, had suffered from cystitis for a long period of time ; the urine was strongly acid, turbid, contained a small quantity of albumin as well as squamous epithelium, leu- cocytes, and some bacteria. A bacillus with all the character- istics of that of typhoid was cultivated, and her blood gave a marked typhoid reaction of 1.01. A second examination of her urine produced similar results ; although the patient was kept in the hospital 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. Profuse urinary flow is sometimes seen in the latter 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. Hutchinson 3 has reported a case of diabetes mellitus following typhoid 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 1 Centralblatt fur Bakk'riologie, 1892, xiv. 2 Gazette des Hopitaux, 1897, No. 10. 3 Transactions of Association of American Physicians, 1888, vol. iii. 4 British Medical Journal, January 14, 1S98. 110 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER 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. As a rule, the lesions consist 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 pharyngitis coming on in the third week may cause death, and Taupin 1 records a case in which it asserted itself in a case of typhoid fever complicated with measles. Gerloczy, 2 a physician of Budapest, has recorded a case of a girl of fourteen years, who 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. Xot 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. Louis and Jenner have seen cases of typhoid ulceration of the oesophagus, and that Roderer and "Wagner have seen oeso- phagitis, as have also Eichhorst and Reimer, and again, Chauffer and Cornil have described a condition of infiltration of the mucous membrane of the oesophagus ^vith a formation of miliary abscess. These changes will be found discussed in the chapter dealing with the stage of convalescence. 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 functions become perverted. On the other hand, when gastric symptoms arise, either as the result of the causes just named, or 1 Journal des Connaissances Med. Chirurgicale, 1839. 2 Deutsche med. Wochenschrift, April 14, 1893. WELL-BE VEL OPED ST A GE OF THE DISEASE. 1 1 1 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 insufficient 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 which 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 lias 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 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 immi- nent because of direct exhaustion. Such cases are not common, but when they occur the -prognosis must be very grave. Some- times it would seem as if the 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 stomach. 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 Penwick 1 has recorded a case in wliich 1 Disorders of Digestion in Infancy and Childhood, 1897, p. 380. 112 COMPLICATIONS AND SEQUELjE OF TYPHOID FEVER. typhoid ulcers nearly perforated, and another in which they did perforate but general peritonitis was prevented by the liver becom- ing adherent to the wall of the stomach. Death occurred in this case from profuse hemorrhage from one of these ulcers. I have only met with one case in which hseruateroesis took place. A woman of twenty-eight years, who was seized with a very severe attack of the disease died at the end of the first week immedi- ately after vomiting a large amount of blood and passing a great Fig. 15. Drawing of the pyloric end of the stomach in a case of enteric fever, a, acute perforating ulcers with clean bases ; b, an ulcer with adherent slough. ( W. Sol- tau Fexyvick. ) quantity by the bowel. Ko autopsy was held, and in all proba- bility the blood had entered the stomach from the small bowel. The following cases are those of Fen wick's : " Fig. 15 represents a drawing of a stomach taken from a girl, eight years of age, who succumbed during the third week of enteric fever. Four well-defined ulcers were found in the pyloric WELL-DEVELOPED STAGE OF THE DISEASE. 113 region, one of which presented a loosely adherent slough. The edges of the ulcers were sharply defined and somewhat under- mined, while their bases were situated in the submucous and muscular coats of the organ. On microscopic examination the lymphoid tissue of the stomach was found to be enormously in- creased, 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 cer- tain circumstances disease of the solitary gastric glands may give rise to a form of perforating ulcer of the stomach which closely resembles the idiopathic type of the disease. "A girl, thirteen years old, was admitted into the hospital with the symptoms of typhoid fever of eight days' duration. Vomit- ing occurred once or twice, but there was no complaint of epigas- tric pain. At the end of the fourth week of the disease, when the temperature had begun to decline, the patient was suddenly seized with severe hsematemesis, after which she became uncon- scious and died. At the necropsy the anterior wall of the stomach was found to be adherent to the under surface of the liver. Scat- tered over the inner surface of the stomach there were numerous sharply defined ulcers, the largest of which was about the size of a florin. The edges were thin 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 rid- dled 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 lie brought up a dark greenish-brown fluid containing red blood-corpuscles in a condition of disintegration, and a clot of blood about 3 by 2 em. in diameter. On the 2i>th, 30th, and :51st the stools were very dark in color, 114 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. and evidently contained blood, and several times he vomited very dark material. He became very ansemic, but made a good recovery. "Alberta C, colored, aged twenty years, admitted June 14, 1894. 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. Throughout the following day she was extremely feeble ; temperature was normal ; patient was delirious. On June 16th there was no further bleeding from the bowels. Toward even- ing the patient was delirious, and her condition was very bad. At 8.15 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 evening. "Dr. H., aged twenty-two years, admitted January 9, 1896. He had a very severe attack, with persistent fever, which re- sisted the baths. These, though given from the outset, did not check the onset of quite active delirium. On January 25th, 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 afternoon he quite suddenly sprang up in bed and vomited a quantity of dark blood. The amount was difficult to estimate, as it went all over the bed linen. 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 1 records a case of a soldier, aged twenty-two years, who 1 Wiener Med. Presse, 1888. WELL-DEVELOPED STAGE OF THE DISEASE. 115 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 post- mortem confirmed the diagnosis, the case is to be considered as a doubtful one. One of the first facts which attracts our attention in regard to the intestine during typhoid fever is that many cases of this disease are recorded in which at the autopsy no signs of typhoid fever could be found in the intestines. Some of these have not been as carefully studied as they should be, but others are certainly authentic. Thus Du Cazal 1 has recorded two instances in which the closest inspection failed to show intestinal lesions, yet typhoid bacilli, which responded to all tests, were found in the spleen, and the symptoms of the disease were present in life. The spleen, mesenteric glands, and kidneys were swollen and con- gested. Bacilli of typhoid fever were obtained not only from an abscess in the spleen, but also from vegetations in the mitral valves and from a hemorrhagic plaque on the surface of the brain. Banti 2 and Karlinski 3 have reported similar cases not so well proven. Karlinski's cases numbered three. Nichols and Keenan 1 have reported nine cases of typhoid fever without intestinal lesions. So, too, Flexner and Harris 5 have recorded such a case, and Chiari and Kraus met with seven out of nineteen cases in five months. Goodall" reports two cases of enteric fever, fatal during the third and fifth week respectively, in which there was no intestinal ulceration. The first patient was a boy of thirteen years, who had been ill a fortnight when admitted to the hospital ; the second was a man of thirty years, who had already been ill ten days. Both of them showed all the clinical evidences of typhoid fever, 1 Bulletin et Soc. Mem. Med. des Hop., 1893, p. 248, and Le Bulletin M.'di- cal, April 16, 1894. 2 Archiv. Italiennes de Biol., December, 1887. 3 Wiener Med. Wochenschrift, 1891, pp. 470and5U, and 1&97, vol. ii. p. 1850. * Montreal Medical Journal, 1898, xxvii. p. 9. 5 Johns Hopkins Hospital Bulletin 1S97, viii. p. 2">9. 6 Clinical Society's Transactions, vol. xx.w, 1897. 116 COMPLICATIONS AND SEQUELM OF TYPHOID FEVER. and in each there was a swelling of Peyer's patches without ulcer- ation. Similarly Fagge 1 records the case of a man of thirty-three years, who had typhoid fever, and whose only lesion in the intes- tine 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, Moore showed before the Pathological Society of Dublin a case of enteric fever in which there was no disease of the glands of the ileum, while the spleen was extremely large, soft, and friable, and Peyer's patches were noted appearing less distinct than usual, though with no hypersemia, and did not present the shaven- beard appearance. Sydney Phillips has reported to the Clin- ical Society, 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 complication, on the thirty-second and seventy -third days. Other cases have been recorded by Beatty, 2 Church, and Coup- land. Again, Hodenpyle, 3 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 4 has also recorded a case of this kind, and Hoeffel 5 has done likewise, there being in his case but slight swelling and reddening of a few Peyer's patches. Schultz claimed to have met with twenty-one 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. 1 Pathological Society's Transactions for 1876. 2 British Medical Journal, June 16, 1897, p. 148. 3 British Medical Journal, December 25, 1897. i "Is the Lesion of Peyer's Patches a Constant Symptom of Typhoid Fever?" Strasburg Thesis for 1870. 5 Gazette Medical e de Strassburg, 1871, No. 14, p. 167. WELL-DEVELOPED STAGE OF THE DISEASE. 117 Since the above remarks ami quotations were put in type a paper upon this subject has been published by J. H. Bryant. 1 In it he reports the case of a child of twenty-one months, who died of typhoid fever at the end of the third week, and whose blood before death gave the 1 Widal test. The autopsy showed that the heart weighed one and one-half ounces, and appeared to be nor- mal. The arteries, mouth, pharynx, (esophagus, and stomach were normal in appearance. The ileum also appeared to be normal. There was no ulceration, and the Peyer'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 was normal. The liver weighed sixteen ounces, and had a normal appearance. The gall-bladder and pancreas were normal. The mesenteric glands were much enlarged, and felt very soft ; on sec- tion they presented a pinkish-gray color, and appeared to be in a condition of acute inflammation ; there was no sign of suppuration or caseation in any of them. The suprarenal capsules were nor- mal. The kidneys weighed three ounces ; they were pale. The spleen w T as a little enlarged. That the case was one of true typhoid fever is proved by the results of careful bacteriological 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 broncho-pneumonia 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 1 British Medical Journal, April 1, 1899. 118 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. 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 forty-eight hours, and then it was only 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 from a typhoid patient, and also from an immunized rabbit, clumped together in a manner characteristic of the bacillus typhi abdominalis." Byrant also quotes the following cases not mentioned in my text before I read his article : Time, 1 in 1889, described a case in which during life the fever was of a recurrent type, and the spleen was found to be consider- ably enlarged. At the necropsy slight swelling only of Peyer's patches was found. The bacillus typhi abdominalis is stated to have been obtained from the spleen and kidneys, but is not suffi- ciently identified as such. Vaillard, 2 in 1890, reported the case of a young soldier who died after an illness of three days' duration. The chief symp- toms 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 1 Jahresbericht iiber die Fortschritte ( Baumgarten ) 1889, 196. 2 La Semaine Medicale, March, 1890, p. 94. WELL-DEVELOPED STAGE OF THE DISEASE. 119 bacillus typhi abdominalis was obtained by culture from the spleen, lungs, and spinal cord ; streptococci were also obtained from the spleen and meninges. Guarnieri, 1 in 1S!)2, 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. Vincent, 2 in 1893 described the case of a man, aged thirty-five years, who died about the twelfth day after the onset of a severe illness 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 grammes ; the mesenteric glands were not enlarged ; bilateral pulmonary congestion was found. The bacil- lus typhi abdominalis and streptococci were obtained from the spleen, liver, kidneys, and heart. Osier mentions a case. The patient was a man, aged sixty years, who was admitted into the hospital under his care. He had been ill for about two months, and on admission was found to be suffering from shortness of breath, and presented signs of pneu- monia affecting the lower lobe of the right lung. Death took place twenty -four hours after admission. A diagnosis of senile pneumonia was made during life. At the necropsy the lower lobe of the right lung showed fresh pneumonia passing on to a condi- tion of gangrene. There was no intestinal lesion. The organs were submitted to a bacteriological examination by Flexner, and pure cultures of the bacillus typhi abdominalis were obtained from the lungs and spleen. Mettenheimer 3 records an epidemic of typhoid fever occurring in the army in which in twenty-one cases the intestinal lesions 1 Rivista Genorale Italiana di Clinica Medica, 1897; Baumgarten's Jahres- bericht, 1897, 234. - Annates de l'lnstitut Pasteur, February, 1893. 3 Jabresberichte iiber die Gesammte Med., 1872, Bd. 2, p. 236. 120 COMPLICATIONS AND SEQUEL M OF TYPHOID FEVER. were entirely limited to the colon. Banti 1 and Karlinski 2 have also reported cases of this character. A case is recorded in Cheadle's 3 service at St. Mary's Hospital of a child of three years who died of typhoid fever, and at the necropsy no ulceration was present in the intestine and Peyer's patches appeared to be normal. Beatty 4 records two cases with a similar condition present. Diarrhoea 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 works 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 typhoid fever of children, 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 diag- nosis of typhoid fever. On the contrary, it is so often absent that its absence is of no negative value whatever, although 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, diarrhcea 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 CurschmannV 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. Mary's Hospital, London, diarrhoea occurred in 115, constipation in 48, but in many of these cases diarrhcea 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. 1 La Riforma Medica, 1887, p. 1448. 2 Wiener Med. Wochen., 1891, pp. 470 and 511. 3 The Lancet, July 31, 1897, p. 254. 4 British Medical Journal, January 16, 1897. 3 Deutsche Archiv. f. klin. Medicin, 1895. WELL-DEVELOPED STAGE OF THE DISEASE. 121 In the Maidstone 1 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 re- ferred to by Dreschfeld in Allbutt's System of Medicine, the discol- oration being seen during convalescence. Quill 2 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 was great pain in the back. Garrod, Drysdale, and Kanthack 3 report three cases. The stools resembled chopped parsley, and the liquid portion of the stools when filtered off contained bili- verdin, which was probably responsible for the discoloration of the excreta. The next point to be considered in this connection is whether diarrhoea is a sign of mild or severe infection. The consensus of opinion seems to be that diarrhoea is usually more active in serious cases. Whether this is an instance of " purging as an effort at elimination," a favorite theory with those who are fond of using purgatives and so-called intestinal antiseptics, with the idea that by so doing they eliminate poisons and prevent their formation, or whether it is a manifestation of severe ulceration of the bowel with an associated catarrh, is difficult to determine. Ord 4 agrees with the view that diarrhoea is usuallv associated with ulceration, and his opinion has been confirmed by the autopsies he has seen. Peabody states the case exactly opposite to this view. That Ord's view is not correct seems proved by the fact that advanced ulceration is often found in cases which have not had diarrhoea and cases of marked diarrhoea are seen in which the 1 Poole. Guy's Hospital Reports, 1898. Wrongly labelled on cover, 1896. 2 British MedicalJournal, October 22, 1898, p. 1252. 3 St. Bartholomew's Hospital Reports, vol. xxxiii. * Transactions Association of American Physicians, 1SSS, vol. iii. 122 COMPLICATIONS AND SEQUELM OF TYPHOID FEVER. 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 produced by the discharges may seriously imperil the patient's chances of recovery. This view is strongly advo- cated by Sydney Phillips, who regards diarrhoea as a symptom adding danger to the progress of the typhoid, as he believes it prevents absorption of nutriment and drains the body of fluid ; he is therefore distinctly opposed to the so-called " purgative treatment." Closely allied to this question of diarrhoea and constipation is that of the gravity of tympanites, a condition almost always pres- ent 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 pas- sages are small in bulk and unsatisfactory 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 abdominal organs. That is the strain put, by the distention, upon those parts of the bowel-wall which are weakened by 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, while in the second instance, either by reason of cardiac susceptibility or pecu- liar application of the pressure, the injury may be grave. While, therefore, the degree of the tympanites is in direct ratio to its evil effects, as a rule, cases are continually met with in which it is excessive and yet in which no bad results ensue. When the tympanites is very excessive constipation may result from paralytic distention of the gut, and, on the other hand, the WELL-DEVELOPED STAGE OF THE DISEASE. 123 paralysis or relaxation of the bowel may, by preventing peri- stalsis, 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 and is not con- stantly iu 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 pressure, 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 iu 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. In 861 cases of this disease without the cold bath in Lieber- meister's clinic at Basel, hemorrhages occurred 72 times, or 8.4 per cent. Griesinger met with 32 cases in 600, or in 5.3 per cent. ; and Louis found them in 5.9 per cent., excluding mild cases ; Berg, in 1626 cases, met with them in 5.5 per cent. The younger Wunderlich has recorded 98 cases of typhoid fever with- out the bath, with hemorrhage in 2 cases, or about 2 per cent. Kraft 1 found in the study of intestinal hemorrhage in typhoid fever that it occurred 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 blood lost. We find, therefore, that in 155!) cases treated without the cold bath there were 99 hemorrhagic cases, or 5.2 per cent. 1 Centralblatt f. die med. Wissenschaften, 1893, p. 137. 124 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER. On the other hand, we find that in bathed patents Wunderlich, Jr., records 155 cases with 16 hemorrhagic patients, or 10.3 per cent. Ininiermann, at Basel, records 146 cases with 6 hemor- rhages, or 4.1 per cent. ; and Liebermeister, 882 cases with 45 hemorrhages — 1183 cases, or 6.8 per cent. This is shown best by the following table : Without Bath. Cases. Hemorrhages. Per cent, Liebermeister . . S61 72 8.4 Griesinger . 600 32 5.3 Wunderlich, Jr. 98 2 2.0 >r Total I With . 1559 Bath. 106 5.2 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. 1 It is interesting to note in this connection that Fitz places the general frequency at 5 per cent, and Loomis at 5 per cent. It is, however, only fair to state that Goltdammer, from nearly 20,000 cases, concludes that the bath does not increase hemorrhages. Brand claims that they are less frequent in the bath treatment, as do also Tripier and Bouveret ; but Eoland G. Curtin tells us that upon investigation he found that since the cold-water treatment has been instituted the number of hemorrhagic cases has consider- ably increased, according to the hospital records that furnish the 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- 1 Onlv 299 were bathed. WELL-DEVELOPED STAGE OF THE DISEASE. 125 rhage seemingly took place while the patient was in a bath, and in one ease 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 Fit/ tells us that it is always a serious symptom, but rarely fatal in private life ; but that it may be very disastrous i- shown by the fact that Liebermeister mentions 49 deaths due to this cause out of 127 deaths; Murchison, 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 Griesiuger's 32 cases 10 died, 7 of these within four days of the hemorrhage. Lieber- meister tells us that among his own cases, 38.6 per cent, died when they had hemorrhage, as against 11 per cent, without this acci- dent, and Tyson tells us that the 7 per cent, mortality in his cases under the bath treatment was due entirely to hemorrhage or per- foration. 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 ex- haustion the patient often does better after their occurrence than before. This fact was at one time insisted upon by Dr. Alfred Stille, and it is certainly true in a certain proportion of cases. While, as a general rule, the dauger is in direct ratio to the quantity of blood lost, recovery may occur even after enormous quantities have been passed. I have had a case which recovered in which no less than four pints of blood were lost at one bleeding and Phillips and Wakefield, in 1882, saw a patient who bled "two chamberfuls " and recovered. As a rule, bleeding from the bowel in typhoid fever arises from ulceration of an arterial twig, but cases do occur where blood comes from a vein which has been opened by ulceration. Phillips has recorded such an instance. In children hemorrhages from the bowel are more rare than in adults because the intestinal lesions are not so marked, as a rule. As an illustration of how rarely intestinal hemorrhage compli- cates typhoid fever in children, the statement of Simon, that in 126 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER. 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. Peefoeattons. Perforation of the bowel in typhoid fever bears no relation to the severity of the general symptoms. 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 fourteen of the cases the patients belonged to the class known as " walking typhoid " cases. Thus Bennett 1 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 abdom- inal pain, and the next day death took place from perforation due to typhoid fever. No typhoid symptoms had been present. Finn- cane 2 reports a case of a man apparently well till two days before death, when typhoid perforations occurred, and Kleinwachter 3 speaks of a woman who, till 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 consider- able degree of coma. The belly wall speedily becomes tense and tympanitic, and all the symptoms of a general diffuse peritonitis speedily ensue. The pain may, however, not be persistent, but pass away or become modified, as the peritoneal inflammation resulting from the escape of fecal matter into its cavity becomes more and more septic. The pulse becomes rapid and running, and collapse may speedily assert itself. When this occurs death speedily comes on, the patient dying in a few hours, or, again, he may rally and survive for several days. Early death is, how- 1 Transactions of the Pathological Society, London, 1866, xvii. 121. 2 Lancet, 1889, ii. 793. 3 Wiener Med. Press, 1880, xxi. 337. WELL-DEVELOPED STAGE OF THE DISEASE. 127 ever, the more common result. Thus in the collection of thirty- four cases made by Fitz, 1 of Boston, 37.3 per cent, died on the first day, 2!). 5 per cent, on the second, 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 movement 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 with 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 tympanitic, 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 diffuse septic peritonitis due to a pus-tube or an old appendicitis. In such cases the perforation 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 enough to produce great pain or infection. This possibility of perforation of the bowel taking place insidiously has been mentioned by Sydney Phillips, 2 of London. To use his words: " In some cases of typhoid fever where nerve-tone is already lost and the tym- panitic belly is soft and doughy, perforation and after-peritonitis 1 Transactions of the Association of American Physicians, 1891, vol. vi. 2 British Medical Journal, November 12, 1898. 128 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER. may occur almost insidiously with little pain, collapse signs or alterations in temperature." The former type of case is illus- trated by the case of a medical student under my care, who while convalescing from a very mild attack of the disease, and who had had a normal temperature 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 my 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 tem- perature, which had been approaching the normal, suddenly rose to 104°, accompanying a chill ; his belly became enormously dis- tended, 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. 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 Lereboullet 1 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. Monod 2 also reports such a case. Dieulafoy 3 goes so far as to assert very positively that peritonitis 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. 1 Academie de Medecine de Paris, October 27 and November 3, 1896. Dis- cussion of a paper entitled " De l'lntervention Cliirurgicale dans les Peritonites de la Fievre Typhoide," by Dieulafoy. 2 Ibid. s Ibid. WELL-DE VEL OPED STA OE OF THE DISEA SE. 129 While such eases, 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 were 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 Laboulbene, 1 who tells us that there was no sign of perforation save a chilliness of the skin and a slight fall of fever. Bartlr makes a similar report, and Jenner 3 reports a case which left bed on the ninth day and died some hours later of perforation, there being no complaint of pain made. The diagnosis of perforation is to be reached by the following signs in addition to those just given. Chief and foremost among these is the demonstration of gas in the peritoneal cavity, so that the liver is pushed away from the abdominal wall in such a man- ner that the ordinary area of liver dulness largely disappears. Percussion of the right hypochondrium is, therefore, an essential procedure in the physical diagnosis of these cases. The only fal- lacy underlying this test is the possibility of a portion of the colon, when greatly distended with gas, slipping up between the liver and the belly-wall, and thus giving resonance ; but this is a rare occurrence. In some cases, however, as already intimated, the symptoms are so insidious, the death so gradual, that a posi- tive diagnosis is not positive, and cases are not rarely seen in which the perforation has not been suspected and is found at the autopsy. There is one precaution to be taken in cases of suspected per- foration which must not be overlooked, namely, that peritonitis may develop from extension of the inflammatory process in the bowel or by reason of the migration of micro-organisms through those parts of the bowel-wall which have been impaired by the ulcerative process. In such cases the pain, swelling, and dia- phragmatic paralysis may all be present without being due to perforation, and so closely may the symptoms of perforation be 1 L'Union Medicalo, 1S77. xxiii. 389. 2 Bulletin de la Soc. Anat., 1884, lix. 1 I J. 3 Medical Times, 1850, xxii. 298. 130 COMPLICATIONS AND SEQUELJE OF TYPHOID FEVER. aped that operation has been performed, with the discovery that no perforation had occurred ; thus in a case under the care of Herringhani, nothing was found at the section and the patient recovered. Perforation may be simulated by rupture of the peri- toneum over a swollen mesenteric gland. Other causes of peritonitis are necrosis of the mesenteric glands, infarction of the spleen, or the development of abscess in an ovary or Fallopian tube. Very rarely peritonitis arises from cholangitis, with or without gallstones, and Liebermeister has recorded two cases in which rupture of the gall-bladder with escape of gallstones into the abdominal cavity took place. What the ordinary percentage of perforation is is in some doubt, but according to Murchison, 1 it is in the neighborhood of 3 per cent. Schulz 2 found it in 1.2 per cent, of 3686 cases of typhoid fever in Hamburg in 1886 and 1887, and Liebermeister 3 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 per- centage reached by Osier in cases bathed and not bathed. The most interesting comparative statement as to the fre- quency of perforations with and without the bath is that made by Mason. Thus in Boston City Hospital the percentage of perforations in males was 1.4, and in females 1.3, while under the cold bath in Brisbane it was 3.6 per cent, in males, and 1.6 per cent, in females. Liebermeister' s statistics, viz., that there were twelve cases of this accident in 973 patients before the bath and fourteen in 1108 after it was introduced, show a very slight difference. The percentage mortality of this accident is very high. Of 1721 autopsies the percentage was 11.3, according to Murchison. 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 1 Continued Fevers of Great Britain. 2 Centralblatt fur Allegemeine Path. Anat., 1891, vol. ii. p. 289. 3 Ziemsen's Encyclopedia, vol. i. WELL-DEVELOPED STAGE OF THE DISEASE. 131 the proportion to be G.5S 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 cent, in women. In 21 cases of perforation in Basel, 15 were men and 6 were women, and Griesinger in 14 cases had 10 men and 4 women. Murchison also found in 24 cases 16 men and 8 women, although the general mortality of the disease among women was slightly higher than among men. So, too, Bristowe, of London, met with this accident in men in 11 cases out of 15, and, again, Nacke 1 collected 106 perforation cases, in which 72 were in men and 34 were in women. The period of the disease in which perforation most commonly takes place is at the end of the third week or later. Thus in twenty- two cases in which reliable information could be obtained by Lie- bermeister, 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 99 later, 62 out of 117 cases in the first four weeks, and 55 later. More accurate statistics are those of Fitz, who in 193 cases obtained facts shown in the following table : Date of Occurrence in Perforation. First Second Third Fourth Fiftli Sixth Seventh week Cases. Cases 4 Eighth week . . 3 .32 Ninth " . 2 48 Tenth " . . 4 42 Eleventh " . 3 27 Twelfth " . . 1 21 Sixteenth " . . 1 5 1 Ueber die Darmperforation im Typhus Abdomlnalis. Dissertation, Wurzburg, 1893. 132 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. 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 1 tells us that out of 20 cases the perforation occurred once near the ileo-ceecal 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 twenty- five to thirty perforations in the jejunum. In 167 cases collected by Fitz, the perforation occurred in the ileum in 136 instances (81.4 per cent.), in the large intestine in 20 (12.9 per cent.), in the vermiform appendix in 5 cases, in Meckel's diverticulum in 4, and in the jejunum in 2. In 19 cases there were two perfora- tions, 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. 2 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, but the woman recovered. An interesting case of typhoid fever with secondary lesions involving the left half of the scrotum has been reported by Spencer. 3 The patient was thought to be suffering from influ- enza ; and had suffered from a hernia in the left inguinal region for nine years. When first seen at the hospital the left half of the scrotum was greatly swollen and distended, the skin being oedema- tous ; the swollen area was tympanitic on percussion, opaque to light, and fluctuated, and at the inguinal 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 post- mortem revealed the fact that the condition of the scrotum had been due to the perforation of a typhoid ulcer. Untersuch. und der path. anat. Yerand. d. Organe beim Abd. Typhus, 1869. Correspondenzblatt fur Schweizer Aerzte, 1896, Xo. 17. London Lancet, April 10, 1897. WELL-DEVELOPED STAGE OF THE DISEASE. 133 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 : Adi: at which Perforation Occiks. 1 to 10 years . 10 20 30 40 50 60 20 30 40 50 60 70 7 = 3.6 per cent. 46 = 23.8 77 =39.8 45 =23.3 14 = 7.2 2 = 1.0 1 = 0.5 In this connection the account given by Taupin 1 of intestinal perforation in children is of great interest. He tells us that he saw two such cases, and that four such were reported in 1834, 1835, and 1838 by Husson and Barrier. Three of these were gravely ill, and when perforation occurred they passed into collapse and died. In the two Taupin saw atrocious pain developed in the right flank and collapse ensued. Death occurred in thirty-six hours, with all the signs of peritonitis. To one unacquainted with the subject it would seem that there could be no question as to the danger of death from this lesion, yet as short a time ago as 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 recovery after the presence of unmistakable signs of perforation. The latter view was that held by most of the earlier writers; 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 occurred, but had been closed. Murchi- son states that rare cases are met with in which recovery takes place. At the present time it is a well-recognized fact that cases may recover, but that, as Murchison says, they arc rare, unless 1 Journal des ( 'onnaissances Med. Chi., 1839. 134 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. surgical aid is given the patient very soon after the accident. (See operative interference.) Perforation does not always produce death, however, 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 1 reports such cases, and Pear- son 2 records a case in which during relapse an ileocoecal abscess formed, the pus having a fecal odor. In another case 3 a man had a perityphilitis on the twenty-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. Schuremen, 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 open- ing formed. Major 1 records a case in which collapse occurred on the eighteenth day of the disease, and three weeks later an abscess burst into the rectum, and the patient recovered. Low's 5 cases 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. In the abdominal pus the bacillus of Eberth was found. Schmidt 6 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 the case reported by O'Carroll, 7 in which perforation of the intestine occurred on the thirty-sixth day, and the patient did not die until the fifty-ninth 1 Transactions of the Medical Society of the State of New York, 1892, 314. 2 British Medical Journal, 1891, i. 861. 3 Adam. Australian Medical Journal, 1887, ix. 182. 4 British Medical Journal, 1891, i. 18. 5 Ibid., 1881, ii. 122. 6 Deutsche medicinische Wochenschrift, 1896, No. 32. 7 British Medical Journal, February 13, 1893. WELL-DEVELOPED STAGE OF THE DISEASE. 135 day, when an adhesive peritonitis was found, and an abscess which had been walled off from the rest of the peritoneum. All of the intestinal ulcers except the one which had perforated had healed. (See also operative interference.) Without doubt many of the cases of so-called perforation which have been reported as ending favorably have been cases in which there Mas no perforation, and only a more or less severe localized peritonitis. The symptoms of this 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-abdominal lesions that its presence from these causes must always be suspected. At the present time the prognostic and therapeutic view of cases of perforation are well expressed by the following quotations from Gairdner, Fitz, Keen, and others : Gairdner 1 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 Jen- ner, 2 in a long life of large experience, saw one case each ; Twee- die, 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 | »< ri- sibility of recovery after perforation of the intestine freely into the peritoneal cavity. Now, Murchison, at p. 524 of the second edition of his work on continued fevers, states that in ten years, between the publication of the first and second edition of that work, he had attended ' more than two thousand cases' of enteric fever; certainly he must have attended even more before the pub- 1 Glasgow Medical Journal, vol. xlvii. p. 100. - ( ollected Essays and Lectures on Fevers, pp. 311 and 484, London, Riving- ton, Percival & Co., 1893. 136 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. lication of the first edition ; so that his personal experience up to that time may fairly be put down as at least five thousand. In another place he estimates the occurrence of perforation of the intestine 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. " When it is remembered that little selection has been made in the cases operated on (Van Hook's dictum is, ' the only contrain- dication 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." Fitz says : " It appears from this statement that of twenty- seven cases of peritonitis in typhoid fever, whatever may have been the cause of the former, though often attributed to intestinal perforation, three recovered after operation, seventeen after reso- lution, and nine after the spontaneous discharge of the pus. The comparison 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 condition 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 Hoffmann already mentioned. " In brief, immediate laparotomy for the relief of suspected intestinal perforation in typhoid fever, is only advised in the milder cases of this disease. In all others, evidence of a circum- scribed peritonitis is to be awaited, and may be expected in the WELL-DEVELOPED STAGE OF THE DISEASE. 137 course of a few days. Surgical relief to this condition should then be urged as soon as the strength of the patient will warrant." Keen says : " When once physicians are not only on the alert to observe the symptoms of perforation, but when the knowl- edge that perforation of the bowel can be remedied by surgical means, has permeated the profession, so that the instant that per- foration takes place the surgeon will be called upon, and, if the case be suitable, will operate, we shall find unquestionably a much larger percentage of cures than have thus far been reported. But even at present we have a reasonably large number from which to draw conclusions. In the table appended to this chapter Dr. Westcott has collected eighty-three well-authenticated cases. This gives, as a general result, sixteen recoveries, or 19.36 per cent, of cures and 80.64 per cent, of deaths. When this is contrasted with Murchison's unchallenged figures of 90 to 95 per cent, of deaths after perforation without operation, we may well take courage for the future." Since Keen's essay was published additional cases have been collected by Piatt, 1 who says that to Keen's list he is able to add three fatal cases published before 1898, but of which he knows nothing more than the result, fourteen cases which have been recorded subsequently, and his own three cases. The additional cases are as follows : J. H. Nicholas, 2 two cases reported to the Royal Academy of Medicine in Ireland, 1889, both fatal. Podres and Obalinski, cited by Gasselewitsch and Wanach, 3 one fatal case. Gasselewitsch, 4 one case ; operation immediately after the onset of symptoms of general peritonitis ; perforation sutured ; death after forty-three hours. J. B. Deaver, 5 a male, aged twenty-seven years ; perforation during the second week ; opera- tion within twenty-four hours ; free gas in the abdomen ; no attempt made to localize the perforation owing to great distention 1 London Lancet, February 25, 1899. 2 The Lancet, August 3, 1889, p. 211). 3 Loc. 7. 2 Revue Med. de la Suisse Romande, February '20, lS'J'.i. 144 COMPLICATIONS AND SEQUELJE OF TYPHOID FEVER.. as occurring in ray own practice. Here a large abscess containing over a pint of pus, having the odor of a typhoid-fever stool, was allowed to escape by an incision. Recovery occurred. In more frequent instances the appendix is the seat of typhoid ulcers, or an ulcer, although the recorded cases in which this lesion has been found are surprisingly few. This scantiness of reports is prob- ably due in large part to the fact that the appendix is not care- fully examined for lesions in making autopsies, for in the cases with which I am acquainted in which the appendix has been care- fully examined, appendicular lesions have been surprisingly fre- quent. At a recent meeting of the Pathological Society of Phila- delphia Stengel made a verbal report of several instances in which typhoid ulcer had been found in the appendix, as did also Sailer, and in a paper on typhoid ulcer of the oesophagus, Ries- man incidentally mentioned appendicular typhoid ulcer as being also present in his case. Keen has well said, therefore, in his essay, that in all cases of operation for intestinal 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 associated appendicular lesions are recorded by Bontecou, 1 Kimura, 2 and Alexandroff 3 (there were three large perforations of the appendix in this case). Additional cases have been chiefly collected by Kelynack, 4 who points out that Murchison 5 saw two cases of appendicular ulcera- tion, one in a girl of thirteen years, four ulcers being present. Two small perforations were found in it. "Nornian Moore 6 records four cases. Death was due in two 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 three due to 1 Journal of American Medical Association, January 28, 1888, p. 106. 2 Sei-i-kwai Medical Journal, 1890, ix. 55. 3 Report of Hospital St. Olga, in Moscow, 1890, 198. 4 Pathology of the Vermiform Appendix, London, 1892. 5 The Continued Fevers, 2d ed., 1873, p. 623, and Trans. Pathological Society, London, 1866, xvii. p. 127. 6 Trans. Pathological Society, London, 1883, xxxiv. 113. WELL-DEVELOPED STAGE OF THE DISEASE. 145 typhoid fever, and in a later paper/ in 167 cases five instances with this lesion. All these quotations throw light on this matter, but the reports of Morin 2 and HeschP give a much higher per- centage. Thus Morin, in (57 collected cases, finds 12 examples of appendicular perforation, or 18.75 per cent., and Heschl, in 56 cases, found this lesion in S, or 14.3 per cent. McArdle 4 has also reported a case. Contrary to the view held by some, that perforation of the appendix often occurs in typhoid fever, it is to be recalled that Fitz in one of his early investigations was only able to find three cases in which this accident occurred as the result of typhoid fever. More recently Fitz has collected five cases in 167 cases of perfo- ration due to typhoid fever. 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 post-mortem records are so scant in this respcet. Fitz asserts that the more closely the symptoms of perforation resemble those of appendicitis the more favorable is the prognosis. Eolleston 5 states that in 14 out of 60 cases of enteric fever seen at St. George's Hospital, London, changes were found in the appendix. In 5 there was tumefaction, in 7 ulceration, and in 2 perforation. Perforation of the bowel occurred in 18 of these 60 cases — a very high percentage. In the very interesting paper by Hopfenhausen 6 on this topic, already quoted, she tells us that she collected statistics con- cerning the appendix in 808 cases which came to autopsy in St. Petersburg," and found perforation of the appendix in eight cases. In one of these the perforation had caused perityphlitis, found post-mortem ; in two others the diagnosis was made in life. In 1 Trans, of Association of American Physicians, 1891. 2 These de Paris, 1869. 3 Schmidt's Jahrbucher, 1853, lxxx. p. 42. 4 Trans. Royal Academy Medicine, Ireland, 1888, vi. 392. 5 Lancet, 1898, vol. i. p. 1401. 6 Revue Med. de la Suisse Romande, February 20, 1899. Etude sur l'etat et l'appendice vermiforme dans le cours de la tievre typhoide. 7 Protocoles des instituts pathologique de l'Hdpital Municipal d'Obouchow, et de l'Hdpital Municipal de Ste Marie-Madeleine, 1S89-1897. 10 146 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. 117 cases general peritonitis was found, and in 109 this was attributed to intestinal perforation. In all probability typhoid fever predisposes a patient to appen- dicitis. Keen has hinted at this without adducing any statistics to prove it, and cases can be found in literature which point to it. In the cases collected by Hopfenhausen, 1 we find this subject also discussed. She found the following statistics : Hopital cantonal de Lausanne Sonnenburg Pozzi Bull Hecker Bossard Douneff Le Guern Jacobson . Schnellen Langheld Hohn . Jacob Total No. of No. of cases proceed- cases ing from observed typhoid fever. 9 200 6 130 1 1 3 12 1 35 2 26 4 52 1 110 2 6 1 32 4 112 1 2 2 25 37 743 The interval between the two diseases in these cases was gener- ally so long that the figures disprove the relationship rather than prove it. Thus, in 5 cases it followed in from twenty-five to forty years ; in 24 from ten to twenty years ; in 2 cases in three years ; in 1 in two years ; 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, 2 in which perityphlitis followed in the same month. 1 Kevue Medicale de la Suisse Komande, February 20, 1899. 2 Uber die Verchwarung und Durchborung des Wurmfortsatzes. Zuricb, 1869. Thesis, WELL-DEVELOPED STAGE OF THE DISEASE. 147 The history of my own case, to which reference has already been made, was as follows : On March 23, 1898, J. R., aged forty-three years, called on me with the statement that he was suffering with general malaise and aching all over the body, and thought that he must have caught a severe cold. Two days later, March 25th, I was sent for to go to his house, and found him with a temperature of 102°. He also complained of a little more soreness upon the right side of his body than upon the left, but this was not par- ticularly localized. As he had a history of an obscure attack of appendicitis eighteen months before, an attack in which he asserted that there was swelling but no pain in the right iliac fossa, I made a careful examination of the region of the appendix, but was unable to discover any induration and but slight tenderness, with a good deal of gurgling. His temperature from this time continued to rise, and the pain in the neighborhood of the appendix increased, but at no time was it very severe. On the 26th I asked Dr. W. W. Keen to see him with me in consultation, but neither of us could determine that there was any inflammation of the appendix. The fever continued high, his condition became worse, and on Monday, April 4th, I asked Dr. Musser to see him with me in consultation, as there had developed in the right iliac region an increased tenderness, some pain on extension of the leg, and the patient was unable to lie upon that side. Nothing connected with the appendix could, however, be discovered, but as there was considerable bulging in a line drawn between the axilla and the anterior superior spine of the ilium, and as this swelling evidently contained pus, it was decided that an operation was needed, and I asked Dr. Keen to see the case. Dr. Keen agreed in the diagnosis, and on Saturday, April 8th, he made an incision from which escaped about a pint and a half of exceedingly offensive pus, with a distinctly typhoidal odor. The stools prior to the operation had been somewhat typhoidal in character, the odor of his body was that of typhoid fever; he had developed a number of rose spots on his abdomeo and back, and the appearance of his tongue was characteristic. An examination of his blood before operation revealed a considerable 148 COMPLICATIONS AND SEQUELJE OF TYPHOID FEVER. number of leucocytes, probably clue to the abscess formation, and gave an imperfect Widal reaction. In the abscess cavity there was found a considerable mass of tissue about the size of my thumb which was at first thought to be a sloughed off appendix, but which on careful examiuation by Dr. Keen apparently con- sisted of a piece of omentum which had been cut off from the general peritoneal cavity. After the operation the patient's temperature rapidly fell so that it reached the normal point in a few days, and while he was exceedingly ill for some days prior to and after the operation, he ultimately made a perfect recovery. An iuoculation was made from the appendix on April 16th. The tube bore the date of April 9th, and contained =-a growth at the time it was received. Stains of the growth and of subsequent cultures showed a short thick bacillus with rounded ends, usually single, some holding together in pairs or short threads of three to six bacilli. Also a few bacilli about the same length as the above, but much thinner and with a tendency to form longer threads. They stained readily with the ordinary aniline dyes. If stained for only two minutes little light granules on the side and near the end were observed, but if stained longer they also reacted to the stain. These spots failed to react to stains for spores, and were probably granular areas. By their growth and reaction to stain they correspond to the bacillus coli communis and proteus vulgaris. A second case without abscess was that of a boy of nine years, who because of ill health had been taken to the seashore, with 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 disappeared 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 hi an irregular form, and he complained at times of violent pain in his abdomen. Two days after his return to Phila- delphia I saw him. At this time there was marked tenderness WELL-DEVELOPED STAGE OF THE DISEASE. 149 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 particularly restless. His tongue was fairly clean, but there was a complete loss of appetite. At this time, the appen- dicular 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 temperature on one or two occasions rose nearly to 105°, and he developed the typical rose spots of typhoid fever, the appendicular irritation and inflammation having been treated during the preceding week by the application of ice-bags. One week after the symptoms of typhoid fever became well marked, distinct appendicular tenderness partly disappeared, and at the end of the third week had entirely disappeared. These two cases are of interest because they illustrate the fact that it is sometimes necessary to make a differential diagnosis between typhoid fever and appendicitis, and also because they illustrate the fact that typhoid fever and appendicitis may exist side by side. Possibly in one or both of these cases the appen- dicular trouble arose from the typhoidal affection. Nervous System in the Developed Stage of the Disease. Delirium. The nervous disturbances of this period vary very greatly. In the average case there is in the early part of the onset no mental change, save that of unfitness for mental occupation, with dreamful sleep which is apt to be restless. Later the patient con- tinually doses off, 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 lie thinks he is actually having, or calls out loudly, as his dream seems to lead him to a 150 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. point where an imperative call or sudden action is needed. Some- times the delusions in the delirium amount to imperative concep- tions, 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 in parents and in young persons 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 in active motions, 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 " speaking in his sleep " as in health, and this may be taken as the natural form of delirium in the disease. Later the stupid condition becomes 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. On the other hand, even in severe cases the mental state often remains but little disturbed throughout the entire illness, 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. On the other hand, 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 that 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 WELL-DEVELOPED STAGE OF THE DISEASE. 151 per cent, died, and in 43 cases in which stupor or coma was pres- ent, 70 per cent. died. Delirium is a grave symptom in typhoid fever in direct proportion to its severity. Zenner 1 asserts that in cases of severe delirium the mortality reaches 50 per cent., and when the delirium is complicated with 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 the writer 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 affections 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 nervous woman or man it is not of great importance unless it be so persistent and long continued that the loss of sleep and rest exhausts the patient. A form of delirium, usually seen in hysterical women and chil- dren, which resembles the condition of the patient suffering from belladonna poisoning, sometimes occurs, in which there is much 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 indi- cate. As it is usually seen in the early stages it in no wise is indicative of profound 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 1 American Lancet, January, 1889. 152 COMPLICATIONS AND SEQTJELJE OF TYPHOID FEVER. semi-stuporous 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 1 records a case of what he calls the mel- ancholic form of typhoid fever, the diagnosis being confirmed by the Widal action and other characteristic symptoms. The patient was restless, had loss of appetite, was delirious upon anarchistic questions, 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 2 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 unconsciousness, 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 a violent hysterical convulsion came on. Repeated attacks occurred on subsequent days until death occurred from exhaustion. 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 becomes severe, and is worthy of relief and study, since it may be due to perios- titis of the skull, to abscess of the middle ear or brain, or to urremia. A combination of more or less active delirium with rest- 1 Lyon Medicale, 1897, p. 291. 2 Medical Bulletin, June, 1895. WELL-DEVELOPED STAGE OF THE DISEASE. 153 lessness and disturbed sleep and severe pain in the head should make a careful search for a local cause necessary. In other cases the pain extends from the head down the spine, even to the sacrum, and from there down the legs, particularly along the pos- terior parts and in the bones. This pain is chiefly seen in onset and in the early stages, and is generally absent by the third week. Hysterical symptoms may be present in children. Thus De Witt 1 reports the case of a boy of twelve years, who suffered on the twenty-third clay from marked hysterical symptoms, supra- orbital neuralgia, and pain and stiffness in the back, the symp- toms coming on simultaneously with high temperature. 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 in the middle ear ; the third form is that in which there is infec- tion with the streptococcus or pneumococcus, and very rarely do we find a meningitis due to the bacillus of Eberth. Osier records three cases in which he made autopsies in suspected typhoid men- ingitis and found no true inflammation, and as long ago as 1839 Taupin called attention to the difference 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. In typhoid fever in children he states that the condition is one of effusion without hyperemia. Keller 2 asserts that true meningitis in a child can be differ- entiated from typhoid fever with meningeal symptoms by the fact that " Kernig's sign " is present in meningitis and absent in en- teric fever. This sign consists in placing the child in the position of dorsal decubitus with the legs in complete extension. After 1 Bulletin de l'Academie Royal de Me"decine de Belgique, November 17, 1889. 2 Revue des Maladies de I'Enfance, September, 1898, p. 450. 154 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. this is done the patient is raised to the sitting posture, when if meningitis be present the knees become flexed and cannot be straightened until the child is once more flat upon its back. Meningitis in children complicating typhoid fever was written upon as long ago as 1825 by Senn, 1 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 symp- toms were those of meningeal irritation. These meningeal symptoms vary greatly in their severity accordiDg 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 headache, but may show its presence 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 diag- nosis is readily made. To quote Hirt, 2 " Of all diseases typhoid fever is most likely to be taken for meningitis," and, again, he tells us that " Ave 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 simply impossible. 1 Recherches sur la Meningite Signe des Enfants, 1825. 2 Nervous Diseases, American edition, p. 18. WELL-DEVELOPED STAGE OF THE DISEASE. 155 So certain, however, is Money 1 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 tubercular meningitis he states that it disappears and then reap- pears every few days, and that this inconsistency of the reflex favors the diagnosis of tubercular meningitis rather than typhoid fever. The possibility of confusing meningitis or, rather, meningeal symptoms with those of typhoid fever was, however, 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 strabis- mus, 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. As an illustration of the rarity of true typhoid meningitis, how- ever, it is of interest to note that from 1855 to 1887 there are only five cases of this affection referred to in the Index Catalogue of the Surgeon-General's office, and as none of these were tested bacteri- ologically 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 iu Munich, only eleven are recorded as suffer- ing from meningitis. Still more rarely is the meningitis due to the bacillus of Eberth, for Wolff, 2 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 two years this subject has been admir- ably discussed by Ohlmacher, 3 of Ohio, and by Keen, 4 of Phila- delphia. Ohlmacher himself records two cases in which during the course of typhoid fever meningeal symptoms developed, and in which careful bacteriological research revealed beyond all doubt the bacillus of Eberth in the meninges. In still another 1 The Lancet, 1889. 2 Berliner klinische Wochenschrift, 1897, No. 10. . 3 Journal of the American Medical Association, 1897, p. 419. 4 Surgical Complications of Typhoid Fever. 156 COMPLICATIONS AND SEQTJELvE OF TYPHOID FEVER. case recorded by Ohlmacher there was found a mixed infection by this bacillus and the streptococcus. Altogether but sixteen cases of true meningeal infection 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 1 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 post-mortem 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 2 reported the case of a woman who developed headache, delirium, strabismus, exophthal- mus, retention of urine and irregularity of the pupils in the course of typhoid fever. At autopsy the characteristic changes of typhoid 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 3 likewise observed at autopsy in a female epileptic, ten years of age, a sero-hemorrhagic leptomen- ingitis with a lobar pneumonia and the ordinary evidences of typhoid fever. Typhoid bacilli were isolated from the meninges and carefully identified. Still another case was reported by Honl, 4 1 International Klin. Rundschau, 1890, vol. iv. No. 3, p. 98 ; No. 4, p. 156. 2 Le Bulletin Medical, 1891, p. 653. 3 Riforma Medica, 1891, vol. iii. No. 210. 4 Centralblatt fiir Bacteriologie, 1893, Bd. xiv. p. 767. WELL-DEVELOPED STAGE OF THE DISEASE. 157 who found a diffuse purulent leptomeningitis in a twenty -one- year-old woman, who died in the course of typhoid fever. An exhaustive differential examination showed the only bacterial spe- cies obtained from the meningeal exudate to be bacillus typhosus. " Cases essentially similar to those just noted have been reported since 1892 by Vincent, 1 Hintze, 2 Mensi and Carbone, 3 Stuhlen, 4 Tietine, 5 Kuhnau/' and a second one by Kamen." " Tictine reported two cases which came under his observation, and he also produced a purulent meningitis in animals by means of subdural inoculations with typhoid cultures. The second one of his cases differs from all others in that the patient was per- fectly 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 six years of age, 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, opisthotonus, 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 fibrino-purulent cerebro- spinal meningitis, with dilatation of the lateral ventricles, and a bronchitis of the medium and smaller bronchioles. Numerous 1 Schmidt's Jahrhucher, 1893, Bd. ccxxxvii. No. 2. 2 Centralblatt fur Bacteriologie, 1893, Bd. xiv. No. 14. ;i Ri forma Medica, 1893, vol. i. p. 14. 4 Berliner klin. Wochenschrift, 1894, No. 15. ' Archives de Med. Experiment, 1894, tome vi. p. 1. fi Berliner klin. Wochenschrift, 1896, No. 2"\ 7 Centralblatt fur Bacteriologie, 1st ahthcilunic, 1897, Bd. xxi. Nos. 11-12. 158 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. typical typhoid ulcers in the stage of healing were found in the ileum and colon ; the mesenteric glands were swollen and soft, and there was softening of the spleen. A thorough bacterio- logical examination of the meningeal exudate resulted in finding typhoid bacilli as the sole bacterial inhabitant." In rare cases where death has occurred from meningitis without enteric fever being suspected, the autopsy has revealed the bacillus of Eberth to be its cause, as has been reported by Curschman. Such instances have been recorded by Ohlmacher and are of in- terest. He tells us that : " In the course of a study of meningitis, Neumann and Schaef- fer 1 (1887) found an extensive purulent 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 the 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 very similar case was reported soon after by Adenot, 2 in which a woman presented profound symptoms of cerebral infec- tion and died in eight days. Absolutely no typhoidal lesions were present in the intestines, spleen, and mesenteric glands, but from the sero-purulent exudate in the soft meninges a bacillus resem- bling the typhoid organism was obtained. The only differential test here applied was the growth on potato, and we now know that this is not sufficient to identify the bacillus of typhoid fever. The case recorded by Balp 3 also belongs in the same category with those of the authors just noted. He found a diffuse purulent men- ingitis 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 differeDtia- tion." 1 Virchow's Archives, 1887, Band. cix. Heft. 3, p. 477. 2 Archives de Med. Experiment et d'Anat. Pathol., 1889, tome i. p. 656. 3 Eivista Generale Ital. et de Chir. Med., 1890, No. 17, p. 406. WELL-DEVELOPED STAGE OF THE DISEASE. 159 A case of purulent cerebro-spinal meningitis complicating typhoid fever has also been reported by Stuhlen. 1 The patient was a man whose wife and children were also sufferers from typhoid fever. He first suffered from wretchedness, headache, chills, and constipation. When admitted to the hospital, four days later, there was stupor, restlessness, and delirium, and on the fifth day sudden collapse, from which he rallied, but persist- ent stupor remained. On the seventh day there was rigidity of the neck and slight jaundice. An examination of the cerebro- spinal pus showed the typhoid bacillus. Very recently Kerr and Moffitt 2 reported to the California Academy of Medicine the case of a man of twenty-eight years, who on admission was found in a stupid mental state when he had been ill for a period of three or four weeks. He had been seized with general 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, weakness, 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, resem- bling tubercular meningitis more closely than typhoid fever. The pulse was fairly slow and dicrotic. There were no spots and no eye-symptoms ; 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 cer- tainly six or eight weeks old ; the brain was covered with a thick purulent exudate, yellow-red in color. Cultures were made which showed mobile bacilli giving the negative glucose test, but clump- ing with typhoid serum. Boden 3 reports the case of a fourteen-year-old child who suf- fered from typhoid fever and was admitted to the Augusta Hos- pital of Cologne, on October 2d, at about the end of the first week of the disease. There was hyperesthesia of the entire body, and 1 Berliner klin. Wochenschrift, April 9, 1894 2 Journal of the American Medical Association, March 18, 1899 :; Miincheher Medicinische Wochenschrift for February 2S, 1899. 160 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. 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 was 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, Kuguan, Daddi, Hintz, and Honl. The frequency of this complication wheu due to true typhoid infection of the meninges in the different periods of the disease is in direct ratio to the length of the malady, namely, 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 cannot be made during life, for the positive test is the bacteriological examination of the skull contents. Nevertheless, the presence of marked meningeal symptoms is of the gravest import in all cases. Sometimes, 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. Cerebral Thrombosis and Embolism. Richardson 1 has recorded a case of a man of forty -three years, who in the third week of the disease suffered from intense headache, chiefly in the left temporal region, accompanied by collapse and a subnormal temperature. He rallied under stimulating treatment, but two 1 Journal of Nervous aud Mental Diseases. WELL-DEVELOPED STAGE OF THE DISEASE. 161 days 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 was a small abscess. No clots were found in the sinuses. There are three interesting points in this case : First, the develop- ment 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 any signs of meningitis at the autopsy, although the symptoms during life seemed to indi- cate the presence of this condition. This last fact is of particular interest in view of the fact worthy of recollection, as already pointed out, that while meningeal symptoms may be well marked in enteric fever, true meningitis is comparatively rare. When it is remembered that thrombosis of the cerebral sinuses is the usual lesion, and that such an authority as Gowers 1 ques- tions whether primary venous thrombosis ever occurs without sinus thrombosis, and that Macewen, 2 in his classical work on the surgery of the brain and cord, says nothing of marantic primary venous thrombosis, the rarity of this condition is noteworthy. Hirt 3 says it may occur in the veins as well as the sinuses, but Dana, 4 Rosenthal, 5 Gray, 6 and Brill 7 fail to describe it. We may call attention to the fact that thrombosis of the cerebral sinuses is usually said to be due to an exhausting disease or to infection. In such a case as that just described both these factors were present. Finally, it is interesting to note that an additional factor in this case still further complicated the clinical diagnosis, namely, a 1 Diseases of the Nervous System. 2 Ibid. 3 Ibid, 4 Ibid. ■> Ibid. G II. id. 7 Article in Dercum's Diseases of the Nervous system. 11 162 COMPLICATIONS AXD SEQUEL JS OF TYPHOID FEVER. history that the patient had had two severe head injuries, one twelve years before and one two months before. A case of evident thrombosis recently occurred in my wards in the person of a student of twenty years. He came under obser- vation 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 neighborhood 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. Xo autopsy was permitted, but from the symptoms I am 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 1 has reported a case of typhoid fever in a little girl of ten years, in which on the seventeenth day of the disease the patient developed aphasia and great restlessness ; the child could understand what was said to it, and there was no paralysis of any of its limbs ; the motor aphasia, however, lasted for a period of a month and a half, when the child 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 influenced 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 indicate a fatal 1 Gazzetta degli ospedali e delle cliniche, January 5, 1899, p. 25. WELL-DEVELOPED STAGE OF THE DISEASE. 163 termination in the near future. In Osier's case death followed convulsions produced l>v 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 ease 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 four days. Recovery eventually took place. During February, 1899, 1 saw in consultation with Dr. Loux, of Philadelphia, a girl in the third week of typhoid fever with typical hysteria, as shown in the facial expression and in the attitude of her body. Her arms were abducted, her forearms completely flexed at a right angle with the arms, and the hands completely flexed at a right angle with her 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. A possible cause of sudden death during typhoid fever, or in convalescence, is said to be bulbar paralysis. Thus Latil 1 men- tions a woman of forty-two years, who suffered from a severe attack of typhoid fever with hyperpyrexia and extreme pros- tration, 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 respiration 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 me 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 1 Revue G^n^rale de Clinique et de Th^rapeutique, March, 21, 1890, 164 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. by a case which has been reported by Libouroux, 1 in "which sud- den death occurred during the third week of the disease, and an autopsy revealed a small hemorrhage in the floor of the fourth ventricle. There was no other condition which could account for the sudden death of the patient. Stiffness of certain muscles isolated or in groups is also met with, and may sometimes resemble that seen in lateral sclerosis of the cord. Iso less authorities than Hughlings Jackson and Angel Money have stated that knee-jerks are never lost in enteric fever. This is scarcely correct, for I have recently seen a case, not excessively ill, in which they were absent for days at a time as completely as in ataxia or some cases of diabetes. 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 cjuiet, 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, for patients with these symptoms often get well. 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 symptoms are most violent, and in patients who have had pro- longed high temperature. The pupils lose their reaction to light, 1 Gazette Hebdomadaire de Medecine et de Chirurgie, March 5, 1890. WELL-DEVELOPED STAGE OF THE DISEASE. 165 and symptoms of meningeal irritation develop, or in their place marked mental changes occur, the patient becoming maniacal or deeply melancholic. More noteworthy than all, the temperature suddenly falls almost to normal, and remains there for several days, as long as the symptoms named continue, when it rises again to the points usually met with at that period of the malady, and proceeds as before. Such cases are very rare. In his enormous experience, Liebermeister only met with " eight or ten cases." Tyson asserts that in cases of typhoid 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 till convalescence is established. 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 complica- tion noted during convalescence. (See chapter on convalescence.) Almost, if not equally rarely, pain in the muscles is developed as the result of a myostitis. Paralysis arising from typhoid 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 considered under the division in which the late complications and sequelae 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 paral- ysis of the extremities complicating or following typhoid fever, I may quote the statement of Alexander who, during an experi- ence of ten vears and a half in the medical clinical 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 about the seventh or ninth day, is usually characterized by its rose-spot appearance. A delicate pink hyperemia 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 166 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. 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 hundred. This is rare. During the past year the writer has been impressed by the fact that the rash has been unusually profuse and exceedingly coarse. The individual spots have been not only large and well-defined, but distinctly elevated and maculo-papular to an extraordinary extent. Further, in these cases repeated crops of this roseola have repeatedly ap- peared 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 my 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 he came under observation a second time he had a profuse rash over his body ; his eyes were injected, and on the mucous mem- brane of the palate and on the roof of the mouth there was a profuse punctated eruption. The subsequent course of this case showed that he was suffering from a mild typhoid relapse. 1 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 13.1 per cent, had no rash. Abnormal eruptions occurring in typhoid fever in children were 1 For a discussion of the various forms of roseolous rash see the author's Text- book of Practical Diagnosis, fourth edition, 1 899. WELL-DEVELOPED STAGE OF THE DISEASE. 167 described as long ago as 1839 by Taupiu, 1 who tells us that a uniform erythema resembling scarlet fever may be present, but is not followed by desquamation or oedema. He also says 2 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 hem- orrhagic exudations or petechia?. 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 bleuatre. They were first described as occurring in typhoid fever in 1837 bv Piedaernel. I have been confident that I have seen them in cases which were not infected by lice, but Hewetson 3 speaks as follows in respect to this question : " There exists a considerable difference of opinion as to the diagnostic value of these spots. Many 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 be found if looked for carefully. Our experience leads us to believe that the latter view is correct, as in the cases of typhoid fever in which the pcliomata were present, we were able in each instance to find either the pediculi or their nits. There have been several cases, other than typhoid fever in which these grayish- blue spots were found, but always associated with pediculi. There are at present two cases in the wards, one with catarrhal jaundice and another admitted for chronic bronchitis and emphysema. In 1 Journal des Connaissances Med. ('hirurgieale, is:} 1 ,). 2 This essay is an exhaustive and excellent account of the disease as seen early in this century. 3 Johns Hopkins Hospital Bulletin, vol. v. 168 C02IPLICATI0NS AND SEQUELS OF TYPHOID FEVER. neither case is there any elevation of temperature, but in both there are numerous steel-gray spots scattered over the abdomen, thorax, inner sides of the thighs, and here and there on the arms and legs. In both the pediculi are numerous, particularly over the pubes, and also in the hair over the various sites where the tache bleuatre are present. In both cases they are quite plenti- ful in the axilla?, but in neither have they been found on the hairs of the head or face. They do not appear to have caused much irritation ; neither patient complained of itching, nor are there marks of much scratching. Indeed, I find that one patient, for- merly an Austrian soldier, is quite indignant at the removal of both hair and pediculi. He tells me that they are considered as bringing luck to the bearer, and each sells for from five to ten kreuzers among the soldiers. They have been carefully carried by him for ten years." Sudamina, due to the retention of sweat drops beneath the epi- thelial layer of the skin, are met with in cases in which sweating has taken place, during high fever, as a rule. It is claimed by Baradat de Lacaze that sudamina may possess definite prognostic value. In quite an exhaustive paper 1 he concludes that the ap- pearance of sudamina at the beginning of the second week of typhoid fever are of little or no value in fixing the prognosis ; but, on the other hand, their appearance again in the second week, or in the period of ambiguity, nearly always indicates the entrance into active convalescence. De Lacaza believes its development at this time means a crisis in the course of the affection. Urticaria may occur, and there may also be a peculiar mottling of the skin due to local capillary atony. The so-called tache cerelorale is a red line with white borders, produced in this and other fevers by drawing the finger-nail over the skin of the patient. Deeper lesions of the skin than those just discussed sometimes complicate typhoid fever. They consist in boils and carbuncles, and are due to infection of the follicles by pyogenic organisms of 1 Revue de Mediein, 1887, p. 275. WELL-DEVELOPED STAGE OF THE DISEASE. 169 the ordinary forms or by the specific organism of enteric fever. They are usually met with in cases which are severe and charac- terized by great lowering of the vitality, and are probably more often met with in convalescence than in the acute period of the fever. The writer suffered from a carbuncle on the back, which came on about the twelfth day of an attack and persisted during a relapse and well into the second convalescence. Bed-sores usually develop only in those cases which are pro- foundly ill, or are not well nursed, in the sense that they lie in bedding which is soiled by discharges. Since the use of the cold bath or sponging they are rarely met with, because this method of treatment causes the patient to change his posture frequently, keeps him clean, and restores the local circulation in the skin where it is anaemic or congested. The most common seat for this lesion to occur is over the sacrum. Superficial gangrene of the skin is very rare, but was met with very early in the history of the recognized disease. Thus Taupin 1 mentions a case of sloughing of the thighs, sacral region, knees, Fig. 16. Superficial gangrene of the skin occurring in author's wards. elbows, and of the face, in a child with typhoid fever. The skin became violaceous in appearance and mortified, and this was accompanied by increase in the delirium. In one case under my care at the present time it developed on the inside of the left calf 1 Journal des Connaissances Med. Chirurgicale, 1839, No. 170 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. of a girl of nineteen years, who had suffered some days before from a series of profuse hemorrhages, for which hypodermoclysis had to be used to save life. None of the areas of injection sloughed, and no injection was given near this spot, which broke down. (See Fig. 16.) Two brown ecchymotic spots formed on the heels where they rested on the bed, but did not slough. The separation of the slough was accompanied by loss of power and sensation in the anterior part of the leg, evidently from periph- eral neuritis. 1 (For further discussion of this subject, see the circulation in the developed stage of typhoid fever, and nervous lesions in convalescence.) Herpes labialis is thought by some to exclude the diagnosis of enteric fever if it be present. Osier reports two cases in which it occurred, 2 and the writer has seen one during the present year. That herpes occurs quite frequently in some epidemics of typhoid fever is shown by the statement of Zinn, 3 who states that it was met with in 5 per cent, of 190 cases in the hospital at Nuremberg. A very extraordinary series of cases of gangrene of the skin has been recorded by Stahl, which occurred in soldiers in St. Agnes' Hospital in 1898. He has kindly permitted me to use the following figures. (See Plates I. and II.) Taupin 4 states that he saw two children die in typhoid fever with severe erythema nodosum, and that sudamina were common in his experience. Hemorrhagic eruptions may occur in the course of typhoid fever, and, as a rule, they appear in the neighborhood of the joints, when the exudation may be small or quite large. Nichols 5 reports four cases in which the hemorrhagic diathesis developed on the thirteenth, eighteenth, twenty-eighth, and thirty - 1 For an interesting paper on infectious disseminated gangrene of the skin, see Caillaud in the Revue Mensuelle des Maladies de l'Enfance, 1897, p. 1. 2 Johns Hopkins Hospital Reports, 1895, vol. v. 3 Miinchener Med. Wochenschrift. 4 Journal des Connaissances Med. Chirurgicale, 1839, No. 7. 5 Montreal Medical Journal, June, 1896. in c CT> D cQ T 0) 3 O 3 o 5" CQ H V a (6 < a> r > m c CD "5 o SB cQ 1 CD Ul ? SB 0) ff W •"^ PC m p O m u ? 3 •o o CD r+ cQ H << TS 3* a T1 CD < CD T ^0 r > -3 W WELL-DEVELOPED STAGE OF THE DISEASE. 171 sixth days of typhoid fever. Only one of these cases died. Very rarely the tendency to hemorrhagic leaking* may become general and result in haemoptysis, hsematemesis, and hemorrhages from the bowels. A case of this character is recorded in the North ( 'arolina Medical Journal for September, 1890, in which a child of ten years suffered from this disease. At the end of the fourth week of the disease there was bleeding from the gums, the nose, and blood in the urine. The spots appeared first on the feet and legs, later on the arms, then on the trunk, and, finally, in the conjunctiva. In other cases hemorrhages other than those just named took place. Thus Hughes and Levy 1 report a case in which a man, after an ordinary attack of typhoid fever, suffered from a relapse in the sixth week. Abscesses developed in both forearms and in the left arm. When an incision was made into the abscess extra- vasations of blood into the intramuscular aponeurotic tissues took place, and afterward this was followed by manifestations of acute purpura, as indicated by petechias, ecchymoses and severe epistaxis. Recovery took place. Another abnormality in the typhoid rash has been described by Day. 2 The eruption was on the chest, abdomen, and back, and occurred in irregular dark patches, slightly raised, and disappeared on pressure, though they left some pigmentation after their dis- appearance. They were not petechias. Day asserts that he has met with ten other cases of this character, and further, that in four of them intestinal hemorrhage was foretold by their occur- rence in connection with fever, a rapid pulse, and a clear mind. Eruptive Diseases in the Course of Typhoid Fever. How frequently scarlet fever complicates typhoid fever is a difficult fact to decide. Murchison 3 says that in ten years he saw only one case of scarlet fever which contracted typhoid fever, and that ensued on the twenty-sixth day. On the other hand, he cites several cases in which typhoid fever patients suffered later from 1 Archives de M<5decine et de Pliar. Militaires, August, 1 s*. cj. 2 Dublin Journal of Medical Sciences, March, 1806. 3 British and Foreign Medico-Chirurgical Review, July 1859, p. 194. 172 COMPLICATIONS AND SEQTJELJE OF TYPHOID FEVER. scarlet fever. This was written in 1859. Later still he wrote 1 that in the wards of the London Fever Hospital, in which all fever cases were treated without isolaton, he had seen eight cases in which the eruption of the two diseases existed simultaneously. In one of these the eruption of scarlet fever appeared in the third week of enteric fever, and in the other on the twenty-second day. Indeed, he goes so far in one place 2 as to assert that scarlet fever appears to predispose to typhoid fever. Sequeira 3 records two cases of typhoid fever complicated by scarlet fever. In one the scarlatinal symptoms developed on the tenth day, and in one five days after the enteric rash. Still more interesting are the cases recorded by Griffiths. 4 Four children, all in the same family, were attacked by both diseases. A boy of eleven years on the sixth day of scarlet fever developed typhoid fever. A girl of thirteen years got scarlet fever three weeks after her brother and enteric fever twelve days later. A girl of three years, who had scarlet fever, suffered from typhoid fever on the eleventh day, and a girl of seven years also on the eleventh day after scarlet fever began. These cases are of special interest in that a nearly simultaneous infection with both fevers must have occurred. Caiger 5 met with two cases of scarlet fever coincident with typhoid fever, and Payne 6 reports one such case. Carmichael 7 also has reported the case of a boy of six years, who, after suffering from scarlet fever and going on to the stage of desquamation, continued febrile from oncoming typhoid fever, and Cosgrove 8 records five cases of concurrent scarlet and typhoid fever seen in the Cork Street Hospital. In four of these the incubation stages were concurrent, the scarlet fever being second- ary, so that the onset was simultaneous. This same author tells us that instead of increasing the severity of the typhoid the 1 The Continued Fevers of Great Britain, third edition, p. 586. 2 Loc. cit., p. 455. 3 British Medical Journal, 1891. vol. i. p. 849. * Lancet, 1893, vol. ii. p. 1307. 5 Lancet, 1894, vol. i. p. 1137. 6 Ibid. 7 Ibid., p. 246. 8 British Medical Journal, January 16, 1897, p. 29. WELL-DEVELOPED STAGE OF THE DISEASE. 173 scarlet fever seemed to abort it, though the cases were fairly severely ill. Coombs 1 reports a case in which a boy of eleven years, who had scarlet fever, his family having typhoid fever, was seized on the seventeenth day of his illness by typhoid fever. Gabe 2 reports another ease. The danger of confusing adventitious scarlatiniform rash in typhoid fever with that of scarlet fever was emphasized by Mur- chison and by Moore 3 and Jenner, 4 and more recently by Bassett. 5 Moore has also seen desquamation take place in this form of rash. 6 A case of a child of eleven and a half years has been reported by Chrystie, 7 which is of particular interest, because of the fact that measles developed during the attack of typoid fever. Death occurred in convulsions. A similarly constituted attack of typhoid fever and measles is also recorded by Matiegka. 8 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, 9 in a girl of ten years, and Ringwood, 10 records a case in which the child had measles and enteric fever simultaneously, followed by a severe attack of diphtheria, scarlet fever, and chicken-pox, all in the space of seven weeks. 1 British Medical Journal, February 27, 1897 2 Loc. cit., April 3, 1897, p. 848. 3 Accidental Rashes in Typhoid Fever, Transactions Royal Academy of Medi- cine in Ireland, 1889, vol. vii. p. 10, and Eruptive and Continued Fevers, 1892, p. 371. 4 Fevers, 1893. 5 British Medical Journal, April! 0, 1897. 6 Loc. cit., January 16, 1897. 7 University Medical Magazine, December, 1888. 8 Prager Med. Wochenschrift, September 25, 18S9. 9 London Lancet, June 30, 1889. 10 Loc. cit. July 7, 1889. CHAPTER IV. THE COMPLICATIONS OF THE PERIOD OF CONVALESCENCE. Temperature, Recrudescence, and Relapse. Recrudescence signifies a temporary 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 absorption from the intestinal canal of some toxic material which temporarily upsets the balance of heat-production and heat-dissipation. In two instances I have seen full doses of strychnine, given as a cir- culatory stimulant, produce repeated exacerbations of the normal temperature to the extent of two or three degrees by reason of its irritant effect on the nervous system. As has already been said, 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 complete. 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. Wnat 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 1 believes that relapses are more frequent in cases with constipation than in those with 1 Transactions of Association of American Physicians, 1888, vol. iii. COMPLICATIONS DURING CONVALESCENCE. 175 diarrhoea, and that reinfection from within explains their fre- quency in these instances. In the writer's experience, relapses have been much more common in constipated cases. 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 Striimpel at 4 to 16 per cent. Berg 1 met with relapse in 12 per cent, of 1626 cases in Curschman's clinic from 1880 to 1892. Eichhorst, in 666 cases in Zurich, found relapses in 4.2 per cent. Zennetz 2 in 384 cases of typhoid fever found 47 relapses, of which 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 3 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 per- centage of 6.8 per cent., which practically agrees with the percent- age obtained by Gerhardt, who in the study of 4000 cases selected from various epidemics, obtained a percentage of 6.3 per cent., while Heman's percentage was 6.5, and Steinthal's, 7.5 per cent. Liebermeister says : " In Basel, before the introduction of this (the bath) treatment, 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 cm- ployed." Biermer has also found relapses more frequent since the introduction of cold baths. Osier met with 1 4 cases of relapse 1 Deutsche Archiv fur klin. Med., 1895. -' Wiener med. Wochenschrift, September 21, 1894. Archiv. fur klin. Medicin, Band xliii. I left. 3. 176 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. in 160 cases bathed, or 8.7 per cent., but mentions five other cases of doubtful relapses, which raises the percentage ; while 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, and Osier tells us 8.7 per cent.; Shat- tuck, 16 per cent. ; Immermann, 15 to 18 per cent.; Baumler, 11 per cent. ; and Jaccoud, 9 per cent., varying from 7 to 15 per cent. At the Presbyterian Hospital in New York Gilman Thomp- son found the relapses in 193 bathed cases to be 13.5 per cent., which is 2 per cent, higher than 284 cases treated by all methods during the same time. There are certain peculiarities in the course of a relapse as to the fever, the circulation, and the other functions which deserve attention. The fever usually rises more abruptly than in the orig- inal 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, while if it has been quite short the relapse is not infrequently much longer. Thus in one case recently seen by the writer, 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 both as to 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 COMPLICATIONS DURING CONVALESCENCE. 177 him more prone to complications and less able to withstand the general toxaemia of the new infection. This is well shown 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 petechia? three times. To quote Liebermeister again : "If we take the reports of the years 1869, 1870, and 1872 at Basel, we find among 467 typhoid fever patients systematically treated with cold baths, 33 deaths and 55 relapses, 6 of which were fatal ; the frequency of relapses, therefore, counting only those patients who 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 given 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, but 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 productive of 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 primary fever has ceased, although it may occur in the course of the disease in the third week, or 12 178 COMPLICATIONS AND SEQUELM OF TYPHOID FEVER. r - t>~. od • — T3 XI IS c ■" x: c c o a; '~ ?* so J: COMPLICATIONS DURING CONVALESCENCE. 179 :::::it::::::::: •K-vg ! ^i- 7.1 81 •km 9 [£;:_ .„ <». 05 •K-V9 ±ZZt2' 08 05 'KM 9 r in; 55 8 •KV 9 08 81 ■KM 9 S 08 95 - •K-VC JJ-" on 85 •KM 9 H4-4-L 001 08 •K'VG _Lj- -f- ^ 1 ,-r, s," •K-J9 511 95 S •K-v 9 i "=>j^ " 9TI ir 'KM 9 ~~~1 ^ 511 tZ f •K-V 9 r-'-'U Mil 95 •KM 9 *\" 811 95 8 •K-vr; ^„!i& n,-l *5 'KM 9 • fi f-C— . 821 f-5 5 ■K-v 9 __ J>» - f f-IT (»- TTJG * <= ^—., 051 <-,' I •K-v 9 ^^^ i- 9?- *5I fZ •km 9 »g^-l 1 851 9," IE •K-v 9 JZ-=f» n 001 05 •KM 9 *sCC ~x_j :: : ff 1-1 IE 09 ■K - v 9 3E = fi 911 SI •k-j 9 ^c^r Sol 95 65 ■KV 9 ?r ' w III 55 •km 9 «si f(i 55 85 •K-v 9 _— -i-t ==,# oil 05 •KM 9 m^r-ZZ H_l 1 zu 1- Z5 •K-vg i J-*f" 911 55 ■KM 9 "r~ -)-+-■ 00T ,"- 95 K-v 9 _L-f--T?* n<. 05 •KM 9 rrF-R. i 1 - eg 001 li- Co •K - v g 1^-r-Jr-rr-^ i r " 88 re TJ9 •— = =^ZI _ .__ T T , 051 05 1-5 •K-vg '"" SS tn •KM 9 511 i- 85 ■K-v 9 - J-~ 5TI M •KM 9 *d~ 9i 05 5o •K-v 9 ZT " " 9G t.- •KM 9 ^Lj ,"s 05 15 •K-vg Jj- — -Frf K 05 •KM 9 '«;"" 001 or: 05 K-v 9 8G 08 •K-.l 9 *^4-L Oil i,- 01 •wv g m: BS •km g •■= TOT 7.7. 81 •wvg or, 08 •km g •■ *i.~ i ! B H'l !:: 11 ■wvg , __. "~ IN I" •KMg f [ sn 55 91 '»vo m--.. | 1 HI | fZ , • ° o o o U_ "* CO CM r— O CD O O ° o o o -2 e= era co i — Q £ a .2 C3 era era cra^^-.?^ ° £ « P ? Q 180 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. even in the fifth week. Henoch records one instance in which relapse took place in a child eighteen days after apyrexia had been established. Fig. 18. F. H i i i i i i A.M. P.M. A.M. F.M. A.M. F.M. A.M. s s a ^ o -j pi -i © o s j si -;' 2^ < © Ci S * HJ'.M. 8a.m. 8 F.M. 8 A.M. + r\r n x 11)0 i tt n -. tl :fc_i4 iu £-3 t t ._„. r 103 r t 102° -\ E - 3 1, : Q 101° |- ■5 '< — %A— i _ r u 4 t 4 t 4 T 4 T 100° o- T ± T T \ t f 4 n t t 4 , t t 4 / p «« ry t t 4 / \ 99 T H ^ , t ± \ X ±/ 3 V / V j/ J -* — i \ ; \ 4 -• ^ / V 98 1— ^ fu.-j v ' v J *f V* !3 tT fv^d \ \ ._ tti— t \ t£ tfct — t' xtfc i 97° i H t -=5 i __I 1 Day of Die. c O -* «S CD »-- 00 cs c -"*« o Pulse. § a s I se s ; 3 ti O © O CO 1Q O §8 S? 5 S3 t- so s; * © -* 3 © L-5 GO p 8 3 ta o oo p Resp. 3° »1 JJ -J O J O i QO OO » CO 'X 00 CO w n a cases also thrombosis usually did not appear until the stage of convalescence, and rarely as early as the third or fourth week. Out of 24 cases, 1 <5 of which were in men and 8 in women, the vessels became plugged eighteen times in the crural vein, five times in the saphenous vein, and once in the popliteal vein. Thrombosis of the crural vein took place in both sides simultaneously twice, 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. Sometimes phlebitis of the calf of the leg develops in place of thrombosis of the femoral vein. Thus Arnaudet 1 records three cases, one in a woman of seventy-five years, another in a woman of fiftv vears, and the last in a man of thirtv-ei^ht vears. The author has recently had under his care a case of this kind occurring in a girl of twenty years, on the left side. In Arnau- det'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 collected by Keen, only 4 involved the upper extremities alone ; 2 involved the arm and leg, and 124 were limited to the legs. Genito-urinary. Orchitis complicating typhoid fever during the progress of the febrile stage is very rare, but a case was recorded by Marcus 2 in 1812, of suppuration of the scrotum in " stupid ner- vous fever." Yulpian 3 also states that this complication may fol- low grave fevers. It is emphatically a symptom of the period of convalescence. Westcott collected for Keen thirty-two cases, but 1 La Xormandie Med., November 1, 1891. 2 Archiv fiir Med. Erfahrungen, Berlin, 1812, i. 546. 3 Dietionnaire de Med., 1844, 2d ed., xxix. 13 194 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER. Eshner 1 has collected forty-two cases, and has reported one in his own care. The contribution of Ollivier 2 to the study of typhoid orchitis is, however, very exhaustive, and to him belongs the credit of summarizing most of the literature up to 1883. The writer has also met with one case ; its history is as follows : The patient was a physician, twenty-two years old, who was admitted to my wards in the Jefferson Hospital on January 29, 1898, with a history of having been ill for ten days with frontal headache lasting four days, with pains in the lumbar region, and with general debility. There Avas diarrhoea, with copious watery evacuations from the bowel, and rose spots were present upon the cheek and the abdomen. Xose-bleed occurred after the patient came under observation. Examination of the blood yielded a positive reaction to the Gruber-Widal test. The urine was albu- minous on each of three occasions, but tube-casts were not found. The disease pursued an ordinary and uncomplicated course, defer- vescence taking place on February 2 2d, and the patient was dis- missed well on March 13th. On March 28th he was seized, without obvious cause, with pain and swelling in the left testicle. The pain was agonizing, and the swelling gradually increased until the testicle became many times its normal size. Dr. Hor- witz noted the pain as being intense in a degree far beyond that ordinarily encountered in cases of orchitis of gonorrhceal origin. The temperature was as high as 101° between March 31st and April 2d, and it reached 100.3° on April 19th. Otherwise it was prac- tically normal. There was also no urethritis or urethral discharge. A slight effusion into the vaginal tunic took place, but there was no noteworthy involvement of the epididymis. With the appli- cation locally of an ice-bag, and of mercurial and belladonna ointments, and the internal administration of opiates, pain was relieved and swelling subsided ; but it became evident that an abscess was forming in the left half of the scrotum. Accordingly, an incision was made by Dr. Horwitz on April 23d, and a consid- erable quantity of pus, together with a portion of the testicle, 1 Philadelphia Medical Journal, May 21, 1898. 2 Eevue de Medecin, 1883, pp. 829, 960. COMPLICATIONS DURING CONVALESCENCE. 195 was evacuated. The operation was a success, and the patient recovered. Ollivier 1 believes that orchitis is more common than is generally thought. He reports three cases of his own. Liebermeister 2 met with it three times in 250 cases, and SoreF found it in 3 cases out of 871 typhoid fever cases seen in ten years. Eshner also quotes Betke, 1 who did not meet with it in the records of 1420 cases, and Dopfer, 5 among 927 fatal cases, did not meet it once. Holscher, 6 in the celebrated 2000 cases in Munich, records a case- ous orchitis in but one instance. As already stated, Eshner's paper is the latest and most exhaus- tive contribution to this subject, and I have used it freely in these pages. He tells us that in " forty-one cases it occurred during the course of the fever in 12, and during convalescence in 29. It set in in 1 case during the second week of the fever, in 5 during the third week, in 1 during the fourth week, in 1 during the seventh week, in 1 at an unstated period of the disease, in 3 toward the close of defervescence, in 8 at an unstated period of convalescence, in 8 during the first week, in 8 during the second week, in 3 during the third week, iu 1 during the fourth week, and in 1 during the sixth week. There was no apparent relation between the severity of the original disease and the occurrence of the complication, which attended mild equally with severe attacks. " The onset is, as a rule, abrupt, and may take place while the patient is still abed or after he has arisen and is up and about. The first manifestation is often pain referred to the scrotum, though sometimes there is a chill, with elevation of temperature, acceleration of pulse, and headache, so that a recrudescence or a relapse may be suspected. The pain may involve the testicle, the epididymis, and even the spermatic cord, and it may extend into 1 Revue de Medecin, 1883, iii. 829, 861. 2 Ziemssen's Handbueh du speciellen Path, und Tlierap, 1874, ii. B. 2, 189. 3 Bulletin et Mem. de la Soc. Med. des Hop., 1889, lvi. 236. 4 Deutsche klinic, 1870, 42 and 48. 5 Miinchener med. Wochenschr. , 1888, p. 620. 8 Ibid., January 20, 1891, p. 4:?. 196 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. the loin. Often a sense of weight or heaviness in the testicle is complained of. The scrotum may become red, tense, and cedema- tous, and effusion may take place into the vaginal tunic of the testicle. Such an effusion was reported in nine of the cases in this collection. The testicle or epididymis or both become swollen and tender, and they may undergo suppuration. Such an outcome was noted in nine of the cases. Micturition is sometimes attended with burning, and the urine may contain the products of catarrhal inflammation, viz., mucus, epithelial cells, and leucocytes. As a rule, however, there is no urethritis and no history of gonorrhoea. " The testicle is usually attacked first, and in a considerable number of cases alone. In a smaller number the epididymis suf- fers alone or first. In the majority, however, both organs suffer. Thus, orchitis occurred alone in 13 cases, epididymitis alone in 6, and both orchitis and epididymitis in 20. Both sides seem to be attacked with equal frequency. The right side suffered in 18 cases, the left also in 18, and both sides in 1. The complication lasts, in its acute phase, for about a week or ten days ; sometimes its duration is much protracted by suppuration, and often swelling and induration persist for a long time. In several instances the testicle was lost wholly or in part. The complication occurs most commonly at the period of life at which typhoid fever is itself most common. Thus of 26 cases in which the age is stated, 17 occurred between fifteen and twenty -nine years. The age distribu- tion of the cases in which information upon the point is given, is as follows :" Between 1 and 4 years 10 " 14 15 " 19 20 " 24 25 " 29 30 " 34 35 " 39 40 " 44 45 " 49 Cases. 1 2 4 9 4 2 2 1 1 Of Eshner's cases, 37 are from French sources, 2 from English, 2 from American, and 1 from a Swiss source. COMPLICATIONS DURING CONVALESCENCE. 197 The cause of this complication is not easy to determine. Some- times it may be due to infection by the bacillus of Eberth, some- times from pyogenic organisms not peculiar to typhoid fever. Probably the latter are the more common cause. That typhoid bacilli may enter the testicle is proved by the fact that they have been found in the testicle in bodies at autopsy by Chantemesse and Widal without there being any signs of orchitis. That the bacillus of Eberth may be the cause is also shown by a case of suppurative epididymitis coming on during convalescence, which Strasburger 1 has reported. The patient was a man of twenty-eight years, who suffered from typhoid fever, the diagnosis being confirmed by the Widal test. The disease ran its normal course, and during defervescence the patient suffered from an abscess of the gum, numerous boils, and, finally, from an abscess of the cheek. A microscopical examination of the pus derived from these boils did not reveal any micro-organisms. Three weeks after the defervescence had commenced the patient suffered from violent pain in the right testicle, which became swollen, and an examination revealed an epididymitis, and forty-eight hours later fluctuation appeared, and puncture revealed a small quantity of pus. Two days later the abscess was excised and the patient made a complete recovery. Cultures of the pus revealed the bacillus of Eberth. Bucquoy has asserted that such attacks are the result of mastur- bation — a habit, he thinks, frequently practised during convales- cence. Hutchinson, on the other hand, thinks that it is due to thrombosis of the spermatic vein. The orchitis or epididymitis of enteric fever differs from that due to gonorrhoea, in that it is less painful and usually less acutely inflamed. It is, however, rapid in its course to recovery or sup- puration, as a rule, and is usually unilateral. Usually the testicle is first affected, and later the epididymis. The following table is that of Eshneiy and gives a complete record of this condition as it exists in literature. Twenty-seven 1 Miinchener medicinische Wochenschrift, January 3, 1899. 2 Philadelphia Medical Journal, May 21, 1898. 198 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. §■§ £ J: &2 a s. >•** .- a a Mi a.s ■ > z. £2 E- 3) .- -oSOcS =3 g 3 o ' o '< c s >va GO Hn %? 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CO OS O 1— 1 CO CO CO CO ^ Tf COMPLICATIONS DURING CONVALESCENCE. 201 of these cases had been previously collected by Ollivier, and ten by Westeott for Keen : While the manuscript of this part of this essay was in the printer's hands the following additional cases were also reported : Bunts, 1 of Cleveland, Ohio, records the following case of typhoid orchitis : W. C, aged thirty-eight years, private in B Troop, First Ohio Volunteer Cavalry, was taken sick with typhoid and ad- mitted to the Regimental Hospital, at Lakeland, Fla., August 1 2, 1898. He had never previously had an attack of typhoid fever. The fever pursued a moderately severe course, and on September 15th he was sent home to Ohio on sick furlough. On his arrival at home he was practically confined to his bed until October 12th. On October 13th he was suddenly attacked by a severe chill and great prostration. He was immediately sent to the hospital, and was confined to his bed for several weeks with what was diag- nosticated by his attending physician as a relapse of the typhoid. On September 29th, fourteen days after his discharge from the hospital at Lakeland he noticed a swelling in the left testicle. The pain was moderately severe, increasing as the swelling increased, and at the time of his admission to the hospital in Cleveland he suffered considerable pain, which, however, was relieved by rest, elevation, and hot applications. The relapse was severe and his condition most critical. However, convalescence eventually en- sued, but the orchitis remained. Xo history of gonorrhoeal or syphilitic infection could be elicited and the orchitis was diag- nosticated to be a sequel of typhoid fever. Strapping was resorted to in the hopes of reducing the swelling, but was abandoned at the end of a week, no improvement having taken place. After this symptoms of softening and breaking down of the organ became manifest, and it was decided to remove the testicle. This was done November 16, 1898, the only item of interest connected with the operation being that the pulse-rate during the entire operation ranged from 160 to 180, ether being the anaesthetic given. The testicle was found entirely disorgan- 1 Medical News, March 25, 1899. 202 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. ized and a considerable amount of pus was also present. The specimen was sent to the Pathological Laboratory of the Western Reserve Medical College and examined by Dr. Howard, who reported that it contained a practically pure culture of the typhoid bacillus. Beckett 1 reports the following case of epididymitis complicating typhoid fever : M. G., aged forty years, ran a rather severe course of typhoid fever ; was much prostrated. During the fourth week of the disease the left epididymis became greatly swollen, and sup- puration resulted. This condition did not cause much constitu- tional disturbance. A free incision and gauze packing soon effected a cure. 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 generally feeble state, and, finally, the disordered condition of the bowels, as represented by the states of diarrhoea or constipa- tion, 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 out 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 1 Southern California Practitioner, March, 1899. COMPLICATIONS DURING CONVALESCENCE. 203 the mucous membrane of the bowel in the disease are not consid- ered. 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, and by George B. Wood in America, and by many other clinicians since his time. In other cases perforation of the bowel may take place with death therefrom long after the fever has departed. Thus Morin 1 has recorded a case in which perforation occurred as late as the one hundred and tenth day. Sometimes these ulcers, by affording 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 resulting from advanced intestinal catarrh and debility. Under the name of diphtheria of the intestinal mucous mem- brane, Liebermeister has described a condition in which the bowel is affected by diphtheroid sloughs. Very rarely, if ever, are these sloughs truly diphtheritic. The ulceration underlying them may be severe enough, however, to result in perforation of the bowel, as already pointed out. Gangrene of the bowel in distinction from ulceration and local necrosis is still more rare. It is probably due almost always, if not always, to thrombosis or embolism of the mesenteric voh'Is. 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 Tho-e cases in which there is gangrene of the appendix are probably due 1 Des Perforations Intestinal dans le Cours de la Fifevre Typhoide, Paris, 1S69. 204 COMPLICATIONS AND SEQUELJE OF TYPHOID FEVER. to appendicitis, produced by direct infection by the bacillus of Eberth 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 1 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. 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 2 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 case, too, about two inches above the ileo-csecal valve there was constriction, almost to the point of occlusion, and a similar nar- rowing existed at the upper end of the contracted portion of the bowel. Above this upper constriction the small bowel was 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, 3 who 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 followed the use of antitoxic serum. Keen collected nine cases in his Toner Lecture in 1876, although some of these were rather those of can- crum oris than true noma, and Hall has reported to Keen a case which, as Keen says, if not one of noma was 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 4 has re- 1 Berliner klin. Wochenschrift, 1869, Nos. 20, 21. 2 Medical Press and Circular, 1886, xlvi. p. 471. 3 Deutsche med. Wochenschrift, 1898, No. 15, p. 232, and No. 38, p. 500. 4 British Medical Journal, April 30, 1893. COMPLICATIONS DURING CONVALESCENCE. 205 corded two fatal cases of noma following- typhoid fever. In one of these both cheeks sloughed ; in the other there was not only sloughing of one check, but gangrene of the skin of the hip. 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 be paid to individual eases. Glossitis may occur in typhoid fever, but is very rare. Osier has recorded a case which developed glossitis ten days after his temperature was normal, but recovery ensued in a few days. Alveolar abscess may also occur, and Liebermeister records a case in which there was emphysema of the cheek of the afflicted side. Franklin 1 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 Winkouroff, 2 as occurring in a little girl six years old. 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 3 as having occurred in two sisters during the course of typhoid fever. In both cases the right cheek was affected. I have under my care at present a woman convalescing from a most grave attack of typhoid fever, with an abscess forming in the wall of the right cheek which is not connected with the parotid gland or Steno's duet. Keim' has reported a fatal case of typhoid fever in a boy of 1 Quoted by Hutinel. 2 Bulletin de la Societe" Anatomique, December, 1887. 3 London Lancet, February 20, 1893. 1 Lehigh Valley Medical Magazine. October, 1891. 206 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. nine years, in which gangrene of the left cheek occurred during convalescence. Two other cases are reported in the same journal. Another case has been reported by Clark, 1 in which a man of twenty-eight years suffered on the thirtieth day of typhoid fever, with bulging of the right cheek, followed by closure of the right eye and great swelliug of the lids, and on the thirty-third day the left eyelids became involved, and on the thirty-fifth day large non-glandular swellings appeared 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 of twelve years, ending fatally, is reported by Ewens. 2 In this case the sloughing really followed an attack of measles and mumps which occurred during convales- cence in typhoid fever. Gangrene of the tongue has been reported once by Gaston David, 3 while Freudenberger 4 has seen it involve the uvula. Spillmann 5 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 typhoid fever. (Esophageal ulceration 6 may lead in some cases to stricture. A case has been reported by Packard, and one by Mitchell which occurred in Osier's wards. A case of ulcer of the oesophagus has been recently reported by Eiesman to the Pathological Society of Philadelphia, March 9, 1899. (Fig. 19.) In regard to lesions coming on at the other end of the ali- mentary canal after enteric fever we find a case of gangrene of 1 London Lancet, April 9, 1893. 2 London Lancet, August 4, 1889. 3 Quelques Considerations sur la Gangrene Typhoide. These de Paris, 1887. * Aertzliche Intelligenzblatt, 1880, xxvii. 7. 5 Merc. Medicale, 1895, No. 13, 145. 6 A valuable paper, by Russell, on oesophageal ulceration in general is to be found in the Scottish Medical and Surgical Journal for April, 1899. COMPLICATIONS DURING CONVALESCENCE. 207 the anus reported to Keen by Betz, of Oakville, Pa., the condition arising in all probability from general thrombosis of the hemor- rhoidal arteries. This patient was a boy of ten years, who at the end of the fifth week complained of irritation about the anus, the parts being found slightly discolored. Within twelve hours the Fig. 19. Riesman's case of ulcer of the oesophagus in typhoid fever. (Case reported in the Philadelphia Pathological Society's Transactions, March, 1899. ) tissues of the ischio-rectal fossa sloughed out and the rectum was found to be gangrenous. It speedily separated, leaving a large opening. Curiously enough, absolute recovery took place, the ♦evacuations being finally perfectly controlled. 208 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. Cases 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 are not medical con- ditions and, therefore, need not be discussed at this time. Passing on to the lesions found in the organs associated with the alimentary canal, we find that inflammation of the parotid gland is an unusual complication of typhoid fever, and is due to extension of infection from a foul mouth through Steno's duct. In rare instances, however, the parotitis is due to true typhoid infection. Thus Janowski 1 records a case of a man of twenty years who died 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, 2 both the bacillus of Eberth and the staphvlococcus were found to be present. Sometimes the inflam- matory process goes no further 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. Xot only may the local necrosis be dan- gerous 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 septi- caemia or pyaemia by infecting the great vessels and lymphatics. Facial palsv 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 stylo- mastoid foramen, the neighboring bony tissues being involved. In regard to the frequency of this condition, we find that Hoff- mann met with suppurative parotitis in 16 cases out of 1600 patients, and that 7 of these died. Ordinary parotitis occurred in 3 cases. In 15 cases the attack was limited to one side, 9 times in the right and 6 times in the left. Keen collected 26 cases in his Toner Lecture of 1876, and 50 more in his recent essay. Thirty per cent, of these died, and 20 of the 28 cases in 1 Centralblatt Bacteriol. und Parasit., 1895, xvii. 685. 2 Lehman. Centralblatt fur klin. Med., August, 1891, 649. COMPLICATIONS DURING CONVALESCENCE. 209 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. 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. The liver may become affected by various conditions in conva- lescence. Of these we find, as most important, abscess, cholangitis, and cholecystitis. Here, again, the exhaustive monograph of Keen may be 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 ba- cillus coli communis, to the staphylococcus, or to the bacillus of Eberth, and is very rare. Osier has not met with it once, and in the Munich 2000 autopsies 1 it was only met with in twelve cases, while Dopfer, in 927 cases, found abscess in only ten of them. Out of the twenty-one cases of solitary abscess no less than nineteen cases died. When there are septic foci elsewhere the abscess is usually secondary and multiple. Louis has recorded a case of hepatic abscess associated with parotid suppuration, and Chvostek one con- secutive to perichondritis of the larynx. Delaire 2 has reported an instance in which an hepatic abscess ruptured into a bronchus ; the abscess was incised and recovery occurred. Lannois reports the following ease, which occurred in the Hopi- taux Militaire de la ( 'haritc in 1881 : A man of twenty-two year-, 1 Holscher. Miinchener med. Woclienschrift, 1S91, Nos. 3 and 4. 2 Gazette des H6pitaux, 1869. 1 I 210 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. after several days of malaise, presented all the signs of adynamic enteric fever. In the third week he became intensely jaundiced, " fairly black; " the liver was enlarged ; there was active delirium and intense pulmonary congestion. Eleven days after the onset of the jaundice a small superficial abscess appeared on the back of the left hand and on the right side of the face. The autopsy revealed the ordinary lesions of typhoid fever, congestion of the lungs, and an enormous hepatic abscess of 3000 grammes (3 quarts). The pus was yellow and greasy, and the gall-bladder was distended with clear liquid and muco-pus. The other case recorded by Lannois 1 is somewhat different from this, in that the symptoms of abscess developed after the fever had ceased. On the third day of apyrexia the patient, who was a young man of twenty-eight years, was seized by a violent chill, followed by high fever and at the same time by signs of " pleuro-pulmonary " dis- ease at both bases, but chiefly at the right base. Ten days later the belly was tympanitic, and there was tenderness in the hypo- chondrium of the right side. Rapid emaciation ensued ; the pulse became feeble, and the patient oppressed. Sharp pain was suffered in the epigastrium. There was no oedema or albuminuria. The autopsy revealed old lesions of enteric fever, and in the vena porta a large thrombus which extended into all the neighboring branches. Ten large abscesses were found in the lower part of the right lobe of the liver. They varied in size from a mandarin orange to that of an egg. The pus was creamy yellow. Pleural effusion was present. Multiple abscesses of the liver have been recorded by Romberg 2 after a severe attack of typhoid fever complicated by hemorrhage and followed by jaundice ; death occurred. Miliary abscesses were scattered through the liver in large numbers, and there was sup- puration of the mesenteric glands with thrombosis of the portal vein and its branches. 1 Kevue de Medecin, 1895, p. 913. Pylephlebite et Absces de Foie Consecutif a la Fievre Typhoide. 2 Berliner klin. Wochensclirift, March 3, 1891. COMPLICA TIONS D URING CONVA LESCENCE. 2 1 1 Another case of multiple hepatic abscess complicating convales- cence in typhoid fever, has very recently been reported by Herman, 1 of Memphis. The patient was a man of twenty -six years, a fireman by occupation, who on the thirty-third day of his illness was seized with a chill and severe lancinating pain in his right side, followed by a rise in temperature and marked tenderness in the liver, but no physical signs of pulmonary trouble. Three days later the patient suffered from rigors and sweats. An aspirator revealed pus, and upon the ninth rib being resected, six ounces of choco- late-colored pus escaped. Later, another rise in temperature with sweats indicated the presence of further pus-formation, and explo- ration revealed additional abscesses which discharged pus when their walls were broken down by the finger of the operator. This happened a third time, and in each instance when the pus was evacuated temporary improvement took place, but the patient finally died from exhaustion. Suppurative pylephlebitis is another rare state and may cause hepatic abscess. It arises usually as the result of thrombosis of the vena porta. Schultz found, in studying the statistics of 3686 cases of typhoid fever in Hamburg, that 302 deaths occurred, but no instance of this condition was met with. Buckling 2 found this lesion in two cases. Romberg, 3 who studied 677 cases with 88 deaths, found one instance, although he refers to four more. Staphylococci were found in the thrombi and in the pus. Osier 4 saw one case in which multiple abscess of the mesentery was pres- ent, and the portal vein outside of the liver was an elongated abscess. So, too, Lannois 5 records a case of thrombosis of the portal, splenic, and inferior mesenteric veins, with multiple hepatic abscesses. In this case the specific bacillus was found in the pus. Klebs 6 has recorded a case of suppurative cholangitis in which the bile passages were dilated into large abscess cavities. Cholecystitis, unlike the hepatic complications of typhoid fever 1 Memphis Lancet, 1899. z Falle von Leber Abscesse, Berlin, 1868. 8 Berlin, klin. Wochenscbrift, 1890, 192. 4 Trans. Assoc. American Physicians, 1897, 382. 5 Eevue ele Medicin, 1895, 909. 6 Handbuch der Pathol. Anatomic 212 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER. just reviewed is as common as they are rare. Thus Louis 1 states that changes in the gall-bladder are much more frequent in the course of typhoid fever than in any other disease. "Westcott collected for Keen 74 cases of true typhoid infection of the gall-bladder, of which 30 were operated on. Notwith- standing this comparatively small number in which the bacillus was proved to be the cause of the affection, literature teems with cases iu which typhoid cholecystitis was present. Aside from Louis's description of it, we find Andral and Grisolle writing on it as long ago as 1835, and later Rokitansky, 2 Frerichs, 3 and Budd 4 recorded such cases. In America as long ago as 1846 Ayres 5 reported the case of a young physician so affected, who died of peritonitis, and Murchison 6 tells us that " fatal peritonitis may result from ulceration of the gall-bladder proceeding to per- foration." Among those who have written on this very important theme still more recently we may name Chiari, 7 Dupr§, 8 Courvoisier, 9 and Hagenmuller, 10 the latter collecting eighteen cases. It was not until 1890 that Gilbert and Girode 11 proved that suppurative cholecystitis arose from typhoid infection. 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 12 records a case in which, at a chole- cystotomy, the bacilli were found in the gall-bladder six months 1 Typhoid Fever, Trans. Bigelow, 1836, vol. i. 269. 2 Manual of Path. Anat. Sydenham translation, vol. ii. p. 160. 3 Disease of Liver, vol. ii. p. 454. Sydenham translation. 4 Diseases of Liver, 3d American ed. , Philadelphia, 1857. 5 New York Journal of Medicine, 1846, vol. vii. p. 315. 6 Continued Fevers of Great Britain, pp. 566 and 634. 7 Ueber Cholecystitis Typhosa. Prager med. Wochenschrift, 1893, No. 22. 8 Les Infections Biliares. These de Paris, 1891. 9 Casuistisch Statistische Beitriige ziir Pathologie und Chirurgie der Galbur- wega, Leipzig, 1890, pp. 76 and 94. 10 Cholecystitis Typhosa. These de Paris, 1876. 11 Mem. de la Societe de Biol., 1890; La Semaine Med., 1890, No. 58, and Mem. de la Societe de Biol., 1893, p. 986. 12 Les Infections Biliares. These de Paris, 1891. COMPLICA TIONS D URING CONVALESCENCE. 213 after the fever ceased, and Chantemesse 1 records an instance eight months after the fever, while von Dungen 2 recites one remarkable instance of cholecystitis fourteen and a half years after the fever. In the pus of this case the Eberth bacillus was fou/nd. The American writers on this topic have been chiefly Mason, 3 of Boston, and Osier. 4 Mason tells us that the 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. In many of these cases gallstones have been found present, and these probably aid in opening the way for infection, but Bernheim 5 and Chantemesse advance the view that the infection aids in forming the stones. So firm are the French in the belief that this view holds true that they called this form of the disease "hepatic typhoid," 7 and Dufourt 8 has recorded nineteen cases of biliary lithiasis which had their first attacks after enteric fever and all of them within ten months of the fever. Gilbert and Four- nier 9 divide cholelithiasis into two groups : those which are the more numerous, being due to the colon bacillus, and the less fre- quent form, due to the bacillus of typhoid fever. A case has been recorded by Anderson 10 in a man of 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 u also reports a case in which a child of five years suffered from a pear-shaped tumor in the hepatic area, and great pain. Operation revealed suppurative cholecystitis, with the 1 Traits de Med, i. 764. 2 Miinchener med. Wochenschrift, 1897, No. 26, 699. 3 Transactions Assoc. American Phys., 1897, xii. p. 23. 4 Ibid., p. 378. 5 Diet. Encyclo. de Dechambre, 1889. Entire art. 6 Quoted by Dupre, loc. cit. 7 Landouzy. Gaz. des Hopitaux, 1883, 8-41, or Matliieu, Rev. de Mc'd., 1886. 8 Revue de Med., Paris, 1893, p. 247. 9 Compte-rendus Soc. Biol., March 5, 1897, p. 936. 111 ( an ada Lancet, 1896. " Quoted by Osier, ibid. 214 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. typhoid bacillus in the pus ; recovery occurred. Hawkins 1 reports a case of this character in which after death there were found typhoid lesions, and Osier 2 records four cases, three of which recovered and 1 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. Cushing 3 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 us that he has recently seen a case in which the pus from a sup- purative lithiasis of the gall-bladder gave the WIdal reaction. This patient had typhoid fever six years before. Cushing 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 found, although there Avas no history of typhoid fever. The blood in Cushing' s case also gave the typhoid reaction. Cushing suggests that the typhoid bacilli enter the gall-bladder, as they have been shown to do by Futterer, 5 and remain alive a long time, during which an agglutinative re- action takes place, forming a clump about which the material for the formation of a stone clusters. Finally, it is interesting to note that in the mind of no less a pathologist than Chiari, it is held that relapses in typhoid fever may ensue from the gall-bladder infection. 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 1 Lancet, January 30, 1897. 2 Ibid. 3 Johns Hopkins Hospital Bulletin, May, 1898, No. 86. 4 Progressive Medicine, March, 1899. 5 Miinchener med Wochenschrift, 1888, No. 19. COMPLICA TIONS D URING CON VA LESCENCE. 215 has occurred, intestinal perforation. Leucocytosis would be indi- cative of acute cholecystitis and appendicitis. The prognosis of cholecystitis is grave. Only one-quarter of the cases collected by Mason got well. The mortality of perfora- tion of the gall-bladder is very high. Twenty-six cases not oper- ated on died ; of four operated on, three recovered and one died. For further statistics the reader is referred to Keen's essay. The following cases illustrating cholecystitis collected by Mason are of interest : "Case 1. Leudet. 1 Female, aged thirty-six years. Fourth week, pyriform tumor in right hypochondrium, disappearing in ten days ; reappearing at intervals during seven weeks. No jaun- dice. Recovery. "Casel. Griesinger. 2 Female, aged twenty years. Sixth week, peritonitis, slight icterus. Painful tumor to right of umbilicus. Swelling of liver ; collapse ; convalescence. In eighth week sud- den return of tumor, with chills, icterus, vomiting ; later, two more relapses. Recovery fifth month. " Case 3. Laveran. 3 Man, aged twenty-three years. Painful symptoms and tumor in region of gall-bladder in sixth week. Recovery. " Case 4. Martin-Solon. 4 Patient died of peritonitis, and twenty-five ulcers of gall-bladder were found. Previous illness not clearly typhoid fever. Entente (?). " Case 5. Husson. 5 Child, aged eight years. Died at end of third week. Perforated gall-bladder. Cystic duct obliterated and converted into fibrous cord. " Case 6. Dumoulin. 6 Man, aged nineteen years. Third week, constant nausea and vomiting. Enormous tumor in right hypo- chondrium, extending to left of umbilicus and into right iliac fossa. Resistance like tense hydrocele. Liver raised. Upper limit line of right nipple. Diagnosis : distended gall-bladder. Repeated 1 Hagenmiiller, ibid. 2 Ibid. 3 Ibid. 4 Bull. Fac. de Med. de Paris, 1820-'21, vii. pp. 370-375. 5 Bull, de la Soc. Anat., 1893, p. 104. 6 Gaz. Med. de Paris, 1884, 3d series, tome iii. p. 551. 216 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. chills, suggestive of hepatic abscess. Coma ; death, sixteenth day. Autopsy : typical intestinal lesions of typhoid ; tumor, size of head, containing two litres of greenish bile ; no gallstones ; adhesions with liver, transverse colon, etc. " Case 7. Archambault. 1 Infant, thirtieth day, signs of intes- tinal perforation. Death twelve days later. Perforation of gall- bladder ; localized peritonitis. "Case 8. Barthez and Rilliet. 2 Girl, aa*ed twelve vears. Six- teenth day, tumor in right hypochondriurn, which gradually disap- peared. Death, fifty-second day. Autopsy : perforated gall- bladder ; circumscribed pus cavity between liver, stomach, gall- bladder, and colon. " Case 9. Ranvier. 3 Man, aged twenty-eight years. Died during convalescence in the fifth week. Autopsy : limited perito- nitis ; perforated gall-bladder ; right side of abdomen filled with yellowish, opaque liquid. Walls of gall-bladder two or three millimetres thick and infiltrated with pus. A small calculus. Fever's patches in stage of cicatrization. Author says he cannot explain this point of suppurative election. "Case 10. L. Colin. 4 Soldier; end of third week of rather mild attack ; jaundice, gastro-abdominal pain. Death eleven days later. Autopsy : peritonitis limited by transverse colon, liver, and abdominal wall. Gall-bladder size of goose-egg ; per- forated. Xo gallstones. Ducts pervious. Typical intestinal lesions. "Case 11. C. E. E. Hoffmann. 5 Female, aged twenty-five years, jaundice sixth week ; eighth week, sinuses discharging through abdominal wall. Death twelfth week. Autopsy : de- struction of gall-bladder. Abscess beneath liver containing twelve gallstones. Lesions of typhoid. 1 Bull, de la Soc. Anat., 1852, p. 90. 2 Maladies des Enfants, 1853, 2d edition, vol. ii. pp. 5, 701. 3 Bull, de la Soc. Anat. de Paris, 1863, 2d series, tome viii. p. 432. 4 Etudes Clin, de Med. Militaire, Paris, 1864, p. 197. 5 Zerstorung der G-allenblase bei Typhus. Virchow's Archiv, 1868, slii. 219- 222. COMPLICATIONS DURING CONVALESCENCE. 217 "Case 12. O. W. Foot. 1 Female, aged thirty-two years. Died in eighth week. Small abscess between coats of gall-bladder com- municating by a narrow orifice with interior. Extensive adhesions of abdominal wall. One cholesterin calculus, twenty-three grains. "Case 13. Burger. 2 Man, aged forty-one years. Twelfth day. pain, and tumor size of apple in region of gall-bladder ; gradual increase in size ; chills; no jaundice. Death from peritonitis in fifth week. Perforation of gall-bladder. Adhesions forming cavity filled with pus. No gallstones ; no abscess of liver. " Case 14. P. L. Legendre. 3 Female, aged thirty years. In second week peritonitis at right upper abdomen. Death twelve days later. Autopsy : perforation of gall-bladder. Pus in peri- toneal cavity. Three gallstones." Mason also gives the following references not already quoted in footnotes : Medical and Surgical i£epo?'fe of the Boston City Hospital, third series, 1882. Budd, George : On Diseases of the Liver, third American edition, Philadelphia, 1857. Harley, John : Article on " Typhoid Fever," Reynolds' System of Medicine, vol. i. Pepper, William : American Journal of the Medical Sciences, January, 1857. Guarnieri : " Contribute alia Patogenesi della Infezione Biliari." Ref. Baumgarten's Jahresbericht, 1892, S. 234. Chiari, H. : " Uber Cholecystitis Typhosa." Prag.med. Woch., 1893, No. 22. Chiari, H. : " Uber das Vorkommen von Typhus Bacillen in der Gallenblase bei Typhus Abdominalis," Eleventh International Medical Congress in Rome. Zeitschrift fur Ueitkunde, 1894, Band xv. S. 199. 1 Enteric Fever. Abscess in Walls of Gall-bladder. Irish Hosp. Gaz., Dublin, 1874, ii. 2 Typhus Abdom. mit Perforat. der Gallenblase in die Bursa Omentalis. Deutsches Archiv. fiir klin. Med., Leipzig, 1873-74, xii. S. 623-630. * Bull, de la Soc. Anat. de Paris, 1881, 4th series, tome vi. p. 193. 218 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. Letieime : " Recherche Bacteriologique sur la Bile Humaine." Archives de Med. Experiment, 1891. Naunyn : Cholelithiasis, Leipzig, 1892. Pisenti : Archiv fur JExper. path. Med. et Pharm., 1886. Ref. Brockbank on Gallstones, Philadelphia, 1896. Sherrington : " Experiments on the Escape of Bacteria with the Secretions." Journal of Pathology and Bacteriology, 1893. Blachstein, A. G. : " Intravenous Inoculation of Rabbits with Bacillus Coli Communis and Bacillus Typhi Abdominalis." Bul- letin Johns Hopkins Hospital, July, 1891, vol. ii., No. 14. Flexner : " Certain Forms of Infection in Typhoid Fever." Johns Hopkins Hospital Reports, vol. v. Robson, Mayo : " Diseases of the Gall-bladder and Bile-ducts." British Medical Journal, March 13, 1897. Brockbank : Op. cit., p. 130. Robson, Mayo : Loc. cit. Monier- Williams and Sheild : Lancet, March 2 ,1895. Malvoz : Recherche Bacteriologique sur la Fievre Typhoide. Paris et Leipzig. Dupre : Op. cit. Dufort : Loc. cit. Guni- precht : Deutsche med. Woch., 1895, No. 14, et seq. Von Hoffmann : Untersuchungen iiber die Pathologisch-anato- mischen Veranderungen der Organe beim Abdominal-typhus. Leip- zig, 1869. Sometimes in typhoid fever the mesenteric and retroperitoneal glands undergo suppuration and break down, causing sepsis. In other instances a subdiaphragamtic abscess forms because of cho- lecystitis, of suppuration of these glands, or from perforation of the bowel. A case of this character is recorded by Klein 1 of left- sided subphrenic abscess due to typhoid fever, in which the pus contained the specific bacillus. Three litres 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. 1 Uber die Pyogene Wirking des Eberthschen Bacillus bei Typhuskornplica- tionen. Inaug. Dissert., Bonn, 1898. COMPLICA TIONS D URING CONVALESCENCE. 219 Tuugol 1 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 2 records a case of suppurating mesenteric gland, the pus of which contained the bacillus of Eberth, and FrankeP 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, 4 Thomson, 5 and Low. 6 Jaundice complicating typhoid fever is exceedingly rare. Lie- bermeister met with it twenty times in 1420 cases, Griesinger ten times in 600 cases, Osier not once in one series of 500 cases. Murchison only saw three cases, all of which were fatal. It is caused by catarrh of the ducts, toxaemia, abscess and gallstones Avith or without cholangitis. Osier, 7 however, records two cases, in one of which the jaundice developed at the onset of a relapse, in the other at the end of the second week. The first case recov- ered, the second died of toxaemia . Another case of Jaccoud's, studied by Sabourin, 8 was that of a man of twenty-nine years, in the third week of the disease, who had intense icterus, great asthe- nia 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. In the tropics jaundice seems to be a more frequent complica- tion of typhoid fever than in the temperate zone, for Jamieson 9 records nine cases, of which four died. Sometimes hypertrophic enlargement of the spleen occurs after 1 Klin. Mittheil ausder Kaiserlich. Hamburg Allegemeine Krankenhaus, 1864. 2 Centralblatt fiir klin. Med., August, 1891, 649. 3 Verhandl. Kongress fiir inner Med., 1887, 179. * British Medical Journal, 1888, i. 1388. 5 Glasgow Medical Journal, 1882, xvii. 244. 6 British Medical Journal, 1881, ii. 122. " Loc. cit. 8 Bevue de Med., 1882, vol. ii. p IJOO. 9 Imperial Maritime Customs Med. Beports, 1891, 37th issue. 220 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. typhoid fever. I have seen two cases ; one is under my care at present, the other was some years ago, and is shown in Fig. 20. A number of cases of rupture of the spleen due to the devel- opment of an abscess and later exposure and traumatism have been recorded during convalescence in typhoid fever. A case of rupture of the spleen, uot due to these causes is, however, reported Fig. 20. Splenic enlargement after typhoid fever. by Santi Flavio, 1 in a man of twenty years, after having been under observation for ten days, suffering from typhoid fever, devel- oped pleural pneumonia with pleural effusion, which required tap- 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 1 Gazetta degli Ospitali, 1S91, No. 43. COMPLICATIONS DURING CONVALESCENCE. 221 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. As an interesting illustration of what a patient may recover from during typhoid fever in the way of an accident extrinsic to his disease, a case is recorded by Heath, 1 of a man of twenty-three years, who at the end of the fourth week of his fever swallowed the clinical thermometer which the nurse had placed in his mouth. 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 was passed unbroken and registered a temperature of 104.7°. Nervous Symptoms in the Far-advanced Stage of the Dis- ease 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 paralysis, as a paraplegia, or as a hemiplegia, and it may be due in the first three instances to peripheral neuritis, in the second instance to a myelitis or neuritis, and in the case of hemiplegia to cerebral lesions, such as thrombosis, embolism, hemorrhage, and meningoencephalitis. Sometimes the monoplegia or partial para- plegia may be due to a poliomyelitis. By far the most common of these affections is the loss of power due to neuritis, a condition which is not commonly met with as a complication of typhoid fever, yet not so rare as the other changes just named. The most exhaustive and interesting monograph con- cerning this complication of the disease is that given us by Ross and Bury, 2 in their essay on " Peripheral Neuritis," first published 1 American Lancet, December, 1888. 2 A Treatise on Peripheral Neuritis. Griffin & Co., 1893. 222 COMPLICATIONS AND SEQUELM OF TYPHOID FEVER. in the Medical Chronicle and afterward in a separate volume. So complete and thorough is their study of the literature of the sub- ject and of the clinical aspect of the condition that much of the following information is to be credited to them. Gubler, 1 among several cases of local palsy after typhoid fever, records the case of a boy of 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. This latter point is of interest in view of the fact that Gowers states that this condition never arises from typhoid fever. Gubler also states the case of a boy who, after an attack of forty-seven days, suffered from paresis in his legs and became unable to raise himself 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 2 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 in the left. So, too, Kraft-Ebing 3 speaks of weakness of the adductors of the thigh and hyperesthesia of the skin supplied by the saphenous nerve. Bailly 4 has recorded paraplegia, anaesthesia, and contractions in these cases, and in two instances paralysis of the palate, and Nothnagel 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 anaesthesia, pain, and tingling sen- sations, and in one of these patients the trouble in the lower 1 Gubler. Arch. General de Med., 1860. 2 Surmay. Arch. General de Med., 1865, tome i. p. 678. 3 Kraft-Ebing. Beobachtungen und Erfahrungen iiber Typhus Abdominalis, 1871. 4 Bailly. These de Paris, 1872. Nothnagel. Deutsches Arch, fur klin. Med., Bd. ix. p. 429. COMPLICA TIONS D URING CON VA LESCENCE. 9 23 extremities was folloAved 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 1 and Benedict, and in one recorded by Eisenlohr, 2 a man of thirty years, eleven days after his temperature became normal, suffered from numbness and loss of power in the left leg and feet, with 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 passing from joint to joint might hav,e aroused a suspicion that the cause was rheumatic, and because certain writers in quoting the case considered it as an instance of paralysis coming on during relapse. As Ross and Bury point out, it is possible that the rheu- matic poison was the cause of both the joint changes and the evidences of neuritis. Additional cases of peripheral neuritis have also been reported by Bernhardt, 3 Vulpian, and others. Thus a case of deltoid paral- ysis has been recorded by Vulpian, 1 which was in all probability due to a peripheral neuritis. A young man of eighteen years, after an attack of typhoid fever, suffered from pain in the arm 1 Leyden. Klinik de Ruckenmarkskrankheiten, 1875, Bd. ii. Abth. 1, p. 247. 2 Eisenlohr. Arch, fur Psychiatrie und Nervenkrankheiten, 187(5, Bd. vi. p. 543. 3 Bernhardt. Deutsch. Arch, fur klin. Med., 1878, p. 363. 4 D'Accident Survenus Pendant la Convalescence de la Fifivre Typhoide. Revue de Medicine, 1883, p. 617. 224 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. and developed loss of power in the right shoulder, with 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 1 published their paper, in 1885, that the first careful microscopical 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 who died during the active period of typhoid infection, but in Avhom no signs of peripheral neuritis had been noted during life. Curiously enough, in three out of these four cases changes indicating parenchymatous neuritis were found to be present, and, still more curiously, one of these patients died as early as the sixteenth day of the disease, while two others died on the thirty-sixth and twenty-fourth days respectively. Other instances of post-mortem 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, and in both cases parenchymatous degeneration of the peripheral nerves was found, in one of which it affected the great saphenous and peripheral nerves, and hi the other a branch of the cutaneous nerve supplying the dorsum of the right foot, and showed com- plete degeneration of many of its fibres. Since these papers have been published, others dealing with the clinical aspect of the case have been placed upon record by Alexander, 2 Handford, 3 Archer, 4 Humphreys, 5 Klumpke-Dejerme, 6 1 Pitres and Vaillard. Compte Rendu. Soc. de Biol., Paris, 1885, S. 8, ii. 661, and Eev. de Med., Paris, 1885, v. 985. 2 Alexander. Deutsche med. Wochenschrift, 1886, vol. xii. 529. 3 Handford, H. Peripheral Neuritis in Enteric Fever. Brain, vol. xi. 237. * Archer. British Medical Journal, 1887, vol. i. p. 727. 5 Humphreys (F. R. ). A Case of Peripheral Neuritis following Typhoid Fever. Abstr. Tr. Hunterian Society, London, 1889-90, 41. 6 Dejerine-Klumpke. Des Polynevrites en General et des Paralysies et Atro- phies Saturnines en Particulier. Paris, 1889, p. 222. COMPLICATIONS DURING CONVALESCENCE. 225 and notably the two cases reported by Bury in the essay which I have named. One of these was in a girl of eighteen years, who 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 after- ward, when it was found there was great wasting of all the mus- cles 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 be extended, and there was atrophy of the thenar and hypothenar 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 chloroform, 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 of 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. Dercum has reported to the author two cases of peripheral neu- ritis after typhoid fever, due to the excessive administration of alcohol during the illness. Thus a girl of fourteen years received one and a half pints a day for some time, and developed typical alcoholic neuritis. These cases give some idea of the character of the various forms of peripheral neuritis which follow typhoid fever. Other instances might be quoted in which there was doubt as to whether paraplegic symptoms were due to neuritis or to damaged tone of the tracts and cells in the spinal cord. Thus Mitchell 1 has recorded a case 1 Mitchell (S. W. ). Boston Medical and Surgical Journal, 1879, c. 245. 15 226 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. 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 1 has recorded a case in which there was paralysis with spastic con- traction of the lower extremities, with 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 trophic changes in the organs supplied by the nerves which are involved is shown by a case reported by Wedenski, 2 of a boy of seventeen years, in whom, two years after typhoid, symmetrical gangrene developed as a result of degeneration of the peripheral nerves. !No lesions were found in the muscles nor in the cerebro-spinal nervous system. Closely associated with the question of true paraplegia follow- ing enteric fever is that partial paraplegia or ataxia of the stage of convalescence in which there is a strange inability of the patient to use his lower limbs. This 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 pathognomonic of this state. In connection with the question as to whether these various forms of paralysis are spinal or peripheral, the following quotation from Ross and Bury is of importance : "While it is probable that a few cases of muscular atrophy which follow typhoid fever depend upon an anterior poliomyelitis, and that a condition similar to that of infantile paralysis is pro- duced, 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 1 Eoss (G. ). International Journal of the Medical Sciences, 1889, p. 25. 2 Wiener Medizinischer Presse. COMPLICATIONS DURING CONVALESCENCE. 227 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 disturbance, succeeded by a limited paral- ysis 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 disappear- ing, are points strongly in favor of an affection of the peripheral nerves." An interesting case of peripheral neuritis after typhoid fever has been recorded by Putnam, of Boston. In this the patient suffered from trophic changes in that small abrasions did not heal. There was marked analgesia, and when seen two years after the attack of the fever, this 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 three other classes of symptoms showing peripheral- nerve disturbances : First, cases in which excessive muscular con- tractions are developed in place of paralysis, but associated with pain and hyperesthesia. Eleven of these cases have been reported by Aran in U Union Ifedicale, July, 18, 1855. The contractions occurred toward the end of the attack of typhoid fever, and never were begun with 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- ited almost incessant fibrillary contractions. By gradual manipu- lation, artificial extension could be obtained, and this gave the patient relief for a short time. In four cases the muscles of the trunk were affected and opisthotonus was produced, the patient being held immovable by the muscular contraction, which also caused great 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 symptoms save an occasional numbness of the affected parts. Although three of the patients died, Aran thinks 228 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. 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 1 has recorded a case of contraction of the hands, and Dewerve refers to this condition as possible of occurrence in the Nouveau Dictionnaire de Ife'dicine et de Chirurgie. So, too, ISoth- nagel 2 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 disturbances 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 Handf ord, and consist of great hyperesthesia of the toes and heels of patients in the latter part of the disease or, more particularly, during convalescence. Finally, a few cases have been recorded in which the rapidly 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 MSdieine for 1885, but in each of these there is good reason to believe that the lesions were really those of neuritis and not really those of myelitis. A case has, however, been reported by Shore in the St. Bartholomeiv's Hospital Reports, vol. xxiii., in which there was acute myelitis of the anterior cornua and involve- ment of three of the eight cervical nerves. 1 Archives Generate de Me"d. xv. 5th series. 2 Deutsche Arch, fur klin. Med., 1872, 9. COMPLICATIONS DURING CONVALESCENCE. 229 Hemiplegia arising from typhoid fever is not as rare as mye- litis, and is far less common than paralysis due to peripheral neu- ritis. By far the most extensive research into the literature of this subject is that of Dr. Francis Hawkins, who has collected in the Clinical Society* Transactions for 1893, vol. xxvi., 17 cases from literature ; 3 of these occurred in children under fifteen years of age, and the time of onset in 14 of the cases was the second week ; in 1 case the third week ; in 6 cases the fourth week, and in 5 cases during convalescence. The right side was paralyzed in 12 of the 16 cases in which the statement as to the side paralyzed was given, and aphasia occurred iu twelve instances. Curiously enough, only two of the seventeen cases died, and in both of these a thrombus plugged the middle cerebral artery. In all prob- ability a great majority of the cases of hemiplegia complicating typhoid fever are due to this lesion. Thus, Osier has recorded a case of a young 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 favorable, he was suddenly seized with uneasy feelings in his head, the pupils were dilated, and in a few minutes he suffered from a short, sharp gen- eral clonic convulsion, beginning almost simultaneously in both arms ; the eyes showed marked conjugate deviation to the left and upward, and the head was also turned to the left. The convul- sions were profound at short intervals for an hour, then became less intense, and finally ceased altogether for several hours ; they were accompanied by profound unconsciousness, and the 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 post-mortem examination held by Flexner revealed thrombosis in the ascending 230 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. 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 thrombosed ves- sels. Out of the well-known 120 cases collected by William Osier of hemiplegia in children there was no instance of hemiplegia fol- lowing typhoid fever, and in 160 cases collected by "Wallenberg, four only occurred after typhoid fever. Osier, 1 however, reports two cases of post-typhoid hemiplegia. One of these occurred in a girl of six years. Almost two months after the beginning of her illness she was seized 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 apha- sia, lasting for seven weeks. Gradually the patient largely recov- ered from this paralysis, but complete recovery did not ensue. The second case was that of a clergyman, aged twenty-five years, who was seized with convulsions fourteen days after going to bed with headache, fever, and diarrhcea. 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 his mental condition was excellent. Another case of this character was reported to the Johns Hop- kins Medical Society by Blurner : 2 that of a little girl who one week after convalescence had begun, and who had been eating solid food, was seized with 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 ; 1 Journal of Xervous and Mental Diseases, May, 1896. 2 Johns Hopkins Hospital Bulletin, April, 1896, p. 72. COMPLICATIONS DURING CONVALESCENCE. 231 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 suffered 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 with no sign of facial paralysis, 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 character seen in the Massachusetts General Hospital. On the tenth day of the illness in one case the ward orderly found at 1 a.m. that the patient was unable to move the right arm and leg ; the face was flushed, the eyes half closed, the pupils equal, and eyeballs rolled upward. The patient's mental condition was very stupid. Eight days later the patient was distinctly better, unable to speak, but evidently understood what was said to him ; he could not protrude his tongue, but later was able to read the paper and to say a few words. The other case was that of a girl of 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-side hemiplegia with motor aphasia. A case of hemiplegia has also been recorded by jSTewbolt, 1 in which a locomotive fireman of 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 was 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. 1 London Lancet, August 27, 1893. 232 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. Still another case of hemiplegia complicating' typhoid fever is recorded by Imradi. 1 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 hemiplegia. The fever ran a typical characteristic course, but recovery occurred. Imradi asserts that there are only fifteen similar cases to be foimd in literature. Vulpian 2 has recorded a case of obstruction of the left Sylvian artery in the course of typhoid fever, causing right 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 male hysteria), Stevens 3 has re- corded the history of a man of twenty-two years who three months after recovery from this disease found he had difficulty in approximating the fingers of his left hand to one another. He tells us that " the fingers are flexed upon the palm of the hand more or less. They can passively and slightly, by voluntary effort, be extended within narrow limits (see figure in Glasgow Medical Journal). The thumb is turned outward and flexed at the interphalangeal joint. Forcible extension of the fingers is accompanied by considerable pain, but the thumb is less painful in this respect. The wrist joint is fixed, evidently largely by mus- cular spasm, and not by definite anchylosis. Movement 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 mus- cles. The position of the thumb in relation to the other fingers is 1 Centralblatt fur de ined. "Wissenschaften, October 25, 1891. 2 Eevue de Medicine, 1884, p. 162. 3 Glasgow Medical Journal. January to July, 1897, vol. xlvii. COMPLICATIONS DURING CONVALESCENCE. 233 further 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 involv- ing the extensors, so that the toes are all drawn well up upon the dorsum of the foot, the first phalanx in each ease being drawn far back upon the metatarsal 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 fairly good in both lower extremities, and no appreciable difference is made out between the two sides. " Sensation is tested in both upper and lower extremities, and found to be normal. The reflexes (tendon) in the left upper extremity are abolished ; in the right, normal. The superficial abdominal and cremasteric reflexes on the right side are easily elicited ; the former can be faintly brought out on the left side, but the latter on the left side cannot be elicited. The 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, decid- ing that the condition was male hysteria. They state : " 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 his 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. 234 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. "3. Apparently normal response of the muscles to faradic irri- tability. "4. The complete disappearance of the symptoms under deep chloroform necrosis. " There were also the peculiar hysterical posture 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 of thirty years suffered in October, 1895, from an attack of typhoid 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 extremities felt numb, although there was no loss of sensation. This condition persisted for a couple of months, when improvement began, first in the leg ; almost complete 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 Mensel may be cited, in which necrosis of the skull followed the formation of a clot in the middle meningeal artery. Aphasia or other disturbances of speech after enteric fever have also been recorded by a number of observers without simultaneous hemiplegia. Thus Hutinel 1 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 readily absorbed exudation. Mental disturbance following typhoid fever is by no means rare, and varies in degree from slight mental enfeeblement and inability 1 Etude sur la Convalescence et les Eechute de la Fievre Typhoi'de, Paris, 1S83. COMPLICATIONS DURING CONVALESCENCE. 235 to do mental work to marked insanity. When the patient is vio- lent 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, which has been contributed to this essay by the author's friend and col- league, Dr. F. X. Dercum, Clinical Professor of Diseases of the Nervous System in the Jefferson Medical College. Rathery 1 and Hutinel have recorded cases of post-typhoid tremor. In one of Rathery's cases it persisted fifteen months after the fever ceased. Similar cases have been recorded by Freund. 2 Fry, 3 of St. Louis, records a case of so-called paralysis agitans following immediately after typhoid fever. The trouble began with the ending of the fever in a tremor, which gradually increased in violence, and chiefly involved the right arm and later the left. Still later the legs were involved. No definite reason for believ- ing the case to be Parkinson's disease and not one of ordinary tremor is vouchsafed. Gubler 4 has recorded amaurosis and strabismus after typhoid fever, and the latter symptom has also been seen by Nothnagel. 5 Paralysis of the soft palate has also been recorded by Gubler, and of the vocal cords by Turck and Nothnagel. All these symptoms are but evidences of the peripheral neurites already discussed. Bouley and Mendel 6 state that paralysis of the vocal cords fol- lowing 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. 1 Des Accidents de la Convalescence, Paris, 1875. 2 Inaugural Dissertation, Breslau, 1885. 3 Journal of Nervous and Mental Diseases, 1897, p. 465. 4 Loc. cit. 5 Loc. cit. 6 Archives Gonerale de Medecine, December, 1S94. 7 Lyon Medicale, March 28, 1897, p. 453. 236 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. 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. Very recently, at a meeting of the Laryngological Section of the College of Physicians of Philadelphia, Dr. MacCoy reported three cases of this rather rare condition of laryngeal paralysis complicating typhoid fever. As he well said in his preliminary remarks : " We can most simply classify these paralyses under the various functions performed by the larynx. Keeping clearly in mind that the chief function 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 life — 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. MacCoy has been good enough to send me the following reports of his cases for mention in these pages : The first case he saw was one of posterior crico-arytenoid paral- ysis. It was double or bilateral, and occurred 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 with a suf- focative attack simulating croup. Getting 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 COMPLICATIONS DURING CONVALESCENCE. 237 accompanied by stridor, and the patient appeared almost mori- bund. Larvngoscopic 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 trepidation to the patient. The effect of the intubation was magi- cal ; complete relief to breathing instantly followed, and in a few minutes the patient was in a quiet sleep. The second subject presented himself for consultation. He was a young man of twenty-three years. He wore a tracheotomy tube. The history showed that he had had 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 bands in the median line. This patient could not do without the tube, and he requires it to the present time. He has a most clever device of a valve and rubber tubing and rubber bulb connected with the canula, by which air is made to close the valve against the mouth of the canula, and so he is enabled to carry on conversation with ease and fluency. In this case intubation was attempted but failed of intro- duction. 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. Larvngoscopic 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 relucant, 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. Finally, cases of chorea have been recorded by Rilliet and 238 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. Barthez, but these may have been cases of tremor rather than chorea. Sometimes in the convalescence a curious state is developed in which the muscles of the lower extremities become painful, some- what brawny, and even slight redness may appear in the skin covering them. Usually this is unilateral, but it may be bilateral. Most commonly it affects the calf of the leg, and pain is developed on pressure or on movement, active or passive. Osier believes this to be a myositis. Whatever it may be, the author can indorse the statement that the condition is painful, from his own experi- ence, although the condition was not well developed. Many years ago V. P. Gibney, of New York, described under the name of "typhoid spine," a condition in which there develops, often some days after the patient is up and about, and often only after some very slight jar or trauma, great tenderness of the spine, and pain in the back and in the legs when they are moved. This condition is not dependent upon a spondylitis, neuritis, or Pott's disease, and is probably a neurosis closely allied to the neuroses seen in severe cases of trauma. Sometimes neurotic patients, particularly women, suffer from hysterical attacks of causeless weeping while convalescence pro- gresses, 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 child whenever one of his fellows came to visit him. Severe hysteria sometimes complicates convalescence in typhoid fever. Thus Simpson 1 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 each succeeding Sunday, the day on which the first attack occurred. Constant vomiting was also present. A condition of very great rarity after enteric fever is tetany. Janeway has reported cases coming on during the height of typhoid fever, the tenth and twenty-fourth days. Pseudo-hypertrophic muscular changes have been recorded as 1 Edinburgh Medical Journal, January, 1896. COMPLICATIONS DURING CONVALESCENCE. 239 occurring after typhoid fever by Lasage. 1 The patient, a man of twenty-seven years, was seized on the nineteenth day of the attack with aeute pain in the left thigh and with other symptoms, which caused a diagnosis to be made of phlegmasia. Swelling of the limb did not, however, disappear, and several months later it was found to be greatly increased, the hypertrophy involving the mus- cular 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-like contractions. At the time the case was reported the condition had persisted for two years. The following references for which I am indebted to Ross and Bury's monograph, may be of interest in this connection : Meyer. Die Elektricitat auf Praktische Medicin, 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 Consecutives aux 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 Brit- ain. Second edition, 1873, p. 225. Teale and Morven, quoted by JNotlmagel. Deutsche Archiv f. Id in. med., 1872. Rehn. " Ein Fall von Lahmung der Glottiserweiterer nach Typhus Abdominalis," Deutsches Arch. f. Min. Med., Bd. xviii. p. 136. Landouzv. Des Paralysies dans les Maladies Aigues. Paris, 1880. Baumler (C). " Ueber Lahmung des Musculus Serratus Antieus major nach Beobachtungen an Cinem Fall von Multiplen Atro- pischen Lamungen im Gefolge von Typhus Abdominalis," Deutsches Archiv. /. hlin. Med., 1880, vol. xxv. p. 305-324. 1 Revue de Medecin, November 10, 1889. 240 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. Stintzing (R.). " Typhus Abclominalis mit Nachfolgender Atro- pischer Lahmung," Aertztl. Int. Bl., Munchen, 1883, vol. xxx. p. 4. Bartholow (R.). " Enteric Paraplegia," Medical News, Phila- delphia, 1883, vol. xliii. p. 609. Rondot (E.). " Contribution a 1' Etude des Paralysies qui Sur- viennent dans la Fievre Typhoide ; Paraplegie et Amyotrophie Myelopathiques d'Origine Typhoi'dique," Gaz. Hebd. de Sci. Med. de Bordeaux, 1885, vol. vi. p. 446. Peliotis. Be la Nivrite Pe'ripherique du Cubital Consecutif a la FiSvre Typhdide. Paris, 1885, Th6se. Raymond. " Deux Cas de My elite Ascenclante Observes pendant la Convalescence de la Dothienenterie," Revue de Medicine, 1885, p. 648. Courtade (D.). "Des Paraplegies Survenant dans le Cours ou pendant la Convalescence de la Fievre Typhoide," U Encephale, Paris, 1886, vol. vi. p. 431. Wiirtz. " Note sur un Cas de Nevrite Tibial Anterieur Survenue dans le Cours d'une Fievre Typhoide," I? Encephale, 1886. Buzzard (T.). Paralysis from Puerperal Neuritis, 1886, p. 102. Bassi (U.). " Nevrite Multipla Consecutiva a Febbre Tifoide," B6v.Veneta di Sc. Med., Yenezia, 1887, vol. vi. p. 585. Oppenhehn and Siemerling. " Beitrage zur Pathologie der Tabes Dorsalis und der Peripherischen Nervenerkrankung," Archiv fur Psychiatrie, 1887, p. 509. Puybaret (J. A. C). Contribution a V Etude des Paralysies dans la Fievre Typhdide, Bordeaux, 1887, Thesis. Stadehnann. " Ueber einen Eigenthiinilichen Mikroskopischen 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- lowing Enteric Fever," Medical Press and Circular, 1889, N. S., vol. xlvii. p. 562. Kebler (J.). "Post-typhoid Paralyses," Cincinnati Lancet- Clinic, 1889, N. S., vol. xxiii. p. 35. COMPLICATIONS DURING CONVALESCENCE. 241 Longstreth (M.). " Neuritis after Typhoid ; Rheumatic Neu- ritis," Physician and Surgeon, Ann Arbor, Mich., 1887, vol. i.\. p. 201. Comte. " Un Cas de Paralysie Generalised a la Suite de la Fievre Typhoi'de," Poiteau Mfrl., Poitiers, 1887, Tome ii. p. 113. Schmidt (F.). " Ueber Neuritsche Lahmungen nach Abdomi- naltyphus," Niirnberg, 1891. Pal. "Uber Multiple Neuritis," Wien, 1891, 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-devel- oped stage of the malady, we find as the most common compli- cation at this time erysipelas. 1 According to Liebermeister, this complication occurs generally during convalescence and seldom at the height of the disease, and he believes it may be a dangerous factor. In 1420 cases of typhoid fever in Basel, erysipelas appeared ten times, and all of the ten recovered. These were all cases of facial erysipelas. Two others developed the disease about bed-sores. In other words, erysipelas occurred in a little less than 1 per cent, of these cases. Griesin- ger 2 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' s Hospital under my care. The first case was separated from the second by an interval of five weeks, and the second from the third by less than a week. They were all in the same ward, but occupied beds at least twenty feet apart. The first case is as follows : Maggie T., aged twenty-two years, was admitted December 16, 1890, with a history of chronic suppuration of the middle ear. She was treated at the dispensary, and rapidly improved, being discharged on December 23d. On January 8, 1891, she was re- 1 See article by Hare and Patek in the Medical News, January, 1891. 2 Infectionskrunkheiten. 16 242 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. admitted with well-defined symptoms of a mild attack of typhoid fever ; which ran a short course, the patient being discharged on January 30th. On February 2d 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 second attack 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 March 5th 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 of listerine was used as 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 16th 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. Total 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 COMPLICATIONS DURING CONVALESCENCE. 243 third week of the typhoid fever. At the onset of the erysipelas there was a chill, followed by a rise of temperature of 2°, and followed, after the use of a cold bath, by a fall to the temperature- course previously pursued. The erysipelas began about the bridge of the nose and extended rapidly over the entire face back to the ears and to the margin of the hair, whence it ceased to spread. The eyes were closed and the lips much swollen. An examination of the serum withdrawn by a lancet showed the characteristic streptococci of erysipelas. Under the use of large doses of tinc- ture of the chloride of iron and an application of ichthyol oint- ment, recovery rapidly took place. The mouth was unusually foul and dry, but no delirium was present. We could not notice that the complication in any way increased the gravity of the case. The third case is as follows : A woman, 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 with 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. 1 According to this authority, 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 1 These de l'Ecole de Me'decine. 18S3-84, t. i. 244 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. 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- tion. The following conclusions of Gerente, however, embody most of his statements : Eysipelas of the face is rarely met with during the course of typhoid fever. I have found it in 64 out of 3910 cases, which is about 1 to 61. These figures are derived from the following statistics : Typhoid fever Erysipelas, eases. cases. Choniel . Louis Forget . Jenner . De Larroque Zuelzer . Liebermeister Zuccarini Griesinger Murchison 1 Total 130 4 134 3 92 1 65 2 105 4 84 3 1420 10 480 18 500 10 900 9 3910 64 agion, it appears to be most fre- ms of typhoid, and in those of Outside of the question of conte quent in the grave, adynamic fori long duration ; it appears to be most frequent in lymphatic subjects. While observed at all the stages of typhoid fever, erysipelas shows itself especially and 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 frequently 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. 1 The number of Murchison's cases is not strictly correct. COMPLICATIONS DURING CONVALESCENCE. 245 We think the statement that erysipelas seriously influences the prognosis in all cases too swooping. Thus, there are cases on record in which 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. The question as to the path by which contagion finds entrance has been much discussed, but the opinion of Griesinger is gener- ally accepted. He believes that the germs gain entrance by means of the inflammation of the frontal or sphenoidal sinuses, and also when ulceration of the buccal mucous membrane exists. Zeulzer also points out that in his ow r n cases and in those of Zuccarini the erysipelas started in the stomatitic spots and ulcerations in the mouth. In all our cases the patients complained very much, both before and after the attack of erysipelas, of the soreness of their mouths. The following cases which have been reported in addition to the three of Gerente are interesting : Armieux 1 reports the case of a soldier in whom typhoid symp- 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 4th a complication arose in an otorrhoea which, by the 2 2d, 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 9th. Thielman 2 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 ileo-csecal region, and the liver was painful and enlarged. The fever was recognized as typhoid, and the patient put upon calomel. The patient was in a delirious condition, but 1 Rev. Me"d. de Toulouse, 1875, ix. 42. 2 Med. Jahresbuch v. Peter-Paul Hospital in St. Petersburg (1840, 1841), 142, 147. 246 COMPLICATIONS AND SEQUELJE OF TYPHOID FEVER. on the following clay there was a slight remission, and he became partly conscious. The erysipelas was seen to be spreading further over the face, but leaving its original seat. There was delirium the following night and semi-consciousness. 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 centre. The patient was noticed to be troubled with occasional cough, and the respirations were somewhat more frequent. Exam- ination showed 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 day after admission. M. Berthoud 1 reports the case of a soldier who had typhoid fever of a meningeal 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 warni, tender, not very painful, but cedematous, 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 but 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 is that the redness of the skin and infiltration were due purely to mechanical causes, viz., the stagnation of the blood. Freudenberger 2 has recorded two cases, in one of which erysip- 1 Gaz. des Hop. de Paris, 1848, vol. v. p. 29. 2 Aertzl. Intelligenzblatt, Miinchen., 1880, xxvii. p. 37. COMPLICATIONS DURING CONVALESCENCE. 247 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 high again, but was easily influenced by antipyretics. The pulse was 140. Potain 1 reports a case of erysipelas coming on during convales- cence from typhoid fever, which was accompanied by a severe chill and fever. The erysipelas began in the pharynx and palate, and did not affect the tonsils. On the next day the inflammation appeared at the corners of the mouth and on the face. Finally, Martinez 2 reports the following cases : A girl, twenty years of age, belonging to the lower class, of lymphatic tempera- ment, with very irregular menstruation, which was often almost absent, was taken ill with typhoid fever. The symptoms were obscure at the onset of the disease, but the most prominent mani- festation was an erysipelatous inflammation of foot and leg. On the fourth day the erysipelas was marked ; there was great fever, cephalalgia, and other typhoid symptoms, such as weakness, gur- gling in the right iliac fossa, dryness and tremblings of the tongue, sordes on the teeth, great stupor, delirium, and a frequent and small pulse. Death took place after some days. Whether the erysipelatous trouble had anything to do with the causation of the typhoid symptoms or not, Martinez does not state, but he mentions the case of another woman in whom an extensive erysipelatous inflammation of the face and scalp produced cerebral symptoms, fever, etc., but they were not so pronounced as to be confounded with those caused by true typhoid fever, as in the present instance. In this case the patient recovered. It is an interesting; fact in this connection that Silvestrini 3 has 1 Erysipele de la Face Consecutif a la Fievre Tvphoi'de. Gaz. des Hup. de Paris, 1880, liii. p. 1106. 2 La Espana Medica, Madrid, March 1, 1860, p. 135. 3 La Riforma Medica, 1894, 196, 197. 248 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER. met with two cases of facial erysipelas in typhoid fever, in which the inflammation was found to be due not to streptococci but solely to the bacillus of Eberth. He asserts that Klebs and Reiner have met with similar cases. Very often in the last week of defervescence and in convales- cence the patient suffers from colliquative sweating of a marked type. It has seemed to the writer that in these cases the flow of sweat was an effort at elimination. Taupin 1 tells us, in an article written as long ago as 1839, that in children it is common to meet during convalescence with very abundant sweating of the upper part of the body, while the lower parts remained dry, and that children convalescing from typhoid fever might be attacked by an eruptive fever. He also speaks of cases attacked by scarlet fever, smallpox, and measles, due, in all probability, to the lack of isolation in fever wards in those days. Amitrano 2 has recorded a case of typhoid fever which, during convalescence, developed the scarlatiuiform rash which desqua- mated. Marked meningeal symptoms developed after the fever subsided, and after desquamation was completed a second eryth- ema of the skin appeared, which was also followed by desquama- tion. This case, perhaps, belongs to the class of dermatitis exfoliativa. (See last chapter for a discussion of typhoid fever complicated by eruptive diseases.) Profuse desquamation of the skin is frequently met with in patients convalescing from typhoid fever. The writer has seen this again and again, and Comby 3 speaks of it as a state met with in the convalescent period in children. Coulon 4 has recorded a case of typhoid fever in a child of ten and a half years, in which there was general desquamation of the skin during convalescence ; previous to that there had been no eruption upon the skin. On the other hand, it is noteworthy that there had been sore-throat, albuminuria, and oedenia, so the case 1 Journal des Connaissance Medico-Chirurgicale, 1839, No. 7. 2 La Kiforma Medica, 1896, No. 146. 3 Gazette des Hopitaux, 1896, No. 39. 4 La Medicale Enfantile, January, 1895. COMPLICATIONS DURING CONVALESCENCE. 249 may have been one of scarlet fever complicating typhoid, and without the ordinary rash. A somewhat unusual lesion of the skin, resulting from typhoid fever, is the development of linese albicantes. Cases of this kind have been reported by Troisier, 1 and Manouvriez and Bouchard have also recorded such instances. It is stated that they occur most frequently in children and young adults. Bucquoy notes that in boys these whitish lines have no special area of distribu- tion, but in girls the breasts and crests of the ileum are the places where they usually appear. Barie has reported the case of a girl of seventeen years, in whom these lines appeared over the knuckle- joints of each hand. A somewhat similar condition, due to localized atrophy of the skin, is recorded by Bradshaw. 2 In his case a girl of thirteen years, who suffered from typhoid fever followed by relapse, and again by a second relapse, finally developed during convalescence upon the inner surface of the lower third of the thigh a number of hori- zontal markings, some of which partially surrounded the limb ; they were about one-half inch in width, regular in contour, and almost exactly alike on both legs. A similar condition has been described by Wilkes. 3 A very rare condition coming on during convalescence in typhoid fever, is reported by Leudet/ namely, the condition of painful oedema of the thorax. Paiu was first felt in the neigh- borhood of the thyroid gland, then in the shoulder-blade ; later a circumscribed oedema of the left side of the thorax developed, which was not reddened, but was painful to the touch. There was no fever and no albuminuria. The condition lasted for four days in its fully developed stage, but had disappeared entirely by the twelfth day. The Thyroid Gland. The thyroid gland may undergo suppu- ration as a result of typhoid fever, as it may in other infectious 1 Bulletin et Memoire de la Sock'te Medicate des Hopitaux, 1S89, No. 12. 2 Bristol Medico-Chirurgical Journal, July, 1889. 3 Guy's Hospital Reports, 1861. * La Normandie Mi'dicale, October 1, 1891. 250 COMPLICATIONS AND SEQTJELJE OF TYPHOID FEVER. processes. Thus Pinchaud 1 has recorded such a complication of convalescence, and Forgue, 2 a Major in the French Army, has made a contribution on this condition. Other observers have recorded a similar state complicating the other infectious diseases, and the view is generally held that the gland becomes infected from the entrance of the bacillus into the blood, by which it is carried to the thyroid gland. The most recent paper on this topic with which I am acquainted is that of Testevin, 3 a Major in the French Army, who under the title of " Thyroidite Infectieuse Suppuree," discusses the literature of the subject. From his paper it is evident that of all the infectious diseases, typhoid fever is the one which most commonly causes these lesions in this gland, and further, that it is emphatically a consecutive or second- ary manifestation chiefly met with in convalescence. In very rare instances the thyroiditis develops with the onset, as set forth by Tavel 4 and Laveran. 5 Finally, it is a noteworthy fact that Chantemesse 6 has found the bacillus of Eberth in the pus of the thyroid gland. A case of suppuration of the right lobe of a goitrous thyroid gland has been recorded by Spirig, 7 in a woman, twenty-two years of age. 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. Joints. Articular lesions complicating convalescence from typhoid fever may be due to direct infection with 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 Des Thyroidites dans la Convalescence de la Fievre Typhoi'de, Paris, 1881. 2 Contribution a l'Etude de la Thyroidite Typique. Arch, de Med. et de Phar. Milit., 1886, 1. vii. 3 Ibid., February, 1899, p. 126. * Ueber die Etiologie der Strumitis, ein Beitriige zur Lehre von den Hemato- genen Infectionen, Bale, 1892. 5 Bevue de Chirurgie, Septembre, 1890, No. 29. 6 Art. Fievre Typhoide in Traite de Med. de Bouchard et Charcot, 1891, 768. 7 Correspondenzblatt fiir Schweizer Aerzte, February 1, 1892. COMPLICATIONS DURING CONVALESCENCE. 251 Robin and Leredde 1 have, however, called attention to the inter- esting: fact that acute articular inflammation 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 it is simply an evidence of the septic process associated with the typhoid fever. Great care should be exercised by the physician that mere articular inflammation does not mislead him in an erroneous diagnosis. 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 occurred 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 1882 Rawden reported in the Liverpool Medico- Chirurgical Jour- nal, an instance of dislocation following typhoid fever, in which, having excised the head of the bone, he found it practically nor- mal, even the cartilage being healthy, excepting for a little absorp- tion at its periphery ; while, on the other hand, Adams, in a case of rheumatic dislocation of the hip, found the capsular ligament 1 Archives Gdnerales de Mc'decine, September, 1894. 252 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. ruptured aucl the torn margins of the rent closely embracing the neck of the bone. AVhile 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 dislocations have usually been due to this condition, and Collier believes that degenerative changes similar to those seen in muscu- lar fibres result in softening of the ligaments and of their attach- ment to the bones. The possibility- of recurrence of the dislocation under such circumstances 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 anchylosis or shortening. In this connection it may be a matter of interest to note that the case of typhoid fever under my care in the wards of the Jefferson Medical College Hospital in the early part of 1897, to which refer- ence is made in Keen's essay, page 97, has been seen by me in March, 1899. She is able to walk without the aid of a crutch, but the knee is permanently anchylosed. It will be remembered that aspiration of this knee-joint obtained fluid which 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 anchylosis in marked flexion, which Dr. Keen thought would require operative treatment later on, has been gradually overcome, so that shortening in the anchylosed limb is very slight. CHAPTER V. THE CONDITIONS WHICH APE TYPHOID FEVEE. These conditions are quite numerous. The following is a list of the more common of these conditions : Malarial fever, ap- pendicitis, sepsis, pneumonia with great asthenia, tuberculosis, particularly of the abdominal contents ; ileo-colitis, ulcerative or septic endocarditis, and cerebro-spinal meningitis. With the important question of the diagnosis from malarial fever I 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 by the parasite of malarial fever may pursue a course in each case almost identical with the other, 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. On the other hand, the use of quinine for several days when without result should not be persisted in, since the case under these circumstances is probably not due to malaria. Speaking of this therapeutic test, Dock well says : "In a case resembling typhoid fever, but really malarial, the microscope is essential to good practice. Without it, quinine may again be used ; but if the temperature does not fall to or near normal, with relief to the other symptoms, it is better to stop qui- nine altogether. Only when microscopical evidence of malaria is present should the drug be pushed after the third day. It is necessary to add that while symptoms persist the patient should be treated as though he had typhoid fever. So erroneously is the so-called therapeutic test conceived, that I have known of patients 254 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. taking quinine in doses of forty grains a day for three weeks, in order to determine the presence of malaria, each fall of one or two degrees of temperature being looked on as proof of a specific effect. I am well aware that some look on massive doses of qui- nine as useful in typhoid fever, but considerable observation has convinced me of the ojoposite view." "With these views, particularly those of the last sentence, the writer is 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 touch of mala- ria, proves that all these signs are not proof of malarial infection. In confirmation of these views we find the interesting report of Ewing, 1 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 tvphoid fever, was the intermittent character of the fever, which 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 temperature, 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, while the subsequent course of the disease demonstrated the purely malarial character of the fever. "These patients might suffer from epistaxis, hseniatemesis, 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 subsultus or cracked tongues, and they did not die, or, if they did, dysen- tery and malaria were demonstrated at or before autopsy." 1 New York Medical Journal, February 4, 1899. CONDITIONS WHICH APE TYPHOID FEVER. 255 Again, 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 nature of the disease. It was either typhoid fever or malaria, but never both, although microscopical 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 this group of cases it is 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 anseinia, 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 post-mortem examina- tion 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 Gilman Thomp- son, 1 in which he reached results identical with those just stated, namely, that the fever of typhoid is apt to run its course, and that malarial manifestations then succeeds it. Sepsis and appendicitis may somewhat closely resemble typhoid fever if the latter affection is insidious and there is pus present which produces toxaemia. Whatever the cause of the sepsis may 1 American Journal of the Medical Science, August, 1894. 256 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. be, the loss of flesh, dry tongue, delirium, low-grade bronchitis, badly nourished skin, and diarrhoea may cause the patient to be most typhoidal in appearance, yet in all such cases we should seek for a possible purulent focus. The absence of the Widal reac- tion and the presence of leucocytosis should rouse our suspicions greatly, and it is not to be forgotten that the presence of pus deep in the pelvis or in the neighborhood of the kidney may not be readily discovered, and only the development of fluctuation or the rupture of the abscess will force the physician to reverse his diag- nosis of typhoid fever. On the other hand, as already pointed out, purulent formations may occur in typhoid fever. Similar facts 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 cerebro-spinal 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 tubercular 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 tubercular meningitis, or paralysis of the muscles of the eyeball, causing squint. So, too, in acute general miliary tuberculosis, the previous his- tory of the patient as to gradual failure of health, and cough, the moderate fever, and the rigors and sweats point to the presence of tuberculosis rather than enteric fever. Further, there will be in some cases marked physical signs of widespread involvement of the lungs in tuberculosis which will be absent hi typhoid fever. It is to be recalled, however, that a roseolous rash may develop in both affections, and that diarrhoea and a dry, brown tongue may mislead the careless very readily. Even intestinal hemorrhage may occur in miliary tuberculosis. 1 1 Senator. Charite Annalen, 1892, vol. xvii. p. 272. CONDITIONS WHICH APE TYPHOID FEVER. 257 Tubercular peritonitis may also cause typhoid symptoms, but as the disease progresses the localization of the abdominal symptoms and, finally, the development of tumor masses or enlargement of the mesenteric glands, can be felt on deep palpation, or, in other cases, the development of ascites makes the diagnosis clear. Finally, it is not necessary for the rather rare disease, general miliary tuberculosis, to be present to make the diagnosis obscure. Some time since I saw in consultation a man of thirty years, who had had for four weeks persistent fever, some cough, diar- rhoea, mild delirium, gradual loss of flesh, and a heavily coated tongue, with sordes. To the attending physician who had made a diagnosis of enteric fever at the start, nothing had occurred to make him change his views, but the appearance of the patient made me suspicious of tuberculosis, and a careful examination of his chest revealed well-advanced tuberculosis of the lungs, the real cause of his illness. Girandau 1 has recorded a case in which a young man suffered from enteric fever, and then speedily developed tuberculous disease of the intestines. Two weeks after the recovery from enteric fever, the patient became ill a second time with diarrhoea, fever, and abdominal pain, and marked wasting. At the autopsy two sets of lesions were found, typhoid lesions side by side with tubercular foci. jSTo traces of old pulmonary lesions or a primary lesion else- where were to be found. An interesting case illustrating how difficult the diagnosis of typhoid fever may be in its earlier stages has recently been under my care : This woman was taken ill some days before I saw her with chilliness, fever, and languor, and with a further history that she had been suffering for a number of months with somewhat similar sensations, without the fever, and had been losing flesh ; during this time she had had constipation alternating with diarrhoea and abdominal pain. When first seen her temperature Mas 103°, her appearance was distinctly that of a typhoid patient ; but, as is seen 1 Revue de Medicine, 1884, p. 564. 17 258 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. in the accompanying chart, her temperature speedily fell to nor- mal, only one sponge bath being required after she came under observation. An examination of her abdomen at this time re- vealed the fact that it was slightly protruding, and that the abdom- inal wall was so thin that the coils of intestine could be readily seen projecting through it. In the neighborhood of the umbilicus there was a sense of increased tenderness on deep palpation, and the re- sistance made one suspect the possibility of there being present a tubercular peritonitis which had caused an exudation, binding the intestines together in a mass. About McBurney's point there was Fig. 21. F . 103° 102° 101° 100° 99° 98° 97° Day of Dis. i \ X a l\ 1 1 p \ / \ / V 1 ' \ \ \ \ i \\ I A / i A / A / , i / A / \ / / L / \, \ / \ \ \ / V /*« s, 7* s A 1 y \ V \( \ \ ; V - CO CS o CN* CO -* ta o ?- Si o cs» CO A case of typhoid fever preceded by appendicitis (?), or by a primary attack of typhoid fever. very distinct tenderness on palpation, and deep palpation produced severe pain. In view of her history, her emaciation, and the symp- toms detailed, I was inclined to consider the case one of tubercular peritonitis, or else one of appendicitis of the subacute or chronic character, with a tendency to exacerbations. In this opinion Pro- fessor Keen agreed with me, and it was arranged that Professor Keen should perform an abdominal section for the purpose of removing the appendix, if it alone was the cause of the difficulty, or of relieving her tubercular peritonitis through the well-known beneficial effects of abdominal section. On the day on which she CONDITIONS WHICH APE TYPHOID FEVER. 259 was to be operated upon, her temperature having been normal for a number of days, and her general condition having steadily improved under treatment designed to prepare her system for operation, she developed marked languor and malaise and febrile movement, which is shown in the accompanying chart (Fig. 21), and three days later developed typical rose rash of typhoid fever, her blood giving the positive Widal reaction simultaneously. The questions which naturally arise in regard to this case are : Did the woman suffer primarily from appendicitis, or from tubercular peritonitis, or did she come under my care at the end of a mild primary attack of typhoid fever after which she had 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 I am inclined to believe that the primary fever could not have been due to tubercular peritonitis. Another interesting case, illustrating how difficult these differ- ential diagnoses may be, is reported by Dreschfeld in Allbutt'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 with a fever. Their symptoms closely resembled those of enteric fever, and one of them pre- sented on the third 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 fourteenth day after admission, or about the seventeenth day of the fever. The post-mortem examination revealed the intestines apparently healthy. Dreschfeld 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 I have already stated, does not exclude enteric fever. Leu 1 has reported a case of puerperal septicaemia which was 1 ChariU' Annalen, 1891, vol. xvi. p. 315. 260 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER. almost indistinguishable froni typhoid fever, for the patient had a rose rash, tympanites, enlarged spleen, intestinal infection, and the pyrexia! curve, 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 Widal reaction, aids us in making a differential diagnosis. Another condition which may closely simulate enteric fever is the gastro-intestinal form of epidemic influenza, for in this condi- tion we have enlargement of the spleen, diarrhoea, tympanites, gurgling, slight evidences of bronchial irritation, and very rarely, indeed, a suspicious roseolar rash. On the other hand, it is per- fectly possible for enteric fever and influenza to occur simulta- neously in the same patient. Under the name of mountain 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 writers 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 surgeon at one of the United States Army stations in the West, has contributed to the American Jour- nal of the Medical Sciences, 1898, vol. cxv., an exhaustive paper upon this subject. Quinine administered to these cases, in full doses, failed to exer- cise any beneficial effect ; prophylactic measures, which are ordi- narily successful in the control of the typhoid epidemic, at once CONDITIONS WHICH APE TYPHOID FEVER. 261 checked the disease, and a comparison of many of the symptoms manifested with those met with in irregular forms of typhoid fever still further indorse the view we have already expressed in regard to the unity of these two diseases. These views in regard to mountain fever are also supported by the paper of Work/ who tells us that eighteen out of fifty cases of mountain fever, so called, had rose spots, and that in five fatal cases the intestinal lesions of the fever were found. The differential diagnosis of typhoid fever in children from the other exanthemata is made as follows : From scarlet fever by the pain in the back, the excited nervous system, the eruption on the second day, and the absence of pain in the abdomen, and the stupor of enteric fever. There is usually in scarlet fever, too, great sore- throat. From measles we are apt to have greater bronchial catarrh, at least at first ; coryza, which is very rare in typhoid fever, and an early eruption. From entero-colitis we distinguish enteric fever by the absence of delirium or stupor in this affection, and the character of the diarrhoea, as well as the greater abdominal tenderness. The value of the Widal test in these cases is never to be forgotten. 1 Medical News, April 8, 1894. CHAPTER VI. DURATION AND IMMUNITY TO SECOND ATTACKS. The duration of typhoid fever varies greatly in different indi- viduals, and still more so in different epidemics, depending upon the vital resistance of the patient and the virulency of the infection. It may, however, be asserted that the average period of fever is twenty-one days, although wide variations from this may occur, the duration being much less or much greater, as already pointed out. Murchison states the mean duration in seventy-five cases to be a fraction more than twenty-four days. Flint states from going to bed to normal temperature sixteen days, with a maximum of twenty -eight days and a minimum of five days. The longest case seen by Flint was fifty-eight days. Of forty-five of Flint's fatal cases the duration was a fraction more than fourteen days. Murchison tells us that the mean stay in the hospital of 500 cases which recovered was 31.24 days ; of 100 fatal cases, 16.52 days, while the average duration of illness before admission of the 600 cases was 10.78 days. Again, Mur- chison tells us that the pyrexia, as a rule, lasts at least three weeks, and the ordinary duration of enteric fever is from three to four weeks. Of 200 cases which recovered, and in which he was able to fix the commencement with tolerable certainty, the dura- tion was : 10 to 14 days in 7 cases ; 15 to 21 days in 49 cases ; 2 to 28 days in 111 cases ; 29 to 35 days in 33 cases. The mean duration of the 200 cases was 24.3 days, and the mean duration of 112 other cases, which were fatal, was 27.67 days. The average duration of residence in St. Thomas' Hospital, London, in 1894, 1895, and 1896, was from 43.1 to 51.8 days, and the average duration of fever from 14.3 to 16.73 days, although a great proportion of the patients were admitted in the first or second week. DURATION AND IMMUNITY TO SECOND ATTACKS. 263 In the Maidstone 1 epidemic, 8 per cent, lasted two weeks ; 27 per cent., three weeks; 31 per cent., four weeks; 17 per cent., five weeks ; 8 per cent., six weeks ; 4.5 per cent., seven weeks ; 84.5 per cent., eight weeks. If we take the twenty-five cases admitted in the first week of the disease given in Wilson's table, we find that the average stay of these patients in the house was forty-one days (40-f), and the average day of normal temperature the nineteenth. The average maximum temperature was 104.6° If the entire 108 cases given in his last table in his article are studied, we find that the average duration of the fever was in the cases admitted in the second week, 23.2 days ; in the third week, 27.3 days, and the average stay in the house of the second-week cases, 40.8 days, and of the third-week cases, 38.8 days. While the general average may be about twenty-one days, very much shorter periods have been seen and noted by every physician of experience, and very important classifications of cases have been made by Liebermeister and Jurgensen. The first of these clinicians speaks of the mildest cases as those in which the rectal temperature never or rarely rises above 103°, and the duration of fever does not exceed eight days. The mild cases do not have a rectal temperature above 104.8°, and the fever lasts sixteen days. The severe cases are those in wliich the rectal temperature rises above 105° and the fever ceases by the twenty-first day. Jur- gensen considers all cases mild which have no fever after the tenth day, and those severe that have fever after this date ; but this view hardly coincides with that of American physicians, who regard a fever ending by the twenty-first day as quite moderate, particularly if the fever does not exceed 104°. There is one class of patients in which the febrile movement very commonly lasts but a week or two, namely, children. Henoch stated years ago that out of 80 cases seen by him there were 11 which lasted 7 to 10 days ; 26 from 10 to 15 days ; 16 from 15 to 20 days ; 21 from 20 to 30 days, and 6 from 30 to 49 days. 1 Poole. Guy's Hospital Keports, 1898. Wrongly labelled on cover, 1896. 264 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. Even in the cases lasting but a week or ten days there were ro- seola, enlargement of the spleen, and diarrhoea. In confirmation of this view, we have the more recent observations of Forchheimer, of Cincinnati, who found in an epidemic of this malady among children that the fever may terminate as early as the sixth day, and Janeway, of New York, remarks that it may end in ten days. It is evident, therefore, that the duration of typhoid fever in children is shorter than in adults, as a rule, as well as milder in the character of its manifestations, and that it is accompanied by less grave intestinal lesions. Musser has recorded the case of typhoid fever in which, though there were no complications, the temperature did not reach normal until seventy-three days had elapsed. In children convalescence is even more prolonged than it is in adults in some cases. As long ago as 1839, Taupin 1 emphasized this fact, stating that pallor, feebleness, and general debility are marked. The question of the frequency of second attacks of typhoid fever is of interest. It is generally considered that an attack renders a patient at least partially immune to other attacks. Moore 2 has recorded 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 3 has reported 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 which he had intestinal hemorrhage, but recovery nevertheless occurred. During the winter of 1897-98 the writer 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 seventeen years, and the third at nineteen years. Death occurred from hem- orrhage of the bowels. In 1626 cases Bey found only one which had a second attack. 1 Journal des Connaissance Me"d. Chirurgicale, July, 1839. 2 Dublin Journal of Medical Science, April, 1893. 3 International Medical Magazine, August, 1893. CHAPTER VII. THE MENTAL COMPLICATIONS. 1 The mental complications of typhoid fever resemble in a gen- eral way the mental disorders resulting from other infectious diseases. They occur by preference in patients in whom there is present a neurotic heredity or who have been subjected, previous to infection, to overwork, loss of sleep, anxiety, or other exhaust- ing nervous strains. Hereditary factors — functional neuroses and insanities — appear to be present in about half the cases. It can- not be claimed, however, that the other predisposing causes possess much etiological value, as mental complications frequently occur in individuals in which these factors have been absent. Sex appears not to exercise any predisposing influence, males and females being affected in about equal number. Age, also, is not a deter- mining factor. It is, however, somewhat significant that typhoid fever attacks by preference individuals of an age at which mental disorders are very prone to occur, namely, youth and early adult life. Notwithstanding, mental diseases of typhoid origin of suffi- cient severity to demand asylum treatment do not appear to be as frequent as this coincidence would suggest. Thus Nasse reported 43 cases among 2000 hospital admissions ; Schlager, 22 cases in 500 ; Christian, 11 in 2000, while Pilgrim found only 13 cases in over 6000 admissions. We should remember, however, that hos- pital statistics cannot be regarded as in any sense representing the real frequency of these disorders. First, a large number of cases do not necessitate commitment, and, secondly, in hospital admis- sions the etiological relation with typhoid fever is not always brought to the attention of the asylum physicians. 1 By F. X. Dercum, M.D., Clinical Professor of Diseases of the Nervous Sys- tem in the Jefferson Medical College. 266 COMPLICATIONS AND SEQUEL M OF TYPHOID FEVER. The occurrence of typhoid insanities appears to depend, among other things, on the character of the individual epidemic ; they occur more frequently in some epidemics than in others. Among special factors it is not improbable that constipation may be a pre- disposing cause, by favoring the retention and absorption of poisons. The mental disturbances of typhoid fever are separable into three groups : First, those which develop during the prodromal or initial period ; secondly, those which arise during the continuance of the fever, and, thirdly, those which occur during or subsequent to convalescence. The affections occurring during the prodromal period cannot be definitely separated from those occurring during the initial period of the fever, inasmuch as cases beginning in the prodromal period may persist after fever has made its appearance. They manifest themselves in one of two forms : First, a form in which mental depression or mental excitement is the leading feature, and, sec- ondly, a form in which the symptoms are those of an acute deli- rium. The first is represented by a class to which Campbell 1 calls attention. They begin in the prodromal period, and are especially prone to occur when this period is protracted. They appear to be directly related to the malaise and degree of nervous prostration. Thev are not infrequently met with in those cases in which the fever is slow in making its appearance or does not become pro- nounced until a considerable time has elasped. They are character- ized by mental depression, less frequently by mental excitement, associated with disordered mental action — probably confusion, with some hallucinations. It is not surprising that the mental condi- tion may entirely mask the underlying disease. The symptoms may be so pronounced as to lead to the commitment of the patient to the asylum, the nature of the case not becoming evident until later. It is extremely probable that in such cases there is a marked hereditary tendency to insanity, and that the depression of the prodromal period of the fever merely acts as an exciting cause. It should be added that these cases are quite rare. We 1 Campbell, Colin M. Diet, of Psycholog. Med., vol. i. p. 506. THE MENTAL COMPLICATIONS. m 267 should, however, remember that if a given case is ulwuiv in its origin, if the mental depression has developed in a manner more rapidly than that seen in melancholia, and if it is otherwise atyp- ical, the commitment should, if possible, be delayed and the case be kept under observation 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, Ave have present, as already stated, the symptom- of an acute delirium. This delirium is characterized by profound mental obtusion, confusion, and hallucinations, Avhich are often terrifying in character. There are manifestations of great fear and often impulses to violent acts. In this form violent assault upon the person, murder, or suicide may occur. It may, indeed, in rare cases attain the violence of typho-mania 1 (delirium grave). (See chapter on onset.) While the delirium is usually accom- panied by terrible hallucinations, the patient seeing frightful ob- jects and hearing terrifying sounds, it is under rare circumstances associated with expansive ideas. Kirn 2 describes a case in which instead of depression there was present delirium of grandeur, only, however, to be followed by depression later on. 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 3 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 alto- gether as the height of the fever is reached. Many cases, how- ever, die before the fever has fully developed. The existence of acute delirium in the prodromal or the initial period of typhoid 1 Xasse. Allegemeine Zeitschr., f. Psych., 1870-71, p. 11. 2 Ibid., vol. xxxix. p. 741. 3 Schmidt's Jahrbucher, vol. ccxiv. 268 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. fever is always to be looked upon as of ill omen. According to Adler, 1 only one-third of the cases presenting this complication recover. The mental complications occurring during the period of fever separate themselves into, first, the ordinary fever delirium ; second, expansive or ambitious delirium, and, third, 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 com- plication, may be present during the entire course of the fever. More 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. 2 The stupor of typhoid fever, like the ordinary fever delirium, is so well known as not to merit description. It may come on as a gradual deepening of the initial apathy and hebetude of the dis- ease, or may be a transition from the fever delirium. More rarely it is the outcome of an acute delirium of the initial period. Its occurrence at an early stage is always of grave significance. When arising during the period of decline it sometimes continues long after the fever has subsided. The insanities which arise during or subsequent to convales- cence are those which principally concern us here. They may arise during the subsidence of the fever, and 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. 1 Allegemeine Zeitschr. f. Psych., vol. liii. p. 753. 2 Cases have been reported by Delasiauve, Christian, Simon, and Liouville. Diet, of Psycholog. Med. vol. ii. p. 986. THE MENTAL COMPLICATIONS. 269 Post-typhoid insanities may make their appearance in one or other of the following forms : 1. Acute delirium. 2. Confnsional insanity, stuporous insanity. 1 3. Cerebral asthenia, pseudo-dementia, pseudo-paresis. 4. Insanity with systematized delusions resembling paranoia. 5. True melancholia or true mania. 1. Acute Delirium. The acute delirium following typhoid fever is indistinguishable from the delirium of exhaustion follow- ing other infectious fevers, shock, trauma, or other profoundly debilitating causes. It is characterized by excessive mental con- fusion, increased rapidity in the flow of ideas, numerous and varied hallucinations, 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 termi- nation of the fever. It appears to coincide with the collapse which follows the disappearance of the fever in some cases. At other times a brief interval of a day or two characterized by insomnia and ominous restlessness precedes the outbreak. Con- sciousness becomes much obscured ; the patient loses the proper recognition of his surroundings ; he becomes illusional, everything seems strange and changed, and in addition he becomes hallucina- tory to an extreme degree. The chairs and other objects of furni- ture are mistaken for strange shapes, persons, or animals. The individuals about his bed are no longer properly recognized ; the pictures upon the walls, the curtains upon the windows, the rugs upon the floor all become animate objects. The hallucinations 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, ter- rify him. It is not strange under these circumstances that he 1 Kraepelin, Lehrbuch Psychiatrie, is one of the few systematic writers to fully appreciate the etiological relation of typhoid fever to these disorders. Paglians, Revue de Med., 1894, xiv. 549 and 656, unfortunately misinterprets, as did the older writers, post-typhoid conditions attended by excitement or depression as mania or melancholia. 270 COMPLICATIONS AND SEQUELJE OF TYPHOID FEVER. 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 halluci- nations and the delusions are of a pleasurable and expansive character, the patient showing 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 allit- erations. 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 some- times during a momentary lull the patient may comply with a given direction. The well-meant attentions of the nurse and friends are misunderstood 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 reaches its height the mind becomes more and more confused, and the motor excitement manifests itself in sense- less struggling or in purposeless and automatic movements, turn- ing about the bed, aimless gestures, pushing, rubbing, etc. The physical condition is indicative of great weakness, the color is pale, the surface of the body is cold and often moist, and the emaciation of the typhoid fever is rapidly and greatly accentuated. The pulse is small, sometimes slow, sometimes rapid ; it is always weak. As a rule, abrasions and ecchymoses are observed on vari- THE MENTAL COMPLICATIONS. 271 ous parts of the body. Generally they arc the unavoidable results of the patient's struggles. Acute delirium is a complication of short duration. It may last 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 surroundings 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 unin- terrupted ; 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 t<» 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 complication is relatively good. The great majority of cases of acute delirium following typhoid fever recover. How- ever, 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 writer once saw in consultation a child in which the delirium proved not to be a sequel of the fever, but was really due to the large quantities of alcohol which had been administered. A marked and typical alcoholic multiple neuritis, sthenic in character and exquisitely painful, was also present. 2. Confusional Insanity. The second form of post-typhoid insanity to claim our attention is confusional insanity. Like the acute delirium following typhoid fever it closely resembles the confusion resulting from other infectious and exhausting diseases. It is characterized by obtusion, mental confusion, incoherence of ideas, illusions, hallucinations, and by a prolonged course. It is much more frequently met with as a sequel of typhoid fever than acute delirium. Typhoid fever most frequently induces exhaustion 272 COMPLICATIONS AND SEQUELJE OF TYPHOID FEVER. gradually ; it is only in exceptional cases in which this exhaustion comes on suddenly that acute delirium ensues. 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 ; gener- ally, however, within the first week. The patient becomes ner- vous, restless, and cannot sleep. Soon 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 becomes confused. After several days the symp- toms 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 looking 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 Avatchful of his surroundings, which he constantly misinterprets. The commonest objects are misunderstood — a spoon is taken for a knife, a ther- mometer inspires deadly fear, a hypodermic injection is regarded as a savage onslaught with a dagger. The patient also catches words and phrases uttered by the bystanders with surprising readiness, always, of course, to misinterpret them. For this reason it is well not to whisper in the patient's presence, nor to make unnecessary gestures, nor to move about the room mysteri- ously. 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 THE MENTAL COMPLICATIONS. 273 urged upon the patient by speech, by the proper presentation of food to vision and to the lips. Frequently, however, it is impos- sible 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 appre- hension, infrequently 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 ex- citement 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 exhibit some tendency to violence. In some cases there is relative quiet from muscular weakness or, perhaps, from inhi- bition. In others the patient holds fast in a senseless sort of man- ner to surrounding objects or persons, or resists in a semi-passive way the attentions of the nurse. In other cases, again, he betrays evidences of automatism and tends to remain for some time in the position in which he has been placed. Symptoms such as these, however, are relatively infrequent. The speech varies considerably. Sometimes whole sentences are littered, at other times merely phrases, fragments, or incoherent and disjointed words. It is, however, much easier to gain some idea 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 18 274 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. might be expected, sleep is much disturbed. Insomnia 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 largely in illusions and hallucinations of taste and smell. The physical condition of the patient is, as a rule, bad. 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, 1 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 irregular, 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 suc- cessful periods of sleep. Convalescence generally sets in very gradually. Generally many weeks elapse before persistent im- provement is noted. The patient begins for short periods of time to properly appreciate his surroundings and to understand what is said to him. The periods of lucidity gradually become prolonged until, from being merely of a few hours' duration, they last through the greater part of the day. During the convalescence the patient is often irritable and hard to please. Sometimes traces of the old distrust and suspicion are seen ; the patient makes absurd charges against his nurse, or is obstinate and intractable. Gradually, however, he becomes more sensible, more friendly, and begins to manifest confidence in those about him. In many instances, too, during this period, the patient is mildly excited or depressed, while in others some of the hallucinations persist after lucidity has made its appearance, but in such case the latter are no longer made the basis of delusions. Rarely, however, fleeting delusions now and then betray themselves. A valuable index as 1 Wood. University Medical Magazine, Dec, 1889, vol. ii. p. 117. THE MENTAL COMPLICATIONS. 275 to impending convalescence is the willingness of the patient to take food. Partial relapses, it should be added, also occur, espe- cially as the result of emotional excitement, the visits of impor- tunate 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. Even after recov- ery 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 confusional insanity is very infrequent. Death from suicide or accident should not be forgotten as a possibility. Stupokous Insanity. Sometimes, though infrequently, cases which begin as confusional insanity merge into stupor, the ner- vous exhaustion becoming so profound that the mental faculties are finally completely suspended. However, cases that become stu- porous 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 gradual development. Several weeks usually elapse before stupor is estab- lished, and during 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 appearance. 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 surroundings gives way to an inability to appreciate them at all. The patient lies motionless in bed, indif- 276 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. ferent apparently to everything about him. In this condition he cannot be made to answer questions and does not speak sponta- neously. 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 ex- tended, or the head turned to one side. These symptoms are often spoken of as cataleptoid, but they have, of course, no relation with true catalepsy. Again, while the great majority of cases are motionless, a very limited number are accompanied by agitation or purposeless movements. The feeding of the patient is often diffi- cult. At times he will swallow food that is placed in his mouth, at other times he will allow it to remain in the mouth, making no effort at swallowing, or will allow it passively to escape upon the pillow. In many cases nasal feeding is the only practicable plan of administering nourishment, and, as a rule, this can easily be carried out and answers every possible purpose. The 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 cedematous. The pulse is small and slow, the respiration shallow. In women the menses cease. Like con- fusional insanity, stupor is an affection of long duration ; several months are always required. Convalescence also is established very gradually. The patient begins by betraying some conscious- ness 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 environment. Readiness of fatigue persists for a long time, and there are fre- quent recurrences of mental confusion which reveal themselves either in the patient's actions or in his conversation. Great care THE MENTAL COMPLICATIONS. 277 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, this 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. Cerebral Asthenia, Pseudo-dementia, Pseudo-paresis. More frequently, perhaps, than any other complication we have following typhoid fever a condition of general mental enfeeble- ment. This is generally of short duration, but is sometimes excessively prolonged. There is present in such cases a slight, though unmistakable, weakness of the intelligence together with abnormal excitability and loss or impairment of emotional con- trol. 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 indica- tive of weakness are also present — e. g., coldness of the extremi- ties, 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 men- tal 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 de- mentia, but one in which the mental faculties are merely sus- pended, not obliterated. It is properly termed a pseudo-dementia. This pseudo-dementia 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 278 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. background 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, 1 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-Robert- son pupil, the condition of the optic nerve as revealed by the ophthalmoscope, are among the factors which should be considered. Pseudo-paresis following typhoid fever almost always terminates in recovery ; besides the course of the disease is different from that of paresis. The mental loss, too, is not as profound or as real. 4. Insanity with Systematized Delusions Resembling Para- noia. A very limited number of cases of insanity following typhoid fever present a series of more or less well-systematized delusions. These delusions are at times remains of the fever deli- rium which 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 Midler, 2 Hurd, 3 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, Avith final dementia, may be the result. Such an outcome, however, appears to be exceptional. 5. True Mania or True Melancholia. In addition to the various forms of mental disorder above described, and which are 1 Christian, Westphal, Kegis. 2 Muller, Loc. cit. 3 Hurd, American Journal of Insanity, July, 1892. THE MENTAL COMPLICATIONS. 279 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 arc 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, gen- erally 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 psychic pain and self -accusatory delusions, as typified by the delusion of the unpar- donable sin, is almost never met with. This is also true of pure mania as typified by excessive exaltation, expansion, and increased rapidity in the flow of ideas, without hallucinations or confusion. Further, cases of the pure insanities following typhoid fever do not, as a rule, like the insanities of exhaustion, develop immedi- ately after or within a short period of the defervescence of the fever, but at rather later periods — weeks and 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- typhoid 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 which 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 compli- cations arising during the fever is almost uniformly good. The 280 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER. fever-delirium, the confusion, the expansive and ambitious ideas vanish with the disappearance of the fever. The various forms of mental derangement which occur as sequela? of typhoid fever also offer a favorable prognosis as a whole. The great majority of cases of post-typhoid confusional or stuporous insanity make a good re- covery, but this is not by any means the constant result. Instead of a continuous progress toward recovery, there may be a series of relapses, followed by incomplete recovery or cases may pass into hopeless chronicity and dementia. This, however, as has already been pointed out, is the outcome in a small percentage of cases only. Pilgrim 1 states that in his opinion only about 50 per cent, of cases due to typhoid fever recover, while 20 per cent, die from exhaustion, and 30 per cent, gravitate into chronic insanity. These statements, however, are not borne out by the experience outside of the asylums. The percentage of favorable results is really much greater. It may be not uninteresting to add a paragraph as to 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. ISasse, 2 Wise, 3 Keay, 4 Charon, 5 and others have placed on record quite a number of cases of recovery. 6 The interesting fact of recovery of insanity after typhoid fever is comparable to the effects of other infectious processes, such as ery- sipelas, and also to the results occasionaly following trauma and surgical operations on the insane. Even in so grave a mental 1 State Hospital Bulletin, New York, Utica, 1896, vol. i. p. 50. 2 Loc. cit. 3 State Hospital Bulletin, New York, Utica, 1896, vol. i. p. 63. 4 Journal of Mental Sciences, 1896, vol. xlii. p. 267. 5 Charon, Arch, de Neurol., 1896, i. p. 330. 6 Hyvert, Arch, de Neurol., 1895, vi. p. 103, believes on the other hand, that typhoid fever affects the mental state of the insane to a less degree than do other infections. THE MENTAL COMPLICATIONS. 281 disease as paresis, au attack of erysipelas or a trauma is occasionally followed by a striking and remarkable remission of symptoms ; similar statements may be made with regard to melancholia and other forms of mental disease associated with depression and im- paired nutrition. In cases in which typhoid fever fails to cure or to improve the mental symptoms, the psychosis already presenl does not appear to be affected injuriously. At least this is NasseV conclusion. One case under the observation of this writer presented a paroxysm 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 1 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 employes. These data evi- dently do not point to any lessened degree of vulnerability on the part of the insane. 1 Hyvert, Arch, de Neurol., 1895, vi. p 103. 2 State Hospital Bulletin, New York, Utica, vol. i. p. 69. INDEX. A BDOMINAL, catarrh, 70 XX pain, 123 Abnormal eruptions in typhoid fever, 166 Abortive typhoid fever, 38, 73 Abrupt onset, 56 Abscess, alveolar, 205 appendicular, 148 of liver, 209 of lung, 97, 1S2 of mesentery glands, 218 of parotid gland, 208 subphrenic, 218 of retroperitoneal glands, 218 subdiaphragmatic, 218 Absence of fever, 70 of intestinal lesions, 115 Acute, delirium, 267, 269 endocarditis, 100 nephritis, l04 pleurisy in onset, 51 pulmonary tubercular consolida- tion, 50 Afebrile abdominal catarrh, 70 Age, mortality in advanced, 36 Albuminuria, 104 Alcoholic neuritis, 225 Alimentary canal in convalescence, 202 in developed stage, 109 in onset, 53 Alveolar abscess, 205 Amaurosis, 235 Ambiguous period, 64 Anus, gangrene of, 208 Aphasia, 162, 234 Aphthous inflammations, 205 Appendicitis, 143, 257 Apyretic typhoid fever, 71 Ascending myelitis, 228 Asthenia, 101 BED, fever, 181 sores, 169 Bilious fever, 54 Blood, bacillus of Eberth in, 103 in developed stage, 101 Bloodv stools, 78 Boils, "241 Bowel, cicatricial contraction of, 204 gangrene of, 203 thermometer in, 221 Bronchitis, 95 pAEBUNCLES, 241 \J Carphologia, 164 Catarrh, afebrile abdominal, 70 Cerebral, asthenia, 277 embolism, 160 thrombosis, 160 Changing fortunes, period of, 64 Children, relapse in, 177 typhoid fever in, 27 Chill in onset, 43 Chills, 75 Cholangitis, 130 Cholecystitis, 42, 89, 211 Chorea, 237 Cicatricial constriction of bowel, 204 Circulation in convalescent stage, 182 in developed stage, 98 Coal-tar products, chill producing, 78 Collapse, 78, 79, 100, 127 Complicating infections, 78 Complications, mental, 265 Conditions which ape typhoid fever, 253 Confusional insanity, 271 Congestion, hypostatic, 96 Constipation, 120, 202 Convalescence, period of, 174 Convalescent stage, circulation in, 182 respiratory affections in, 181 Convulsions, 162 Course of fever in relation to prognosis, 83 Croupous pneumonia, 67, 96 Cystitis, 109 DEATH, sudden, 184, 188 Delirium in developed stage, 149 in onset, 57 Desquamation of skin, 248 Developed stage, 63 alimentarv canal in, 109 blood in, 101 circulation in, 98 respiratory system in, 85 Diagnosis of perforation, 129 Diarrhoea, 80, 202 in typhoid fever, 120 serous, 55 Dicrotism, 98 Diphtheria of intestine. 203 Dislocation of joints, 251 Duration, 262 284 INDEX. EMBOLISM, 185 cerebral, 160 Emphysema of mediastinum, 93 Empyema, 98 Endarteritis, 187 Endocarditis, 185, 186 acute, 100 ulcerated, 80 Eosinophils, 80 Epididymitis, 194 Epilepsy in relation to typhoid fever, 165 Epistaxis, 88 late, 89 Eruptions, abnormal, 166' Eruptive diseases in the course of fever, 171 Erysipelas, 241 Exhaustion, 101 FAINTNESS, 78 Fall of temperature, sudden, 78 Fever, bilious, 54 gastric, 54 infantile remittent, 54 pneumo-typhoid, 47 remittent malarial, 74 septic, 75 worm, 54 Foetus, infection by typhoid fever, 33 Forme cardiaque, 99 Frequency of hemorrhages, 123 of typhoid fever in children, 27 GALL-BLADDER, 80 Gallstones, 213 Gangrene, 170 of anus, 208 of bowel, 203 of extremities, 192 of lung, 97, 98, 182 of mouth, 205 of perineum, 208 of skin, 241 of tongue, 206 superficial, 169 Gastric fever, 54 symptoms in onset, 54 Genito-urinary complications of con- valescence, 193 tract in developed stage, 104 Glossitis, 205 Green stools, 121 HEMATURIA, 52, 104 Headache, 152 Heart muscle in tvphoid fever, 183 Hebetude, 150 Hemiplegia, 229 Hemoptysis, 97 Hemorrhages, 123 frequency of, 123 from stomach, 111 in children, 125 intestinal, 78 Hemorrhagic diathesis, 170 eruptions, 170 infarction of lungs, 96 nephritis, 104 Hemorrhoidal arteries, thrombosis of, 207 Hernia, scrotal, 132 ventral, 132 Herpes labialis, 170 High temperatures, 66 Hyperpyrexia, 66 Hypostatic congestion of lungs, 96 Hysteria, 163, 238 Hysterical convulsions, 152 IMMUNITY, 262 I Indigestion, 202 Infantile remittent fever, 54 Infarction, 185 of lung, 96 Infections, complicating, 78 Influenza, 79 Insanity, 152, 268_ Insidious perforation, 128 Intercurrent relapse, 67, 177 Intestinal hemorrhage, 78 lesions, absence of, 115 Intestines in typhoid fever, 115 JAUNDICE, 219 J Joints, 250 KIDNEY, miliary abscess of, 107 Kidneys, in onset of fever, 52 Knee-jerks, absence of, 164 T APAROTOMY in perforation, 135 Li Laryngeal form of typhoid, 51 paralysis, 235 ulceration, 90 Laryngo-typhus, 91 typhoid, 51 Larynx, necrosis of, 94 perichondritis of, 89 Late epistaxis, 89 Leucocytes in complications, 102 Linea albican tes. 249 Liver, abscess of, 209 Lobular pneumonia, 95 Localized atrophy of skin, 249 ISDEX. 285 Lung, abscess of, 182 gangrene of, 182 Lungs, hemorrhagic infarction of, 96 hypostatic congestion of, 96 tuberculosis of, 79 MAIDSTONE epidemic, 121 Malaria, 253 Malarial fever, remittent, 74 Maniacal delirium, 58 Measles, complicating, 173 Mediastinal emphysema, 93 Mediastinum, suppuration of, 93 Melancholia, 278, Meningitis, 153 Mental complications. 265 disturbances, 234 Mesentery glands, abscess of, 218 Miliary abscess of kidney, 107 tuberculosis, 96, 256 Morbidity, decrease of, 18 Mortality, decrease of, 18 of perforation, 130 relation of age to, 36 Mountain fever, 260 Mouth, gangrene of, 205 Multiple abscess of liver, 210 relapses, 180 Myelitis, ascending, 228 Mvostitis, 237 YTECKOSIS of larynx, 94 11 Nephritis, acute, 104 hemorrhagic, 104 Nephro-typhoid, 52 Nervous symptoms in convalescence, 221 in developed stage, 149 in onset, 56 Neuritis, 165 peripheral, 221 Noma, 204 G^DEMA of thorax, 249 -j 'Esophagus, inflammation of, 110 ulceration of, 110, 206 Onset, 37 abrupt, 56 chill in, 43 delirium in, 57 in alimentary canal, 53 in kidneys, 52 nervous symptoms in, 56 respiratory infection in, 47 rigor in, 43 skin in, 62 temperature in, 37 unusual temperature variations in, 40 Orchitis, 193 PAIN, abdominal, 123 Paralysis, 165, 221 agitans, 235 laryngeal, 235 of vocal chords, 235 pseudo-hypertrophic, 23S Paranoia, 27" Parotid gland, abscess of, 208 Parotitis, 209 Percentage of perforation, 130 Perforation, 78, 126 diagnosis of, 129 of bowel, 202 treatment of, 135 Pericarditis, 188 Perichondritis of larynx, 89 Perineum, gangrene of, 208 Period, ambiguous, 64 of convalescence, 174 of "steep curves," 64 Peripheral neuritis, 221 Peritoneum, tuberculosis of, 79 Peritonitis, 129, 204 Pharyngeal involvement in developed stage, 109 Pharvngo-tvphoid, 53 Phlebitis, 67, 191 of calf of leg, 193 Pleurisy, 67, 97 acute, in onset, 51 Pneumonia, croupous, 96 lobular, 95 Pneumothorax, 97 Pneumo-typhoid fever, 47 Pregnancv complicating tvphoid fever, 32," 64 typhoid fever during, 32 Profuse urinary flow, 109 Prognosis, course of fever in relation to, 83 in post-typhoid insanity, 279 Pseudo-dementia. 277 hypertrophic paralysis, 238 paresis, 277 Puerperal septicaemia, 259 Pulmonary abscess, 97 tubercular consolidation, 50 Pulse rate, 98 Pvelitis, 107 Pyemia, 80 Pylephlebitis, 211 Pyonephrosis, 109 Pyuria, 107 RAPID pulse, 99 Recrudescence, 174 Relapse, 174 from gall-bladder infection, 214 in children. 177 intercurrent, 67, 177 286 INDEX. Relation of age to mortality, 36 Remittent malarial fever, 74 typhoid fever, 74 Respiratory affections in convalescent stage, 181 infection in onset, 47 system in developed stage of dis- ease, 85 Retention of urine, 53 Retroperitoneal glands, abscess of, 218 Rigor, 75, 181 in onset, 43 Rose rash, 80, 165 SCARLET fever, 248 complicating typhoid, 171 Scrotal hernia in typhoid fever, 132 Second attacks, 262 Septic fever, 75 Septicaemia, 80 Skin in convalescence, 241 localized atrophy of, 249 in onset, 62 in well-developed stage, 165 Spleen, affections of, 103 enlargement of, 220 rupture of, 220 Spleno-typhoid, 103 "Steep curves," 64 Stomach, 110 typhoid ulcers of, 111 hemorrhage of, 111 Stools, bloody, 78 green. 121 Strabismus, 235 Stupor, 268 Stuporous insanity, 275 Submaxillary glands involved, 110 Subphrenic abscess, 218 Subsultus tendinum, 164 Sudamina, 168 Sudden death, 184, 188 fall of temperature, 78 rises in temperature, 57 Sudoral typhoid fever, 44 Suffocative attacks, 92 Suppuration of mediastinum, 93 Syphilis, 80 Systematized delusions, 278 TACHE bleuatre, 73, 169 cerebrale, 168 Temperature, absence of febrile, 70 in convalescence, 174 in developed disease, 63 in onset, 37 in children, 42 rises in, 67 sudden fall of, 78 variations from usual in onset, 40 Tetany, 238 Thermometer in bowel, 221 Thorax, oedema of, 249 Thrombosis, 182 cerebral, 160 of hemorrhoidal arteries, 207 Thyroid gland, 249 Tongue, gangrene of, 206 Treatment of perforation, 135 Tremor, 235 Trichinosis, 80 True mania, 278 Tubercular consolidation, 50 Tuberculosis, 95, 185, 256 of lungs, 79 of peritoneum, 79 Typhoid bacilli in urine, 108 fever, abortive, 38, 73 apyretic, 71 change in type of, 27 conditions resembling, 253 constipation in, 120 diarrhoea in, 120 eruptions, 166 general considerations of, 17 in children, 27 in pregnancy, 32 infection of fetus by, 33 intestines in, 115 laryngeal form, 51 low temperatures in, 70 remittent, 74 sudoral, 44 "Typhoid-spine," 238 Typho-malarial fever, 81 Typhus, laryngo, 91 levissimus, 73 ULCER of stomach, 111 Ulcerative endocarditis, 80 Ulceration and diarrhoea, relation of, 121 of larynx, 90 oesophageal, 110, 206 Urine, retention of, 53 typhoid bacilli in, 108 Urticaria, 168 VARICOSITY of subcutaneous veins 192 Varieties of onset, 37 Veins, varicosity of, 192 Ventral hernia in typhoid fever, 132 Violent diarrhoea in onset, 55 Vocal cords, paralysis of, 235 Vomiting, 55, 111 w ORM fever, 54 Catalogue of Books PUBLISHED BY Lea Brothers & Company, t-j 706, 708 & 710 Sansom St., Philadelphia. / 111 Fifth Avenue, New York. 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