I— I ^rV^^P H^^X^LJ
l
THE (MEDICAL COMPLICATIONS,
ACCIDENTS AND SEQUELS
OF
n
TYPHOID OR ENTERIC FEVER.
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.
1 899.
Entered according to the Act of Congress, in the year 1899, by
LEA BROTHERS & CO.
In the Office of the Librarian of Congress. All rights reserved.
DORNAN, PRINTER,
PHILADELPHIA.
in
i — 1
cn
THIS
ESSAY IS
DEDICATED
TO MY HONORED COLLEAGUE,
W. W. KEEN, 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 sequelae. Anyone who has
had even a limited experience with typhoid fever has -met with
I cases in which the manifestations wandered so far from the clas-
v?
sical descriptions of the disease as to be puzzling and obscure, or
-i with instances in which the malady has been so altered in its
course by intercurrent affections as to be unusual and to call forth
<i .
\ 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. Dercum, to add a chapter on this
phase of the subject, which is of great interest.
~X^ Finally, I desire to acknowledge my great indebtedness to
the several authors who have enriched medical literature by
A special contributions to this subject, and from whose writings
„ and bibliographical researches I have gained much valuable
"K. material. The first of these is the essay of my honored col-
•y^
vj^league, Dr. AV. W. Keen, on the Surgical Complications and
\h Sequelae of Typhoid Fever. In many instances Dr. Keen, in com-
pleting his statistics, steps into the bounds 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,
APRIL, 1899.
CONTENTS.
CHAPTER I.
GENERAL CONSIDERATIONS 17
CHAPTER II.
VARIETIES OF ONSET .......... 37
CHAPTER III.
THE ABERRANT SYMPTOMS, STATES, OR 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 SEQUELS OF
TYPHOID OR ENTERIC FEYER.
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 sequelae 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 discuss 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 ix MUNICH FROM 1851 TO 1896.
Year.
Inhabitants.
Annual.
Per 100,000
inhabit'nts.
Year. Inhabitants. Annual, inhabitants?
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, '
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
148
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. Not only are
these facts true of the cities just named, but it is also true that
the frequency, severity, and mortality of typhoid fever are steadily
decreasing all over the world, as is shown by the following inter-
esting tables of Dreschfeld in regard to England 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 SEQUELAE OF TYPHOID FEVER.
ANNUAL MORTALITY, PER MILLION PERSONS LIVING, PROM FEVER IN
ENGLAND.
Period.
Enteric
cases.
Period.
Enteric
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
DEATH-RATE
FROM ENTERIC FEVER
IN LONDON
AND MANCHESTER
PER MILLION.
Year.
London.
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
1888 .
. 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.
38O
S8O
4GO
ft.
37O
370
360
4=4=0
35O
3SO
4=3 O
34O
34O
43 O
33O
330
41O
33O
40O
310
31O
3OO
3OO
38O
2OO
19O
3SO
360
3TO
iro
3SO
t
A
3OO
16O
34O
3oO
1GO
33O
34O
33O
13O
31O
33O
ISO
300
tf
31O
3OO
38O
10O
3TO
18O
360
iro
3SO
q
16O
34O
33O
33O
310
V;
30O
ISO
ISO
IT'O
Chart showing decreasing mortality of typhoid fever per million persons living
in England, London and Manchester.
Solid line, England. Broken line, London. Dotted line, Manchester.
Not only is the decrease in mortality seen in England, but in
Philadelphia and New York, as follows. The decrease in cases
and in mortality in Philadelphia is shown in the following chart
in broken and complete lines (Fig. 2) :
22 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
FIG. 2.
NUMBER
OF
^
f$
CO
-fj
SO
Si
-r>
GO
o
55
— i
C5
CO
gg
Ci
CO
co
O5
CO
-*
§
10
0
CO
0
C5
CO
r-
Ci
CO
CO
C5
CO
CASES
£ Q'
BETWEEN
21
*
B
1
f
4500-4200
20
\
J\
i \
/
/
4200-3900
10
\
1
A
;
1
\
V-
-•«,
/
3900-3600
IS
I
t ;
s
1
3600-3300
IT
I
\ /
\ i
\
A
\
^
A
j
3300-3000
16
I
V
'v
'>
/
3000-2700
15
1
^
\
\
2
2700-2400
14
\
A
/ s
v3
2400-2100
13
V
s/
2100-1800
12
\
\
1800-1500
11
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.
PHILADELPHIA.
Year.
Cases.
Deaths.
Per cent, of
mortality.
1888 .
, " . . 3573
785
21.9
1889 .
, .. . 4631
736
15.8
1890 .
. 3182
566
20.9
1891 .
. 3531
683
19.3
1892 .
. 2304
440
19.1
1893
. 2519
456
18.1
1894 .
. 2357
370
15.7
1895 .
. 2748
469
17.0
1886 .
. 2490
402
16.1
1897 .
. 2994
401
13.3
1898
. 4749
566
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.
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 per 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 SEQUELS OF TYPHOID FEVER
FIG. 4.
Chart showing decreasing number of cases annually in New York.1
FIG. 5.
ANNUAL
DEATH RATE
OF
»
n
T,
N
00
X
00
00
00
a
GO
00
0
o
00
H
a
GO
01
a
CO
CO
C3
X
i
a
X
10
a
00
o
0
00
l^
0
0
o.aa
A
O.34
/
\
0.33
V
/
v
,/*-
— N
0.22
V
V
N
O.S1
\
*
O.2O
O.19
\
O.18
V
0.17
•
\
0.16
s
\
O.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.
Bryant1 states that out of 608 cases treated in Guy's Hospital
from 1879 to 1893 14 per cent, died.
Again, in the Gazette Medicale des Hdpitaux 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
per cent. ; 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 decrease
in mortality is evident :
1 Guy's Hospital Keports, 1893.
26 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER.
Basel (Liebermeister)
Basel (Liebermeister)
Maidstone, England ....
Boston (Mason) .....
Homerton (Collie) ....
Glasgow (Collie) ....
Societe Me"dicaledes H6pitaux (1879)1
Jaccoud
Eiess
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.
9,017
7.8
All kinds of cold
27,116
10.02
In other words, 27,116 cases in Switzerland, America, England,
Germany, and France show that good nursing and careful non-
meddlesome treatment will give a mortality of 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.
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
Basel (1873)
Glasgow "
Homerton "
Basel (1874)
Glasgow "
Homerton "
1 These statistics are based upon the fact that twenty -one chiefs of hospital
service reported to the Socie'te' 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 Phillips1 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 iu 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 SEQUELAE 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 Rocaz1 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 Pepper3 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. s American System of Medicine, vol. ii.
GENERAL CONSIDERATIONS. 29
376 cases and 26 autopsies in children from this disease, and
Barthez and Sanne state that the disease is as frequent among
children as among adults.
On the other hand, there is an immense amount of evidence to
prove that the disease is so rare as to be almost a curiosity in chil-
dren. Thus William Perry Northrup has taken the statistics of
the New York Foundling Hospital, the New York Infant Asy-
lum, the Children's Hospital of Philadelphia, and finds that in
the twenty years at the New York Foundling Hospital with 1800
cases under care, 1100 of which were boarded in the country,
returning to the hospital when ill, not a single case has been seen
by himself, J. Lewis Smith and O'Dwyer. Further, in 2000
autopsies on children Northrup did not find a case, perhaps be-
cause typhoid fever rarely brings a child to autopsy, and during
-an epidemic in Stamford, Conn., in 1895, out of 400 cases at all
ages, but four cases of enteric fever developed under four years of
age.
Holt1 states that he has never met with enteric fever in a child
under two years of age. He never saw a case in the New York
Infant Asylum in a service of eight years, although 15,000 cases
were admitted in that time.2 One case was admitted to the Babies'
Hospital in seven years at the age of two and one-half years.
In this connection it is interesting to note that Taupin,3 writing
sixty years ago, says that the rarity of this fever in children is
more apparent than real, and points out that the mild manifesta-
tions of the disease are overlooked.
Notwithstanding these statistics, we find that typhoid fever
does occur quite frequently in the hands of some practitioners.
Thus Forchheimer4 treated 70 cases in 1888 in one epidemic,
and Morse, in analyzing 284 cases in the Boston City Hospital in
which this disease appeared, found 3 under five years of age, 77
between five and ten years, and 204 between ten and fifteen years.
1 Diseases of Children.
* Probably all these did not come under his term of service.
3 Journal des Connaissances He'd, and Chir., 1839, No. 7.
4 American Lancet, March, 1889.
30 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
Holt quotes 970 cases of enteric fever in children collected from
eight authors whose names he does not give. Of these 970 cases,
8 per cent, occurred under five years ; 42 per cent, between five
and ten years, and 50 per cent, between ten and fifteen years.
He also quotes an epidemic of 115 persons, of whom three were
under two years of age.
Wightman1 has recorded 24 cases of typhoid fever in children
under thirteen years of age ; 3 of these died, and typical spots
were seen in 15 ; constipation in 10, and typical stools in only 3
cases. So, too, Davis2 has recorded 33 cases in children, all of
whom were under ten years of age, and in all of whom but 3 the
disease developed abruptly.
Ssokolow,3 in a study of 581 cases of typhoid fever, the majority
of which occurred between four and ten years, found that it was
abortive in 4.3 per cent., mild in 26 per cent., ordinary in 51 per
cent., and severe in 18 per cent. In 3.6 per cent, there was an
abrupt onset with vomiting, and in 3.2 per cent, it was abrupt
with a chill ; diarrhoea occurred in only 1 0 per cent.
Bridges has met with the disease in infants at fifteen and eighteen
months of age, and Bond saw eleven children, affected in one-house
epidemic, between the ages of three and twelve years. Head4 has
collected 22 cases between four and one-half months and ten
years, and Griffith reports cases at three, seven, eleven, and thir-
teen years. England records one at eight months of age, and
Boobbyer one in an infant of eight months. Murchison recorded
one at six months. Ogle has recorded a case at four and one-half
months, and Fuller one at five months.
Further than this, Dr. Mart,5 of German, Ohio, has recorded
the fact that in six years he had treated seventeen cases of unques-
tionable typhoid in children ranging from fourteen months to five
years of age ; that three of these cases were less than twenty-four
1 British Medical Journal, May 5, 1894.
2 Alabama Medical and Surgical Age, August, 1894.
3 Centralblatt fur innere Med., May 18, 1895.
* Brooklyn Medical Journal, October, 1890.
5 Cleveland Medical Gazette, vol. xii. p. 510.
GENERAL CONSIDERATIONS. 31
months old, and in each instance there were other members of the
family sick with the fever at the same time, showing that the
infection was present in the household.
H. J. Lee,1 of Cleveland, reports a case of typhoid fever in an
infant six months old, and states, although he does not give the
reference for the same, that he finds one case reported as young as
four and one-half months f another at six months, and a good
many under two years.
O'Malley3 records three cases of typhoid fever at twenty-one
months, three years, and six years in one family.
Xot only may typhoid fever occur in very young children, but
it is to be remembered that this source of infection may cause the
disease among adults. Thus Boobbyer4 records an instance in
which out of a family of eight persons five became infected
through an infant of eight months. The child had been restless
and had constant diarrhoea, but the fact that it was suffering from
typhoid fever was not recognized.
That severe typhoid fever may occur very early in life is shown
by the statement of Osier, that perforation of the bowel from this
cause has occurred in a child five days old, and Earle has reported
a case to Keating of fatal intestinal hemorrhage due to typhoid
fever at twenty-two months.
Further than this, Sbrana,5 who has treated seventy-two cases
of typhoid fever in children in Tunis, tells us that a symptom
which was never lacking was splenomegaly appreciable from the
fifth or sixth day of the fever. The nervous symptoms were more
marked in girls than in boys. The mortality was 11.1 per cent.,
and the complications were meningitis, suppuration, parotiditis,
peritonitis from perforation, purulent pleurisy, aphasia lasting as
long as three weeks, dilatation of the stomach during convales-
cence, and orchitis.
1 Cleveland Journal of Medicine, 1897, vol. ii. p. 400.
2 Probably Ogle's case. 3 University Medical Magazine, 1896-97, p. 637.
4 British Medical Journal, January 26, 1890.
5 Quoted in the American Journal of Obstetrics for March, 1899, from the
Archives de Me"d. des Enfance, January, 1899.
32 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
Wurtz1 records the case of a girl of eight years, who developed
a swelling over the sternum during the second week of typhoid
fever. Puncture drew pus and an incision gave exit to a necrosed
piece of the sternum, the entire body of the bone being involved
in the necrotic process. Typhoid bacilli were demonstrated micro-
scopically in the pus. Death occurred in the fifth week. At the
autopsy an abscess lined by pyogenic membrane was found between
the sternum and pleura, extending upward to the manubrium.
There was broncho-pneumonia in both lungs, and in the ileum
there were a few typhoid ulcers, the rest of the intestine showing
healing ; the right arytenoid cartilage showed a chondritis.
In the Maidstone2 epidemic of 1897 and 1898, 22 per cent, of
the cases admitted to the hospital were in children under ten
years of age, and 52 per cent, were under fifteen years.
I think it is fair to conclude therefore that Taupin's assertion,
in 1839, that typhoid fever is not a rare disease in children is
correct.
At the present time the diagnosis of typhoid fever in children
must rest largely upon the chance development of the character-
istic rash and enlarged spleen, and more than all upon the Widal
test, for the moderation in all the symptoms so characteristic of the
affection in childhood, and the fact that a swollen spleen and liver
and a coated tongue with fever are so commonly met with in
various children's ailments, make an absolute diagnosis without
this test in many instances almost impossible.
Typhoid fever is not common in pregnancy, but when it occurs
it is a serious matter, for abortion often follows, particularly if the
fever be high. The percentage of abortion is about 56 per cent.
In 310 cases collected by Sacquin, 199 aborted. The mortality,
according to Brieger, was 19 in 91 cases, and according to Vinay,
17 per cent, in 183 cases.
Death to the foetus does not always occur as a result of prema-
1 Quoted in the American Journal of Obstetrics for March, 1899, from the
Jahrbuch f. Kinderheilkunde, vol. xliv., No. 1. I have not been able to see
the original article.
2 Poole. Guy's Hospital Eeports, 1898. Wrongly labelled on cover 1896.
GENERAL CONSIDERATIONS. 33
ture birth due to typhoid fever ; thus Touvenaint1 reports a case
of premature birth at the end of the seventh month, the child
surviving and the mother dying.
Typhoid fever may also affect the foetus in utero. This For-
dyce has proved, and he also asserts, that the child may survive.
It is possible, too, for it to escape the infection. Flexner has exam-
ined such a case for Osier.
Griffith found the Widal reaction in a child of seven weeks
whoso mother had typhoid fever at the time of its birth.
So, too, fitienue2 has recorded the examination of a foetus ex-
pelled by a woman in the fifth month of pregnancy, on the
twenty-ninth day of typhoid. The spleen and intestines of the
child showed no signs of the disease, and the placenta was healthy,
but an examination of the blood in the right side of the heart and
of that of the spleen revealed innumerable typhoid bacilli.
Mosse and Dannie also record a case in which a woman suffered
from typhoid fever in the eighth month of pregnancy. At birth
the blood of the child, the blood of the placenta, and the milk of
the mother gave the AVidal reaction, as did the child thirty-three
days after birth.
Another interesting illustration of the fact that the foetus may
become infected by the typhoid bacillus through the mother is
shown by a case reported by Eberth,3 of a woman who suffered
from typhoid fever in the fifth month of pregnancy and miscar-
ried, and in the cardiac and splenic blood of the foetus the specific
bacillus was found.
Mosse and Fraeukel4 have made a report upon the agglutination
test in placental blood to the Societ6 Meclicale des H6pitaux, in
which they confirm the statements already made, that the Widal
test can be obtained from the placenta, and also that it is possible
to obtain it from the milk of the mother and the blood of the
foetus.
1 Journal de Medicine de Paris, July 8, 1894.
2 Gazette Hebd. de Medecine et de Chirurgie, 1896, No. 16.
3 Centralblatt fiir Bakteriologie and Parasitenkunde, May 13, 1890.
4 Journal des Practicians, January 28, 1889.
3
34 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER.
The following very interesting case in this connection has just
been reported to me by my friend, Dr. Wilmer Kruseii :
Mrs. B., aged twenty-seven years, a native of Ireland, a house-
wife by occupation, was admitted to the hospital February 7,
1899, eight months pregnant. From her attending physician it
was learned that for a week prior to her admission she had had a
typical typhoid temperature and stools, but no spots. On admis-
sion her temperature was 100.5°; the pulse was 100 ; respirations,
24. The temperature fell steadily till it reached 95° at 10 A.M.
of February 8th, remaining there all that day ; the pulse ranging
between 80 and 94, and the respirations between 18 and 32.
About 1 A.M., February 8th, she developed labor pains, which
lasted until 3 A.M., when they ceased entirely ; the pains were
never severe, and labor progressed very slowly. The temperature
was subnormal all the time, but began to rise toward morning, and
reached 99° at 8 A.M.; the pulse, 100 ; respirations, 36. The tem-
perature continued to rise slowly. At noon on February 9th very
mild labor pains again began, but soon ceased. At 3 P.M. the
child's head had descended entirely without any pain whatever. No
progress being made, forceps was applied and the child delivered
a few minutes past 3 P.M. Temperature, 100.4°; pulse, 136 ; respi-
rations, 36. Temperature then went up, and at 6 P.M. was 103.4°,
and continued with daily remissions, as is usual in typhoid. A
superficial median laceration occurred ; it was sewed up, but no
healing process took place, and the stitches had to be removed.
About the tenth day after admission, the temperature became very
irregular, ranging from 97° to 106.2°; pulse from 110 to 150;
respirations, 20 to 44. The vaginal discharge had been copious
and offensive, and continued so until the twenty-second day in the
hospital. The temperature continued to be irregular throughout
the remainder of the disease. From February 18th to February
24th the temperature became reversed, so that it was highest
about 6 A.M. and lowest about 6 P.M., being still very irregular.
From February 24th the temperature again assumed its former
character, highest in the evening and lowest in the morning. The
vaginal discharge had completely stopped by February 28th, having
GENERAL CONSIDERATIONS. 35
been very slight for the preceding three or four days. March 3d,
the temperature was 98.4° at 10 A.M. ; pulse, 92 ; respirations, 24.
The child progressed nicely. The Widal reaction was taken March
2<1 with a very high dilution, and proved to be negative, though
there was a distinct tendency to agglutination. It was taken again
March 4th with a dilution of 1 part of serum to about 25 parts of
water. The result was a positive reaction in eleven minutes.
A somewhat similar case has also been recorded by Batty Sha'w.1
A woman suffering from typhoid fever in the fifth month of preg-
nancy and her child gave a feeble Widal test five weeks after birth
on two occasions, but on two other occasions the test was negative.
Two cases illustrating typhoid infection during the last weeks
of pregnancy have recently come under my care, having been
transferred to me from the Jefferson Maternity Wards by Dr. E.
P. Davis. In both of them the fever began practically simul-
taneously with parturition, indicating that the patient had become
infected during the last two weeks of pregnancy. In neither one
of them were the typhoid manifestations severe so far as nervous
and circulatory symptoms were concerned, but in one the tempera-
ture was fairly high and persistent. The blood of the children
did not give the Widal test.
In patients over forty years, typhoid fever is a rare but grave
disease, the mortality increasing with the years. The fever, as
already indicated, is apt to be mild, but death comes more com-
monly than in comparative youth from complications like pneu-
monia and heart lesions (Fig. 6).
Dreschfeld has reported a case of typical typhoid fever in a
man of seventy-five years, and another in a man of eighty-two
years. In the latter case he states that recovery took place.
While it is generally true that the period of incubation of
typhoid fever extends over a period from ten days to two weeks,
recent ^reports indicate that in certain instances this period may
only cover a few days. Thus Janehen-Graz2 has recently reported
thirty-six cases of typhoid fever occurring among soldiers, in whom
1 London Lancet, 1897, vol. ii. p. 539.
2 Miinchener Medicinische Wochenschrift, 1898, p. 936.
36 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER.
definite proof was adduced that they had all become infected at
the same time by drinking infected water. As a result the incu-
FIG. 6.
AGE
10
11-16
10-20
21-25
20-30
31-35
30-40
41-45
40-^50
51^5
50-00
til
PERCENT
5O
40
30
20
10
0
f
1
/
/
/
i
/
/
/
/
7
/
/
'
/
^
/
A,
^
, —
/
s
^
|X
/
">
/
/
X
-•^
^
, — •
^•^
^"
•^
/
/
^
Chart showing the increasing mortality of typhoid with advancing years.
(CURSCHMAN. )
bation period in three cases was only two days, in seven cases
three days, in six cases four days, and in thirteen cases five to
seven days.
CHAPTER II.
VARIETIES OF ONSET.
BEFORE attempting to consider the variations which take place
in the stage of onset in typhoid fever, it is necessary to have some
standard type of an average case of the disease in this period.
The usual mode of onset, as described by Dreschfeld in Allbutt's
System of Medicine, is as follows :
" In many ordinary cases the onset is insidious. The patient
complains of pain in the limbs, of excessive fatigue, of cold and
chilly sensations, of headache often very severe, of loss of appe-
tite, and of sleeplessness. Epistaxis is a very common symptom,
and generally occurs about the second or third day of the disease.
These symptoms become more severe, the patient has to take to
his bed, and from this day we generally reckon the duration of
the fever. In many cases, however, as shown by the changes after
death, the beginning of the morbid process must be dated from
the very first symptom. The tongue becomes furred, and is at
first moist ; there is a steady rise of temperature, the evening tem-
perature being generally one and a half degrees (F.) higher than
the morning temperature, so that about the fourth day the tem-
perature reaches 103° F. or 104° F.; the pulse rises to 90 or 100,
rarely higher except in very severe cases, or in very young or de-
bilitated subjects, is dicrotic and indicative of low blood-pressure ;
there is increased thirst ; the abdomen is slightly distended and
tender on pressure ; diarrhoea may as yet be absent, and there may
be constipation, or there may be two or three fluid stools from the
first. Beyond headache, which persists for a few days, and sleep-
lessness, there are as yet no other symptoms ; the skin is dry, but
there are paroxysms of profuse perspiration. The spleen is as
yet but little enlarged, and there are as yet no roseolar spots,
38 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
though when perspiration is profuse sudamina are noticed ; the
urine has febrile characters, and as yet does not show the diazo re-
action. This stage lasts about seven days, and constitutes the
first week of the enteric fever."
If this be taken as a type of an average case, we find at once that
on either side of this type undoubted cases occur which by their
extreme mildness may be overlooked, or by their great severity may
mislead the physician into the diagnosis of some more acute and
rapidly progressing affection. In the mildest of these cases there
is little to be found indicative of enteric fever save, as Lieber-
meister puts it, " the long duration of an apparently trifling indis-
position in which the patient presents a general impairment of
health, malaise, physical and mental depression, and headache,
with loss of appetite, the tongue being coated, and the pulse often
distinctly slower than normal." No fever may be present. So
moderate may all the symptoms be that a differential diagnosis
between subacute gastro -intestinal catarrh and mild typhoid fever
may be practically impossible except by the aid of Widal's test,
which rarely gives results so early as the days of onset. Certain
of the German writers have gone so far as to assert that all cases
of subacute catarrh of this character depend for their existence
upon mild typhoid infection.
Not only may the course of the malady be very mild indeed,
but its length may be so brief as to throw doubt on its specific
character, the whole illness lasting twelve to seventeen days, and
then recovery being established. Sometimes even less time elapses
before the fever ceases and the patient is manifestly convalescing.
Then, again, the abortive type of this fever presents itself, in
which, after an illness beginning with quite characteristic manifes-
tations, often of considerable severity, the symptoms rapidly
ameliorate, and convalescence is established within ten days of the
onset. This is well illustrated by the following temperature chart
of a student recently under my care. On March 8th he first
began to suffer from symptoms which were severe enough to make
him seek medical aid and go to bed. Prior to this date he had
felt but slightly unwell and this only for a few days. As is seen
VARIETIES OF ONSET.
39
in the chart, his temperature fell by crisis on the seventh day of
his illness, although the positive Widal reaction endorsed the
diagnosis of true typhoid fever. Curiously enough, such cases are
often ushered in suddenly by marked signs — high fever and indi-
cations of grave illness — and yet so speedily pass on to the fall
by lysis that it seems as if the attack must be due to some other
infection. Such cases are recorded in which an initial fever of
106° in the axilla has been followed by a normal temperature as
early as the seventh day.
FIG. 7.
F. 104'
103'
102°
101°
100°
97°
Day of Di
7\
Abortive typhoid fever ending by the seventh day, and by crisis instead of lysis.
In the malignant forms of infection the symptoms of onset
may be of three types, viz., mild, followed by symptoms of increas-
ing severity ; severe, with rapidly fatal developments, and, finally,
aberrant symptoms pointing rather to the cranial contents, tho-
racic organs, or other parts of the body than to the abdominal
contents. These various types will be found fully discussed in
the following pages, but as an illustration of the cerebral type, a case
reported by Green1 may be cited. A child aged four years, had
Australian Medical Gazette for August 29, 1897.
40 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
been quite well until four days before admission, when he was
seized with an attack of giddiness while playing, turned around
and around, and fell ; but there was no loss of consciousness
and no convulsive movements. Two hours later he vomited.
There was no ear trouble. A week later, the seventh day of
the attack, the child had a convulsion, lasting two minutes,
which affected both sides of the body, and again on the eleventh
day of his illness he had a very severe convulsion, lasting two
hours, affecting both sides, although after it passed off there was
marked twitching of the right side and conjugate deviation of the
eyes to the right. The next day hemiplegia affecting the right
side was well developed. The convulsions proceeded off and on
for two days, affecting only the right side. Afterward vomiting
became a constant symptom, and death occurred on the thirtieth
day of illness and nineteen days after the first severe convulsion.
At the autopsy a large portion of the temporo-sphenoidal lobe of
the left side was discovered to be quite soft and pulpy, and on
making a transverse section of this area the softening was found
to affect the lenticular nucleus and to abut very closely to the
anterior horn of the internal capsule. There was no hemorrhage,
but the left middle cerebral artery was filled with a blood-clot.
When it is possible for a disease to present such widely various
symptoms as have just been detailed, in its early stages, and
when we are told by Liebermeister that " there is not a single
symptom belonging to typhoid fever that is pathognomonic," it
is evident that errors in diagnosis must occur even in the most
skilful hands.
Temperature Variations from the Usual in Onset. Leaving
the general consideration of the types of onset for a discussion
of the individual symptoms of this period, we may take up the
question of the range of temperature. The normal variation or
character of the fever of onset has already been described in the
preceding pages, but marked variations from that course are often
present.
In this connection Dreschfeld quotes with approval a state-
ment of Wunderlich's, which seems to the writer entirely too dog-
VARIETIES OF ONSET. 41
inatic, in regard to the character of the oncoming fever, and it is
certainly entirely at variance with more recent observations. I
quote it to illustrate the older view of the disease : "Any fever
which on the second day reaches to 104° F. is not enteric fever, nor
is it enteric if the fever does not approach 104° F. on the evening
of the fourth day ; on the other hand, enteric fever may be diag-
nosed if in a middle-aged person suffering from an acute febrile
attack the evening temperature on the fifth day, or within the first
week, is between 103° and 105°, and alternates with morning tem-
peratures, which are 1.4° to 1.7° lower, unless some other disorder
can be discovered to explain the height of the fever. It is well
to state that by morning temperature we mean the temperature
about 9 A.M. ; by evening temperature that about 6 P.M." These
views certainly do not hold true to-day for the ordinary types of
the disease. Attention has already been called to the very low
temperature seen in the mild forms of the disease and to the high
fever sometimes met with even in the so-called abortive cases.
During the stage of onset variations in the temperature of the
patient may be due to complicating states which are about to be
described, or they are perversions of the ordinary temperature of
the initial days, occurring without assignable cause. The presence
of a consolidation in the lung, of a pleurisy, or of a serious
lesion in any one of the organs of the body, may entirely alter
the chart in this period of the malady ; and predominant local-
ized symptoms may still further mask the case.
This is well shown by the following case recorded by Morris.1
Aside from its obscure mode of onset this case is also of interest
since, as a rule, hepatic infection manifests itself after an attack
of typhoid fever rather than before :
On September 21, 1898, he was called in consultation by Dr. R.
E. Doran, of AVillard State Hospital, to see Mr. J. L. B., twenty-
six years of age, who had been suddenly seized forty-eight hours
previously, with a sharp pain below the right inferior costal mar-
gins, which rapidly extended as an acute general peritonitis, with
1 New York Medical Journal, January 28, 1899.
42 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
a temperature reaching 102° F., but apparently without accom-
panying rigors. The patient was constipated until the day on
which Dr. Morris arrived. On examination a mass was easily
palpated at the site of the gall-bladder, and the peritonitis seemed
to be most intense at that point. They diagnosticated empyema
of the gall-bladder and operated. The peritoneum was deeply
congested and was covered with coagulated lymph in the vicinity
of the gall-bladder. The gall-bladder was distended with a mix-
ture of thin, greenish mucus and thick, tenacious yellow pus. Dr.
Morris did not have his culture-tubes at hand, and no bacterio-
logical examination of the pus was obtained, much to his regret.
He drained the wound and the gall-bladder with a small wick
drain and closed the incision, excepting for the drainage opening.
On the evening of the day of operation the temperature rose to
103° F. and dropped on the following morning to 100° F. ; the
pulse to 88 ; the respirations to 24. On the evening of the second
day after operation the temperature rose to 106° F. Up to this
time the bowels had not moved, but two high enemata of Epsom
salts caused a number of loose movements, and the symptoms of
dangerously progressive infection subsided rapidly. After this the
symptoms of typhoid fever supervened, and the case ran a typical
course as one of typhoid fever, ending in recovery in about four
weeks, excepting for a small biliary fistula, which was closing
spontaneously at last reports from Dr. Doran.
In nervous children or women the irritation of the heat centres
often results in a sudden rise like that which is met with in the
more acute maladies of an infectious type. And it is a well-known
fact that typhoid fever in children is more apt to be ushered in by
a chill and high fever than it is in adults, as has been well pointed
out by Jacobi and J. Lewis Smith. A case of this character is
reported by Guinon,1 in which a child of two and one-half years
was seized with high fever and with all the symptoms of pernicious
malarial infection. Nine days later it suffered from collapse with
all its characteristic symptoms, and the day following passed stools
1 Eevue Mensuelle des Maladies PEnfance, 1897, p. 236.
VARIETIES OF ONSET. 43
which were typhoid in appearance. Collapse again occurred, and
on the twelfth day symptoms of meningitis developed. Finally,
a rose rash appeared, the spleen and liver were found to be en-
larged, and the case proved itself to be one of unmistakable
typhoid fever. The early age of the child, the sudden onset, the
flushed face, the high fever, the collapse, and, finally, the meiiin-
geal symptoms are of interest.
In some instances in which high temperature is noted when
the physician first sees the patient, it is not in reality the earliest
perversion of normal temperature in that a mild and unnoticed
fever has been present for some days, even though the patient has
felt perfectly well.
High initial temperatures should place the physician on his
guard, because they may mean severe infection or some grave
complication which he must search for and discover, and parti-
cularly is this the case if the initial temperature is ushered in or
is followed by a chill or rigor. In some of these cases careful
study of the history of the patient will reveal an exposure to
malarial infection, and an examination of the blood may reveal
the presence of the malarial parasite, although, as pointed out
further on, this organism is apt to be absent from the blood dur-
ing the active period of typhoid fever.
The more sudden the appearance of the disease, and the more
rapid the rise of temperature in the beginning of the first week, so
much the more should one expect in general a short and even
abortive attack, and the more rapidly the temperature falls, as
the end of the first week is approached, the better the prognosis,
particularly if the daily fluctuations are marked.
Very sudden development of true hyperpyrexia at this stage,
unless it is due to some severe complication, is very rare.
Chills. In some instances, not commonly met with, typhoid
fever is ushered in by severe chills. As already pointed out,
these are most apt to appear in children, and they may indi-
cate the development of some coincident infection. Chills may,
however, be due to the typhoid infection itself. They are met with
more frequently at the onset of a relapse than at the primary
44 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
onset. In a case recently under the writer's care, a man of thirty-
five years, after several days of malaise, without fever, was seized
with a violent rigor and at once became so ill that he was forced
to go to bed, where he passed through a severe attack of the disease.
Under the name of " sudoral typhoid fever/' Jaccoud records,
in La Semaine M6dicale for March 12, 1897, his belief in this
special type, in which chills and sweats are prominent symp-
toms. The onset of the malady is sudden, and is accompanied
by severe headache in the retro-orbital and occipital regions
with shivering, fever, and sweats, so that the patient resembles
one suffering from an intermittent malarial attack. These
attacks are often quotidian and the febrile movement is hyperpy-
retic. The peculiar symptoms cease by the fifth day, and are
followed by the usual course of typhoid fever. Quinine does no
good in these cases, and they are not due to malarial infection.
A second form is characterized by the primary appearance of head-
ache and fever followed by sweating, which is profuse and asserts
itself much later than in the form just described. The febrile
movement is distinctly intermittent in type, but not so markedly
so as in the form just named. In other cases, in place of a marked
rigor, the patient has a subjective sensation of coldness in some
part of the body, which can also be perceived by the physician if
he touches the spot. In these forms the irregular manifestations
may last three weeks and then gradually cease in the fourth week.
Sometimes these cases are, however, very prolonged, and Borelli
has reported instances lasting seventy or ninety days. Indeed,
Jaccoud regards the length of the attack as characteristic. There
are practically no complications. Albuminuria is extremely rare,
but intestinal hemorrhage of mild degree is not uncommon. Peri-
tonitis from perforation, Jaccoud asserts, is quite unknown in these
forms, and he regards " sudoral typhoid fever" as a mild type of
the disease. Notwithstanding the close resemblance of these types
to double infection by the malarial organism and the typhoid
bacillus, both Jaccoud and Borelli believe them to be pure typhoid
fever, because they occur in persons who have never been exposed
to malarial infection, and because quinine is useless.
VARIETIES OF ONSET. 45
The differential diagnosis is necessarily difficult in the early
stages of the disease, although in general Jaccoud would have us
believe that it is easy. It must depend largely upon the absence
of any history of malarial exposure, upon complete development
of most of the characteristic signs of typhoid fever, and, finally,
upon the absence of any signs of the malarial organism in the
blood and the presence of the Widal reaction. In cases of " abor-
tive sudoral typhoid fever," in which the disease runs a very
short course and stops abruptly, the diagnosis is very difficult.
Jaccoud describes such a case as follows :
" In the patient referred to the headache and the temperature
chart justified the diagnosis of mild typhoid fever, but the diges-
tive organs were intact ; there was no abdominal tympanism and
no diarrhea. The spleen was of perfectly normal size, the tongue
a little dry, but otherwise showed absolutely none of the char-
acteristics of typhoid fever. There was absolutely nothing in the
lungs. The fever alone, and the slightly stupefied appearance of
the patient, led us to assume the existence of some typhoid infec-
tion. There also existed on his body a measly eruption ; but this
was a superadded element, due probably to the large doses of anti-
pyrine which he had taken, and also to some alcoholic frictions
which had been given. Beside he was a grocer by trade, and
grocers are specially exposed to skin irritations which not infre-
quently give rise to cutaneous affections. On the first days he
had presented a certain degree of ocular catarrh, with redness of
the conjunctiva and watery eyes. Then abundant perspiration
appeared on the forehead, the nose, and the chest, drenching those
parts completely. The fever developed in this way for ten days,
the headache was general and persistent, but not very intense, and
during the whole of this time there was nothing worthy of note,
except the hypersudation and the rubeolar eruption.
" The case was evidently one of abortive typhoid fever of the
sudoral variety, and could be classed in the mixed form which I
have described. There was one abnormal point, viz., the subsi-
dence of the fever, which was complete on the tenth day. Such
rapid termination, not very unusual in ordinary typhoid fever, is,
46 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
I repeat, almost exceptional in sudoral typhoid. The differential
diagnosis between sudoral typhoid and malaria — i. e., typho-mala-
ria, is, on the whole, easy, and hesitation between the two cannot
last long, the administration of quinine salts, which are without
action on sudoral typhoid, settles the question."
The violent headache of so-called sudoral typhoid fever, which
is sometimes the only prodrome, may lead one to think of influ-
enza, and in particular of the nervous form of that disease ; but
in influenza the pain is not localized in the head alone. It ap-
pears early and is very intense, but is also general all over the
body ; the temperature may remain normal, or, if there is fever,
the temperature-curve is totally different from that of typhoid
fever. The evolution of the influenza itself, which is in general
of short duration when it remains uncomplicated, helps considera-
bly in the differential diagnosis.
One might be misled into diagnosing measles when, along with
the ocular catarrh, there is a discrete eruption of rose-colored
spots, or else a true roseolar eruption like that of the patient
under consideration. The absence, however, of all eruption on
the face and neck, of broncho-pulmonary catarrh, the insignifi-
cance of the ocular catarrh, and the character of the temperature
chart, all enable us, Jaccoud thinks, to eliminate this hypothesis
without much difficulty.
The writer has had under his care during the winter, 1898-99,.
a case which followed this course :
A man of twenty-five years, a cigarmaker by occupation, was
taken ill with what was supposed to be " malaria " or " grippe "
on February 4th, but felt better and returned to work on the 6th.
On the 7th he felt very ill, and entered my wards on the 8th.
At this time he had marked swelling, as if from a phlebitis, of the
left leg, which entirely disappeared in twenty-four hours. He
presented all the characteristic symptoms of ordinary typhoid
fever by the tenth day of the disease, but his temperature made
the following extraordinary chart, each rise being followed by
profuse sweating. He also had profuse night-sweats. He never
had typhoid fever before, nor were there any signs of tuberculosis
VARIETIES OF ONSET.
47
or tilcerative endocarditis. His blood showed no signs of the
malarial organism and gave the Widal reaction on the thirteenth
day.
FIG. 8.
To save space this chart which showed in detail rigor after rigor and fever
after fever, has been reduced to a morning and evening chart, and, therefore,
only shows two or three paroxysms.
(For a discussion of so-called typho-malarial fever and of malaria
complicating typhoid fever, see chapter on the fever in the well-
developed stage of the disease, and that on other diseases which
ape typhoid fever.)
Respiratory Conditions in Onset. Several cases have im-
pressed upon me the fact that so-called " pneumo-typhoid fever "
is a more common state than is generally thought, although it is
true the standard text-books all describe this form of the disease.
By pneumo-typhoid fever I refer to that form of typhoid fever
in which the bacillus of Eberth exercises its primary influence
48 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
upon the pulmonary parenchyma, producing signs and symptoms
which are practically identical with those of ordinary croupous
pneumonia, even to the rusty sputum, although the usual rigor of
onset, as seen in true croupous pneumonia may be absent or modi-
fied, and the onset in general is more insidious. In these cases
toward the ninth or tenth day the high fever falls but slightly in
place of the characteristic crisis, and when diarrhoea and rose spots
appear, the possibility of the entire illness being due to a typhoid
infection comes upon the mind of even the careful physician for
the first time. This condition must not be confused with the so-
called typhoid-pneumonia in which there is a double infection of
the patient, his lung bearing the chief influence of the micrococcus
lanceolatus and his intestinal canal and general system that of the
bacillus of Eberth, nor the state in which the pulmonary consoli-
dation results from asthenia or other causes incidental to the prog-
ress of an exhausting malady, and which is usually a catarrhal
pneumonia or a congestion by stasis. As Osier has well said,
" typhoid fever is a multiple infection in which the chief lesion
of the disease may be found in other organs than the bowels/' and,
in a larger number of cases than is thought, pneumonia begins the
attack of illness, and only later on does the character of the specific
infection make itself manifest. The following case illustrates this
fact very well, and is one of a number which have been met with
by the author :
Z., a girl, aged ten years, was taken ill with a rigor and fever
on November 10th, having been well enough to be up and out of
doors at dancing-school the day before. The fever speedily rose to
points ranging from 103° to 105°, and remained about these points
for the first few days, when it gradually became a little less marked.
It failed to respond readily to the use of cold spongings and the
cold sheet, as a rule, although at times this treatment reduced it
considerably. There was but little cough, and at times none of it
for two or three days, but the child was somewhat dyspnceic, par-
ticularly at night, and cyanosis was marked. The pulse was
usually as high as 120 to 130, and restlessness was constant. At
times, particularly at night, there was delirium. An examination
VARIETIES OF ONSET. 49
of her chest revealed at the right middle lobe the physical signs
of consolidation — that is, bronchial breathing, dulness on percus-
sion, and absence of vesicular sounds, with exaggerated breathing
elsewhere. At the left apex similar signs were present, and it was
evident that the child had pneumonia. The facial expression, the
somewhat dry lips and tongue, and the color of the patient's skin,
combined with the fact that pneumonia sometimes is due to infec-
tion by the bacillus of Eberth, made Dr. Kirkpatrick, the physi-
cian who courteously called me in consultation, and myself cautious
as to the diagnosis and the prognosis of the case, and, equally
important, careful as to our treatment. The parents were told of
the condition of the lung and of our suspicion that something
other than a pure pneumonic infection was present, and we waited
for the day of ordinary crisis with anxiety. On the ninth the
temperature fell somewhat and seemed to give promise of relief,
but on the next day it maintained its course ; the tongue was
found to be more enteric in appearance, and the rose rash of
typhoid fever appeared on the chest and belly. Further, careful
palpation and percussion at this time showed a slightly enlarged
spleen and liver, an alteration in those organs not previously
found, and diarrhoea, or, rather, looseness of the bowels, sup-
planted a tendency to constipation.
Under our older ideas of these diseases it would have been
thought that a primary croupous pneumonia had merged into a
typhoid fever by a gradual process of developing asthenia, or,
again, that a double infection with the micrococcus lanceolatus
and the bacillus of Eberth had taken place, whereas, at the present
time we know that while such a double infection is possible, a
single typhoid fever infection may result in primary pulmonary
symptoms.
Still another case is that of B., a man of sixty-five years, who
was taken ill with general malaise and wretchedness on a certain
Friday. Fever and chilly sensations developed, but he kept on
his feet for two days, when he was so ill that he had to go to bed.
When seen by me in consultation on the fourth day of his illness
there was rapid respiration (42 per minute), a pulse-rate of 120,
4
50 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
some cyanosis, a feeble, painful cough, and consolidation of the
entire lower lobe of the right side, with exaggerated breathing on
the left side of the chest. His temperature rose from 102° to
103°, and the bowels were costive to a marked degree. The spu-
tum was rusty. A diagnosis of croupous pneumonia was made,
and not until the tenth day of his illness did a persistent diarrhoea
of ochre-colored stools, with spots, appear. The spleen had been
found enlarged from the first visit that I paid him.
The difficulty in diagnosing these cases lies in the distinctly
local manifestations and the fact that in some patients the fever
may be quite high, delirium of an active form may be marked,
and every symptom pointing to intestinal typhoid lesions may be
absent. The question naturally arises as to the frequency with
which this form of enteric fever occurs, but statistics concerning
it are difficult to collect, since in many instances the condition is
never recognized, or is recognized very late, and is not by any
means always reported.
There is danger in these cases of still another error in diagnosis,
and care must be exercised that a diagnosis of " pneumo-typhoid "
is not made, when in reality the condition is one of tuberculosis
of the lung, for in some cases of this character the rapid onset of
fever, rigor, quickened respiration, cough, and the development of
physical signs of consolidation, coupled with the continuance of
fever after the time for ordinary crisis, will show that the disease
is not croupous pneumonia. As a matter of fact, the cases of
acute tubercular pulmonary consolidation simulating pneumonia at
first or "pneumo-typhoid" afterward, are much more frequent
than is pneumo-typhoid itself, and careful study of the case itself,
or its history, and the microscopical examination of the sputum
may reveal the tubercular character of the process. In all cases of
suspected pulmonary tuberculosis, however, the absence of bacilli
from the sputum will not negative the diagnosis of this malady,
for until some tissue breakdown occurs the bacilli may not appear
in the sputum.
It has already been pointed out that there is a form of pneumonia
ushering in typhoid fever quite different in cause from that just
VARIETIES OF ONSET. 51
named, namely, that due to double infection with the specific
organism of croupous pneumonia and that of typhoid fever. Such
cases have been described particularly by Chantemesse. In such
instances the febrile movement of the pneumonia merges into that
of enteric fever. The early differential diagnosis of these two
conditions is practically impossible unless, perchance, the bacillus
of Eberth is found in the feces, which is not possible before the
ninth day, or the Widal test gives a positive reaction, which it
rarely does in the early days of the malady.
Acute pleurisy, like acute pneumonia, may usher in enteric
fever, this condition being due to the ordinary causes of pleurisy
being present simultaneously with typhoid-fever infection, or be-
cause of specific infection of the pleura by the typhoid bacillus.
Thus Talamon1 has recorded a case of enteric fever in which the
onset was characterized by acute pleurisy, but the condition differed
from that ordinarily seen in this affection by reason of the intensity
and persistency of the fever, and by the general depression and
sleeplessness, headache, and vertigo.
Talamon insists that there is a distinct difference to be noted
between pleural-typhoid and acute febrile pleurisy, for in the
typhoidal infection the symptoms are out of all proportion to the
physical signs. The only condition which may closely resemble
pleuro-typhoid is tuberculous pleurisy, but in tuberculous pleurisy
the temperature is remittent, whereas that of typhoid is rarely so.
Finally, the development of the other symptoms of typhoid will
clear up the diagnosis.
A very much more rare respiratory disorder which may usher
in typhoid fever is that chain of symptoms known as laryngo-
typhoid, in which great hoarseness or aphonia develops with dis-
tinct evidence of acute laryngitis. These cases are quite differ-
ent from those of severe ulcerating laryngitis seen in advanced
stages of the disease, and which will be considered later on in
the chapters on the well-developed and convalescing stages of the
disease. Such instances are well illustrated by a patient described
1 La Medicine Moderne, May 28, 1892.
52 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
by Bayer.1 A physician presented himself for treatment because
of aphonia and difficulty in swallowing, which was found to be
due to acute laryngo-pharyngitis. These local symptoms were
improved by treatment, but in a few days the man was seized with
a severe chill, followed by fever and pain in the throat, an exami-
nation of which revealed a number of small superficial ulcers on the
soft palate and on the pharynx ; later the characteristic rose spots
appeared on the skin. More interesting than all, particles of tissue
removed from the heads of the ulcers just named contained the
bacillus of Eberth. The inflammation extended to the ears, and
deafness resulted. The patient finally died from intestinal hemor-
rhage and pneumonia. The finding of the bacillus in such cases
would enable an early diagnosis to be made.
Almost equally rarely does a severe bronchitis usher in typhoid
fever as a true pulmonary or primary manifestation, although, as
the disease progresses, more or less bronchial inflammation is
usually found.
Symptoms of Onset in the Kidneys. In very rare instances
typhoid fever develops with marked evidences of acute nephritis,
the urine being smoky or bloody in appearance, and containing
albumin and casts. This form is sometimes called " nephro-
typhoid," and by the French "fievre typhoide d, forme renale."
Gaillard2 recently reported to the Soci6t6 M6dicale des Hopi-
taux, for Bagot, the following interesting case of hsematuria usher-
ing in typhoid fever. The patient was a lad of ten and one-half
years, who was taken ill on June 28th with hsematuria. On July
3d the patient suffered from a good deal of tenesmus, pain in the
urethra, and the urine contained red blood-cells but no casts. On
July 7th distinct febrile movement was noted, the child com-
plained of severe lumbar pains, which also extended into the
limbs. He then passed through a typical attack of typhoid fever,
reaching a normal temperature on July 26th, nearly a month after
the onset of his attack. The urine contained no blood after the
eighteenth day of his illness. Bagot asserts that there is no doubt
1 Revue de Laryngologie, d'Otologie et de Rhinologie, July 15, 1893.
2 La Presse Me'dicale, February 11, 1899.
VARIETIES OF OXSET. 53
whatever about the correctness of the diagnosis. That this patient
had a distinct tendency to hffimaturia seems indicated, however,
by the fact that in subsequent illnesses, other than that due to the
typhoid infection, he also suffered from this condition of haema-
turia. (For further remarks see later chapters.)
Retention of urine is sometimes met with in the early stages
of typhoid fever but usually passes away in a few days.
Symptoms of Onset in the Alimentary Tract. Tonsillar
inflammation, associated with severe pharyngitis, sometimes begins
the course of enteric fever, and escapes correct diagnosis as to its
cause for a considerable period of time because of the situation of
the lesions, and also because tonsillitis of an active form is so com-
monly associated with marked evidences of general systemic infec-
tion, the patient oftentimes appearing profoundly ill and suffering
from general wretchedness, febrile movement, a heavily coated
tongue, impaired hearing, and mental hebetude.
A case of this character is under my care in private practice at
the present time. A woman of thirty years was taken ill with
what appeared to be a severe attack of acute tonsillitis with high
fever. As the fever failed to disappear with the subsidence of
the tonsillar swelling and pain, and as an epidemic of typhoid
fever was present, her blood was examined for the Widal reaction,
and it was found, and simultaneously other symptoms of enteric
fever developed.
A peculiar form of ulceration of the pharynx has been recorded
by Bouveret,1 Devignac, Dengnet, Wagner, and Calm. They call
it " pharyngo-typhoid." The ulcers are superficial, clean-cut, and
appear chiefly on the soft palate. (See also later chapters.)
(For oesophageal lesions see the next chapter.)
Probably the most common perversions of the early manifes-
tations of enteric fever are to be found in association with the
functions of the gastro-intestinal tract. So common are they, and
so localized are the dominant symptoms in these cases, that the
malady seems quite distinct from true typhoid fever, and is often
1 Berliner klin. Wochenschrift, 1885, No. 14.
54 COMPLICATIONS AND SEQUEL J£ OF TYPHOID FEVER.
called the gastric form of typhoid fever. In some instances, it is
true, fever of mild degree develops in cases of gastric catarrh of a
more or less severe form, but they are not characterized by the pro-
found degree of illness seen in the gastric type of enteric fever, in
which persistent vomiting and epigastric disturbance followed by
diarrhoea are the main symptoms in the early or initial stages.
Such gastric types are more commonly met with in children. As
well pointed out by Bristowe, undoubted enteric fever in child-
hood, at which age recovery commonly occurs even if the disease
is overlooked, is often called, for want of a better name and a
certain diagnosis, by the conscience-quieting term of " infantile
remittent fever," "bilious fever," and "gastric fever," or even
" worm fever." (See Frequency of Enteric Fever in Childhood,
in Chapter I.)
The gastric manifestations when severe are, perhaps, more rap-
idly discovered to be due to enteric fever than if the infection
be mild when the other typhoid symptoms are not marked.
These gastric symptoms are rarely met with in the great cities of the
eastern part of the United States, and vary in different epidemics,
although they are asserted by Murchison to have been commonly
met with in his experience. On the other hand, Hutchinson, in
his classic article in Pepper's System of Medicine, tells us that these
acute gastric symptoms with nausea and active vomiting have been
unusual in his experience. When vomiting ushers in the disease
in a child it does not seem to be as evil a prognostic sign as when
this symptom begins the attack in an adult. I saw a year ago a
case, in consultation with Dr. Orville Horwitz, in which persistent
vomiting was the first sign of the disease, and preceded a very
severe illness. Vomiting in a child is readily produced by any
disturbing ailment, but in an adult it probably results from a
more or less profound infection, and rapidly causes exhaustion if
it is persistent, as it is apt to be in this class of patients. When
the vomiting is mild, or, in other words, is repeated but once or
twice, it is not, of course, of any gravity, and no less an authority
than Murchison intimates that such cases often seem to be bene-
fited by it if it be not too persistent.
VARIETIES OF ONSET. 55
A severe and continued vomiting attack in a case free from
malaria and associated with persistent febrile movement ought to
arouse the suspicion of typhoid infection to a sufficient degree to
cause the physician to be on the watch for further confirmatory
symptoms, particularly if the illness is not relieved by the ordinary
measures utilized for the cure of such an illness.
Another variety of onset, represented by disturbance of the
gastro-intestinal functions, is that characterized by the sudden
development of violent diarrhoea of the serous type, instead of
the constipation usually met with during the first week of the
disease. Such cases are not common, but are represented by .the
following case in my own experience. A man of thirty-five years,
apparently in perfect health, and whose appetite had been excel-
lent up to and including the morning of the beginning of his
illness, began to suffer after a moderately heavy luncheon from
slight headache, which he attributed to indigestion, to which he
was subject. He ate no supper because of nausea, and was seized
at twelve o'clock midnight with an active, watery diarrhoea,
resembling a mild attack of cholera morbus, in that the abdom-
inal pain was not very severe. No vomiting occurred. By the
use of chlorodyne in full doses he was able to remain out of bed
for four days, but at the end of that time was seized with a severe
rigor followed by moderate fever rising to 104°. He then devel-
oped mild typhoid symptoms, but, ten days after the fever ceased,
suffered from a severe relapse. It was found that just thirteen
days prior to the diarrhoea he had eaten raw clams contaminated
by sewage, and that eight other persons who ate of the same lot of
clams also had the disease. The active diarrhoea in this case, fol-
lowed by wretchedness and general malaise, was naturally supposed
to be in no way connected with a definite and specific infection.
Still another case of this kind is that of a patient admitted to
my wards with a history that up to January 16th he had been in
good health, but on that day, while working in a sugar-house, and
exposed to high temperature, he had taken large draughts of cold
water, which speedily produced symptoms of cholera morbus, fol-
lowed by headache and anorexia, and these again by the early
56 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
symptoms of enteric fever, which caused him to come under my
care a week later with, as additional symptoms, signs of conges-
tion of the middle lobe of the right lung. Rose spots appeared
on the ninth day of his illness.
Pepper and Stengel1 have reported seven cases of abrupt onset
in typhoid fever, and they assert that Moore, in his Text-book of
Eruptive and Continuous Fevers, published in 1892, is the only
authority who calls particular attention to these cases in which
the disease begins abruptly and with vehemence, characterized by
decided rigors, violent headache, and rapid rise of temperature.
Moore thinks that the whole course of the disease is becoming
more typhus-like than formerly. Pepper and Stengel's seven
cases may be divided into two classes : those in which the prelimi-
nary symptoms were simply gastro-intestinal in character, vomit-
ing, purgation, and high fever being present, and others in which
violent headache and catarrh of the throat, nose, and bronchial
tubes was marked.
Symptoms of Onset Connected with the Nervous System. Of
the nervous manifestations of typhoid invasion three chief types
may be mentioned, namely, (a) that in which the patient suffers
from delusions or aberration of mind and wanders from home
until he becomes so ill as to fall and be taken to a hospital, or,
perhaps, loses his life through exhaustion, or accident due to his
stupid mental state, or by means of deliberate suicide. (6) The
second class is that in which acute maniacal symptoms ensue,
(c) The third class in which evidences of meningitis are marked ;
so marked that true meningitis is supposed to be present, or in its
place meningitis secondary to croupous pneumonia. In many of
these cases there is little doubt that the pulmonary lesions of
typhoid infection are responsible for the meningeal signs, while,
on the other hand, it is possible for direct infection of the men-
inges by the typhoid organism to occur, although this is rare.
(See further on.)
Some years ago myself and Patek collected the following cases
1 Philadelphia Medical Journal, vol. i. No. 2.
VARIETIES OF ONSET. 57
of mental disturbance in onset which we1 found in the literature
of the subject :
Murchison2 reports the case of a German who was much
excited over the Franco-Prussian War. After about four days
of discomfort and malaise, he suddenly passed into a state of
acute maniacal delirium, requiring two men to control him.
There was an absolute refusal of food, a temperature of 102°,
with a dry tongue and rapid pulse, slight diarrhoea, and no
spots. The patient was subdued by large doses of chloral, and
the fever ran its course. The same author also states that in
several instances he has known acute mania to develop on the first
day of an enteric fever, and that under these circumstances the
case is very apt to be mistaken for insanity.
Wilson3 asserts that delirium may be an early symptom of
enteric fever, and quotes Riberalba, who reported four cases which
were delirious on admission to the hospital. Louis saw two cases
which were delirious on the first night of their illness. Bristowe
has also reported a case in which maniacal delirium existed on the
second day. Mottet mentions an instance of typhoid fever com-
plicated with mania to such a marked extent that the patient was
placed in an asylum before the true nature of the ailment was
discovered, and Henrot and Bucquoy have seen the disease ushered
in with the delirium of grandeur. Finally, Daly4 records an
instance in which aggressive mania came on on the fifth day, fol-
lowing a condition of stupor.
From a careful examination of a large amount of literature I
am convinced that prodromal insanity in enteric fever is most
rare and, when it occurs, is almost always fatal, while the insanity
which is in the nature of a sequela may be looked upon as devoid
of immediate or remote danger to mind or body.
In very rare instances delirium may be almost the first symp-
tom of typhoid fever. Indeed, it may actually precede the devel-
1 Hare and Patek, Medical News, 1892.
2 Lancet, 1870, vol. ii. p. 807.
3 Philadelphia Medical Times, 1884-85, vol. xv. p. 577-681.
4 The Medical News, 1882, vol. xl. p. 68.
58 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
opment of pyrexia ; thus in seventeen cases which have been
collected from literature by Aschaffenbourg,1 seven were charac-
terized by the development of delirium before the fever, and the
latest period at which it was observed among these cases of early
delirium was the end of the first week. As a rule, the delirium
lasted only a few days, but the mortality was high, six of the
seventeen patients dying. Among these cases the delirium occurred
in two forms, either the patients were exceedingly restless and
violent, finally becoming torpid, or there was a condition of confu-
sional insanity, in which the patients sang, prayed, danced, or were
gay or sad.
The following cases met with by Patek and myself are of
interest : Annie M., aged twenty-four years, was admitted to
St. Agnes' Hospital, March 18, 1891. She had been feeling
badly for some time, but until four days previously had been able
to do her work. On the 14th she had a severe headache, vomited
a little, suffered from pain in the stomach, and had some diarrhoea,
these symptoms being followed on the subsequent day by not very
profuse epistaxis. She walked a considerable distance to the hos-
pital, and on her admission, at 10 P.M., her temperature was found
to be 105°. The resident physician found that her tongue was
thickly coated, dry and brown. On the next day when seen by
us in the wards the tongue was unusually clean even for that of a
healthy person. The patient was delirious and so violent that it
required four or five persons to keep her in bed. The tempera-
ture, after an unusually prolonged and severe struggle, was found
to be 106°.
At this time every symptom of typhoid fever was completely
masked by the insanity. The bowels were moved and the passages
were of normal consistency and color. The urine was somewhat
scanty and high colored, and the pulse full and strong. There
were no rose spots or other enteric symptoms. At the end of
twenty-four hours the patient, still being in a condition of wild
insanity was removed to a cell, the impression being that it might be
1 Archives de Neurologie, March, 1895.
VARIETIES OF ONSET. 59
a case of hysterical mania with hyperpyrexia. Twenty-four hours
later the insanity had disappeared, and the typhoid symptoms as-
serted themselves ; the delirium became more quiet and muttering,
and she was taken back to the wards. During the following week
she was constantly delirious, and frequently maniacal, although
there were short momentary intervals of sanity. During this time
a large number of rose spots appeared on the abdomen and chest,
the tongue became heavily and typically furred, the temperature
followed a characteristic course, the typhoid odor was present, and
an occasional nose-bleed helped to confirm the diagnosis of typhoid
fever. The patient rapidly became worse, and died thirteen days
after admission, without becoming sane, except for the brief inter-
vals named.
The second case is as follows :
Mr. A., a resident of Milwaukee, aged thirty-four years ; mar-
ried ; one child. A sister died of convulsions of unknown nature
but a short time before the onset of his illness. Family history
otherwise negative. At the age of seventeen years the patient,
according to the statement of his physician, had an attack of
typhoid fever, attended with as much, if not more, delirious
excitement than this, the second attack. The history of the case
begins with the circumstance that Mr. A. was nursing his wife,
who was down with a mild attack of typhoid. The patient's first
complaint was of headache and insomnia. The visiting physician,
seeing him on the following day, ordered him to bed, recognizing
the case as one of typhoid fever, rather because of the existence
of a like case in the same house and from the mere complaint of
malaise, than from any symptoms particularly characteristic of the
disease. The patient obeyed the instructions of the physician, and
went to bed, still complaining of insomnia. Hardly had he fallen
into a mild slumber when, not more than an hour later, he sud-
denly awoke, delirious, and grew steadily more so. During the
following night he became maniacal, rushed to the room of the
nurse (she had been procured since the husband's illness), burst
open the door, threw the nurse to the floor, and assaulted her in
a most violent manner, kicking and striking her, and accusing her
60 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
of wishing to harm his wife and child. The nurse finally man-
aged to escape, and ran for the physician, who lived across the
street. In the meantime the patient jumped through a window
leading to a small balcony over the front portico, and leaped to
the ground, where he was found a few minutes later by the physi-
cian. Strange to say, the man suffered little injury, being slightly
bruised by the fall, and somewhat cut by the glass ; but stranger
still was the fact that he was now quite rational, telling the physi-
cian all that had transpired and what he had done. The patient
was again put to bed, now apparently quite comfortable. The
physician left him to see the wife in an adjoining room. Hardly,
however, had he gone when Mr. A. suddenly sprang from the
bed, rushed into the kitchen, where he seized a large knife, and
then rushed back, bent upon assaulting the physician. He was,
however, overpowered and again forced to bed. He now rested
comfortably, and when seen the following day was doing well.
That evening a condition of hyperpyrexia suddenly intervened,
and in a few hours the patient was dead.
The following case is of interest in this connection, and was
seen by me through the courtesy of Dr. Higbee, of Philadelphia,
who called me in consultation.
An unusually large, muscular man, about thirty-five years of
age, after two or three days of wretchedness and malaise, with
slight headache, developed fever of moderate degree on the fourth
day, and that evening became maniacally delirious, so that it
required four or five of his fellow- workmen to hold him in bed.
On these workmen becoming exhausted the following night two
male nurses were put in charge of him, but he fought them so
vigorously that they refused to take care of the patient when the
morning arrived, as they stated he was so powerful that he threw
them all about the room.
When I saw him after two nights of violent delirium of this
character, he was perfectly himself, mentally, and described his
condition and his sensations to me, using unusually good English
for a man in his walk of life, and evidently having an intelligent
idea of the chief symptoms to which he was subject. He had no
VARIETIES OF ONSET. 61
recollection of his delirium, but he had been told by his wife of
the struggles that they had had with him on the previous night.
An exceedingly careful examination of his chest revealed at the
apex of the right lung, anteriorly, a small patch where there was
impaired resonance and the other physical signs of pulmonary con-
solidation, and after consultation, Dr. Higbee and I agreed that it
was one of those cases of pneumonia in which there was a re-
markably small pulmonary lesion, accompanied by severe menin-
geal and cerebral symptoms. Something about the case, however,
made me suspicious of a typhoid infection, and I stated to Dr.
Higbee that while there were no symptoms of typhoid fever
present that I could point to, I was suspicious of the development
of this disease. That evening the man again became maniacally
delirious to such an extent that his family recognized that it was
impossible to keep him at home, and he was admitted to the
hospital, where he died hi forty-eight hours from exhaustion.
The autopsy revealed typical typhoid ulceration of the bowel and
other pathological evidences of well-marked typhoid fever.
This case illustrates very well not only the fact that pneumonia
and typhoid infection may exist side by side, the pulmonary con-
dition being, perhaps, directly due to the infection of the bacillus
of Eberth, but also that cerebral symptoms of great severity may
usher in both typhoid fever and pneumonia.
Osier records two cases of curious aberrant mental state in the
stage of onset. In one, a young girl began her illness by doing
odd things and having laughing and crying spells ; the other,
also a young woman, was distinctly " off her head," so that she
was regarded as a pure mental case.
There is still another nervous type of onset which is exceed-
ingly rare, namely, that of rapidly developing stupor and coma.
Very rarely in children the disease is ushered in by a convul-
sion, as in a case recorded by Osier, and in the case of convul-
sions reported by Green, and detailed in an earlier part of this
essay. Convulsions when met with in adults are usually seen in
the later portions of the disease, and depend upon embolism or
thrombosis of important cerebral vessels.
62 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
The Skin in the Stage of Onset. As is well known, the
characteristic rash of typhoid fever does not make its appearance,
as a rule, until the seventh or ninth day, and, therefore, it cannot
be considered a symptom of onset in typhoid fever. Cases do occur,
however, in which in this stage of the disease aberrant rashes
develop. Thus the writer has under his care at the present time
a man of twenty-two years, who entered the hospital on the third
day of his illness so covered by a profuse scarlatiniform rash that
a differential diagnosis as to its true character was impossible. It
persisted for three days, and then gradually faded, and the case
ran a course of typical typhoid fever. (See the chapters on the
skin in the well-developed and convalescent stages.)
CHAPTER III.
THE ABERRANT SYMPTOMS, STATES, OR COMPLICATIONS OF
THE WELL-DEVELOPED STAGE OF THE DISEASE.
Temperature in the Developed Disease. We may pass on,
then, to a consideration of excessive symptoms and complications of
the developed disease, and the febrile process naturally first attracts
attention. Before we attempt to study the unusual febrile condi-
tions seen in patients who have passed the stage of onset and are
in the well-developed period of the malady, it may be well to con-
sider briefly what the normal or usual febrile movement really is.
This Striimpel well describes when he says that the second division
of the curve represents the so-called fastigium, and corresponds to
the height of the disease. " During this time the fever presents
in most of the severer cases the general character of febris continua
— that is, the spontaneous remissions of the fever seldom exceed
2°. Almost always the lower temperatures come in the morning
hours and the higher in the evening. In cases of average severity
the morning remissions touch 102° to 103°, and the evening
exacerbations 104° to 105°. Temperatures which reach or exceed
106° are seen only in very severe cases. Considerable morning
remissions are always a favorable symptom, while morning tem-
peratures of 104° or higher generally show the case to be severe.
The duration of the fastigium varies with the severity and obsti-
nacy of the case. It may last only a few days or one and a half
to two weeks ; in violent cases still longer."
Ampugnani1 has proved that the natural maximum occurs
between 3 and 6 P.M., and the natural minimum between 5 and
8 A.M.
At the end of the fastigium the temperature gradually falls
1 London Medical Record, January, 1889.
64 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
by lysis until it reaches the normal, or perhaps more frequently
there is before the lysis another period which has been called by
Wunderlich the " ambiguous period/' in which the morning tem-
peratures are each day almost normal and the evening tempera-
tures only slightly lower each day. In other cases the evening
temperature for some days remains as high as before. Murchison
called this period " the stage of changing fortunes/' and Striimpel
has called it " the period of steep curves," and has also stated that
the longer a case lasts the more marked becomes the irregularity
of the fever at this time.
The case recorded in this chart was one of very great interest,
because as the fever of the early stage of the disease was not
marked, and the abdominal symptoms were prominent, the ques-
tion arose as to whether the patient, who was five months pregnant,
was suffering from appendicitis, uraemia, sepsis from pelvic disease,
septic endocarditis, or typhoid fever. There was scantiness of the
urine, half the normal amount of urea, albuminuria, and marked
signs of general toxaemia. There was also great tenderness of
the belly, particularly over the appendix, and considerable pain
in this region, even when the patient was lying still. In addition
there was also great difficulty in urination and obstinate constipa-
tion, and the pregnant uterus so filled the lower segment of the
belly and displaced the bowels that diagnosis was unusually diffi-
cult. Auscultation over the prsecordium revealed a distinct en-
docardial murmur, probably due to the anaemia of pregnancy.
Had these steep curves been met when the patient was first seen
I think the case would have been considered one requiring opera-
tion, because they would have led me and the surgical consultant
to believe that the symptoms were septic. The development of
a profuse rose rash and the Widal reaction cleared the diagnosis
some days before the period of steep curves began.
Having set up a normal standard for the course of typhoid fever,
we find that variations from this standard occur under circum-
stances, many of which are indicative of some condition well worthy
of the physician's attention, while, on the other hand, some aber-
rant types are without significance so far as our present knowledge
WELL-DEVELOPED STAGE OF THE DISEASE.
65
If
•5 "
^
66 COMPLICATIONS AND SEQUELAE 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.
2
£
•K'Vg
S
S oo
S 1
• .s
-> 02
t- a
c; es
_2 o
° 60
0)
WELL-DEVELOPED STAGE OF THE DISEASE.
69
70 COMPLICATIONS AND SEQUELAE 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 studying 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.
Strabe1 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, Fraentzel1 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 39 per cent, for the forty-one patients. Guite"ras2 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. Vallin3 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 Medicale, 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
Wendland.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 fiir klinische Medizin, 1881, p. 226.
2 Transactions of the Association of American Physicians, 1887.
3 Archives Generale de Med., November, 1873; see also Liebermeister and
Hagenbach Aus der med. klin. zu Basel, 1869, p. 9.
4 Deutsche Medizinal Zeitung, August 29, 1893.
<r
>
o
"o-
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 — t<n-ln' bfciit'/fre. Close 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, 1020; 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 levissimus, Griesinger first described
forms of enteric fever in which the febrile movement was not only
very mild, but in which the symptoms in general were of the most
moderate form, the entire course of the disease lasting only eight
to fourteen days.
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
AVidal 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 SEQUELS 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.
i
I
i
I
¥
A
/
1
ino°
/
/
1
/
\
/
1
/
\
/
n
/
^]
J
\
i
mi0
|
j
\
;
\
\
™
mn°
g
•7
s
•r
3
-
r?
i
00 °1
~
\
-
\
•^
\
s
s
Qft°
s,
'
f\
\
I
s,
/\
1 \
v
s
/
\
97°
\
Day of Dis.
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.
Strumpel 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 normal
point, and Pepper has expressed the belief that these great varia-
tions are in part the result of marked sepsis and intestinal ulcera-
tion. Thus 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-
omew'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 Church2 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 Jane way,3 that the use of the coal-tar products in the course
1 Johns Hopkins Hospital Keports, 1895, No. 5.
2 St. Bartholomew's Hospital Keports, 1896.
s Transactions of the Association of American Physicians, 1894.
76 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
WELL-DEVELOPED STAGE OF THE DISEASE.
77
I'll
mi
~nT
WIT
ffl
mi
-ni
MII_
KiT_
nil
"rnT
«m
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 gastro-intes-
tinal accidents, but in the case of intestinal hemorrhage the fall
may occur some time, it may be several hours, before the appear-
ance of a bloody stool enforces the belief upon the nurse that hem-
orrhage is present. For this reason an unexplained marked fall
of temperature should always be regarded with suspicion, and the
appearance of the next stool watched with interest. The pulse
should be carefully studied for signs of loss of blood, and the
facial 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 DISEASE. 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. Herringham1 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, 1896.
2 Kevue 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 trichiniasis1 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 eosinophiles), 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 SEQUELS 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 hi 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. Fiedler1 found that
when the temperature reached 106° more than half died, and
Wunderlich states that at 106.1° the danger is considerable, at
107° the deaths are almost twice as numerous as the recoveries,
and at 107.2° and over recovery is rare. Concerning the influence
1 Deutsches Arch, fiir klin. Medicin, Bd. 5. 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 Maidstone1 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
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 Beports, 1898. Wrongly labelled on cover, 1896.
* 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
tAventy 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 Costa1 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.
e
£
L_o
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 very probable, and Luca-
tello1 believes that he has proof that it is the cause of the affec-
tion. On the other hand, Dittrich2 asserts that the proces- i>
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. Bv this means their vitality
o *
is impaired and their invasion by pyogenic micro-organisms is
rendered easy. Lemcke3 records a case of this affection occur-
ring in a Swede aged twenty-four years. A similar case has been
reported by Tooth,4 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.
2 Handbuch 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 SEQUELAE 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,
Eppinger1 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, Griider2 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. In 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 this
lesion may occur in the second week of the disease. Griesinger
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 Landgraf1 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 Lewy2 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 arvtenoid 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. "VVestcott, in collecting statistics
for Keen's well-known monograph on the Surgical Complication*
of Typhoid Fever, collected thirty-eight others. Basing his
views upon his statistics, and in particular upon fourteen original
1 Deutscher Medicinischer Wochenschrift, January 6, 1890.
2 Archiv fur Kinderheilkunde, Bd. lx., heft. 3, 1888.
3 Bulletin de la Societe Anatomique.
4 Archiv fur klin. Chirurgie, 1884, vol. xxx. p. 225.
92 COMPLICATIONS AND SEQUELAE 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 wrill read
the cases of death from suffocation without operation (52 cases,
49 deaths), he will find that, almost without exception, suffocation
occurred early and 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 rede ma 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, l without even any symptoms.' '
Liining'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 Wilks1 records the case of a patient of twelve years, who on
the twelfth day of the disease developed general emphysema
due to this cause. Denham2 records a similar case in a boy of
ten years, and ChomeP another in a man of twenty years, from a
perforation of the thyroid cartilage. One instance is recorded
by Liming in which an abscess had destroyed the arytenoids and
rendered the cricoid necrotic, so that the anterior mediastinum
was filled with pus, and Retslay4 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.
3 These de Paris, 1877.
4 Retslay, Ueber Perichrondritis Larynge'a Berlin, Dissert. 1870, No. 10.
94 COMPLICATIONS AND SEQUELAE 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. Liin-
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
Liining'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 redema." 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 oases 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 probably
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. Mettenheimer1 saw
thirteen cases of this character out of thirty-eight deaths from
typhoid fever or its sequelae.
1 Beobachtungen ueber die typhoiden Erkrankungen der franzosischen Konigs-
gefangenen in Schwerin, Berlin, 1879.
96 COMPLICATIONS AND SEQUELJS 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
oedema 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. nearly 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 blood in the
sputum and, if the embolus is septic 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. Creagh1 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. Fraenkel3 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 011 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,4 pulmonary abscess once,5 gangrene of the lung
once,6 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.
* Eendu. La France Me"dicale, 1885, vol. ii. p. 1809.
5 Kamsey. Aunals of Surgery, January, 1890, p. 39.
6 Griesinger. Infectionskrankheiten.
7 Barr. Liverpool Medico-Chirurgical Journal, 1893, vol. xiii. p. 346.
7
98 COMPLICATIONS AND SEQUELAE 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. Mongour1 has recently written a con-
firmatory paper on this theme.
In still other instances the heart-sounds are like those of a
foetus, the long pause being absent. This is called " embryocar-
dia," and indicates distinct cardiac feebleness.
These circulatory changes have been chiefly discussed by French
clinicians. Bernheim2 has described a variety of typhoid fever
that he calls " forme cardiaque," the chief signs of which are a
condition of asystole and cardiac feeblenees. Demange3 has also
written on this topic, and Potain is quoted by Homolle in his
1 La Presse Medicale, April 21, 1897.
2 Association pour 1'Avancement des Sciences ; Congres de la Rochelle, 1882.
3 Revue de Medecin, 1 885, p. 1025.
100 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
article on typhoid fever, in Jaccoud'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 diarrhosa 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 circulator}7 system in the stage of con-
valescence.)
Acute endocarditis complicating typhoid fever has been reported
by Carbone.1 The patient was a young women who 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.
Connell2 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, 1750, 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 of the blood-
cells. In the third week the red cells begin to decrease, and may
get as low as in cases of pernicious anaemia. 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 case in most instances.
The most noteworthy fact about the blood in this fever is that,
102 COMPLICATIONS AND SEQUELS 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 :
Leucocytes.
Perforation. Case I (a). Five days before perforation . . 8,300
(6). At time of perforation . . . 24,000
Case II. At time of perforation . . . 18,500
Phlebitis. 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
(b). At time of onset .... 16,200
Otitis media. Case I (a). At entrance ..... 5,300
(b). Mastoid abscess .... 16,400
Case II (a). At entrance 8,400
(b). Two weeks later, after opening drum
membrane (sero-purulent discharge) 11,200
Case III (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 may 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 has 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. No
perforation of the abscess wall had occurred.
Under the name spleno-typhoid, Eiselt3 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 book 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, 1894.
2 La Presse Medicale, February 1, 1899.
3 La Semaine Medicale, 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 hsema-
turia, the autopsy fails to reveal marked renal change, or instead
of nephritis an infarction. Such cases have been reported by Horn-
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 Stevens1 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. 1Q5
has exhausted the literature. He quotes Guimet 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 66 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.
Hanford1 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 cases, and tube
casts in 103 ; altogether 21 out of these 229 cases had definite
nephritis, and 10 had red cells in the urine ; 2 suffered from
hemorrhagic nephritis, but only 5 of these cases died, and none
of them from the renal difficulty.
1 London Lancet, April 28, 1889.
2 Miinchener Medicinische Wochenschrift, February 14, 1899.
106 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER.
Rostoski1 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.
Rostoski2 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-DEVELOPED 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 AVidal's reaction.
In 147 cases admitted to the German Hospital of Philadelphia1
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 betwreen 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 lymphomata of this
disease. Konjajeff1 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 shown2 that typhoid bacilli were pres-
ent in the urine of nine out of twenty -eight cases 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 Richardson3 reports sixty-six further
cases, of which fourteen showed the presence of bacilli in the
urine.
Petruschky4 has estimated that in one case a single cubic centi-
metre of urine contained 170,000,000 typhoid bacilli.
Horton Smith5 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 Centralblatt 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. 1Q9
Petruschky1 has pointed out that the bacillus of typhoid is often
found in the urine some weeks after the temperature is normal.
To sum up the evidence from a clinical point of view, we find
that pyuria in typhoid fever is not a grave sign, but that if the
specific bacillus is found in the urine the patient must be kept under
observation till it disappears, since it may lead to serious mischief.
Pyonephrosis has been recorded by Fernel.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. Hutchinson3 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 Centralbktt fur Bakteriologie, 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, 1898.
HO COMPLICATIONS AND SEQUELAE 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
Taupin1 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 with 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-DEVELOPED STAGE OF THE DISEASE.
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 has resulted in great danger or even in death.
Vomiting in typhoid fever may be an unimportant or very
grave complication. Often it occurs because of indigestion or
irritability of the stomach, and stops as soon as the diet is altered
or the quality and mode of using stimulants is changed. Its
gravity depends largely upon its persistency, because if it ensues
on taking food the patient speedily dies from lack of nourishment,
and if it is of the 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-
rhao-e mav occur. Soltau Fenwick1 has recorded a case in which
O •>
1 Disorders of Digestion in Infancy and Childhood, 1897, p. 386.
112 COMPLICATIONS AND SEQUELS 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 hsematemesis 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. Soi>
TATJ FENWICK. )
quantity by the bowel. No 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. H3
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 he 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 cm. in diameter.
On the 29th, 30th, and 31st 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 anaemic, 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 1 6th
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."
Weiss1 records a case of a soldier, aged twenty-two years, who
1 Wiener Med. Presse, 1888.
WELL-DEVELOPED STAGE OF THE DISEASE. H5
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 Cazal1 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. Banti2 and Karlinski3 have reported similar cases not so
well proven. Karlinski's cases numbered three.
Nichols and Keenan4 have reported nine cases of typhoid fever
without intestinal lesions. So, too, Flexner and Harris5 have
recorded such a case, and Chiari and Kraus met with seven out
of nineteen cases in five months.
Goodall6 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 H6p., 1893, p. 243, and Le Bulletin Medi-
cal, April 16, 1894.
2 Archiv. Italiennes de Biol., December, 1887.
3 Wiener Med. Wochenschrift, 1891, pp. 470 and 511, and 1697, vol. ii. p. 1850.
4 Montreal Medical Journal, 1898, xxvii. p. 9.
5 Johns Hopkins Hospital Bulletin, 1897, viii. p. 259.
6 Clinical Society's Transactions, vol. xxx., 1897.
116 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
and in each there was a swelling of Fever's patches without ulcer-
ation. Similarly Fagge1 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. Brunschwig4 has also recorded
a case of this kind, and Hoeffel5 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.
" Is the Lesion of Peyer's Patches a Constant Symptom of Typhoid Fever?"
Strasburg Thesis for 1870.
5 Gazette Medicale de Strassburg, 1871, No. 14, p. 167.
WELL-DEVELOPED STAGE OF THE DISEASE. H7
Since the above remarks and 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 Widal test. The autopsy showed that the
heart weighed one and one-half ounces, and appeared to be nor-
mal. The arteries, mouth, pharynx, resophagus, 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. Xowhere 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 was 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 wras expected that the usual typical ulceratiou 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.
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 :
Thue,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. H9
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 1892, described a case of typhoid fever which
during life presented the characteristic symptoms of the disease.
No intestinal lesion, however, was found at the necropsy, but the
bacillus typhi abdominalis was obtained by culture from the biliary
passages, liver, and spleen.
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 Fever'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.
Mettenheimer3 records an epidemic of typhoid fever occurring
in the army in which in twenty-one cases the intestinal lesions
1 Rivista Generate Italiana di Clinica Medica, 1897; Baumgarten's Jahres-
bericht, 1897, 234.
2 Annales de 1'Institut Pasteur, February, 1893.
3 Jahresberichte iiber die Gesammte Med., 1872, Bd. 2, p. 235.
120 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
were entirely limited to the colon. Banti1 and Karlinski2 have
also reported cases of this character.
A case is recorded in Cheadle's3 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. Beatty4 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, diarrhoea occurs in Baltimore in not more
than 30 per cent, of his cases, and is an active form in only about
12 per cent. So, too, we find that in Curschmann's5 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 diarrhoea
had been set up by a purge given before the diagnosis was
made, so that his experience in no way militates against the
statistics just cited.
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.
5 Deutsche Archiv. f. klin. Medicin, 1895.
WELL-DEVELOPED STAGE OF THE DISEASE. 121
In the Maidstone1 epidemic 50 per cent of the cases were con-
stipated. Murchison found it in 93 out of 100 cases.
When the diarrhea 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. Quill2 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 Kanthack3
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.
Ord4 agrees with the view that diarrhoea is usually associated with
ulceratiou, 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 Medical Journal, October 22, 1898, p. 1252.
3 St. Bartholomew's Hospital Reports, vol. xxxiii.
* Transactions Association of American Physicians, 1888, vol. iii.
122 COMPLICATIONS AND SEQUELS 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 evea 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 in one spot, and if it becomes fixed it probably depends
upon a localized complication. Pressure upon the belly-wall is
apt to increase the pain. It is, however, a noteworthy fact that
later on in the disease, when tympanites is often excessive and
the bowel greatly distended, there is apt to be little or no pain
even on 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 in different epidemics, independently of any specific
line of treatment over and above rest in bed. Lack of such rest
at any stage of the malady certainly predisposes the patient to
this accident.
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.
Kraft1 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 1559
cases treated without the cold bath there were 99 hemonrhagic
cases, or 5.2 per cent.
1 Centnlblatt f. die med. Wisseoschaften. 1893, p. 137.
124 COMPLICATIONS AND SEQUEL JE 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. Immermann, 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 861 72 8.4
Griesinger 600 32 5.3
Wunderlich, Jr 98 2 2.0
Total .... 1559 106 5.2
WITH BATH.
Cases. Hemorrhages. Per cent.
Liebermeister 882 55 6.2
Immermann ..... 146 6 4.1
Wunderlich, Jr 155 16 10.3
Total .... 1183 77 6.8
To these may be added : In America, with baths, Wilson's 140
cases with 10 hemorrhages, or 7 per cent.; Osier's 356 cases with
12 hemorrhages, or 3.4 per cent.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 Roland 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 case immediately after a bath.
An important point in this connection is the question as to the
real danger to the patient from hemorrhage. In this opinions
greatly differ. Thus Fitz tells us. that it is always a serious
symptom, but rarely fatal in private life ; but that it may be very
disastrous is 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 Griesinger'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 danger 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.
PERFORATIONS. 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 Bennett1
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-
cane2 reports a case of a man apparently well till two days before
death, when typhoid perforations occurred, and Kleinwachter3
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, 29.5 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, witheut
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 tvphoid fever where nerve-tone is alreadv lost and the tym-
V I
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 Lereboullet1 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. Monod2 also reports such a
case.
Dieulafoy3 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 1' Intervention Chirurgicale dans les Peritonites
de la Fievre Typhoide," by Dieulafoy.
2 Ibid. s Ibid.
WELL-DEVELOPED STAGE OF THE DISEASE. 129
While such cases, due to pin-hole perforation, may occur, they
cannot be considered common.
Fitz mentions 56 cases in which the onset of symptoms of per-
foration were severe ; 1 5 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. Barth2 makes a similar report, and Jenner3 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 Me"dicale, 1877, xxiii. 389.
2 Bulletin de la Soc. Anat., 1884, lix. 142.
3 Medical Times, 1850, xxii. 298.
9
130 COMPLICATIONS AND SEQUELAE 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
Herringham, 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. Schulz2 found it in 1.2 per cent, of 3686 cases of typhoid
fever in Hamburg in 1886 and 1887, and Liebermeister3 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 6.58 per cent., which agrees with Holscher's
statistics.
Hoffmann found that out of 250 deaths in typhoid fever 20
were due to perforation.
Perforation is very much more frequently seen in men than in
women. Fitz in 444 cases found 71 per cent, in men and 29 per
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, Nacke1 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 hal'f 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 OCCURKENCE IN PERFORATION.
Cases. Cases.
First week ... 4 Eighth week . . .3
Second " . . . 32 Ninth " . . .2
Third " . . .48 Tenth " . . .4
Fourth " . . .42 Eleventh " . . .3
Fifth " . . .27 Twelfth " . . .1
Sixth " . . .21 Sixteenth " . . .1
Seventh " . . .5
1 Ueber die Darmperforation im Typhus Abdominalis. Dissertation, Wurzburg,
1893.
132 COMPLICATIONS AND SEQUELJE 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). Hoffmann1 tells us that
out of 20 cases the perforation occurred once near the ileo-csecal
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 redema-
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.
1 Untersuch. und der path. anat. Verand. d. Organe beim Abd. Typhus, 1869.
2 Correspondenzblatt fur Schweizer Aerzte, 1896, No. 17.
8 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 :
AGE AT WHICH PERFORATION Occrus.
1 to 10 years 7 = 3.6 percent.
10 " 20 " 46 = 23.8 "
20 " 30 " 77 = 39.8
30 " 40 " 45 = 23.3 "
40 " 50 " 14 = 7.2 "
50 " 60 " 2 = 1.0 "
60 " 70 " 1 = 0.5 "
In this connection the account given by Taupin1 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 are rare, unless
1 Journal des Connaissances Med. Chi., 1839.
134 COMPLICATIONS AND SEQUELJE 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. Eisner1 reports such cases, and Pear-
son2 records a case in which during relapse an ileoco3cal abscess
formed, the pus having a fecal odor. In another case3 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, X. 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. Major4 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's5 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.
Schmidt6 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," 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.
fi Deuteche 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 was 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 :
Gairdner1 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 ; Murchisou 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 pos-
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.
2 Collected Essays and Lectures on Fevers, pp. 311 and 484, London, Riving-
ton, Percival & Co., 1893.
136 COMPLICATIONS AND SEQUELAE 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 Platt,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. 219. s Loc. cit.
4 St. Petersburger Medicinische Wochenschrift, 1898, No. 2 (Centralblatt f.
Chirurgie, 1898, No. 19).
5 American Journal of the Medical Sciences, 1898, vol. cxv. pp. 189-192.
138 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
of intestines ; irrigation and drainage ; recovery ; Widal's reac-
tion obtained. H. C. Deaver (reported by J. B. Deaver),1 a male,
aged thirty-six years ; perforation in the third week ; operation
after thirty-six hours ; death. Burrell and Bottomley,2 two cases,
one recovery and one death. Haiidford and Anderson (Notting-
ham),3 a male, aged twenty-seven years ; perforation on the thirty-
third day of a mild attack ; operation after twenty-two and a
half hours ; perforation sutured ; peritoneum cleaned by sponges ;
wound closed without drainage ; recovery. Pickering Pick (re-
ported by Rolleston),4 a male, aged twenty-one years ; typhoid
perforation of the appendix ; the appendix removed ; death on
the second day. A case mentioned by Dr. Goodall in the discus-
sion upon Mr. Pick's case at the Clinical Society of London : A
girl, aged eight years ; perforation during relapse ; sutured ; death
after four days. J. B. Deaver,5 a female, aged twenty-three years ;
perforation on the twenty-first day ; operation fifteen or sixteen
hours afterward ; perforation sutured ; death after two and a half
days. Woodward,6 a male, aged eighteen years ; perforation at
the end of the second week ; operation after nine and a half
hours ; perforation sutured ; the patient recovered from the oper-
ation, but died nine days later from typhoid fever. At the
necropsy the peritoneum was found uninflamed, with the exception
of a local dry peritonitis around the seat of perforation. Gushing,7
three cases : (1) A male, aged nine years ; perforation at the end
of the second week ; sutured ; abdomen opened twice subsequently,
once for a supposed second perforation and once for kinking of the
intestine from adhesions ; recovery. (2) A male, aged eighteen
years, perforation in the fifth week ; sutured ; death in four hours.
(3) A male, aged thirty-one years ; perforation at the end of the
1 Loc. cit.
2 Medical and Surgical Reports, Boston City Hospital, 1898, p. 126.
3 British Medical Journal, 1898, vol. ii. p. 220.
4 Transactions of the Clinical Society of London, 1898, vol. xxi. p. 234.
5 Annals of Surgery, 1898, vol. xxviii. p. 144.
6 Boston Medical and Surgical Journal, 1896, vol. cxxxix. p. 317.
7 Johns Hopkins Bulletin, Nov., 1898 (British Medical Journal, Epit., Feb.
4, 1899.)
WELL-DEVELOPED STAGE OF THE DISEASE. 139
fourth week ; sutured ; death after eight hours. In a fourth case
no perforation was discovered at the time of operation ; the patient
recovered. Bigger and Campbell1 (a case reported to the Ulster
Medical Society) : A male, aged thirty-six years ; perforation
during the third week ; operation after ten and one-half hours ;
perforation closed by Lembert's sutures ; death on the fourth day.
Altogether we have 103 cases, with 21 recoveries. The success-
ful cases on record are as follows : Mikulicz (1884), Wagner
(1891), Van Hook (1891), Abbe, Netschajew and Trojanow,
Dandridge, Ferraresi (1894), Hill, Murphy, Price (two cases),
Watson, Sifton (1895), Finney, Brunton and Bowlby (1896),
Panton (1897), Deaver, Burrell and Bottomley, Handford and
Anderson, and Gushing (1898). In England, including Platt's
own cases, but excluding the doubtful case mentioned by Greig
Smith,2 thirteen operations are now on record. Dr. Platt's own
case is the third reported in that country in which the result
has been successful.
As this book goes through the printers' hands I find the follow-
ing case reported by Dr. Hugh M. Taylor,3 of Richmond, Virginia.
The patient was a " little boy," age not given, who suffered
from a typhoid perforation. Operation was performed fifteen
hours after the first onset of symptoms. A quantity of sero-
puruleiit fluid escaped from the peritoneum but no gas. The
perforation was found in the lower portion of the ileum which
was closed. The patient recovered, the final report being made
four weeks after the operation was performed.
The Russian cases referred to above are, in brief detail, as fol-
lows : In 1891 Netschajew and Trojanow operated upon a man
aged thirty-one years, who presented signs of perforation. The
operation was practised six hours after the entrance of the patient
into the hospital. Marked evidences of serous peritonitis were
found, and fecal matter was in the peritoneal cavity. Resection
of the perforated portion was performed. Death followed, and
1 British Medical Journal, 1899, vol. i. p. 89.
2 Abdominal Surgery, fourth edition, p 776.
3 Virginia Medical Semi-monthly, March 24, 1899.
140 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
autopsy revealed typhoid ulcers in the ileum. In 1893 the same
authors operated upon a man of twenty-eight years, who presented
similar symptoms. On entering the hospital a diagnosis of the
ambulatory form of typhoid fever was made, with intestinal per-
foration. The operation took place seventeen hours after entrance.
A general sero-purulent peritonitis was found, the fluid being filled
with fibrinous flakes. Quite a large perforation was present ; 4
cm. of the intestine was excised. The abdominal wall was not
immediately sutured, but the opening in it was packed with sterile
gauze, and complete recovery followed.
A third case was that of Kohltzoff, and occurred in a man of
twenty-four years, who had typhoid fever and congestion of the
lungs. He had symptoms of perforation, with excessive fever.
The operation was performed four hours after the perforation.
Sero-sanguinolent fluid was found in the peritoneal cavity, and 20
cm. from the ileo-csecal valve there was a perforation. A resec-
tion of the perforated portion of the intestine was performed.
Death occurred in two days. At the autopsy numerous typhoid
ulcers were found near the point of ulceration.
In the fourth case, belonging to Trojanow, a patient twenty-nine
years of age had been sick for fifteen days with fever. He was
seized with violent pain in the belly, folloAved by intense chills,
vomiting, and hiccough. There was abdominr 1 swelling and gen-
eral pain. The symptoms were those of perforitive peritonitis.
The operation began sixteen hours after the accident. Abundant
sero-purulent fluid was found in the abdominal cavity, and per-
foration of the intestine had occurred 10 cm. from the ileo-csecal
valve. Resection of the perforated segment was performed, and
death occurred fourteen hours afterward. The autopsy revealed
typhoid ulcers in the ileum.
In addition to these cases Gasselewitsch and Wanach report five
more. The first of these was a man, thirty -six years of age, who had
had typhoid fever fifteen days. After eight days he had had bloody
stools, violent pain in the belly, followed by intense chills, vomit-
ing, and hiccough. The belly was swollen and the pain was gen-
eral. The pulse was 120, the temperature febrile. An operation
WELL-DEVELOPED STAGE OF THE DISEASE. 141
was performed two hours after the perforation. On exploring the
intestines two perforations were found, one 2 cm. in diameter, the
other much smaller. Twenty centimetres of the intestine was
resected, and death followed in about two hours. At the autopsy
ten ounces of fetid pus was found in the belly. The parietal and
visceral peritoneum were covered with punctiform hemorrhages.
The part of the intestine resected was 37 cm. from the csecum.
Their second case was a man of twenty-four years, who had been
ill some time with typical typhoid fever. Seven days after
entrance into the hospital he was seized with violent chills and
fever and all the symptoms of perforative peritonitis. The opera-
tion was done seventeen hours after the accident, ether being
given after a preliminary injection of cocaine. Perforation of the
intestine was found. The mesenteric glands were enlarged and
were adherent to the intestine in places. Thirty centimetres of
the intestine was resected. Death occurred in six hours after the
operation. The autopsy revealed profound typhoid ulceration at
the lower extremity of the ileum. There were also signs of
catarrhal pneumonia. The third case was in a young man of
nineteen years, who had been sick five days. His fever was high,
and he had bloody stools. Four weeks after his entrance into the
hospital he had perforation of the intestine. His condition re-
mained grave, and on opening the peritoneal cavity it was found
to be filled with bloody fluid, and there were intestinal adhesions.
Death occurred in three days. Again, the autopsy revealed per-
foration and ulceration. A man of twenty-seven years presented
mild symptoms of typhoid fever. Six days after his entrance he
was seized with violent pain in the belly and with chills and
sweating. There was also meteorism. Twenty-four hours after
these symptoms the operation was performed. Again the belly
was found filled with sero-purulent fluid. Thirty centimetres of
the intestine was removed and contained four ulcers. Notwith-
standing injections of saline solution the patient died eight hours
after operation. Again the autopsy confirmed the diagnosis. In
the fifth case a man of twenty-nine years entered on the seventh
day of typhoid fever ; six days later violent pain in the c$ecal
142 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
region came on, with moderate fever. Surgical intervention took
place thirteen hours after the accident. The abdominal cavity
was filled with serous fluid. The walls of the intestines were
oedematous. Resection was performed. Death occurred in three
days. The autopsy revealed the characteristic lesions and pneu-
monia of both bases of the lungs. Altogether, these authors
quote seventy-one instances of perforation in the course of typhoid
fever, with seventeen recoveries.
The number of deaths in operation for perforative peritonitis
in typhoid fever is necessarily high.
In summing up his views on the question of operative inter-
ference, Keen says : " Mr. Gairdner, Assistant Physician of
the Belvidere Fever Hospital, in analyzing forty-seven cases of
peritonitis in typhoid fever with reference to surgical interference,
in a very careful and judicious paper in the Glasgow MedicalJournal,
February, 1897, page 67, reaches the following conclusions, which
well express my own feelings, and it is all the more worthy of
consideration as the opinion of a thoughtful physician rather than
that of an over-sanguine surgeon : ' The treatment of peritonitis
in the course of enteric fever by laparotomy has hitherto had a
moderate success. There is every reason to believe that greater
success is possible, and in any case the results are better than
those of any other treatment. Laparotomy offers a fair chance to
about 49 per cent, of cases, while 19 per cent, of the whole would
certainly have a good chance. Nothing but experience can deter-
mine what the results will be —better or worse than might be
expected prima facie. If there is a good cause at least for
attempting surgical interference, it becomes incumbent on the
profession to afford every facility for making the attempt. This,
of course, applies particularly to authorities responsible for hos-
pitals in which enteric fever is treated.' '
My own feeling in this matter is well summed up in the
words of Mikulicz,1 who said at Magdeburg in 1884 : " If suspi-
cious of a perforation one should not wait for an exact diagnosis
1 Quoted by Thayer in Progressive Medicine, 1899, vol. i.
WELL-DEVELOPED STAGE OF THE DISEASE. 143
and for peritonitis to develop to reach a pronounced degree, but,
on the contrary, one should immediately proceed to an exploratory
operation, which in any case is free from danger." Again, Gush-
ing1 says : " When the diagnosis is made, operation is indicated
whatever the condition of the patient. As Abbe's case exemplifies,
no case may be too grave. A precocious exploration from an
error in diagnosis is not followed by untoward consequences, such
as must invariably be expected after a neglected and tardy one."
The only modification I would make of these two opinions is that
in sudden acute cases followed by speedy collapse, the patient
should be given sufficient time to rally before the operation is
performed.
The relation of typhoid fever to appendicitis is one of great
interest. It has been thought by some that appendicitis arising
in typhoid fever was a mere coincidence ; by others that its
origin depended upon a general infectious process, and, again,
by others, that it was due to the direct infection with the
bacillus of Eberth. Probably all these views hold true in indi-
vidual cases. The richness of the appendix in lymphoid tissue,
and the fact that typhoid fever is particularly prone to attack
such tissues, renders this organ peculiarly susceptible on theo-
retical grounds. That this view is correct is proved by the
research of Hopfenhausen,2 who preserved the appendices obtained
from thirty cases of typhoid fever and studied them under Stilling
in the University of Lausanne. She concludes that moderate
changes in the appendix may be found in nearly all cases of this
character, and that it is most marked in the earlier stage of the
malady, and consists chiefly in cellular infiltration, specific lesions
being rare and not being sufficient to produce the more severe
forms of appendicular disease.
True appendicitis complicating typhoid, in the sense of inflam-
mation of this part severe enough to produce abscess, is undoubt-
edly a very rare affection. One such case is reported further on,
1 Johns Hopkins Hospital Bulletin, 1898, vol. ix. p. 257.
2 Eevue MeU de la Suisse Komande, February 20, 1899.
144 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
as occurring in my 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 AlexandrofP (there were three large perforations of
the appendix in this case).
Additional cases have been chiefly collected by Kelynack,4 who
points out that Murchison5 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. Norman Moore6 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,1 in 167 cases five instances
with this lesion. All these quotations throw light on this matter,
but the reports of Morin2 and HeschP give a much higher per-
centage. Thus Morin, in 67 collected cases, finds 12 examples of
appendicular perforation, or 18.75 per cent., and Heschl, in 56
cases, found this lesion in 8, or 14.3 per cent. McArdle4 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.
Rolleston5 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 Hopfenhausen6 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,7 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, lux. p. 42.
4 Trans. .Royal Academy Medicine, Ireland, 1888, vi. 392.
5 Lancet, 1898, vol. i. p. 1401.
6 Kevue M£d. de la Suisse Romande, February 20, 1899. Etude sur I'&at et
1'appendice vermiforme dans le cours de la fievre typhoide.
7 Protocoles des institute pathologique de l'H6pital Municipal d'Obouchow,
et de 1'Hopital Municipal de Ste Marie-Madeleine, 1889-1897.
10
146 COMPLICATIONS AND SEQUELJE 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 :
No. of No. of
cases proceed- cases
ing from observed,
typhoid fever.
H6pital cantonal de Lausanne .... 9 200
Sonnenburg 6 130
Pozzi 1 1
Bull 3 12
Hecker 1 35
Bossard 2 26
Douneff 4 52
LeGuern 1 110
Jacobson 2 6
Schnellen 1 32
Langheld 4 112
Hohn . 1 2
Jacob 2 25
Total 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 Revue Medicale de la Suisse Romande, February 20, 1899.
3 Uber die Verchwarung und Durchborung des Wurmfortsatzes. Thesis,
Zurich, 1869.
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 some\\liat
typhoidal in character, the odor of his body was that of typhoid
fever ; he had developed a number of rose spots on his abdomen
and back, and the appearance of his tongue was characteristic. An
examination of his blood before operation revealed a considerable
148 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
number of leucocytes, probably due 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 examination 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 inoculation 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 in 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 he thinks he is actually
having, or calls out loudly, as his dream seems to lead him to a
O^ * f
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. Zenner1 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 SEQUELAE 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. Taty1 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 Coumenges2
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
uraemia. A combination of more or less active delirium with rest-
1 Lyon M&licale, 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
AVitt1 reports the case of a boy of twelve years, who suffered on
the twenty-third day 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 hypersemia.
Keller2 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 1'Academie Royal de Me"decine de Belgique, November 17, 1889.
2 Revue des Maladies de 1'Enfance, September, 1898, p. 450.
154 COMPLICATIONS AND SEQUEL JE 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
according 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 " we might believe that at least the characteristic
temperature-curve, the splenic enlargement, and the rose spots
would be sufficient to make a mistake impossible ;" but this is by
no means always the case ; there are instances in which typhoid
fever cannot with certainty be excluded, and then the differential
diagnosis is 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 Money1 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 in 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 SEQUELAE 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 Kamen1 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 caecal
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 Fernet2 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. Silva3 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
Tictine,5 Kuhnau,6 and a second one by Kamen.7
" 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 Jahrbucher, 1893, Bd. ccxxxvii. No. 2.
2 Centralblatt fur Bacteriologie, 1893, Bd. xiv. No. 14.
3 Kiforma Medica, 1893, vol. i. p. 14.
4 Berliner klin. Wochenschrift, 1894, No. 15.
5 Archives de Med. Experiment, 1894, tome vi. p. 1.
6 Berliner klin. Wochenschrift, 1896, No. 25.
7 Centralblatt fur Bacteriologie, 1st abtheilung, 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-
fer1 (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 Balp3 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
iudol tests are all that Balp mentions having used for differentia-
tion."
1 Virchow's Archives, 1887, Band. cix. Heft. 3, p. 477.
2 Archives de He'd. Experiment et d'Anat. Pathol., 1889, tome i. p. 656.
3 Rivista 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 Moffitt2 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.
Boden3 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 hyperasthesia of the entire body, and
1 Berliner klin. Wochenschrift, April 9, 1894.
2 Journal of the American Medical Association, March 18, 1899
:! Miinchener Medicinische Wochenschrift for February 28, 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, Kugnan, Daddi, Hintz, and Honl.
The frequency of this complication when 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. Richardson1 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 and 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 Gowers1 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.
Hirt3 says it may occur in the veins as well as the sinuses, but
Dana,4 Rosenthal,5 Gray,6 and Brill7 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. l Ibid.
3 Ibid, 4 Ibid. 5 Ibid. 6 Ibid.
7 Article in Dercum's Diseases of the Nervous system.
11
162 COMPLICATIONS AND SEQUELS 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. No 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.
Lopriore1 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 by thrombosis of the branches of the left
middle cerebral artery in twelve hours. If they occur in neurotic
children or females the outlook is not so gloomy, as they probably
do not depend upon an actual lesion in the brain. Thus West has
recorded a case in which convulsions developed in the third week
of typhoid fever in a child, recurring on two successive days.
These were followed by hemiplegia which, however, gradually
disappeared in 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 Latil1 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 Generale de Clinique et de Therapeutique, March, 21, 1890.
164 COMPLICATIONS AND SEQUELS 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.
No 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 quiet, the patient lying with the
eyes closed, may lead the careless attendant to report prolonged
sleep, when in reality true sleeplessness is present. When insom-
nia is due to feeble circulation, the use of alcohol stimulation will
usually relieve the condition, and morphine may be useful.
We come, then, to the consideration of subsultus tendinum and
carphologia. Both of these are signs of grave illness, particu-
larly the latter, but they are neither of them as mortal in their
prognostic import as the older authors thought, 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 Hebdomadal re 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 years 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 hypersemia 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, 1899.
WELL-DEVELOPED STAGE OF THE DISEASE. 167
described as long ago as 1839 by Taupin,1 who tells us that a
uniform erythema resembling scarlet fever may be present, but
is not followed by desquamation or oedema. He also says2 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 petechise. In other cases they may be as
large as a silver half-dollar, and do not disappear on pressure. It
is as if the rash developed and then hemorrhage took place into
the spot.
Another form of skin manifestation in typhoid fever is the
tache bleuatre. They were first described as occurring in typhoid
fever in 1837 by Piedagnel. I have been confident that I have
seen them in cases which were not infected by lice, but Hewetson3
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 peliomata 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. Chirurgicale, 1839.
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 COMPLICATIONS AND SEQUELAE 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 axillae, 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 paper1 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 cer6brale 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 Keyue de M^dicin, 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 Taupin1
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. 7.
170 COMPLICATIONS AND SEQUELAE 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, 2and 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.)
Taupin4 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.
Nichols5 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 1'Enfance, 1897, p. 1.
2 Johns Hopkins Hospital Reports, 1895, vol. v.
3 Miinchener Med. Wochenschrift.
4 Journal des Connaissances He'd. Chirurgicale, 1839, No. 7.
5 Montreal Medical Journal, June, 1896.
(f)
o
CD
3
CQ
1
0)
3
0>
w
£ y
~
O 3
M
O
0
3
•D
S'
»
5'
cQ
H
•0
0
a
a>
o
13
r
w
c
73
0>
1
O
cQ
0)
3
0>
W
o
0
3
•o
o'
CD
r*
5'
cQ
r
>
H
WEL L-DE VEL OPED STAGE OF THE DISEASE. ] 7 1
sixtli days of typhoid fever. Only one of these cases died. Very
rarely the tendency to hemorrhagic leakings may become general
and result in haemoptysis, hsematemesis, and hemorrhages from
the bowels. A case of this character is recorded in the North
Carolina 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 Levy1 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
piirpura, as indicated by petechia?, 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 petechise. 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. Murchison3 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 Me"decine et de Phar. Militaires, August, 1892.
2 Dublin Journal of Medical Sciences, March, 1896.
3 British and Foreign Medico-Chirurgical Keview, July 1859, p. 194.
172 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
scarlet fever. This was written in 1859. Later still he wrote1
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 place2 as to assert that scarlet fever
appears to predispose to typhoid fever.
Sequeira3 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.
Caiger5 met with two cases of scarlet fever coincident with
typhoid fever, and Payne6 reports one such case.
Carmichael7 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
Cosgrove8 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. s British Medical Journal, 1891, vol. i. p. 849.
4 Lancet, 1893, vol. ii. p. 1307. 5 Lancet, 1894, vol. i. p. 1137.
6 Ibid. ~ 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. Coombs1 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.
Gabe2 reports another case.
The danger of confusing adventitious scarlatiniform rash in
typhoid fever with that of scarlet fever was emphasized by Mur-
chison and by Moore3 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," 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 Bashes 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 10, 1897.
6 Loc. cit., January 16, 1897.
7 University Medical Magazine, December, 1888.
8 Prager Med. Wochenschrift, September 25, 1889.
8 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. What the average frequency
of this unfortunate occurrence is is difficult to determine, because
different epidemics differ greatly in the results they produce, so-
that in one epidemic relapses will occur with great constancy, and
in another almost none will occur. Ord1 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. Berg1 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. Zennetz2 in 384 cases of typhoid fever found 47
relapses, of which 1 7 were entirely uncomplicated. In the Maid-
stone epidemic relapses occurred in 16 per cent., and were more
common in females than in males. Schmidt3 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 em-
ployed." Biermer has also found relapses more frequent since
the introduction of cold baths. Osier met with 14 cases of relapse
1 Deutsche Archiv fiir klin. Med., 1895.
2 Wiener med. Wochenschrift, September 21, 1894.
3 Archiv. fiir klin. Medicin, Band xliii. Heft. 3.
176 COMPLICATIONS AND SEQUEL JE 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 Oilman 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 1 1 1
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 petechise 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 SEQUELS OF TYPHOID FEVER.
•K-V8
•KM 8
u 11 *ni|py up
£ «
2 **>
-S .S
COMPLICA TIONS D URINO CONVALESCENCE. 1 79
6
180 COMPLICATIONS AND SEQUEL JS 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.
106 c
105 c
104°
103 c
102 c
101°
100 c
97°
Day of Dis.
Pulse.
Resp.
Case of typhoid fever in which, according to the patient's story, he had been
sick only three days, but in which the disease ended by a rapid fall in lysis, fol-
lowed by a severe rigor and rise of temperature. The Widal test was positive,
and the rash and enlarged spleen were present.
Not only may a patient suffer from a single relapse, but rarely
from several relapses. Hutchiuson1 has recorded a case in which
three well-marked relapses occurred, and Anders2 has done so also.
The chart (Fig. 17) shows two relapses.
1 American System of Medicine, Pepper, vol. i. p. 303.
2 Medical and Surgical Keporter, July, 1882, p. 66.
COMPLICATIONS DURING CONVALESCENCE. 181
Multiple relapses have also been recorded by Johnston.1 In
one case a patient of thirty-nine years had two relapses, and was
in the hospital eighty-one days. A second case had two relapses.
A third case after a primary attack had two relapses, and the
patient was in the hospital 107 days.
A case of typhoid fever is recorded by Carslaw,2 which suf-
ered from four relapses before ultimate recovery ; and I have
now under my care a case in his third relapse.
Rigors of considerable severity may occur during convalescence
from typhoid fever without possessing any great significance.
This is shown in the chart on page 178, and also in that on page
180 (Fig. 18).
Similar cases are recorded by Herringham. Thus he records
an instance in which after a mild attack of fever a rigor occurred
during the post-febrile period after an enema ; another case in
which there were several attacks of pyrexia and one rigor during
this time, and still a third, in which recurrent collapse appeared
during lysis, and rigors in the post-febrile period without any dis-
coverable cause. He believes that ague can be excluded in all of
his cases. Herriugham also advances the view that in these cases
the heat mechanism of the body is so easily upset that very slight
causes provoke febrile movement, and in this view the writer con-
curs. Osier reports two cases of chills without any distinct appar-
ent cause in the later weeks of typhoid fever. In both these cases
the chills were followed by hyperpyrexia.
Some years ago Da Costa pointed out that during convalescence
from typhoid fever a persistent moderate fever may develop, which
is cured by getting the patient out of bed, Shattuck also speaks
of such cases. I have had under my care several instances of this
character. The getting up ought not to be made till it is evident
that the fever is simply a " bed fever " and not a relapse.
Respiratory Affections in the Convalescent Stage of the
Disease. Aside from the laryngeal (see earlier and later pages)
and other respiratory difficulties met with in the active stage of
1 Medical Chronicle, May, 1892. 2 London Lancet, July 19, 1891.
182 COMPLICATIONS AND SEQUELJS OF TYPHOID FEVER.
the disease, there are no others to be considered at this point save
pulmonary abscess, gangrene, and tuberculosis. The latter condi-
tion will be discussed in a later chapter dealing with the diseases
which ape enteric fever.
Abscess and gangrene of the lung are rare sequences of enteric
fever. They arise from one of two causes : either they are due to
septic matter which has passed into the bronchial tubes during the
stage of stupor, or to septic emboli which first cause consoli-
dation and then tissue break-down. Griesinger met with gangrene
of the lung in seven cases out of 118 post-mortems, and Lieber-
meister found fourteen cases in 230 autopsies of typhoid fever
patients.
The question as to whether typhoid fever predisposes the patient
to infection by the bacillus of tuberculosis is one of great interest.
Cases convalescing from typhoid fever are sometimes met with in
which tuberculosis is rapidly developing. In some instances this
is due to the fact that the profound depression of the patient's
vitality renders him unusually susceptible to any infectious pro-
cess, but more frequently it is probably due to the fact that the
patient has had at some previous time a localized tubercular pro-
cess which has been walled off from the general system by the
usual methods taken by the body for its protection. With the
progress of a prolonged exhausting malady vital resistance has de-
creased, and the local and comparatively harmless process rapidly
spreads throughout the body.
In connection with this matter it is interesting to note that
Loison and Simonin,1 in 114 typhoid fever cadavers, found tuber-
culosis five times, and they point out that typhoid fever may
hasten the development of pre-existing tubercular infection. So,
too, Sarda and Yillard2 have found the diseases coexisting.
Zinn3 states that post-mortem examination of the fatal
cases in 190 patients revealed the fact that six of them showed
1 Archives de Me'decine et de Pharmacie Milita're, Paris, October, 1893.
2 Gazette des H6pitaux, November 30, 1893.
3 Miinchener med. Wochenschrift.
COMPLICA TIONS D URINQ CONVA LESCENCE. \ 83
tuberculosis of the lung in association with old foci at the
apex.
In cases of typhoid fever which are convalescent the presence
of irregular and prolonged febrile movement should raise a sus-
picion of the presence of pulmonary tuberculosis.
The Circulation in the Later Stages of the Disease and in
Convalescence. There are few, if any, diseases which do not
have special predilection for the heart muscle or its valves which
so gravely interfere with proper circulation as does typhoid fever.
The length of the febrile movement and its severity, the gravity
of the toxaemia, the wasting of the patient, his inability in certain
cases to take sufficient nourishment, and the impaired action of
various other vital organs than the heart, all tend to produce
weakness in the heart muscle and actual degenerative changes in
its nerve-supply and fibres. As long ago as 1875 Hayem3 made
one of his characteristically thorough studies concerning the heart
muscle in typhoid fever, in which he showed that a granular
parenchymatous degeneration is present in many cases, and that
even fatty degeneration may be met with in prolonged severe cases
associated with great anaemia. Hyaline changes are not commonly
found, but a segmenting myocarditis, in which the intercellular
cement substance is softened may be present, although this is, per-
haps, a post-mortem change. Many years ago Stokes asserted that
the heart muscle of patients dead of enteric fever was so softened
that if it were held upside down by its great vessels the muscle
would collapse over the hand like a mushroom overspreads its
stem. In some cases, on the other hand, the heart seems to escape
almost completely.
As it is not the intent of this essay to deal with the microscopical
alterations which occur, but rather the objective symptoms of the
disease, little further need be said of these changes themselves,
except that in this connection the researches of Hoffmann are of
1 Legons Clinique sur les Manifestations Cardiaques et le Fifcvre Typhoide,
Paris, 1875.
184 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
interest. He found in an examination of a large number of hearts
in typhoid fever patients 56 instances in which the heart muscle
was normal or little changed ; 39 in which it was slightly granu-
lar, the striations still being visible ; 46 in which the muscle was
granular; 19 in which it was slightly waxy; 1 in which was
granular degeneration, and 1 in which it was very waxy.
It is worthy of note that these changes are responsible in a
large proportion of cases for the sudden deaths which occur in the
convalescent period of the disease, even more commonly than in
the course of the disease itself. So frequent is this condition of
sudden cardiac failure an accident of convalescence rather than
of the febrile attack, that Graves tells us that even if the fever
has departed and everything about the patient is favorable, we
are not justified in banishing all anxiety or in relaxing vigilance,
as a sudden effort on the part of the patient may cause fatal syn-
cope. Instances of this sort have been recorded among the older
writers by Bailly, Graves,1 Jaccoud, and Louis. More recently
Dewerve2 reports that in 48 cases analyzed by him the heart
was found softened, pale, and of a " dead-leaf color " in fifteen
instances ; had undergone fatty or granular degeneration in six-
teen instances, and in three others there was proliferative endar-
teritis of the small vessels of the heart.
Dewerve also found in analyzing these cases that it occurred
most frequently in persons between the ages of twenty-two and
twenty-five years, probably because this is the age most frequently
affected by enteric fever, and that old age and infancy rarely suf-
fered from it. The accident itself is far more common in men
than in women, for this writer found it in the proportion of
114 to 26.
It is interesting to note that this condition is not a sequel of
severe cases alone, for Dewerve asserts, on the contrary, that it is
emphatically a sequel of a moderate form of the fever (forme moy-
enne). Further, violent effort is not necessary to produce it, for
1 Clinical Medicine.
2 De la Mort Subite dans le FiSvre Typhoide, Arch. Gen. de Med., 1887 vol.
ii. p. 385.
COMPLICA TIONS D UBINO CON VA LESCENCE. \ 85
it has occurred after so slight a movement as extending the arm,
by emotion, and may develop without any such cause, the patient
being found dead in bed in the posture they were in when asleep.
Liebermeister records the case of a woman who ate a hearty dinner
after convalescence from a mild illness of typhoid fever. She
then rose to go to the closet, fell in a faint and died in ten min-
utes, and another case of a man who was unable to take the
upright posture for many weeks without suffering from nausea,
vomiting, collapse, and partial syncope, but who ultimately recov-
ered. The autopsy in the case of the woman revealed no lesions
save profound cerebral anaemia.
(For sudden death due to nervous lesions, see chapter on
developed stage of the disease, nervous symptoms.)
There are, however, other causes of sudden failure of the heart
than myocardial degeneration, namely, embolism or thrombosis of
the coronary artery or arteries, heart-clot, thrombosis or embolism
of the cavse or pulmonary veins, and pericarditis with effusion
which, pressing on the heart when a change in position is
attempted, causes sudden death. In the cases already quoted as
having been analyzed by Dewerve (48 cases), there were eight
with thrombosis of the coronary arteries. In eight other cases
aute-mortem clots were found in the right ventricle. Liebermeis-
ter reports one case at Tubingen, in which death occurred as a
result of embolism of that branch of the pulmonary artery that
goes to the lower lobe of the right lung. In this case the embolus
arose from thrombosis of the right crural vein, and was accompa-
nied by extensive hemorrhagic infarction. Clots in the coronary
arteries may arise from within the heart cavities from granulations on
the endocardium. Further than this, Beaumanoir,1 Fritz,2 Vallette,8
Forgues,4 Drewitt,5 and others have met with these formations.
1 La Progrfis Medicale, 1891, vol. ix. p. 364.
2 Charite Annalen, vol. vi. p. 169.
3 Contribution a 1' Etude de la Gangrene des Membres Pendant la Cours de
Fievre Typhoide, These de Paris, 1890, Ferrand.
4 Rec. de Mem. de Med. Militaire, 1880, 3d series, vol. xxxvi. p. 386.
3 Lancet, 1890, vol. ii. p. 1023.
186 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
According to Drewitt, however, these clots are formed in the
the heart in the acute period of the disease, and then are dislodged
when the circulation increases in tone during convalescence. Yiti1
has found the bacillus of Eberth in the granulations of endocarditis,
and, furthermore, has produced these lesions in rabbits by inocu-
lating them with the bacillus, and Vincent2 has recorded the case
of a previously healthy soldier, Avho died from enteric fever, and
in the vegetations of his mitral valves these specific bacilli were
found. Girode3 has made a similar report. Hayem,4 also, has
recorded a case in which endocardial difficulty was recognized in
life, and two days later symptoms of plugging of the arteries in
both legs ensued. First pulsation ceased in the dorsales pedes,
then in the popliteals, and finally in the femorals, and gangrene
developed. An embolus was found in the femoral artery, but did
not extend below the knee. The autopsy showed ante-mortem
cardiac clots, endocarditis, thrombosis of the aorta, and multiple
infarctions in the kidney. On the other hand, it must not be for-
gotten that endocarditis complicating typhoid fever is rare. Osier
says he has seen only two cases. Only eleven cases occurred in
2000 cases in Munich. Pericarditis is also very rare (14 in 2000
cases in Munich).
Liebermeister tells us that endocarditis is rare in typhoid fever,
and mentions but one case of the severe form, accompanied by a
development of excessive warty growths with perforation of two
of the semilunar folds, and consequent infarction of the kidneys
and spleen, double pleural pneumonia and death. He believes,
however, that a mild form of endocarditis without ulceration is
more commonly met with.
In other cases embolism of the pulmonary artery results from
thrombosis of the femoral vein and causes sudden death. Thus
1 Atta della Roy. Accad. del Fisiocritia de Sieria, 4th series, vol. ii. fasc. 5 and
6, 1890.
2 Merc. Medicale, February 17, 1892, p. 73.
3 Comptes Rendu Soc. Biol., 1889, p. 622.
4 Progres Medicale, 1875.
COMPLICA TIONS D URING CONVALESCENCE. 187
Nawercke1 records a case of this character in which the patient
dropped dead when at stool, death coming on in ten minutes, and
Bouley2 reports a case of ascending thrombosis of the femoral veins
into the cava and from there into the right auricle.
In other instances an endarteritis may involve the coronary
vessels and cause sudden death, if we can rely upon the views of
Landouzy and Siredey.3 These investigators tell us that from the
clinical point of view the manifestations of cardio-vascular discnsc
in typhoid fever may present two different aspects. Sometimes
the rapid spread of the lesions in the heart and vessels is accom-
panied by a rapid pulse, with great feebleness of the heart and,
perhaps, by its sudden arrest. Sometimes, on the contrary, these
changes are developed so slowly and insidiously that death occurs
more or less remotely and with variable degrees of cardiopathic
change. The symptoms usually met with in the first variety may
be classed as those of collapse, with great lack of power in the
cardiac muscle. The pulse becomes extremely rapid, small,
irregular ; the face is livid, the eyes sunken, the voice feeble, and
the extremities cold. The temperature may be subnormal. The
urine is scanty or suppressed. The respirations are embarrassed,
and the lungs are affected by hypostatic congestion. Finally,
coma and death come on. This form of collapse may come on as
early as the second or third week. The feeble apex beat and
rapid pulse indicate a diffuse alteration in the heart muscle, which
is usually a fatty degeneration of its fibre (granulo-graisseuse).
In cases of sudden death, on the other hand, the lesions are chiefly
connected with the walls of the cardiac vessels, the symptoms being
in abeyance for the most part till the fatal moment, but dependent
upon gradually increasing degenerative processes.
In other cases where the changes are less marked, the patient
1 Correspondenzblatt fur Schweizer Aertze, 1879, 485.
2 Progres Medicale, 1880, viii. 998
8 Contribution it 1'Histore de I'Arte'rite Typhoidique, Rev. de Medicine, 1885.
Those interested should also read a paper by Landouzy and Siredey, Etude
des Angio-Cardiaques Typhoidiques Leurs Consequences Immediates, Prochaine
et Eloign^es. Revue de He'd., 1887, p. 804.
188 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
does not suffer from severe and alarming symptoms, but instead of
these the patient is affected by a disordered circulation and lack of
tone in the heart and vessels. The chief signs of these conditions
are intermittence of the pulse and a harsh diastolic murmur at the
cardiac base.
The cardiac lesions in mild cases may be entirely recovered from
so far as symptoms are concerned, but the actual lesions themselves
often remain, and Landouzy and Siredey record a case in which a
second attack of typhoid fever came on two years after the first, and
at the autopsy old and new lesions were found in the myocar-
dium.
As a matter of fact, the cardiac changes of typhoid fever are
closely allied to those that are found in cases affected by other
infectious diseases of a severe type.
Sudden death in typhoid fever may occur as early as the tenth
day. M6ry reported such a case to the Socie"t£ Anatomique in
October, 1887. He states that the myocardium did not show any
histological changes and that the patient had been treated by the
Brand bath. In discussing this case, Cornil spoke of the diffi-
culty of discovering any satisfactory cause for these accidents, and
referred to the fact that some persons believed them to be due to
changes in the nervous ganglion of the heart — a hypothesis which
does not permit of verification.
Pericarditis, as already stated, is rarely due to typhoid infec-
tion, although it may complicate its course, being produced by
another cause. Thus Hutchinson records a case in which a patient
convalescing from enteric fever suffered from erysipelas, then
from pleurisy, and finally from pericarditis. Surely this case was
due rather to the streptococcus than to the bacillus of Eberth.
Liebermeister only saw four cases of pericarditis, and all recovered.
Very rarely sudden death ensues without our being able to find
any of the causes given. Dejerine1 has recorded two such cases,
in which no sign of cardiac degeneration could be found. In such
1 Comptes Rendus Societe Biologic, 1885, p. 769.
COMPLICATIONS DURING CONVALESCENCE. 139
instances an embolism of an artery supplying an important vital
spot in the medulla may be the cause.
Dieulafoy1 asserts that in such cases there may be another cause
of death, namely, reflex irritation along the vagus from the abdom-
inal cavity, and which, being transmitted along the efferent
branches of this nerve, inhibits the heart's action and causes fatal
syncope. In other instances he thinks that the respiratory centre
is rapidly affected, and that death results. Such reasoning, in
view of our knowledge of the functions of the parts of the ner-
vous system just named, seems very hypothetical.
Death due to the causes enumerated may come on more gradu-
ally than has been intimated so far. Thus dyspnrea, irregularity
of the pulse, a bruit de souffle, and, rarely, partial syncope, may
begin the end.
Passing from these changes to those met with in the general
bloodvessels, we find that marked inflammatory processes often
affect these parts in the course of typhoid fever. One of the most
important studies made upon this subject is that of Bari6,2 who
asserts, as a result of his work, that both the large and small ves-
sels may be affected by. inflammation, although the vessels of the
lower extremities are the ones most often and most severely
affected. Thus in twenty-two out of twenty-four cases this was
true. It takes place generally when the patient first leaves his
bed and begins to move about. It is just as apt to follow mild as
severe attacks, and it occurs in two forms, namely, as an acute
obliterating arteritis and as an acute parietal arteritis. He
describes the change as follows :
" The first variety is constituted anatomically by an embryonal
infiltration of the three coats, and disappearance of the smooth con-
dition of the intima, which becomes uneven and granular. This
leads, as a consequence, to the production of a secondary throm-
bosis, which in course of time becomes a dense gray mass adherent
to the parietes of the artery. Very often the inflammation of the
1 De la Mort Subite dans la Fievre Typhoide, Paris, 1869.
2 Contribution a 1'Histoire de 1' Arterite Aigue Consecutif a la Fievre Typhoide,
Revue de Medicine, 1883, p. 1, and 1884.
190 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
artery is accompanied by a certain amount of periarteritis. If the
lumen of the affected artery is completely obliterated and the col-
lateral circulation is not quickly established, mortification ensues,
and the limb assumes the appearance of dry gangrene. In excep-
tional cases, in consequence of the simultaneous occurrence of
venous thrombosis or of phlebitis, moist gangrene may follow the
mummifying variety, or substitute itself for it.
" The principal symptoms of obliterating arteritis are as fol-
lows : Acute pain occurring more or less suddenly and seated in
the course of the affected artery, sometimes localized in a restricted
region, as, for instance, the thigh, calf, or Scarpia's triangle, some-
times occupying the whole length of the limb, and increased by
pressure upon assuming the erect position and by the movements
of walking ; diminution of the fulness and, finally, suppression of
the pulsations of the artery ; swelling of the limb without oedema
or redness ; bluish mottling of the skin ; sometimes, although
rarely, purpura ; diminution of the temperature of the limb with
or without disturbance of sensibility, such as formication and par-
tial anaesthesia, and, finally, the occurrence in the course of the
artery of a hard and tender cord.
" The parietal arteritis is only a variety of the preceding and
has, consequently, the same symptoms but in a less degree of
development, except, of course, that the hard, painful cord is
absent. It is said, however, that the diminution of the pulsations
of the artery is occasionally preceded by an exaggeration of their
amplitude, and that in a few cases the temperature of the affected
limb has been observed to be higher than that of the other.
" It must be borne in mind that some of the symptoms of the
obliterating variety may arise from an embolus, but the presence
of a valvular murmur and of other signs of disease of the heart,
and the suddenness of the seizure, will enable us to recognize
without difficulty the cases dependent upon this cause.
" The therapeutic indications in the milder forms are best ful-
filled by rest in bed, the application of emollients or soothing
ointments to the limb and wrapping it in cotton. In cases in
which gangrene has occurred the patient should be supported by
COMPLICATIONS DURING CONVALESCENCE. 191
tonics and a liberal diet, and appropriate antiseptic dressing should
be applied to the part."
Other reports on this subject have been made by Ferrand,1 Des-
champs,2 Mettler,3 Quervain,4 and Haushalter.5
In addition to these interesting researches there are others of
even greater interest, as, for example, those of Rattone,6 who in
four cases found the bacillus of Eberth in the arterial walls and
obtained pure cultures from this source. The result of this infec-
tion and endarteritis is to aid in the formation of thrombi, and
these in turn, by plugging of the vessel, cause rapid dry gangrene
of the tributary part. (See lesions in the skin.)
The bacilli are supposed to reach the arterial wall by the blood-
stream rarely, or by the blood-stream in the vasa-vasorum.
The veins are very much more apt to be affected by thrombus
than the arteries, as every one with a large experience with typhoid
fever well knows. Haushalter and Vaques have found the bacilli
in the walls of these vessels, and Rattone and Haushalter have
found them in the thrombi themselves, and also that the endothe-
lium under the clot was destroyed.
As a result of this thrombosis with phlebitis we may have devel-
oped phlegmasia alba dolens, but very rarely gangrene because
the collateral circulation is more free in the veins.
The clots in the veins may be single or multiple, and may be of
very extraordinary size. In de Santi's case7 a clot extended from
the vena cava in the iliac vein down into the femoral vein, and
one extraordinary case is recorded by Beaumanoir,8 in which clots
were in the arteries of both legs, in the right ventricle, in the pul-
monary artery, in the femoral veins, and in the aorta. Cases of
clots reaching from the femoral vein to the vena cava are recorded
1 These de Paris, 1890. 2 Ibid., 1886.
'6 Philadelphia Medical Times, February 19, 1887, p. 339, and New York Medi-
cal Journal, March, 1895, p. 289.
4 Centralblatt fur Innere Med., August 17, 1895, p. 793.
5 Mercredi Medicale, September 20, 1893, p. 453.
6 Delia Arterite Tifosa in Dehu.
7 Kec. Mem. de MeU Milit., 1879, series 3, xxxv. 502.
8 Progres Med., 1891, ix. 364.
192 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
by Dumontpalier,1, Sorel,2 Bouley,3 and Mackintosh.4 A case of
thrombosis of the iliac veins and the lower part of the ascending
vena cava has been reported by Pansini5 in a case under his care.
(Edema, lividity, pain and loss of power in the legs were present.
Pansini refers to a statistical article of Vimont, who up to 1890
collected 112 cases from the literature of this character.
A curious case of varicosity of the subcutaneous veins of the
trunk and extremities is reported by Mackintosh6. The veins
involved were the jugular and internal mammary and external
pudic, the superficial epigastric, internal saphenous, and superfi-
cial circumflex on both sides. It is supposed by the reporter that
a thrombus formed at the junction of the iliac veins and inferior
vena cava which, becoming engorged, necessitated a collateral cir-
culation. Curiously enough, the patient survived.
Plugging of the veins to a great degree usually results in moist
gangrene, as has already been stated.
In regard to the vessels most commonly affected by plugging,
we gain very interesting information once more from Keen's classic
essay. Out of 90 cases of gangrene, and Keen believes all these
cases were due to plugging of vessels, 46 had arterial plugging, of
which 8 were bilateral, 19 on the right side, and 19 on the left
side. In the veins in 52 cases there was bilateral involvement on
both sides in 4 cases ; on the right side in 10 cases, and on the left
side in 38 cases. Again, in those cases which did not proceed to
gangrene, Keen found plugging in the arteries in 1 5 cases, of which
4 were bilateral, 6 on the right side, and 5 on the left, and in the
veins, out of 47 cases, 3 were bilateral, 13 on the right side, and
31 on the left.
These statistics support the earlier ones presented to us by
Liebermeister, who met with 31 cases of thrombosis in the veins
of the lower extremities among 1743 typhoid fever patients, the
1 Comptes Rendu Soc. Biol., 1879, 6th series, vol. iv. parts 283.
2 L' Union Medicale, 1882, p. 521.
3 Progres Med., 1890, viii. 998.
* Glasgow Med. Journal, 1892, vol. xxviii. p. 54.
5 Centralblatt fur Innere Med., June 6, 1896.
6 Glasgow Medical Journal, July, 1893.
COMPLICATIONS DURING CONVALESCENCE. 193
majority of whom were men. In his 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, 16 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 Arnaudet1 records three
cases, one in a woman of seventy-five years, another in a woman
of fifty years, and the last in a man of thirty-eight years.
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 Marcus2 in 1812, of suppuration of the scrotum in " stupid ner-
vous fever." Vulpian3 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 Normandie He'd., November 1, 1891.
2 Archiv fiir Med. Erfahrungen, Berlin, 1812, i. 546.
8 Pictionnaire de Med., 1844, 2d ed., xxix.
13
194 COMPLICATIONS AND SEQUEL JE OF TYPHOID FEVER.
Eshner1 has collected forty-two cases, and has reported one in his
own care. The contribution of Ollivier2 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 was diarrhoea, with copious watery
evacuations from the bowel, and rose spots were present upon the
cheek and the abdomen. Nose-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 22d, 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 gonorrhoeal 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 Revue de Medecin, 1883, pp. 829, 9GO.
COMPLICATIONS DURING CONVALESCENCE. 195
was evacuated. The operation was a success, and the patient
recovered.
Ollivier1 believes that orchitis is more common than is generally
thought. He reports three cases of his own. Liebermeister2 met
with it three tunes in 250 cases, and SoreP found it in 3 cases
out of 871 typhoid fever cases seen in ten years. Eshner also
quotes Betke,4 who did not meet with it in the records of 1420
cases, and Dopfer,3 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, in 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 Handbuch du speciellen Path, und Therap, 1874, ii. B. 2, 189.
3 Bulletin et Mem. de la Soc. Med. des H6p., 1889, Ivi. 236.
4 Deutsche klinic, 1870, 42 and 48.
5 Miinchener med. Wochenschr., 1888, p. 620.
6 Ibid., January 20, 1891, p. 43.
196 COMPLICATIONS AND SEQUEL J£ 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 :"
Cases.
Between 1 and 4 years 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.
1 an
10 '
d 4 years
14 "
15 '
19
11
20 '
24
a
25 '
29
a
30 '
34
it
35 '
39
it
40 '
44
11
45 <
49
ii
COMPLICA TIONS D URING CON VALESCENCE. \ 97
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 Strasburger1 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 Eshner,2 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 SEQUELJE OF TYPHOID FEVER.
o
Ad
ii
. oj
II
03 fc.'
p» 03
M "g
03 °
'C -^
Ss
§1
03
suppu-
8
•3ft
l-i M
43 03
. , <*H
sll
M - )
SI
b
Remarks.
Mild typhoid fever
Grave general state
Urine contained g]
ter ; effusion ; sup
'o 'o
"ft "a
03 -J 03
> g >
d a-o e
o >.° >>
«a.I
'a ^*ti3
*l»«j
>.£ ftg
No effusion.
Typhoid fever of
intensity , testicli
increased in size.
Effusion.
Epididymis scan
larged ; cyst in h
epididymis.
Grave typhoid feve
ration.
*"* 03 ±. ^
<IH 1
'*H —
**-i
•2*3 8 °
° •'»
O O
§•0 g N
. a a
h_O _C
J3
>:,
b b
"B § % *•
'13 3*0
Q
03
03 03
"§"
,
0> 0^3
g f»J>
3g g
S
T3
•a
"S ol "OS'S,*
sSg1
-03^.3
. 3 .
CO ^ CO
8
C3 C3
03 03
B
'3 a '3
>>
S
8 ^
o 55
^ Q
0 ..2 S'K
'jo 03 M®2
2i'cg2
SJai?
w''"
Nodular ii
tail of ep
Testicle en
3 =32 *2^2
^•'3'o's'a 3-0
2-5'a'O'ft'g'ft
W!a>!°£"
Complete
Complete
Complete
Recovery.
Testicle es
'O 03^ W
13 od
-O m'O
M-O CO
..
fl .— S "-*
»"S
08 9 o3 g
oj a
o3 9 c3
a as a
'a
^ 03
<0) >» 0) >»
03
03 >>03
0> >>il>
>>03 >>
_03
>> 03
03 o:
j fli
13S oS
[o
Cj2 O
O »^ O
S Q S
"o
•O "Jj
[3 [t
pH £p '-5 "O '.3 *O
'^*C '^
T3 'O'.n
*O '^'C
tg
S 3
~ 0) ft 03 ft
03
S'ftS
S'Si^
ftoTft
03
o, S
S 2
H ""H «>
H
EH *H
H ^H
W^ 03
H
W H
EH H
"aid
5
• a
«
5
S 2
£
o>.2
**-» *«-t
60
0 "*
G
60
60
.60 .60
60
2 §
S S
5
j S
3 :
a
S
p^ S
S
O CO r
.
5 §
en «
.
Cfl°
co oi
•
a! :
33
1 i
M n ^>
03
OJ 03
&»>
a!
1
•a :
-O
a\0
T3 *C
T3
73 fO
•O
o •
00
™
JS
00 00
to
05
OO O)
50
q
7-1
•H •*
Date of
appearance.
10th day of fever.
20th day of fever.
During conval-
escence.
1st or 2d week of
convalescence.
8th dav of con-
A - a j,
aJ1*!*!. I
co a ° | ® a 8
f^l^fsf 'g
co 2 S Q
escence.
During conval-
escence.
16th day of fever.
During conval-
escence, 25th
day of fever.
19th day of fever.
llth day of con-
valescence.
During conval-
escence.
In course of
fever.
03
t- Tj.
00
?3 '3
O C*J
<t
««' S^ r
.•§??
^
03
oo"
03
ros
. 'o j* d
^ M
g^w
v
'O .
i
*|j
^W
•^"
c'2<
a CN
^
sills!
ft|a|
S
a P,
i
gft
— 'S
03 — H ' ~ ' — ' aa
S~ -"^ a,
•f
!§ *i
? . §-• I*
1 £~'°.'la3
.«S3
S
t»S
•81
5
^.J
o
«B
(§
., b 8^1 «'B«Sia . m jj •"• fe a' Q.
00
§
"?}j
>
iili
H EH
T3 • 'C 03
3
03 0"
2"s
•s«-
«d
QJrH
rrt .
r
ft
in
also Oil
^s
t3 ^ 'O
3 S 3
3 |°
3 S
"2
B
i— i
Woo
P
1
c
S 3
0> CJ
>> s
3
a
•B
a
^" —
o> —
rrH O
'o
o> 'S
*3 "3
•3-25
5 0
'o o
3
8
—
1
03
^ §
a
"*"
^ ^
t3 o) tn
2^ G
a c
_g
0
>
M
O CQ
as
a
QJ !P
0 0
i '^
'^ S .2
5 <
a a
3
=
a
d
-H C*
CO
•* U5
» r-
00 OS 0
_, ^
E2 ^3
ie
«0
(^
Z;
T— <
i-l rt
FH rH
"^
"
^^
COMPLICATIONS DURING CONVALESCENCE. 199
Epididymis principally in-
volved.
Epididymis principally in-
volved.
Epididymis principally in-
volved.
Mild attack of typhoid fever.
Grave typhoid fever; effu-
sion.
Typhoid fever of moderate
severity.
•i°2sj2.£ ^-S j
JS^I^f • §as>l!
t3 ,,* ai a> as a> S a ^ a> •— °S °C
PUP flitlfl
Typhoid fever of ordinary
severity.
Suppuration in testicle;
typhoid-bacilli found in pus.
Suppuration ; typhoid
bacilli found in pus.
sill iiMig
tagw ^ 2-0 2* 33 3
S ft i5 <« . H.3 <*_ boaS
bi si li
..S^gpSg SS? ^"3 „""«
Q ^ !p3 <2 g ^ a o °^ ••G*-ScnJ3'O-^
sec.- 5-c'E-J a'Hi.scK-g'ti.cS
« a> — -S s a)^J «j ci^S^j H^ aS-2
00 H M M M oo as
Recovery.
Recovery.
Portion of testicle
sloughed.
Recovery.
Atrophy of testicle.
no 1"O x"O x
•o to
§a
la
§a
= •53 ^'S
as e as a
•gi's^ «
s
il
-
= i
=
^* i
o
>>aj
>• 0
HT;
•32
•32
m >>
•32
"3 "3 '32'32
"3
3) ^» ^ £*•» © >>
K
~
I
'C *U
?
2 =
i^
il.
"i2
So.
3 T> *3 *O '^ *C
QJ QJ <[> C« ^j — ,
1
=2=i2= 2
—
I
H
^
*H
o>H
EH •
EH «
EH ®
EH H H *£-" *
H
EH »E-< *EH H
H
H
**
d
-Z
so
d
-J
d
d
S S S +;
bo bo bo <~
3
bo
d « | i
d
1
2
-1
5
^S
2
X
^
05 OS S J
H
j 2 2 S
3
X
.
*
-
.
x-
X
^
• . j3 «
X
09 03
• JH Ji x
n
R
v : a/ >.
=:
at
--
oS
08
i
a! v u d
03
"O
•s
-e
T
•o
•0
^
f • £ *&
•o
•o ^ ^ -a
•a
«
;-
"*
2
*•
01
rH
" ' •* 2
00
S « S ^
CO
3d day of con val-
escence.
Close of defer-
vescence.
5th day of con-
valescence.
1st week of con-
valescence.
3d day of con-
valescence.
During deferves-
cence.
13th day of con-
valescence.
§ § § I
o . o ^ 3 . S ^
x's i
c a 6 e
o o p o
j oj 4) *^" qj
J*H U > *H ® IM o
5Or-^ OU Ofi
5 >>S,^ ^H . .0)
*5"3o ^'S-j:'5'
»~^-s tiSa'=^'
Convalescence.
Convalescense.
3
S
a
3
s
55 558
3
f S S 8
x*0 «
CZ
a . s
•6
S
d
£
3
B
1
»co
E-i
2'
2'
M
el'
C. 2 :
-1
I§"
•d
S
•d
S
PI
li'l l
I
Laveran
Laveran
Ijaveran
>,
^
^
Larquier
Larquier
Sad rain
a"
CO
Hamilton
Harrison
M
_4>
O
(4
O
Ollivier
I!
ill
00 * 00
200 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
uppuratio
cilli in pu
ver of or
s3 g-3 t-sSo-3 S«S
Is il 1*^1*|
03 O 5
.5 '53 be
•a 3 o
>-!tl >>
o a> o.
oe^
;fs
—___ . l-Ii
cs~2 « £• -^2 a 2 -a ~ 'g ° « ft -a •-' 2 .5
•SS'o'C „ 0.2 _2'3 c <s « gS" "o d 5--
I •§,§.? Sflf^l&lia •asll
i^z S^i^lasSBa Sags
O W H •< S H
Eff
ty
Typ
se
23
a'S
_bcp,
3 2. 2
-ail
^ ™ O"
- —
M kn
a a
WWW
H H
•W1"" o> .« «7 • Q 0?
rt»3_: tf as ^ j _)
32
^ >
a g
t? 3
r °rH
5.^tf
igs g
a3 . _j
sr
Reporter.
9
1
3
bO bfi
a 3
a H
Messerer and
Gasser
Salles and
Barjon
Berthoud
Berthoud
Eshner
Hare and
Horwitz
o
8
S g
8 § a
M
CO
3
COMPLICATIONS DURING CONVALESCENCE. 201
of these cases had been previously collected by Ollivier, and ten
by Westcott 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 12,
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 1 2th.
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. No 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 SEQUELS 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.
Beckell1 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.
COMPLICA TIONS D URING CON VALESCENCE. 2 03
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 Morin1
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 vessels,
and in Hoffmann's 250 cases at autopsy this lesion was found no
less than nine times. In six of these it affected the ileum, in two
the vermiform appendix, and in one the sigmoid flexure. Those
cases in which there is gangrene of the appendix are probably due
1 Des Perforations Intestinal dans le fours de la Fievre Typhoide, Paris, 1869.
204 COMPLICATIONS AND SEQUELS 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. Tschudnowsky1 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.
Young2 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, Little] ohn4 has re-
1 Berliner klin. Wochenschrift, 1869, Nos. 20, 21.
2 Medical Press and Circular, 1886, xlvi. p. 471.
s 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 cheek, 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 cases.
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.
Franklin1 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 Donald3 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
duct.
Keim4 has reported a fatal case of typhoid fever in a boy of
1 Quoted by Hutinel.
2 Bulletin de la Socie^ Anatomique, December, 1887.
3 London Lancet, February 20, 1893.
4 Lehigh Valley Medical Magazine. October, 1891.
206 COMPLICATIONS AND SEQUELS 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 swelling of the lids, and on the thirty -third day the
left eyelids became involved, and on the thirty-fifth day large
non-glandular swellings 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 Freudenberger4 has seen it involve the uvula.
Spillmann5 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.
CEsophageal ulceration6 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
Riesman 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 Qnelques Considerations sur la Gangrene Typhoide. These de Paris, 1887.
4 Aertzliche Intelligenzblatt, 1880, xxvii. 7.
5 Merc. Medicale, 1895, No. 13, 145.
6 A valuable paper, by Russell, on resophageal 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
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 SEQUELAE 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 Janowski1 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
staphylococcus were found to be present. Sometimes the inflam-
matory process goes no further than swelling and hypersemia ; 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. Not 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 palsy may result either from destruction of the facial
nerve, by its section in incising the abscess, or by reason of the
pressure exercised upon the nerve as it passes through the 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 anses-
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 autopsies1 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. Delaire2 has reported an
instance in which an hepatic abscess ruptured into a bronchus ;
the abscess was incised and recovery occurred.
Lannois reports the following case, which occurred in the Hopi-
taux Militaire de la Charite in 1881 : A man of twenty-two years,
1 Holscher. Miinchener med. Wochenschrift, 1891, Nos. 3 and 4.
2 Gazette des Hopitaux, 1860.
14
210 COMPLICATIONS AND SEQUELAE 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 Lannois1 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 tune 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. Eapid 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 Romberg2
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 Revue de Medecin, 1895, p. 913. Pylephlebite et Absces de Foie Consecutif
si la Fievre Typhoide.
2 Berliner klin. Wochenschrift, March 3, 1891.
COMPLICA TIONS D URING CONVALESCENCE. 21 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. Buckling2 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. Osier4
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, Lannois5 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.
Klebs6 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. 2 Fiille von Leber Abscesse, Berlin, 1868.
3 Berlin, klin. Wochenschrift, 1890, 192.
4 Trans. Assoc. American Physicians, 1897, 382.
5 Revue de Medicin, 1895, 909. 6 Handbuch der Pathol. Anatomie.
212 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
just reviewed is as common as they are rare. Thus Louis1 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 in 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
Budd4 recorded such cases. In America as long ago as 1846
Ayres5 reported the case of a young physician so affected, who
died of peritonitis, and Murchison6 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 Dupre,8 Courvoisier,*
and Hagenmuller,10 the latter collecting eighteen cases.
It was not until 1890 that Gilbert and Girode11 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, 184(1, 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 Beitrage ziir Pathologic 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 Socie'te de Biol., 1893, p. 986.
12 Les Infections Biliares. Th<5se de Paris, 1891.
COMPLICATIONS DURING CONVALESCENCE. 213
after the fever ceased, and Chantemesse1 records an instance eight
months after the fever, while von Dungen2 recites one remarkable
instance of cholecystitis fourteen and a half years after the fever.
In the pus of this case the Eberth bacillus was found.
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 Bernheim5
and Chantemesse6 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 Dufourt8 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-
nier9 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 Anderson10 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 Traite 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, 841, or Matliieu, Rev. de MeU, 1886.
8 Revue de Med., Paris, 1893, p. 247.
9 Compte-rendus Soc. Biol., March 5, 1897, p. 936.
10 Canada Lancet, 1896. " Quoted by Osier, ibid.
214 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
typhoid bacillus in the pus ; recovery occurred. Hawkins1 reports
a case of this character in which after death there were found
typhoid lesions, and Osier2 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.
Gushing3 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. Hektoen4 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. Gushing has also
reported in the Johns Hopkins Hospital Bulletin for May, 1898,
a case in which cholecystotomy was performed for a cholecystitis,
in which the typhoid bacillus was found, although there was no
history of typhoid fever. The blood in Gushing' s case also gave
the typhoid reaction. Gushing 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.
COMPLICATIONS DURING CONVALESCENCE. 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.
" Case 1. 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. s Ibid.
4 Bull. Fac. de Me"d. 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 SEQUELAE 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, aged twelve years. Six-
teenth day, tumor in right hypochondrium, 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.
Foyer'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. No 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 He'd. Militaire, Paris, 1864, p. 197.
5 Zerstorung der Gallenblase bei Typhus. Virchow's Archiv, 1868, xlii. 219-
222.
COMPLICA TIONS D URING CON VALESCENCE. 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 Reports 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." Prog. m*d. 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 Heilkunde, 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. fur 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.
L£tienne : " Recherche Bacteriologique sur la Bile Humaine."
Archives de Med. Experiment, 1891.
Naunyn : Cholelithiasis, Leipzig, 1892.
Pisenti : Archiv fur Exper. 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 : LOG. cit.
Monier- Williams and Sheild : Lancet, March 2 ,1895.
Malvoz : Recherche Bacteriologique sur la Fievre Typhoide.
Paris et Leipzig. Dupr6 : Op. cit. Dufort : Loc. cit. Gum-
precht : Deutsche med. Woch., 1895, No. 14, et seq.
Von Hoffmann : Untersuchungen uber 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 Klein1 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 Typhuskomplica-
tionen. Inaug. Dissert., Bonn, 1898.
COMPLICATIONS DURING CONVALESCENCE. 219
Tungel1 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.
Lehman2 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
with 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 Jamieson9
records nine cases, of which four died.
Sometimes hypertrophic enlargement of the spleen occurs after
1 Klin. Mittheil aus der Kaiserlich. Hamburg Allegemeine Krankenhaus, 1864.
2 Centralblatt fiir klin. Med., August, 1891, 649.
3 Verhandl. Kongress fur inner Med., 1887, 179.
4 British Medical Journal, 1888, i. 1388.
5 Glasgow Medical Journal, 1882, xvii. 244.
6 British Medical Journal, 1881, ii. 122. 7 Loc. cit.
8 Revue de Med., 1882, vol. ii. p 600.
9 Imperial Maritime Customs Med. Reports, 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, not due to these causes is, however, reported
FIG. 20.
Splenic enlargement after typhoid fever.
by Sauti 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 hypochoudrium, the action of the heart became rapid and
feeble, and oedema of the left leg Avas present. After a brief
1 Gazeitii degli <>s|.it:ili, 1-01, X<>. 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
meningo-encephalitis. 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 SEQUELS 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 Avas
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.
Surniay2 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-Ebing3 speaks of weakness of the
adductors of the thigh and hypersesthesia of the skin supplied by
the saphenous nerve. Bailly* has recorded paraplegia, anaesthesia,
and contractions in these cases, and in two instances paralysis of
the palate, and Nothnagel5 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.
5 Kraft-Ebing. Beobachtungen und Erfahrungen iiber Typhus Abdominalis,
1871.
4 Bailly. These de Paris, 1872.
5 Nothnagel. Deutsches Arch, fur klin. Med., Bd. ix. p. 429.
COMPLICATIONS DURING CONVALESCENCE. 223
extremities was followed by weakness in the upper limbs. In still
another the patient at the beginning of convalescence first had a
feeling of numbness and creeping in the left leg, and after this,
paralysis of that limb gradually developed. Later on the exten-
sors of the right hand became paralyzed, and four days later some
of the muscles of the left hand.
Similar cases have been reported by Leyden1 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 oedematous 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 have 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,4 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, fiir Psychiatric nnd Nervenkrankheiten, 1876, Bd. vi. p. 543.
3 Bernhardt. Deutsch. Arch, fiir klin. Med., 1878, p. 363.
4 D' Accident Survenus Pendant la Convalescence de la Fievre 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 Vaillard1 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 whom 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 in 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-Dej6rine,6
1 Pitres and Vaillard. Compte Rendu. Soc. de Biol., Paris, 1885, S. 8, ii.
661, and Rev. de Med., Paris, 1885, v. 985.
* Alexander. Deutsche med. Wochenschrift, 1886, vol. xii. 529.
3 Handford, H. Peripheral Neuritis in Enteric Fever. Brain, vol. xi. 237.
4 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 Polyndvrites 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 Koyal 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 Mitchell1 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 Ross1
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 Ross (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 hyperaesthesia. Eleven of these cases have been reported
by Aran in L' Union Mtdiccde, July, 18, 1855. The contractions
occurred toward the end of the attack of typhoid fever, and never
were begun writh 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 SEQUELAE 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.
Gubler1 has recorded a case of contraction of the hands, and
Dewerve refers to this condition as possible of occurrence in the
Nouveau Dictionnaire de Medicine et de Chirurgie. So, too, Noth-
nagel2 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 Handford, and consist of great
hyperaesthesia 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 Medicine 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. Bartholomew's Hospital Reports, vol. xxiii., in
which there was acute myelitis of the anterior coruua and involve-
ment of three of the eight cervical nerves.
/•
1 Archives G^nerale de Me"d. xv. 5th series.
2 Deutsche Arch, fiir 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's 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 in 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 folloAving 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 SEQUELAE OF TYPHOID FEVER.
parietal and parieto-temporal 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 diarrhosa. 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 Blumer :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 Nervous 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 Newbolt,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 SEQUELAE 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 recover}7 occurred.
Imradi asserts that there are only fifteen similar cases to be
found in literature.
Vulpian2 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), Stevens3 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 Revue 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 case 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 Hutinel1 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 enf eeblement and inability
1 Etude sur la Convalescence et les Kechute de la Fievre Typho'ide, Paris, 1883.
COMPLICATIONS DURIXG 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.
Rathery1 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.
Gubler4 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 Mendel6 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. Bernoud7 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. * Loc. cit.
5 Loc. cit. 6 Archives G£ne"rale de Me\iecine, December, 1894.
1 Lyon Medicale, March 28, 1897, p. 453.
236 COMPLICATIONS AND SEQUELAE 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. Laryngoscopic examination showed a complete double
paralysis of the openers, the vocal bands remaining fixed in the
median line. Accompanying paralysis of the arytenoid muscles
with loss of tension enabled the patient to get a little air through a
small triangular slit at the most posterior portion of the glottis.
As promptly as possible an adult intubation tube was inserted into
the larynx. This was accomplished without much distress or
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 dyspnoaa. Laryngoscopic examination
showed complete apposition of the vocal bands in the median line
with enough relaxation of tension and arytenoidal paralysis to
allow a little air to enter. Intubation was strongly urged, but the
visiting physician was 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 SEQUELJE 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 Simpson1 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-hyper trophic 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 acute 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 Elektricitdt auf Praktische Medicin, Berlin, 1861,
p. 311.
Leudet. " Remarques sur les Paralysies Essentielles Consecu-
tives & la FiSvre Typhoi'de," Gaz. Med. de Pat-is, 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 Notlmagel. Deutsche Archiv f.
klin. med., 1872.
Rehn. "Ein Fall von Lahmung der Glottiserweiterer nach
Typhus Abdominalis," Deutsches Arch. f. Ein. Med., Bd. xviii. p.
136.
Landouzy. Des Paralysies dans les Maladies Aigues. Paris, 1880.
Baumler (C.). " Ueber Lahmung des Musculus Serratus Anticus
major nach Beobachtungen an Cinem Fall von Multiplen Atro-
pischen Lamungen im Gefolge von Typhus Abdominalis/'/M/fec/ies
Archiv. f. klin. Med., 1880, vol. xxv. p. 305-324.
1 Revue de Medecin, November 10, 1889.
240 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
Stintzing (R.). " Typhus Abdominalis mit Nachfolgender Atro-
pischer Lahmung," Aertztl. Int. SI., Munchen, 1883, vol. xxx. p. 4.
Bartholow (R.)- " Enteric Paraplegia/' Medical News, Phila-
delphia, 1883, vol. xliii. p. 609.
Rondot (E.). " Contribution 5, 1'fitude des Paralysies qui Sur-
viennent dans la Fi6vre Typhoi'de ; Paraplegic et Amyotrophie
Myelopathiques d'Origine Typhoidique," Gaz. Hebd. de Sci. Med.
de Bordeaux, 1885, vol. vi. p. 446.
Peliotis. De la Nevrite Peripherique du Cubital Consecutif a
la Fievre Typho'ide. Paris, 1885, Th6se.
Raymond. " Deux Gas de My elite Ascendante Observes pendant
la Convalescence de la Dothi6nent6rie," Revue de M&dicfine, 1885,
p. 648.
Courtade (D.). " Des Paraplegics Survenant dans le Cours ou
pendant la Convalescence de la Fievre Typhoi'de," U Enc6phale,
Paris, 1886, vol. vi. p. 431.
Wiirtz. " Note sur un Cas de N6 vrite Tibial Ante"rieur Survenue
dans le Cours d'une Fievre Typhoi'de," L'Encephale, 1886.
Buzzard (T.). Paralysis from Puerperal Neuritis, 1886, p. 102.
Bassi (U.). " N^vrite Multipla Consecutiva a Febbre Tifoide,"
Rev.Veneta di Sc. Med., Venezia, 1887, vol. vi. p. 585.
Oppenheim and Siemerling. " Beitriige zur Pathologic der
Tabes Dorsalis und der Peripherischen Xervenerkrankung,"
Archiv fur Psychiatric, 1887, p. 509.
Puybaret (J. A. C.). Contribution a 1? Etude des Paralysies dans
la Fievre Typho'ide, Bordeaux, 1887, Thesis.
Stadelmann. " Ueber einen Eigenthiimlichen Mikroskopischen
Befund in den Plexus Brachialis bei einer Neuritis in Folge von
Typhus Abdominalis," Neurol. Centralb., 1887, p. 285.
Growers. 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. ix.
p. 201.
Comte. "Un Gas de Paralysie Generalised a la Suite de la
Fievre Typhoi'de," Poiteau Med., Poitiers, 1887, Tome ii. p. 113.
Schmidt (F.). " Ueber Neuritsche Lahmungen nach Abdomi-
naltyphus," Nurnberg, 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-
ger2 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 Infectionskrankheiten.
16
COXPHCATIOXS JLSD SEQUELJE OF TYPHOID FEVER.
admitted with weD-denned symptoms of a mild attack of typhoid
fever, which ran a short course, the patient being discharged on
January 30th. On Fehraary 3d she entered the house, complain-
ing of pain in die abdominal region and in the knees and elbows ;
the pains were not very severe, bat the joints were somewhat
swollen ; die tongue was brown and dry. and all the symptoms,
tare ami appearance of the patient, pointed to a second attack of
typhoid fever, although at fiat the case was treated as one of
i hi •• Hi m Tie •••jii •••••! did not exceed 103°, and die
patient went llmimjh a moderately severe attack of typhoid fever
• •"him! complication, except for very marked enlargement of the
glands of tike neck, which was idEmcd very promptly by the use
of mi iee-eoDar. OBI March 5th a well-defined erysipdatous
swelling fy|m*i*J over the left side of the face, about the temples
lar bones, and gradually *«to^l«J over the entire face and
part <of the scalp, The eyes were completely' eland, and the lips
very much swollen. The mouth was very painful, being covered
with sores to such mi extent that it was impossible for the tongue
t*> be iwx^radkid, JUM! it m^ impos^bl^ for food to be t^<^ Hie
throat was Terr dry, ami a spray of Ksterine was used as month-
wash, The ordSnaiy treatn^ent for typht^ fever was at once with-
" •• -_ i: :i- :>..-:'. -.-.: ^.-- :•:: :. :i.ir--- :• :^ : ::_• r.:. -.:•• :
• :' - :_:••- r.:_— . . "":. "-: ::„- -;•••::„-:.- -L
improved^ ami by March 15th aft inflammation had entirely dis-
.:.•• "-• .-• -:-j L.~.J - :.- ------- '~ :.- :. '.:. ::.- • :•- : -;.-
next two w«eks cmimii passed awav. The patient during this
mr M. * m.
time inmimmil to manifest symptoms of typhoid fever, and was
••able to leave her bed oa aeemmt of this disease for three weeks
after the cttAiuelafi had disappeared. Tool lecuicif eventnaDv
» M. M. M. * .
took place.
The seomd cue was that «f JL EL, a fimili aged twenty yean,
: - -- • - :_; ;• - --•-'.: L -•_• -• : .- - : ; - i_- :
- - :' - ' - • : i :-• .: - : _ • - - - - - • • -. ;;.
bat was without any »iliionimirilj severe njmplnmiii It was
estimated dot at the time the et^aueLg developed die was in the
243
third week of die typhoid fever. At the onset of die erysipelas
there was a dull, followed by a rise of temperature of 2% and
followed, after the use of a cold huh. by a fall to the temperatnre-
eourse 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 dosed and the lips much swollen. An examination
of the serum withdrawn by a lancet showed the characteristic
streptococci of erysipelas. Under die use of large doses of tinc-
ture of die chloride of iron and an application of khthvol oint-
ment, recovery rapidly took place. The month was onnsnally foul
and dry, bat no delirium was present. We could not notice that
die complication in any way increased die gravit* of die case.
The third case is as follows : A woman, aged nineteen years, a
Swede, was admitted in die early stages of typhoid, which ran a
mild course.,, devoid of delirium or any symptoms of importance,
except diat on an afternoon, about die middle of die third week
of her illness, she developed a sudden rise of temperature to 10HP,
followed at once, on die use of cold bathing, by a fid! to 98®, wnh
IOBB of die puke at bodi wrists. As a precautionary Measure, she
was treated as if suffering from intestinal hemorrhage, and soon
rallied, developing during die next twelve hours a typical patch
of erysipelas on die right side of die nose and over die malar
bone. There was no further disturbance of die typhoid tempera-
ture, and die disease remained limited to dttt side of the face.
The patient was treated with iron and ichthyoL
By far die most exhaustive study which we have found con-
cerning: erysipelas as a complication of typhoid fever is that of
Gerente." According to due authority, die complication cones on
in one of every sixty-one cases, which would give a much higher
percentage dian that of IJebermefcler or Griesinger. Gerente
states that females are more commonly affected than males, which
fe a curious fact, because males are more exposed and more fre-
quently have typhoid fever. In regard to the period of the disease
<L L
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,
cases. cases.
Chomel 130 4
Louis ......... 134 3
Forget 92 1
Jenner ......... 65 2
De Larroque ........ 105 4
Zuelzer 84 3
Liebermeister ....... 1420 10
Zuccarini ... f .... 480 18
Griesinger 500 10
Murchison1 900 9
Total 3910 64
Outside of the question of contagion, it appears to be most fre-
quent in the grave, adynamic forms of typhoid, and in those of
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 sweeping. 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 own 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 :
Armieux1 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 otorrhcea
which, by the 22d, was growing steadily worse, so that the patient's
condition was critical. Now facial erysipelas made its appearance,
beginning in the auditory canal. Early in November osteitis of
the humerus set in, and the patient died on November 9th.
Thielman2 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 Kev. Me"d. de Toulouse, 1875, ix. 42.
2 Med. Jahresbuch v. Peter-Paul Hospital in St. Petersburg (1840, 1841),
142, 147.
246 COMPLICATIONS AND SEQUELAE OF TYPHOID FEVER.
on the following day 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. Berthoud1 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 warm, tender, not very painful, but oedematous, the
redness extending to the right and left inguinal regions as far as
the anterior superior spinous process, and also to the internal
aspect of the thigh. The skin in these parts was swollen 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.
Freudenberger2 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.
Potain1 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, ami
did not affect the tonsils. On the next day the inflammation
appeared at the corners of the mouth and on the face.
Finally, Martinez2 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 Silvestrini3 has
1 Erysipele de la Face Consecutif il la Fievre TyphoYde. Gaz. des H6p. 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 SEQUELS 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.
Taupin1 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.
Amitrano2 has recorded a case of typhoid fever which, during
convalescence, developed the scarlatiniform 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 Comby3 speaks of it as a state met with
in the convalescent period in children.
Coulon4 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 oedema, so the case
1 Journal des Connaissance Medico-Chirurgicale, 1839, No. 7.
2 La Riforma Medica, 1896, No. 146.
3 Gazette des Hopitaux, 1896, No. 39.
4 La Me'dicale 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 lineae 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. Bari6 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,4 namely, the condition of
painful oedema of the thorax. Pain was first felt in the neigh-
borhood of the thyroid gland, then in the shoulder-blade ; later a
circumscribed osdema of the left side of the thorax developed,
which was not reddened, but was painful to the touch. There
was no fever and no albummuria. 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 Societe Me'dicale des H6pitaux, 1889, No. 12.
2 Bristol Medico-Chirurgical Journal, July, 1889.
3 Guy's Hospital Reports, 1861.
* La Xormandie Medicale, October 1, 1891.
250 COMPLICATIONS AND SEQUELJE OF TYPHOID FEVER.
processes. Thus Pinchaud1 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
Suppur6e," 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
Tavel4 and Laveran.5
Finally, it is a noteworthy fact that Chantemesse6 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 Thyroidite"s dans la Convalescence de la Fievre Typho'ide, Paris, 1881.
2 Contribution a 1'Etude de la Thyroidite Typique. Arch, de Med. et de Phar.
Milit., 1886, 1. vii.
3 Ibid., February, 1899, p. 126.
4 Ueber die Etiologie der Strumitis, ein Beitriige zur Lehre von den Hemato-
genen Infectionen, Bale, 1892.
5 Revue de Chirurgie, Septembre, 1890, No. 29.
6 Art. Fievre Typho'ide in Traite" de M£d. de Bouchard et Charcot, 1891, 768.
7 Correspondenzblatt fur Schweizer Aerzte, February 1, 1892.
COMPLICATIONS DURING CONVALESCENCE. 251
Robin and Leredde1 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 G£n£rales de M^decine, September, 1894.
252 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
ruptured and the torn margins of the rent closely embracing the
neck of the bone. While it is true that unobtrusive monarticular
synovitis with effusion may take place in convalescent patients, the
literature of the subject does not reveal the fact that post-typhoidal
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 FEVER.
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, Avith 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 SEQUELAE 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 opposite 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
typhoid 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, ha3matemesis,
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 anaemia, but that active sporu-
lation of the malarial parasite very rarely occurs during the course
of established typhoid fever.
" 3. On the other hand, since malarial paroxysms often reappear
during convalescence, a scanty growth of the parasite must often
persist during the course of typhoid fever, and it is possible that
some of the irregularities of temperature observed in these cases
are referable to this partly suppressed growth.
" 4. That the anatomical evidence of a 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 Oilman 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 toxfemia. Whatever the cause of the sepsis may
1 American Journal of the Medical Science, August, 1894.
256 COMPLICATIONS AND SEQUELAE 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 in 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. Charit6 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, hi 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.
Girandau1 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. No 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 was 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
1021
101
100'
99"
98'
97'
Day of Dis.
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.
Leu1 has reported a case of puerperal septicaemia which was
Annalen, 1891, vol. xvi. p. 315.
260 COMPLICATIONS AND SEQUELS OF TYPHOID FEVER.
almost indistinguishable from typhoid fever, for the patient had a
rose rash, tympanites, enlarged spleen, intestinal infection, and the
pyrexial curve, which is characteristic. The fact that puerperal
septicsemia 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, diarrhea, 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,1 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.
CHAPTEE VI.
DUKATION 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 Maidstone1 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 (40f ), 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 day-.
The severe cases are those in which 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 1 1
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 Eeports, 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, Taupin1 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.
Moore2 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 Leidy3 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 SEQUELAE 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 Campbell1 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.
They 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 clasped. 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. 267
should, however, remember that if a given case is obscure in its
origin, if the mental depression has developed in a manner more
rapidly than that seen in melancholia, and if it is otherwise 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 phy*i<-<il
examination of the patient.
In the second form of mental disorder of the prodromal or
initial period, we have present, as already stated, the symptoms of
an acute delirium. This delirium is characterized by profound
mental obtusion, confusion, and hallucinations, which are often
terrifying in character. There are manifestations of great fear
and often impulses to violent acts. In this form violent assault
upon the person, murder, or suicide may occur. It may, indeed,
in rare cases attain the violence of typho-mania1 (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. Kirn2 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 Blanc3 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 Nasse. Allegemeine Zeitschr., f. Psych., 1870-71, p. 11.
2 Ibid., vol. xxxix. p. 741. 3 Schmidt's Jahrbiicher, vol. ccxiv.
268 COMPLICATIONS AND SEQUELAE 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. Confusional 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 Psychiatric, is one of the few systematic writers to fully
appreciate the etiological relation of typhoid fever to these disorders. Paglians,
Eevue 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 are 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 to
lead to stupor, and the patient may remain in this condition for a
prolonged period of time. The final prognosis, however, of even
this form of 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 SEQUELAE 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 watchful 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-pass i\ «•
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
uttered, 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 SEQUEL JE 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.
STUPOROUS 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 :i<
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 Ws
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 \«
appreciate them at all. The patient lies motionless in bed, iudif-
276 COMPLICATIONS AND SEQUELAE 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 redematous. 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 recover)-, 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 vrry
gradual. Sometimes it is incomplete, permanent mental impair-
ment resulting. Everv now and then there are added to this
278 COMPLICATIONS AND SEQUELAE 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 Miiller,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, with 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 Miiller, 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
are employed by many medical writers, many cases of so-called
mania and melancholia have been placed upon record as resulting
from typhoid fever. A close examination, however, reveals that
they are in most instances cases of an insanity of exhaustion, 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 hi 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 sequelse 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. Pilgrim1 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. Nasse,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, an 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 present
does not appear to be affected injuriously. At least this is
Nasse's1 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. Nasse1
further observed a greater percentage of recoveries from typhoid
fever in the insane than among the hospital attendants. Wise,2
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
ii 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, 182
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, 104
pleurisy in onset, 51
pulmonary tubercular consolida-
tion, 50
Afebrile abdominal catarrh, 70
Age, mortality in advanced, 36
Albnminuria, 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
Bloody stools, 78
Boils, 241
Bowel, ctcatricial contraction of, 204
gangrene of, 203
thermometer in, 221
Bronchitis, 95
CARBUNCLES, 241
' Carphologia, lt>4
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
alimentary 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.
FMBOLISM, 185
JL cerebral, 160
Emphysema of mediastinum, 93
Empyema, 98
Endarteritis, 187
Endocarditis, 185, 186
acute, 100
ulcerated, 80
Eosinophiles, 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
T7AINTNESS, 78
-T Fall of temperature, sudden, 78
Fever, bilious, 54
gastric, 54
infantile remittent, 54
pneumo-typhoid, 47
remittent malarial, 74
septic, 75
worm, 54
Fostus, 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
HJEMATUKIA, 52, 104
Headache, 152
Heart muscle in typhoid 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
1 Indigestion, 202
Infantile remittent fever, 54
Infarction, 185
of lung, 96
Infections, complicating, 78
Influenza, 79
Insanity, 152, 268
Insidious perforation, 128
lutercurrent relapse, 67, 177
Intestinal hemorrhage, 78
lesions, absence of, 115
Intestines in typhoid fever, 115
JAUNDICE, 219
u Joints, 250
KIDNEY, miliary abscess of, 107
Kidneys, in onset of fever, 52
Knee-jerks, absence of, 164
T APAEOTOMY in perforation, 135
-U 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 albicantes. 249
Liver, abscess of, 209
Lobular pneumonia, 95
Localized atrophy of skin, 249
INDEX.
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
Myostitis, 237
NECROSIS of larynx, 94
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
^DEMA of thorax, 249
(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, 238
Paranoia, 278
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
Pharyngo-typhoid, 53
Phlebitis, 67, 191
of calf of leg, 193
Pleurisy, 67, 97
acute, in onset, 51
Pneumonia, croupous, 96
lobular, 95
Pneumothorax, 97
Pneuruo-typhoid fever, 47
Pregnancy complicating typhoid 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
Pyelitis, 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
C CARLE! fever, 248
O 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
ITACHE 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, 1 7
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
ITLCER of stomach, 111
U Ulcerative endocarditis, 80
Ulceration and diarrhoea, relation of,
121
of larynx, 90
cesophageal, 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 SJooks
PUBLISHED BY
Lea Brothers & Company,
706, 708 & 710 Sansom St., Philadelphia.
Ill Fifth Avenue, New York.
The books in the annexed list will be sent by mail, post-paid, to any Post-Office in the
United States, on receipt of the printed prices. No risks of the mail, however, are assumed
either on money or books. Intending purchasers will therefore in most cases find it more
convenient to deal with the nearest bookseller.
STANDARD MEDICAL PERIODICALS.
Progressive Medicine.
A Quarterly Digest of New Methods, Discoveries and Improvements in the Medical and
Surgical Sciences by Eminent Authorities. Edited by DR. HOBABT AMOBY HARE. In
four abundantly illustrated, cloth bound, octavo volumes of 400-500 pages each, issued
quarterly, commencing March 1, 1899. Per annum (4 volumes), $10.00, delivered.
The Medical News.
WEEKLY, $4.00 PER ANNUM.
Each number contains 32 quarto pages, abundantly illustrated. A crisp, fresh weekly
professional newspaper.
The American Journal of the Medical Sciences.
MONTHLY, $4 OO PER ANNUM.
Each issue contains 128 octavo pages, fully illustrated. The most advanced and enter-
prising American exponent of scientific medicine.
The Medical News Visiting List for 1899.
Four styles, Weekly (dated for 30 patients); Monthly (undated, for 120 patients per
month ) ; Perpetual ( undated, for 30 patients weekly per year ; and Perpetual ( undated, for
60 patients weekly per year). Each style in one wallet-shaped book, leather bound, with
pocket, pencil and rubber. Price, each, $1.25. Thumb-letter index, 25 cents extra.
The Medical News Pocket Formulary for 1899,
Containing 1600 prescriptions representing the latest and mostly approved methods of
administering remedial agents. Strongly bound in leather, with pocket and pencil. Prio-.
$1.50, net.
COMBINATION RATES.
ALONE. IN COMBINATION.
American Journal of the Medical Sciences $4.00! $ \
Medical News 4.oo/'P7*a [$15.00
Progressive Medicine 10.00
Medical News Visiting List 1.25
Medical News Formulary 1.50. net.
In all $20.75 f°r $16.00
First four above publications In combination Si5-75
All above publications in combination 16.00
Other Combinations will be quoted on request. Full Circulars and Specimens free.
LEA BROTHERS & CO.'S PUBLICATIONS.
ABBOTT (A. C.). PRINCIPLES OF BACTERIOLOGY: a Practical Manual for
Students and Physicians. New (4th) edition enlarged and thoroughly revised. In one
handsome 12mo. volume of 543 pages, with 106 engravings, of which 19 are colored.
Cloth, $2.75.
ALLEN (HARRISON). A SYSTEM OF HUMAN ANATOMY; WITH AN
INTRODUCTORY SECTION ON HISTOLOGY, by E. O. SHAKESPEARE, M.D.
Comprising 813 double-columned quarto pages, with 380 engravings on stone on 109 full-
page plates, and 241 woodcuts. One volume, cloth, $23. Sold by subscription only.
A TREATISE ON SURGERY BY AMERICAN AUTHORS. FOR STUDENTS
AND PRACTITIONERS OF SURGERY AND MEDICINE. Edited by EOS-
WELL PABK, M.D. In two magnificent octavo volumes. Vol. 1., General Surgery, 799
pages, with 356 engravings and 21 full-page plates in colors and monochrome. Vol. II.,
Special Surgery, 796 pages, with 451 engravings and 17 full-page plates in colors and
monochrome. Complete work now ready. Price per volume, cloth. $4. 50 ; leather, $5. 50. Net.
AMERICAN SYSTEM OF PRACTICAL MEDICINE. A SYSTEM OF PRAC-
TICAL MEDICINE. In Contributions by Eminent American Authors. Edited by
ALFRED L. LOOMIS. M.D., LL.D., and W. GILMAN THOMPSON, M.D. In four very hand-
some octavo volumes of about 900 pages each, fully illustrated. Complete work just ready.
Per volume, cloth, $5 ; leather, $6 ; half Morocco, $7. For sale by subscription only.
Prospectus free on application.
AMERICAN SYSTEM OF DENTISTRY. IN TREATISES BY VARIOUS
A UTHORS. Edited by WILBUR F. LITCH, M.D., D.D.S. In four very handsome super-
royal octavo volumes, containing about 4000 pages, with about 2200 illustrations and many
full-page plates. Volume IV., preparing. Per volume, cloth, $6; leather, $7; half
Morocco, $8. For sale by subscription only. Prospectus free on application to the Publishers.
AMERICAN TEXT-BOOK OF ANATOMY. See Gerrish, page 7.
AMERICAN TEXT-BOOKS OF DENTISTRY. IN CONTRIBUTIONS BY
EMINENT AMERICAN A UTHORITIES. In two octavo volumes of 600-800 pages
each, richly illustrated :
- PROSTHETIC DENTISTRY. Edited by CHARLES J. ESSIG, M.D., D.D.S.,
Professor of Mechanical Dentistry and Metallurgy, Department of Dentistry, University
of Pennsylvania, Philadelphia. 760 pages, 983 engravings. Cloth, $6 ; leather, $7. Net.
- OPERATIVE DENTISTRY. Edited by EDWARD C. KIRK, D.D.S., Professor
of Clinical Dentistry, Department of Dentistry, University of 1'ennsylvania. 700 pages,
751 engravings. Cloth, $5.50; leather, $6.50. Net.
AMERICAN SYSTEMS OF GYNECOLOGY AND OBSTETRICS. In treatises
by the most eminent American specialists. Gynecology edited by MATTHEW D. MANN,
A.M., M.D., and Obstetrics edited by BARTON C. HIRST, M.D. In four large octavo
volumes comprising 3612 pages, with 1092 engravings, and 8 colored plates. Per volume,
cloth, $5 ; leather, $6 ; half Russia, $7. For sale by subscription only. Prospectus free.
ASHHURST (JOHN, JR.). THE PRINCIPLES AND PRACTICE OF SUR-
GER Y. For the use of Students and Practitioners. Sixth and revised edition. In one
large and handsome 8vo. volume of 1161 pages, with 656 engravings. Cloth, $6 ; leather, $7.
A SYSTEM OF PRACTICAL MEDICINE BY AMERICAN AUTHORS. Edited
by WILLIAM PEPPER, M.D., LL.D. In five large octavo volumes, containing 5573 pages
and 198 illustrations. Price per volume, cloth, $5 ; leather, $6 ; half Russia, $7. Sold
by subscription only. Prospectus free on application to the Publishers.
A PRACTICE OF OBSTETRICS BY AMERICAN AUTHORS. See Jewett,
page 9.
ATTFIELD (JOHN). CHEMISTRY; GENERAL, MEDICAL AND PHAR-
MACEUTICAL. Fourteenth edition, specially revised by the Author for America.
In one handsome 12mo. volume of 794 pages, with 88 illustrations. Cloth, $2.75;
leather, $3.25.
BALL (CHARLES B.). THE RECTUM AND ANUS, THEIR DISEASES
AND TREATMENT. New (2d) edition. In one 12mo. volume of 453 pages, with
60 engravings and 4 colored plates. Cloth, $2.25. See Series of Clinical Manuals, page 13.
Philadelphia, 706. 708 and 710 Sansom St.— flew York, 111 Fifth Avenue.
LEA BROTHERS & CO.'S PUBLICATIONS.
BARNES (ROBERT AND FANCOURT). A SYSTEM OF OBSTETRIC MED-
ICINE AND SURGERY, THEORETICAL AND CLINICAL. The Section on
Embryology by PROF. MILNES MARSHALL. In one large octavo volume of 872 pages
with 231 illustrations. Cloth, $5 ; leather, $6.
BACON (GORHAM) AND BLAKE (CLARENCE J.). ON THE EAR. One
12mo. volume, 398 pages, with 109 engravings and one colored plate. Just Readw
Cloth, $2, net.
BARTHOLO W ( ROBERTS ) . CHOLERA ; ITS CA USA TION, PRE VENTION
AND TREATMENT. In one 12mo. volume of 127 pages, with 9 illustrations.
Cloth, $1.25.
BARTHOLO W (ROBERTS). MEDICAL ELECTRICITY. A PRACTICAL
TREATISE ON THE APPLICATIONS OF ELECTRICITY TO MEDICINE
AND SURGERY. Third edition. In one octavo volume of 308 pages, with 110 illus-
trations.
BELL (F. JEFFREY). COMPARATIVE ANATOMY AND PHYSIOLOGY.
In one 12mo. volume of 561 pages, with 229 engravings. Cloth, $2. See Student tf Series
of Manuals, p. 14.
BERRY ( GEORGE A. V . DISEASES OF THE EYE; A PRA CTICA L TEE A T-
ISE FOR STUDENTS OF OPHTHALMOLOGY. Second edition. Very hand-
some octavo volume of 745 pages, with 197 original illustrations in the text, of which 87
are exquisitely colored. Cloth, $8.
BILLINGS (JOHN S.). THE NATIONAL MEDICAL DICTIONARY. Includ-
ing in one alphabet English, French, German, Italian and Latin Technical Terms used in
Medicine and the Collateral Sciences. In two very handsome imperial octavo volumes,
containing 1574 pages and two colored plates. Per volume, cloth, $6 ; leather, $7 ; half
Morocco, $8.50. For sale by subscription only. Specimen pages on application.
BLACK (D. CAMPBELL). THE URINE IN HEALTH AND DISEASE,
AND URINARY ANALYSIS, PHYSIOLOGICALLY AND PATHOLOGI-
CALLY CONSIDERED. In one 12mo. volume of 256 pages, with 73 engravings.
Cloth, $2.75.
BLOXAM (C. L.). CHEMISTRY, INORGANIC AND ORGANIC. With
Experiments. New American from the fifth London edition. In one handsome octavo
volume of 727 pages, with 292 illustrations. Cloth, $2 ; leather, $3.
BRICKNER (SAMUEL M.) ON THE SURGICAL PATIENT. Preparing.
BROADBENT (W. H.). THE PULSE. In one 12mo. volume of 317 pages, with
59 engravings. Cloth, $1.75. See Series of Clinical Manuals, page 13.
BROWNE ( LENNOX ) . THE THR OAT AND NOSE AND THEIR DISEASES.
New (4th) and enlarged edition. In one imperial octavo volume of 751 pages, with 235
engravings and 120 illustrations in color. Cloth, $6.50.
KOCH'S REMEDY IN RELATION ESPECIALLY TO THROAT
CONSUMPTION. In one octavo volume of 121 pages, with 45 illustrations, 4 of
which are colored, and 17 charts. Cloth, $1.50.
BRUCE (J. MITCHELL). MATERIA MEDIC A AND THERAPEUTICS.
New (6th) edtion. In one 12mo. volume of 600 pages. Shortly. See Students' Series of
Manuals, page 14.
PRINCIPLES OF TREATMENT. In one octavo volume. Preparing.
BRUNTON (T LAUDER). A MANUAL OF PHARMACOLOGY, THERA-
PEUTICS AND MATERIA MEDIC A ; including the Pharmacy, the Physiological
Action and the Therapeutical Uses of Drugs. In one octavo volume.
BRYANT (THOMAS). THE PRACTICE OF SURGERY. Fourth American
from the fourth English edition. In one imperial octavo volume of 1040 pages, with 727
illustrations. Cloth, $6.50 ; leather, $7.50.
BUMSTEAD (F. 3.) AND TAYLOR (R. W.). THE PATHOLOGY AND
TREATMENT OF VENEREAL DISEASES. See Taylor on Venereal Diseases,
page 15.
BURCHARD (HENRY H.). DENTAL PATHOLOGY AND THERAPEUTICS,
INCLUDING PHARMACOLOGY. Handsome octavo, 575 pages, with 400 illus-
trations. Just ready. Cloth, $5 ; leather, $6. (Net.)
Philadelphia, 706, 708 and 710 Sansom St.— New York, 111 Fifth Avenue.
LEA BROTHERS & CO.'S PUB L/C AT/0 MS.
BURNETT (CHARLES H.). THE EAR: ITS ANATOMY, PHYSIOLOGY
AND DISEASES. A Practical Treatise for the Use of Students and Practitioners.
Second edition. In one 8vo. volume of 580 pages, with 107 illustrations. Cloth, $4 ;
leather, $5.
BUTLIN (HENRY T.). DISEASES OF THE TONGUE. In one pocket-size
12mo. volume of 456 pages, with 8 colored plates and 3 engravings. Limp cloth, $3.50.
See Series of Clinical Manuals, page 13.
CARTER (R. BRUDENELL) AND FROST (W. ADAMS). OPHTHALMIC
SURGERY. In one pocket-size 12mo. volume of 559 pages, with 91 engravings and
one plate. Cloth, $2.25. See Series of Clinical Manuals, page 13.
CASPARI (CHARLES, JR.). A TREATISE ON PHARMACY. For Students
and Pharmacists. In one handsome octavo volume of 680 pages, with 288 illustrations.
Cloth, $4.50.
CHAPMAN (HENRY C.). A TREATISE ON HUMAN PHYSIOLOGY. In
one octavo volume of 925 pages, with 605 illustrations. Cloth, $5.50 ; leather, $6.50.
CHARLES (T. CRANSTOUN). THE ELEMENTS OF PHYSIOLOGICAL
AND PATHOLOGICAL CHEMISTRY. In one handsome octavo volume of 451
pages, with 38 engravings and 1 colored plate. Cloth, $3.50.
CHEYNE (W. WATSON). THE TREATMENT OF WOUNDS, ULCERS
AND ABSCESSES. In one 12mo. volume of 207 pages. Cloth, $1.25.
CHURCHILL (FLEET WOOD). ESSAYS ON THE PUERPERAL FEVER.
In one octavo volume of 464 pages. Cloth, $2.50.
CLARKE (W. B.) AND LOCKWpOD (C. B.). THE DISSECTOR'S MANUAL.
In one 12mo. volume of 396 pages, with 49 engravings. Cloth, $1.50. See Students' Series
of Manuals, page 14.
CLELAND (JOHN). A DIRECTORY FOR THE DISSECTION OF THE
HUMAN BODY. In one 12mo. volume of 178 pages. Cloth, $1.25.
CLINICAL MANUALS. See Series of Clinical Manuals, page 13.
CLOUSTON (THOMAS S.). CLINICAL LECTURES ON MENTAL DIS-
EASES. New (5th) edition. Crown 8vo., of 736 pages with 19 colored plates. Cloth,
$4. 25, net. Just Ready.
B£j&° FOLSOM'S Abstract of Laws of U.S. on Custody of Insane, octavo, $1.50, is sold in
conjunction with Clouston on Mental Diseases for $5.00, net, for the two works.
CLOWES (FRANK). AN ELEMENTARY TREATISE ON PRACTICAL
CHEMISTRY AND QUALITATIVE INORGANIC ANALYSIS. From the
fourth English edition. In one handsome 12mo. volume of 387 pages, with 55 engrav-
ings. Cloth, $2.50.
COAKLEY (CORNELIUS G.). THE DIAGNOSIS AND TREATMENT OF
DISEASES OF THE NOSE, THROAT, NASO-PHARYNX AND TRACHEA.
•In one 12mo. volume of about 400 pages, fully illustrated. Preparing.
•COATS (JOSEPH). A TREATISE ON PATHOLOGY. In one volume of 829
pages, with 339 engravings. Cloth, $5.50 ; leather, $6.50.
COLEMAN (ALFRED). A MANUAL OF DENTAL SURGERY AND PATH-
OLOGY. \\ith Notes and Additions to adapt it to American Practice. By THOS. C.
.STELLWAGEN, M.A., M.D., D.D.S. In one handsome octavo volume of 412 pages, with
331 engravings. Cloth, $3.25.
CONDIE (D. FRANCIS). A' PRACTICAL TREATISE ON THE DISEASES
OF CHILDREN. Sixth edition, revised and enlarged. In one large 8vo. volume of
719 pages. Cloth, $5.25 ; leather, $6.25.
CORNIL (V.). SYPHILIS: ITS MORBID ANATOMY, DIAGNOSIS AND
TREATMENT. Translated, with Notes and Additions, by J. HENRY C. SIMES, M.D.,
and J. WILLIAM WHITE, M.D. In one 8vo. volume of 461 pages, with 84 illustrations.
Cloth, $3.75.
CULBRETH i DAVID M. B. ) . MA TERIA MEDIC A AND PHARMA COLOGY.
In one handsome octavo volume of 812 pages, with 445 engravings. Cloth, $4.75.
Philadelphia, 706, 708 and 710 Sansom St.— New York, 111 Fifth Avenue.
LEA BROTHERS & CO.'S PUBLICATIONS.
CULVER (E. M.) AND HAYDEN (J. R.). MANUAL OF VENEREAL DIS-
EASES. In one 12mo. volume of 289 pages, with 33 engravings. Cloth, $1.75.
DALTON (JOHN C.). A TREATISE ON HUMAN PHYSIOLOGY. Seventh
edition, thoroughly revised. Octavo of 722 pages, with 252 engravings. Cloth, $5; leather,$6.
- DOCTRINES OF THE CIRCULATION OF THE BLOOD. In one hand-
some 12mo. volume of 293 pages. Cloth, $2.
DAVENPORT (F. H.). DISEASES OF WOMEN. A Manual of Gynecology.
For the use of Students and General Practitioners. New (3d) edition. In one hand-
some 12mo. volume, 387 pages and 150 engravings. Cloth, $1.75, net. Just Ready.
DAVIS (F. H.). LECTURES ON CLINICAL MEDICINE. Second edition. In
one 12mo. volume of 287 pages. Cloth, $1.75.
DAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. For Students and
Practitioners. In one very handsome octavo volume of 546 pnges, with 217 engravings,
and 30 full-page plates in colors and monochrome. Cloth, $5 ; leather, $6.
DE LA BECHE'S GEOLOGICAL OBSERVER. In one large octavo volume of 700
pages, with 300 engravings. Cloth, $4.
DENNIS (FREDERIC S.) AND BILLINGS (JOHN S.). A SYSTEM OF
SURGERY. In Contributions by American Authors. In four very handsome octavo
volumes, containing 3652 pages, with 1585 engravings, and 45 full-page plates in colors
and monochrome. Complete work just ready. Per volume, cloth, $6 ; leather, $7 ; half
Morocco, gilt back and top, $8.50. For sale by subscription only. Full prospectus free.
DERCUM (FRANCIS X.), Editor. A TEXT-BOOK ON NERVOUS DIS-
EASES. By American Authors. In one handsome octavo volume of 1054 pages, with
341 engravings and 7 colored plates. Cloth, $6 ; leather, $7. (Net.)
DE SCHWEINITZ (GEORGE E.). THE TOXIC AMBLYOPIAS; THEIR
CLASSIFICATION, HISTORY, SYMPTOMS, PATHOLOGY AND TREAT-
MENT. Very handsome octavo, 240 pages, 46 engravings, and 9 full-page plates in
colors. Limited edition, de luxe binding, $4. (Net.)
DRAPER (JOHN C.). MEDICAL PHYSICS. A Text-book for Students and Prac-
titioners of Medicine. Octavo of 734 pages, with 376 engravings. Cloth, $4.
DRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF MODERN
SURGERY. A new American, from the twelfth London edition, edited by STANLEY
BOYD, F.R.C.S. Large octavo, 965 pages, with 373 engravings. Cloth, $4 ; leather, $5.
DUANE (ALEXANDER) . THE STUDENT'S DICTION AR Y OF MEDICINE
AND THE ALLIED SCIENCES. Comprising the Pronunciation, Derivation and
Full Explanation of Medical Terms. Together with much Collateral Descriptive Matter,
Numerous Tables, etc. New edition. With Appendix. Square octavo volume of 690 pages.
Cloth, $3 ; half leather, $3.25 ; full sheep, $3.75. Thumb-letter Index, 50 cents extra.
DUDLEY (E. C.). A TREATISE ON THE PRINCIPLES AND PRAC1ICE
OF GYNECOLOGY. For Students and Practitioners. In one very handsome octavo
volume of 6^2 pages, with 422 engravings, of which 47 are colored, and 2 full page
plates in colors and monochrome. Cloth, $5.00, net; leather, $6.00, net.
DUNCAN (J. MATTHEWS). CLINICAL LECTURES ON THE DISEASES
OF WOMEN. Delivered in St. Bartholomew's Hospital. In one octavo volume of
175 pages. Cloth, $1.50.
DUNGLISON (ROBLEY). A DICTIONARY OF MEDICAL SCIENCE. Con-
taining a full Explanation of the Various Subjects and Terms of Anatomy, Physiology,
Medical Chemistry, Pharmacy, Pharmacology, Therapeutics, Medicine, Hygiene, Dietetics.
Pathology, Surgery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecology,
Obstetrics, Pediatrics, Medical Jurisprudence, Dentistry, etc., etc. By ROBLEY DUNGLI-
SON, M.D., LL.D., late Professor of Institutes of Medicine in the Jefferson Medical Col-
lege of Philadelphia. Edited by RICHARD J. DUNGLISON, A.M., M.D. Twenty-first
edition, thoroughly revised and greatly enlarged and improved, with the Pronunciation.
Accentuation and Derivation of the Terms. With Appendix. Imperial octavo of 1
pages. Cloth, $7 ; leather, $8. Thumb-letter Index, 75 cents extra.
DUNHAM (EDWARD K.). MORBID AND NORMAL HISTOLOGY. Octavo,
450 pages, with 360 illustrations. Cloth, $3.25, net. Junt Ready.
Philadelphia, 706, 708 and 710 Sansom St.— Mew York, 111 Fifth Avenue.
LEA BROTHERS & CO.'S PUBLICATIONS.
EDES (EGBERT T.). TEXT-BOOK OF THERAPEUTICS AND MATERIA
MEDIC A. In one 8vo. volume of 544 pages. Cloth, $3.50 ; leather, $4.50.
EDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for Students and
Practitioners. In one handsome 8vo. volume of 576 pages, with 148 engravings.
Cloth, $3; leather, $4.
EGBERT (SENECA). HYGIENE AND SANITATION. In one 12mo. volume of
359 pages, with 63 illustrations. Just ready. Cloth, $2.25, net.
ELLIS (GEORGE VINER). DEMONSTRATIONS IN ANATOMY. Being a
Guide to the Knowledge of the Human Body by Dissection. From the eighth and revised
English edition. Octavo, 716 pages, with 249 engravings. Cloth, $4.25 ; leather, $5.25.
EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRACTICE OF
G YN^ECOLOG Y. For the use of Students and Practitioners. Third edition, enlarged
and revised. 8vo. of 880 pages, with 150 original engravings. Cloth, $5 ; leather, $6.
ERICHSEN (JOHN E.). THE SCIENCE AND ART OF SURGERY. A new
American from the eighth enlarged and revised London edition. In two large octavo
volumes containing 2316 pages, with 984 engravings. Cloth, $9; leather, $11.
ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. See American Text-books
of Dentistry, page 2.
FARQUH ARSON (ROBERT). A GUIDE TO THERAPEUTICS. Fourth
American from fourth English edition, revised by FRANK WOODBURY, M.D. In one
12mo. volume of 581 pages. Cloth, $2.50.
FIELD (GEORGE P.). A MANUAL OF DISEASES OF THE EAR. Fourth
edition. Octavo, 391 pages, with 73 engravings and 21 colored plates. Cloth, $3.75.
FLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND PRACTICE
OF MEDICINE. New (7th) edition, thoroughly revised by FREDERICK P. HENRY,
M.D. In one large 8vo. volume of 1143 pages, with engravings. Cloth, $5; leather, $6.
- A MANUAL OF AUSCULTATION AND PERCUSSION; of the Physi-
cal Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fifth
edition, revised by JAMES C. WILSON, M.D. In one handsome 12mo. volume of 274
pages, with 12 engravings.
A PRACTICAL TREATISE ON THE DIAGNOSIS AND TREAT-
MENT OF DISEASES OF THE HEART. Second edition, enlarged. In one
octavo volume of 550 pages. Cloth, $4.
A PRACTICAL TREATISE ON THE PHYSICAL EXPLORATION
OF THE CHEST, AND THE DIAGNOSIS OF DISEASES AFFECTING
THE RESPIRATORY ORGANS. Second and revised edition. In one octavo vol-
ume of 591 pages. Cloth, $4.50.
- MEDICAL ESSA YS. In one 12mo. volume of 210 pages. Cloth, $1.38.
ON PHTHISIS : ITS MORBID ANA TOMY, ETIOL OGY, ETC. A Series
of Clinical Lectures. In one 8vo. volume of 442 pages. Cloth, $3.50.
FOLSOM (C. P.). AN ABSTRACT OF STATUTES OF U. S. ON CUSTODY
OF THE INSANE. In one 8vo. volume of 108 pages. Cloth, $1.50. With Clouston
on Mental Diseases (see page 4), at $5.00, net, for the two works.
FORMULARY, THE NATIONAL. See Stille, Maisch & Caspari's National Dispensa-
tory, page 14.
FORMULARY, POCKET. See page 1.
FOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New (6th) and
revised American from the sixth English edition. In one large octavo volume of 923
pages, with 257 illustrations. Cloth, $4.50 ; leather, $5.50.
FOTHERGILL (J. MILNER). THE PRACTITIONER'S HAND-BOOK OF
TREATMENT. Third edition. In one handsome octavo volume of 664 pages.
Cloth, $3.75 ; leather, $4.75.
FOWNES (GEORGE). A MANUAL OF ELEMENTARY CHEMISTRY (IN-
ORGANIC AND ORGANIC). Twelfth edition. Embodying WATTS' Physical and
Inorganic Chemistry. In one royal 12mo. volume of 1061 pages, with 168 engravings, and
1 colored plate. Cloth, $2.75 ; leather, $3.25.
Philadelphia, 706, 708 and 710 Sansom St.— Hew York, 111 Fifth Avenue.
LEA BROTHERS & CO.'S PUBLICATIONS.
FRANKLAND (E.) AND JAPP (F. R.). INORGANIC CHEMISTRY. In one
handsome octavo volume of 677 pages, with 51 engravings and 2 plates. Cloth, $3.75 ;
leather, $4.75.
FULLER (EUGENE). DISORDERS OF THE SEXUAL ORGANS IN THE
MALE. In one very handsome octavo volume of 238 pages, with 25 engravings and
8 full-page plates. Cloth, $2.
FULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR-PASSAGES.
Their Pathology, Physical Diagnosis, Symptoms and Treatment. From second English
edition. In one 8vo. volume of 475 pages. Cloth, $3.50.
GANT (FREDERICK JAMES ). THE STUDENT'S SURGERY. A Multum in
Parvo. In one square octavo volume of 845 pages, with 159 engravings. Cloth, $3.75.
GERRISH (FREDERIC H.). A TEXT-BOOK: OF ANATOMY. By American
Authors. Edited by FREDERIC H. GERRISH, M. D. In one imp. octavo volume, richly
illustrated. Preparing.
GIBBES (HENEAGE). PRACTICAL PATHOLOGY AND MORBID HIS-
TOLOG Y. Octavo of 314 pages, with 60 illustrations, mostly photographic. Cloth, $2.75.
GIBNEY (V. P.). ORTHOPEDIC SURGERY. For the use of Practitioners and
Students. In one 8vo. volume profusely illustrated. Preparing.
GOULD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. volume of 589
pages. Cloth, $2. See Students' Series of Manuals, page 14.
GRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. New
American edition of 1897, thoroughly revised. In one imperial octavo volume of 1239
pages, with 772 large and elaborate engravings. Price with illustrations in colors, cloth,
$7 ; leather, $8. Price, with illustrations in black, cloth, $6 ; leather, $7.
GRAY (LANDON CARTER). A TREATISE ON NERVOUS AND MENTAL
DISEASES. For Students and Practitioners of Medicine. Second edition. In one
handsome octavo volume of 728 pages, with 172 engravings and 3 colored plates. Cloth,
$4.75; leather, $575.
GREEN (T. HENRY). AN INTRODUCTION TO PATHOLOGY AND MOR-
BID ANATOMY. New (8th) American from eighth and revised English edition.
Oct. 595 pages, with 215 engravings and a colored plate. Cloth, $2.50, net. Just Ready.
GREENE (WILLIAM H.). A MANUAL OF MEDICAL CHEMISTRY. For
the Use of Students. Based upon BOAVMAN'S Medical Chemistry. In one 12mo. volume
of 310 pages, with 74 illustrations. Cloth, $1.75.
GROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DISEASES,
INJURIES AND MALFORMATIONS OF THE URINARY BLADDER,
THE PROSTATE GLAND AND THE URETHRA. Third edition, revised by
SAMUEL W. GROSS, M.D. Octavo of 574 pages, with 170 illustrations. Cloth, $4. SO.
HABERSHON <S. 0.). ON THE DISEASES OF THE ABDOMEN, comprising
those of the Stomach, (Esophagus, Caecum, Intestines and Peritoneum. Second Amer-
ican from the third English edition. In one octavo volume of 554 pages, with 11 engrav-
ings. Cloth, $3.50.
HAMILTON ( ALLAN McLANE ) . NER VO US DISEASES, THEIR DESCRIP-
TION AND TREATMENT. Second and revised edition. In one octavo volume of
598 pages, with 72 engravings. Cloth, $4.
HAMILTON (FRANK H.). A PRACTICAL TREATISE ON FRACTURES
AND DISLOCATIONS. Eighth edition, revised and edited by STEPHEN SMITH,
A.M., M.D. In one handsome octavo volume of 832 pages, with 507 engravings.
Cloth, $o.50; leather, $6.50.
HARDAWAY (W. A.). MANUAL OF SKIN DISEASES. New (2d) edition.
In one 12mo. volume, 560 pages with 40 illustrations and 2 colored plaUs. otn,
$2. 25. net. Just Ready.
HARE (HOBART AMORY). A TEXT-BOOK OF PRACTICAL THERA-
PEUTICS, with Special Reference to the Application of Remedial Measures to U
and their Employment upon a Rational Basis. With articles on various subj<*ts_by well
known specialists. New (7th) and revised edition. In one octavo volume of / /o pages.
Cloth, $3.76, net; leather, $4.50, net.
PRACTICAL DIAGNOSIS. The Use of Symptoms in the Diagnosis of Disease.
New (3d ) edition, revised and enlarged. In one octavo volume of t 5 pages, w
engravings, and 13 full-page plates. Cloth, $4.75, net. Just Ready.
Philadelphia, 706, 708 and 710 Sansom St.— Mew York, 111 Fifth Avenue.
LEA BROTHERS & CO.'S PUBLICATIONS.
HARE (HOB ART AMORY), Editor. A SYSTEM OF PRACTICAL THERA-
PEUTICS. By American and Foreign Authors. In a series of contributions by emi-
nent practitioners. In four large octavo volumes comprising 4600 pages, with 476
engravings. Vol. IV., now ready. Regular price, Vol. IV., cloth, $6 ; leather, $7 ; half
Russia, $8. Price Vol. IV. to former or new subscribers to complete work, cloth, $5 ;
leather, $6 ; half Russia, $7. Complete work, cloth, $20 ; leather, $24 ; half Russia, $28.
For sale by subscription only. Full prospectus free on application to the Publishers.
HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES AND
PRACTICE OF MEDICINE. Fifth edition. In one 12mo. volume, 669 pages,
with 144 engravings. Cloth, $2.75; half bound, $3.
A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 12mo.
volume of 310 pages, with 220 engravings. Cloth, $1.75.
A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising Manuals
of Anatomy, Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and
Obstetrics. Second edition. In one royal 12mo. volume of 1028 pages, with 477 illus-
trations. Cloth, $4.25; leather, $5.
HAYDEN (JAMES R.). A MANUAL OF VENEREAL DISEASES. New (2d)
edition. In one 12mo. volume of 304 pages, with 54 engravings. Just ready. Cloth,
$1.50, net.
HAYEM (GEORGES) AND HARE (H. A.). PHYSICAL AND NATURAL
THERAPEUTICS. The Remedial Use of Heat, Electricity, Modifications of Atmos-
pheric Pressure, Climates and Mineral Waters. Edited by Prof. H. A. HARE, M.D.
In one octavo volume of 414 pages, with 113 engravings. Cloth, $3.
HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. 12mo., 198 pages,
with 80 engravings. Cloth, $1. 25. See Students1 Series of Manuals, page 14.
HERMANN ( L. ) . EXPERIMENTAL PHARMA COL OGY. A Handbook of the
Methods for Determining the Physiological Actions of Drugs. Translated by ROBERT
MEADE SMITH, M.D. In one 12mo. vol. of 199 pages, with 32 engravings. Cloth, $1.50.
HERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In one handsome
12mo. volume of 429 pages, with 80 engravings and 2 colored plates. Cloth, $2.50.
HILL (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS DISORDERS.
In one 8vo. volume of 479 pages. Cloth, $3.25.
HILLIER (THOMAS). A HANDBOOK OF SKIN DISEASES. Second edition.
In one royal 12mo. volume of 353 pages, with two plates. Cloth, $2.25.
HIRST (BARTON C.) AND PIERSOL (GEORGE A.). HUMAN MONSTROS-
ITIES. Magnificent folio, containing 220 pages of tezt and illustrated with 123 engrav-
ings and 39 large photographic plates from nature. In four parts, price each, $5. Limited
edition. For sale by subscription only.
HOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS USED IN
MEDICINE AND THE COLLATERAL SCIENCES. In one 12mo. volume of
520 double-columned pages. Cloth, $1.50; leather, $2.
HODGE (HUGH L.). ON DISEASES PECULIAR TO WOMEN, INCLUDING
DISPLACEMENTS OF THE UTERUS. Second and revised edition. In one
8vo. volume of 519 pages, with illustrations. Cloth, $4.50.
HOFFMANN (FREDERICK) AND POWER (FREDERICK B.). A MANUAL
OF CHEMICAL ANAL YSIS, as Applied to the Examination of Medicinal Chemicals
and their Preparations. Third edition, entirely rewritten and much enlarged. In one
handsome octavo volume of 621 pages, with 179 engravings. Cloth, $4.25.
HOLDEN (LUTHER). LANDMARKS, MEDICAL AND SURGICAL. From
the third English edition. With additions by W. W. KEEN, M.D. In one royal 12mo.
volume of 148 pages. Cloth, $1.
HOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Principles and
Practice. A new American from the fifth English edition. Edited by T. PICKERING
PICK, F.R.C.S. In one handsome octavo volume of 1008 pages, with 428 engravings.
Cloth, $6 ; leather, $7.
- A SYSTEM OF SURGERY. With notes and additions by various American
authors. Edited by JOHN H. PACKARD, M.D. In three very handsome 8vo. volumes
containing 3137 double-columned pages, with 979 engravings and 13 lithographic plates.
Per volume, cloth, $6 ; leather, $7 ; half Russia, $7.50. For sale by subscription only.
Philadelphia, 706, 708 and 710 Sansom St.— New York, 111 Fifth Avenue.
LEA BROTHERS & CO/5 PUBLICATIONS.
HORNER (WILLIAM E.). SPECIAL ANATOMY AND HISTOLOGY. Eighth
edition, revised and modified. In two large 8vo. volumes of 1007 pages, containing 320
engravings. Cloth, $6.
HUDSON (A.). LECTURES ON THE STUDY OF FEVER. In one octavo
volume of 308 pages. Cloth, $2.50.
HUTCHISON (ROBERT) AND RAINY (HARRY). CLINICAL METHODS.
An Introduction to the Practical Study of Medicine. In one 12mo. volume of 562 pages,
with 137 engravings and 8 colored plates, Cloth, $3.00. Jugt ready.
HUTCHINSON (JONATHAN). SYPHILIS. 12mo., 542 pages, with 8 chromo-
lithographic plates. Cloth. $2.25. See Series of Clinical Manual*, page 13.
HYDE (JAMES NEVINS). A PRACTICAL TREATISE ON DISEASES OF
THE SKIN. New (4th) edition, thoroughly revised. Octavo, 815 pages, with 110-
engravings and 12 full-page plates, 4 of which are colored. Cloth, $5.25; leather, $6.25.
JACKSON (GEORGE THOMAS). THE READY-REFERENCE HANDBOOK
OF DISEASES OF THE SKIN. New (3d) edition. In press. 12mo. volume of
600 pages, with 73 engravings, and one colored plate.
JAMIESON (W. ALLAN). DISEASES OF THE SKIN. Third edition. Octavo,
656 pages, with 1 engraving and 9 double-page chromo-lithographic plates. Cloth, $6.
JEWETT (CHARLES). ESSENTIALS OF OBSTETRICS. In one 12mo. volume
of 356 pages, with 80 engravings and 3 colored plates. Cloth, $2.25. Just ready.
THE PRACTICE OF OBSTETRICS. By American Authors. One large octavo-
volume of 763 pages, with 441 engravings in black and colors, and 22 full-page colored
plates. Just ready. Cloth, $5.00, net ; Leather, $6.00, net.
JONES (C. HANDFIELD). CLINICAL OBSERVATIONS ON FUNCTIONAL
NER VO US DISORDERS. Second American edition. In one octavo volume of 340
pages. Cloth, $3.25.
JULER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE AND
PR A CTICE. Second edition. In one octavo volume of 549 pages, with 201 engrav-
ings, 17 chromo-lithographic plates, test-types of Jaeger and Snellen, and Holmgren'*
Color-Blindness Test. Cloth, $5.50; leather, $6.50.
KIRK (EDWARD C.). OPERATIVE DENTISTRY. See American Text-books of
Dentistry, page 2.
KING (A. F. A.). A MANUAL OF OBSTETRICS. Seventh edition. In one 12mo.
volume of 573 pages, with 223 illustrations. Cloth, $2.50.
KLEIN (E.). ELEMENTS OF HISTOLOGY. New (5th) edition. In one pocket-
size 12mo. volume of 506 pages, with 296 engravings. Cloth, $2.00, net. Just Ready.
See Students' Series of Manuals, page 14.
LANDIS ( HENRY G.). THE MANAGEMENT OF LABOR. In one handsome
12mo. volume of 329 pages, with 28 illustrations. Cloth, $1.75.
LA ROCHE (E.). YELLOW FEVER. In two 8vo. volumes of 1468 pages.
Cloth, $7.
PNEUMONIA. In one 8vo. volume of 490 pages. Cloth, $3.
LAURENCE (J. Z.) AND MOON (ROBERT C.). A HANDY-BOOK OF
OPHTHALMIC SURGERY. Second edition. In one octavo volume of 227 pages,
with 66 engravings. Cloth. $2.75.
L^AI^^lNSORSmP^FETHEFpRESS,- MYSTICS AND ILLUMINATI;
THE ENDEMONIADAS; EL SANTO NINO DE LA GUARDIA; BRI-
ANDA DE BARDAXI. In one 12mo. volume of 522 pages. Cloth, $2.50.
A HISTORY OF AURICULAR CONFESSION AND INDULGENCES
IN THE LATIN CHURCH. In three octavo volumes of about 500 pages each.
Per volume, cloth, $3. Complete work just ready.
FORMULARY OF THE PAPAL PENITENTIARY. In one octavo vol-
ume of 221 pages, with frontispiece. Cloth, $2.50.
Philadelphia, 706, 708 and 710 Sansom St.— New York, 111 Fifth Mrenue.
10 LEA BROTHERS & CO.' S PUBLICATIONS.
LEA (HENRY 0.). STUDIES IN CHURCH HISTORY. The Else of the Tem-
poral Power — Benefit of Clergy — Excommunication. New edition. In one handsome
12mo. volume of 605 pages. Cloth, $2.50.
SUPERSTITION AND FORCE; ESSAYS ON THE WAGER OF LAW,
THE WAGER OF BATTLE, THE ORDEAL AND TORTURE. Fourth
edition, thoroughly revised. In one handsome royal 12mo. volume of 629 pages.
Cloth, $2.75.
AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY IN THE
CHRISTIAN CHURCH. Second edition. In one handsome octavo volume of 685
pages. Cloth, $4.50.
LEE (HENRY) ON SYPHILIS. In one 8vo. volume of 246 pages. Cloth, $2.25.
LEHMANN (0. G.). A MANUAL OF CHEMICAL PHYSIOLOGY. In one
8vo. volume of 327 pages, with 41 engravings. Cloth, $2.25.
LOOMIS (ALFRED L.) AND THOMPSON (W. OILMAN), Editors. A SYS-
TEM OF PR A CTICAL MEDICINE. In Contributions by Various American Authors.
In four very handsome octavo volumes of about 900 pages each, fully illustrated in black
and colors. Complete work just ready. Per volume, cloth, $5 ; leather, $6 ; half
Morocco, $7. For sale by subscription only. Full prospectus free on application to the
Publishers.
LUFF (ARTHUR PA MANUAL OF CHEMISTRY, for the use of Students of
Medicine. In one 12mo. volume of 522 pages, with 36 engravings. Cloth, $2. See
Students' Series of Manuals, page 14
LYMAN (HENRY M.). THE PRACTICE OF MEDICINE In one very hand-
some octavo volume of 925 pages with 170 engravings. Cloth, $4.75; leather, $5.75.
LYONS (ROBERT D.). A TREATISE ON FEVER. In one octavo volume of 362
pages. Cloth, $2.25.
MACKENZIE (JOHN NOLAND). THE DISEASES OF THE NOSE AND
THROAT. In one handsome octavo volume of about 600 pages, richly illustrated.
Preparing.
MAISCH [JOHN M.). A MANUAL OF ORGANIC MATERIA MEDIC A.
Sixth edition, thoroughly revised by H. C. C. MAISCH, Ph.G., Ph.D. In one very
handsome 12mo. volume of 509 pages, with 285 engravings. Cloth, $3.
MANUALS. See Students' Quiz Series, page 14, Students' Series of Manuals, page 14, and
Series of Clinical Manuals, page 13.
MARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo. volume of
468 pages, with 64 engravings and a colored plate. Cloth, $2. See Series of Clinical
Manuals, page 13.
MAY (C. H.). MANUAL OF THE DISEASES OF WOMEN. For the use of
Students and Practitioners. Second edition, revised by L. S. RAU, M.D. In one 12mo.
volume of 360 pages, with 31 engravings. Cloth, $1. 75.
MEDICAL NEWS POCKET FORMULARY. See page 1.
MITCHELL (JOHN K.). REMOTE CONSEQUENCES OF INJURIES OF
NERVES AND THEIR TREATMENT. In one handsome 12mo. volume of 239
pages, with 12 illustrations. Cloth $1.75.
MITCHELL (S. WEIR). CLINICAL LESSONS ON NERVOUS DISEASES.
In one very handsome 12mo. volume of 299 pages, with 17 engravings and 2 colored plates.
Cloth, $2.50. Of the one hundred numbered copies with the Author's signed title
page a few remain ; these are offered in green cloth, gilt top, at $3.50, net.
MORRIS (HENRY). SURGICAL DISEASES OF THE KIDNEY. In one
12mo. volume of 554 pages, with 40 engravings and 6 colored plates. Cloth, $2.25. See
Series of Clinical Manuals, page 13.
Philadelphia, 706, 708 and 710 Sansom St, — New York, 111 Fifth Avenue.
LEA BROTHERS & CO.'S PUBLICATIONS. 11
MORRIS (MALCOLM). DISEASES OF THE SKIN. New (2d) edition. In one
12mo. volume of 601 pages, with 10 chromo-lithographic plates and 26 engravings.
Juxt ready. Cloth, $3.25, net.
MULLER (J.). PRINCIPLES OF PHYSICS AND METEOROLOGY. In one
large 8vo. volume of 623 pages, with 538 engravings. Cloth, $4.50.
MUSSER (JOHN H.). A PRACTICAL TREATISE ON MEDICAL DIAG-
NOSIS, for Students and Physicians. New (2d) edition. In one octavo volume of
931 pages, illustrated with 177 engravings and 1 1 full-page colored plates. Cloth. $6:
leather, $6.
NATIONAL DISPENSATORY. See SUM, Maisch & Caspari, page 14.
NATIONAL FORMULARY. See StiUe, Maisch & Caspar!* National Dispensatory,
page 14.
NATIONAL MEDICAL DICTIONARY. See Bitting*, page 3.
NETTLESHIP (E.). DISEASES OF THE EYE. New (5th) American from sixth
English edition. Thoroughly revised. In one 12mo. volume of 521 pages, with 161
engravings, 2 colored plates, test-types, formulae and color-blindness test Cloth, $2.25.
Just ready.
NORRIS (WM. F.) AND OLIVER (CHAS. A.). TEXT-BOOK OF OPHTHAL-
MOLOGY. In one octavo volume of 641 pages, with 357 engravings and 5 colored
plates. Cloth, $5 ; leather, $6.
OWEN (EDMUND). SURGICAL DISEASES OF CHILDREN. In one 12mo.
volume of 525 pages, with 85 engravings and 4 colored plates. Cloth, $2. See Series of
Clinical Manuals, page 13.
PARK (ROSWELL), Editor. A TREATISE ON SURGERY, by American Authors.
For Students and Practitioners of Surgery and Medicine. In two magnificent octavo
volumes. Vol. I., General Surgery, 799 pages, with 356 engravings and 21 full-page plates
in colors and monochrome. Vol. II., Special Surgery, 796 pages, with 451 engravings
and 17 full-page plates in colors and monochrome. Complete work now ready. Price per
volume, cloth, $4.50; leather, $5.50. Net.
PARRY (JOHN S.). EXTRA-UTERINE PREGNANCY. ITS CLINICAL
HISTORY, DIAGNOSIS, PROGNOSIS AND TREATMENT. In one octavo
volume of 272 pages. Cloth, $2.50.
PARVIN (THEOPHILUS). THE SCIENCE AND ART OF OBSTETRICS.
Third edition In one handsome octavo volume of 677 pages, with 267 engravings and
2 colored plates. Cloth, $4.25 ; leather, $5 25.
PAYNE (JOSEPH FRANK). A MANUAL OF GENERAL PATHOLOGY.
Designed as an Introduction to the Practice of Medicine. In one octavo volume of 524
pages, with 153 engravings and 1 colored plate.
PEPPER'S SYSTEM OF MEDICINE. See page 2.
PEPPER (A. J.). SURGICAL PATHOLOGY. In one 12mo volume of 511 pages,
with 81 engravings. Cloth, $2. See Students' Series of Manuals, page 14.
PICK (T. PICKERING). FRACTURES AND DISLOCATIONS. In one 12mo.
volume of 530 pages, with 93 engravings. Cloth, $2. See Series of Clinical Manuals, p. 13
PLAYFAIR (W. S.). A TREATISE ON THE SCIENCE AND PRACTICE
OF MIDWIFERY. New (7th) American from the Ninth English edition. _In 01
octavo volume of 700 pages, with 207 engravings and 7 full page plates. Cloth, $;
leather, $4.75, net. Just Ready.
THE SYSTEMATIC TREATMENT OF NERVE PROSTRATION AND
HYSTERIA. In one 12mo. volume of 97 pages. Cloth, $1.
POCKET FORMULARY. See page 1.
Philadelphia, 706, 708 and 710 Sansom St.— Mew York, 111 Fifth Avenue.
12 LEA BROTHERS & CO: S PUBLICATIONS.
POLITZER (ADAM). A TEXT-BOOK OF THE DISEASES OF THE EAR
AND ADJACENT ORGANS. Second American from the third German edition.
Translated by OSCAB DODD, M.D , and edited by SIR WILLIAM DALBY, F.E.C.S. In
one octavo volume of 748 pages, with 330 original engravings.
POWER (HENRY). HUMAN PHYSIOLOGY. Second edition. In one 12mo.
volume of 396 pages, with 47 engravings. Cloth, $1.50. See Student's Series of Manuah.
page 14.
PROGRESSIVE MEDICINE. See page 1.
PURDY (CHARLES W.). B RIGHT'S DISEASE AND ALLIED AFFEC-
TIONS OF THE KIDNEY, In one octavo volume of 288 pages, with 18 engrav-
ings. Cloth, $2.
PYE-SMITH (PHILIP H.). DISEASES OF THE SKIN. In one 12mo. volume
of 407 pages, with 28 illustrations, 18 of which are colored. Cloth, $2.
QUIZ SERIES. See Student Quiz Series, page 14.
RALFE (CHARLES H.). CLINICAL CHEMISTRY. In one 12mo. volume of
314 pages, with 16 engravings. Cloth, $1.50. See Students' Series of Manuals, page ]4.
RAMSBOTHAM (FRANCIS H.X THE PRINCIPLES AND PRACTICE OF
OBSTETRIC MEDICINE AND SURGERY. In one imperial octavo volume of
640 pages, with 64 plates and numerous engravings in the text. Strongly bound in
leather, $7.
REICHERT (EDWARD T.). A TEXT-BOOK O'N PHYSIOLOGY. In one
handsome octavo volume of about 800 pages, richly illustrated. Preparing.
REMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEMISTRY.
New (5th) edition, thoroughly revised. In one 12mo. volume of 326 pages. Cloth, $2.
RICHARDSON (BENJAMIN WARD). PREVENTIVE MEDICINE. In one
octavo volume of 729 pages. Cloth, $4 ; leather, $5.
ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF MODERN
SURGERY. In one octavo volume of 780 pages, with 501 engravings. Cloth, $4.50;
leather, $5.50.
- THE COMPEND OF ANATOMY. For use in the Dissecting Room and in
preparing for Examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents.
ROBERTS (SIR WILLIAM). A PRACTICAL TREATISE ON URINARY
AND RENAL DISEASES, INCLUDING URINARY DEPOSITS. Fourth
American from the fourth London edition. In one very handsome 8vo. volume of 609
pages, with 81 illustrations. Cloth, $3.50.
ROBERTSON (J. McGREGOR). PHYSIOLOGICAL PHYSICS. In one 12mo
volume of 537 pages, with 219 engravings. Cloth, $2. See Students' Series of Manuals,
page 14.
ROSS (JAMES). A HANDBOOK OF THE DISEASES OF THE NERVOUS
SYSTEM. In one handsome octavo volume of 726 pages, with 184 engravings. Cloth,
$4.50; leather, $5.50
SAVAGE (GEORGE H.). INSANITY AND ALLIED NEUROSES, PRACTI-
CAL AND CLINICAL. New (2d) and enlarged edition. In one 12mo. volume ot
551 pages, with 18 typical engravings. Cloth, $2. See Series of Clinical Manuals, page 13.
SCHAFER ( EDWARD A. ) . THE ESSENTIALS OF HISTOL OGY, DESCRIP-
TIVE AND PRACTICAL. For the use of Students. New (5th) edition. In one
handsome octavo volume of 350 pages, with 325 illustrations. Cloth, $3, net. Just ready.
A COURSE OF PRACTICAL HISTOLOGY. New (2d) edition. In one
12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25.
Philadelphia. 706, 708 and 710 Sansom St.— New York, 111 Fifth Avenue.
LEA BROTHERS & CO.' S PUB L ICA TIOMS. 18
SCHMITZ AND ZUMPT'S CLASSICAL SERIES.
ADVANCED LATIN EXERCISES. Cloth, 60 cents; half bound, 70 cents.
SCHMITZ' S ELEMENTARY LATIN EXERCISES. Cloth, 50 cente
SALL UST. Cloth, 60 cents ; half bound, 70 cents.
NEPOS. Cloth, 60 cents ; half bound, 70 cents.
' VIRGIL. Cloth, 85 cents; half bound, $1.
CURTIUS. Cloth, 80 cents ; half bound. 90 cents.
SCHOFIELD (ALFRED T.). ELEMENTARY PHYSIOLOGY FOR STU-
DENTS. In one 12mo. volume of 380 pages, with 227 engravings and 2 colored plates.
Cloth, $2.
SCHREIBER (JOSEPH). A MANUAL OF TREATMENT BY MASSAGE
AND METHODICAL MUSCLE EXERCISE. Translated by WALTER MENDEL-
SON, M.D., of New York. In one handsome octavo volume of 274 pages, with 117 fine
engravings.
SENN (NICHOLAS). SURGICAL BACTERIOLOGY. Second edition. In one
octavo volume of 268 pages, with 13 plates, 10 of which are colored, and 9 engravings.
Cloth, $2.
SERIES OF CLINICAL MANUALS. A Series of Authoritative Monographs on
Important Clinical Subjects, in 12mo. volumes of about 550 pages, well illustrated. The
following volumes are now ready: BROADBENT on the Pulse, $1.75; YEO on Food in
Health and Disease, new (2d) edition, $2.50; CAETER and FROST'S Ophthalmic Surgery,
$2.25; HUTCHINSON on Syphilis, $2.25; MARSH on Diseases of the Joints, $2; MORRIS
on Surgical Diseases of the Kidney, $2.25; OWEN on Surgical Diseases of Children, $2;
PICK on Fractures and Dislocations, $2; BUTLIN on the Tongue, $3.50; SAVAGE on
Insanity and Allied Neuroses, $2 ; and TREVES on Intestinal Obstruction, $2.
For separate notices, see under various authors' names.
SERIES OF STUDENTS' MANUALS. See next page.
SIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICROSCOPICAL
AND CHEMICAL METHODS. New (2d) and revised edition. In one handsome
octavo volume of 530 pages, with 135 engravings and 14 full-page plates in colors
and monochrome. Cloth, $3.50.
SIMON (W.). MANUAL OF CHEMISTRY. A Guide to Lectures and Laboratory
Work for Beginners in Chemistry. A Text-book specially adapted for Students of Phar-
macy and Medicine. New (6th) edition. In one 8vo. volume of 536 pages, with 46
engravings and 8 plates showing colors of 64 tests. Cloth, $3.00, net. Just Ready.
SLADE (D. D.). DIPHTHERIA ; ITS NATURE AND TREATMENT. Second
edition. In one royal 12mo. volume, 158 pages. Cloth, $1.25.
SMITH (EDWARD). CONSUMPTION; ITS EARLY AND REMEDIABLE
STAGES. In one 8vo. volume of 253 pages. Cloth, $2.25.
SMITH (J. LEWIS). A TREATISE ON THE DISEASES OF INFANCY
AND CHILDHOOD. New (8th) edition, thoroughly revised and rewritten and
greatly enlarged. In one large 8vo. volume of 983 pages, with 273 illustrations and
4 full-page plates. Cloth, $4.50 ; leather, $5.50.
SMITH (STEPHEN). OPERATIVE SURGERY. Second and thoroughly revised
edition. In one octavo vol. of 892 pages, with 1005 engravings. Cloth, $4; leather, $6
SOLLY (S EDWIN). A HANDBOOK OF MEDICAL CLIMATOLOGY.
In one handsome octavo volume of 462 pages, with engravings and 1 1 full-page plates,
5 of which are in colors. Cloth, $4.00.
volume of 163 pages, with a chart showing routes of previous epidemics. >th, $1.25.
_ THERAPEUTICS AND MATERIA MEDIC A. Fourth and revised edition.
In two octavo volumes, containing 1936 pages. Cloth, $10; leather, $12.
Philadelphia, 706, 708 and 710 Sansom St.— Hew York, 111 Fifth Avenue.
14 LEA BROTHERS & CO.'S PUB LIC AT/0 MS.
STILLE (ALFRED), MAISCH (JOHN M.) AND CASPARI (CHAS. JR.).
THE NATIONAL DISPENSATORY: Containing the Natural History, Chemistry,
Pharmacy, Actions and Uses of Medicines, including those recognized in the latest Phar-
macopoeias of the United States, Great Britian and Germany, with numerous references
to the French Codex. Fifth edition, revised and enlarged in accordance with and em-
bracing the new U. S. Pharmacopoeia, Seventh Decennial Eevision. With Supplement
containing the new edition of the National Formulary. In one magnificent imperial
octavo volume of 2025 pages, with 320 engravings Cloth, $7. 25 ; leather, $8. With
ready reference Thumb-letter Index. Cloth, $7.75 ; leather, $8.50.
STIMSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY. New
(3d) edition. In one royal 12mo. volume of 614 pages, with 306 engravings. Cloth, $3.75.
A TREATISE ON FRACTURES AND DISLOCATIONS. In two hand-
some octavo volumes. Vol. I., FRACTURES, 582 pages. 360 engravings. Vol Jl., DISLO-
CATIONS, 540 pages, 163 engravings. Complete work, cloth, $5.50 ; leather, $7.50. Either
volume separately, cloth, $3 ; leather, $4.
STUDENTS' QUIZ SERIES. A New Series of Manuals in question and answer for
Students and Practitioners, covering the essentials of medical science. Thirteen volumes,
pocket size, convenient, authoritative, well illustrated, handsomely bound in limp cloth,
and issued at a low price. 1. Anatomy (double number) ; 2. Physiology ; 3. Chemistry
and Physics ; 4. Histology, Pathology and Bacteriology ; 5. Materia Medica and Thera-
peutics ; 6. Practice of Medicine ; 7. Surgery (double number) ; 8. Genito-Urinary and
Venereal Diseases ; 9. Diseases of the Skin ; 10. Diseases of the Eye, Ear, Throat and
Nose; 11. Obstetrics; 12. Gynecology; 13. Diseases of Children. Price, $1 each, except
Nos. 1 and 7, Anatomy and Surgery^ which being double numbers are priced at $1.75 each.
Full specimen circular on application to publishers.
STUDENTS' SERIES OF MANUALS. A Series of Fifteen Manuals by Eminent
Teachers or Examiners. The volumes are pocket-size 12mos. of from 300-540 pages, pro-
fusely illustrated, and bound in red limp cloth. The following volumes may now be
announced: HERMAN'S First Lines in Midwifery, $1.25; LUFF'S Manual of Chemistry,
$2 ; BRUCE' s Materia Medica and Therapeutics (sixth edition), shortly; BELL'S Comparative
Anatomy and Physiology, $2 ; EOBERTSON'S Physiological Physics, $2 ; GOULD'S Sur-
gical Diagnosis, $2; KLEIN'S Elements of Histology (5th edition), $2.00, net; PEPPER'S
Surgical Pathology, $2; TREVES' Surgical Applied Anatomy, $2; POWER'S Human
Physiology (2d edition), $1.50; RALFE'S Clinical Chemistry, $1.50; and CLARKE and
LOCKWOOD'S Dissector's Manual, $1.50
For separate notices, see under various authors' names.
STURGES (OCTAVIUS). AN INTRODUCTION TO THE STUDY OF CLIN-
ICAL MEDICINE. In one 12mo. volume. Cloth, $1.25.
BUTTON (JOHN BLAND). SURGICAL DISEASES OF THE OVARIES
AND FALLOPIAN TUBES. Including Abdominal Pregnancy. In one 12mo. vol-
ume of 513 pages, with 119 engravings and 5 colored plates. Cloth, $3.
TUMORS, INNOCENT AND MALIGNANT. Their Clinical Features and
Appropriate Treatment. In one 8vo. volume of 526 pages, with 250 engravings and
9 full-page plates. > Cloth, $4.50.
T AIT (LAWSON ) . DISEASES OF WOMEN AND AJBD OMINAL S UR GER Y.
In two handsome octavo volumes. Vol. I. contains 554 pages, 62 engravings, and 3
plates. Cloth, $3. Vol. II., preparing.
TANNER (THOMAS HAWKES). ON THE SIGNS AND DISEASES OF
PREGNANCY. From the second English edition. In one octavo volume of 490 pages,
with 4 colored plates and 16 engravings. Cloth, $4.25.
TAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. New American
from the twelfth English edition, specially revised by CLARK BELL, ESQ., of the N. Y.
Bar. In one octavo volume of 831 pages, with 54 engravings and 8 full-page plates.
Cloth, $4.50; leather, $5.50. Just ready.
Philadelphia, 706, 708 and 710 Sansom St.— New York, 111 Fifth Avenue.
LEA BROTHERS & CO.' S PUBLICATIONS. 15
(ALFRED S.). ON POISONS IN RELATION TO MEDICINE
AND MEDICAL JURISPRUDENCE. Third American from the third London
edition. In one 8vo. volume of 788 pages, with 104 illustrations. Cloth, $650-
leather, §6.. 00.
TAYLOR (ROBERT W.). THE PATHOLOGY AND TREATMENT OF
VENEREAL DISEASES. In one very handsome octavo volume of 1002 pages with
230 engravings and 7 colored plates. Cloth, $5 ; leather, $6. Net.
- A PRACTICAL TREATISE ON SEXUAL DISORDERS IN THE MALE
AND FEMALE. In one octavo volume of 448 pages, with 73 engravings and 8 plates.
Cloth, $3. Net. Just ready.
Including Diagnosis, Prognosis and Treatment. In eight large folio parts, measuring
14 x 18 inches, and comprising 213 beautiful figures on 58 full-page chromo-lithographic
plates, 85 fine engravings, and 425 pages of text. Complete work now ready. Price per
part, sewed in heavy embossed paper, $2.50. Bound in one volume, half Russia, $27 ;
half Turkey Morocco, $28. for sale by subscription only. Address the publishers. Spec-
imen plates by mail on receipt of 10 cents.
TAYLOR (SEYMOUR) . INDEX OF MEDICINE. A Manual for the use of Senior
Students and others. In one large 12mo. volume of 802 pages. Cloth, $3 75.
THOMAS (T. GAILLARD) AND MUNDE (PAUL P.). A PRACTICAL
TREATISE ON THE DISEASES OF WOMEN. Sixth edition, thoroughly
revised by PAUL F. MUNDE, M.D. In one large and handsome octavo volume of 824
pages, with 347 engravings. Cloth, $5 ; leather, $6.
THOMPSON (SIR HENRY). CLINICAL LECTURES ON DISEASES OF
THE URINARY ORGANS. Second and revised edition. In one octavo volume of
203 pages, with 25 engravings. Cloth, $2.25.
THE PATHOLOGY AND TREATMENT OF STRICTURE OF THE
URETHRA AND URINARY FISTULA. From the third English edition. In
one octavo volume of 359 pages, with 47 engravings and 3 lithographic plates. Cloth,
$3.50.
THOMSON (JOHN). A GUIDE TO THE CLINICAL EXAMINATION AND
THE A TMENT OF SICK CHILDREN. In one crown octavo volume of 350 pages
with 52 illustrations. Cloth, $1.75, net. Just ready.
TODD (ROBERT BENTLEY). CLINICAL LECTURES ON CERTAIN
ACUTE DISEASES. In one 8vo. volume of 320 pages. Cloth, $2.50.
TREVES (FREDERICK). OPERATIVE SURGERY. In two 8vo. volumes con-
taining 1550 pages, with 422 illustrations. Cloth, $9; leather, $11.
A SYSTEM OF SURGERY. In Contributions by Twenty-five English Sur-
geons. In two large octavo volumes, containing 2298 pages, with 950 engravings and
4 full-page plates. Per volume, cloth, $8.
• A MANUAL OF SURGERY. In Treatises by 33 leading surgeons. Three
12mo. volumes, containing 1866 pages, with 213 engravings. Price per set, $6. See Stvr
dents' Series of Manuals, page 14.
THE STUDENTS' HANDBOOK OF SURGICAL OPERATIONS. In
one 12mo. volume of 508 pages, with 94 illustrations. Cloth, $2.50.
SURGICAL APPLIED ANATOMY. In one 12mo. volume of 583 pages
with 61 engravings. Cloth, $2. See Students' Series of Manuals, page 14.
INTESTINAL OBSTRUCTION. In one 12mo. volume of 522 pages, with 60
illustrations. Cloth, $2. See Series of Clinical Manuals, page 13.
TUKE (DANIEL HACK). THE INFLUENCE OF THE MIND UPON THE
BODY IN HEALTH AND DISEASE. Second edition. In one 8vo. volume of
467 pages, with 2 colored plates. Cloth, $3.
VAUGHAN (VICTOR C.) AND NOVY (FREDERICK O.). PTOMAINS,
LEUCOMAINS, TOXINS AND ANTITOXINS, or the Chemical Factors in the
Causation of Disease. Third edition. In one 12mo. volume of 603 pages. Cloth, $3.
Philadelphia, 706, 708 and 710 Sansom St.— New York, 111 Fifth Avenue.
16 LEA BROTHERS & CO.' S PUBLICATIONS.
VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1899. Four
styles : Weekly (dated for 30 patients) ; Monthly (undated for 120 patients per month) ;
Perpetual (undated for 30 patients each week) ; and Perpetual (undated for 60 patients
each week). The 60-patient book consists of 256 pages of assorted blanks. The first
three styles contain 32 pages of important data, thoroughly revised, and 160 pages of
assorted blanks. Each in one volume, price, $1.25. With thumb-letter index for quick
use, 25 cents extra. Special rates to advance-paying subscribers to THE MEDICAL NEWS
or THE AMERICAN JOURNAL OF THE MEDICAL, SCIENCES, or both. See page 1.
WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND PRAC-
TICE OF PHYSIC. A new American from the fifth and enlarged English edition,
with additions by H. HARTSHORNE, M.D. In two large 8vo. volumes of 1840 pages, with
190 engravings. Cloth, $9 ; leather, $11.
WEST (CHARLES). LECTURES ON THE DISEASES PECULIAR TO
WOMEN. Third American from the third English edition. In one octavo volume of
543 pages. Cloth, $3.75; leather, $4.75.
ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD-
HOOD. In one small 12mo. volume of 127 pages. Cloth, $1.
WHARTON (HENRY R.). MINOR SURGERY AND BANDAGING. Third
edition. In one 12mo. volume of 594 pages, with 475 engravings, many of which are
photographic. Cloth, $3.
WHITLA (WILLIAM). DICTIONARY OF TREATMENT, OR THERA-
PEUTIC INDEX. Including Medical and Surgical Therapeutics. In one square
octavo volume of 917 pages. Cloth, $4.
WILLIAMS (DAWSON). MEDICAL DISEASES OF INFANCY AND
CHILDHOOD. In one 12mo. volume of 629 pages, with 18 illustrations. Cloth,
$2.50, net. Just ready.
WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. A new and
revised American from the last English edition. Illustrated with 397 engravings. In
one octavo volume of 616 pages. Cloth, $4 ; leather, $5.
THE STUDENT'S BOOK OF CUTANEOUS MEDICINE In one 12mo
volume. Cloth, $3 50.
WINCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED. Trans-
lated by JAMES K, CHADWICK, A.M., M.D. With additions by the Author. In one
octavo volume of 484 pages. Cloth, $4.
WOHLER'S OUTLINES OF ORGANIC CHEMISTRY Translated from the
eighth German edition, by IRA REMSEN, M.D. In one 12mo. volume of 550 pages.
Cloth $3.
YEARBOOK OF TREATMENT FOR 1899. A Critical Review for Practitioners of
Medicine and Surgery. In contributions by 24 well-known medical writers. 12mo., 488
pages. Cloth, $1 50." Shortly.
YEAR-BOOKS OF TREATMENT for 1892, 1893, 1896, 1897 and 1898, similar to
above Each, cloth, $1.50.
YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New (2d) edition.
In one 12mo. volume of 592 pages, with 4 engravings. Cloth, $2.50. See Series of
Clinical Manuals, page 13.
A MANUAL OF MEDICAL TREATMENT, OR CLINICAL THERA-
PEUTICS. Two volumes containing 1275 pages. Cloth, $5.50.
YOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo. volume of 475
pages, with 286 illustrations. Cloth, $4 ; leather, $5.
Philadelphia, 706, 708 and 710 Sansom St.— New York, 111 Fifth Avenue.
Date Due
4978-
PRINTED IN U.S.A.
CAT. NO. 24 161
/
WC270
H27te
1899
Hare, Hobart Amory.
Medical complications, accidents and
sequelae of typhoid...
MEDICAL SCIENCES LIBRARY
UNIVERSITY OF CALIFORNIA, IRVINE
IRVINE, CALIFORNIA 92664
Live Music Archive
Librivox Free Audio
Metropolitan Museum
Cleveland Museum of Art
Internet Arcade
Console Living Room
Books to Borrow
Open Library
TV News
Understanding 9/11