Rigor mortis is generally more marked and more prolonged than after typhus. Emaciation is often extreme in cases in which death has taken place after the third week, especially if they have been attended by much diarrhoea and fever. No traces of the characteristic rose-colored eruption are found after death, no matter how profuse it may have been during life. Sudamina, on the other hand, persist, and discolorations of the dependent portions from settling of blood are always present in the dead body.
The lesions of typhoid fever may be divided into two classes. The first class includes certain changes in the glands of Peyer, the solitary glands of the intestines, the spleen, and other lymphatic structures of the body. These changes, which consist essentially in a medullary infiltration of these glands, will be minutely described presently. They are peculiar to the disease, and are just as characteristic of it as the condition of the lungs and their membranes found in pneumonia and pleurisy are characteristic of those diseases. They are usually most developed in grave cases, but occasionally they are slight and but little marked in cases in which the general symptoms were severe. They therefore cannot be regarded as the sole cause of the latter. It is more probable that they are themselves the results of the local action of the typhoid poison, and bear somewhat of the same relation to typhoid fever that the eruption in small-pox does to that disease. The second class is made up of lesions which are met with not only in this disease, but in other diseases accompanied by high fever, and are therefore unquestionably the result of the general process. They consist essentially of parenchymatous degenerations of various organs and tissues, and are generally more marked in typhoid fever because the pyrexia is not only of high grade, but also of longer duration than in other diseases.
We shall first consider the lesions peculiar to typhoid fever. Among the most important of these are the changes which occur in the agminated and solitary glands of the intestines. These have been usually described as passing through four stages, as follows: (1) the stage of medullary infiltration; (2) the stage of softening or sloughing; (3) the stage of ulceration; (4) the stage of cicatrization. These stages are said to last almost a week, and correspond to certain definite periods of the disease, but it is not uncommon to find in the same intestine glands in two or more of these stages. Indeed, the same gland may sometimes be found ulcerating at one side while cicatrization is going on at the other.
In the first stage the agminated glands are enlarged, each patch preserving its oblong shape, and being flattened on the surface and elevated from half a line to two lines above the surrounding mucous membrane, from which it is separated by an abrupt border, and which it may in a few cases overhang like a fungous growth. The solitary follicles are also swollen, and may vary in size from a hempseed to a split pea. In very severe cases all the glands may be more or less involved, but in mild cases the changes may be limited to three or four of the patches of Peyer, although the solitary glands rarely wholly escape. It is uncommon also for the latter to be alone affected, but a few such cases have been reported. In these the mucous membrane appears to be studded with pustules, and hence Cruveilhier designated this variety as the forme pustuleuse. The mucous membrane covering the affected glands is reddish-green in color, and that in their immediate vicinity is often injected. The changes above described occur early in the disease—Murchison has seen them in two cases in which death took place at the end of the first day—and they are often well marked at the end of the third or fourth day. They are usually limited to the glands in the lower part of the ileum, the agminated glands being often found perfectly healthy four feet above the ileo-cæcal valve. In mild cases, indeed, the lesions may be confined to those nearest to this valve. So, too, the changes in the solitary glands may be confined to the last twelve inches of the smaller intestine, but this is by no means universally the case, for these glands are not only often found enlarged higher up in the small intestine, but also occasionally in the cæcum. The agminated glands are sometimes found enlarged in the bodies of those who have died of measles and of some other diseases, but the degree of enlargement is rarely as great as in typhoid fever, and the further changes presently to be described are never found except in the latter disease.
Under the microscope the medullary infiltration upon which the enlargement of the glands depends is found to be due to proliferation of the cellular elements. In the case of the agminated glands this proliferation may be limited to the follicles or it may extend to the intercellular tissue, and even to the adjacent mucous membrane. In the former case the patches have a reticulated aspect; they are soft and but little elevated. These are the plaques molles of Louis and the plaques reticulées of Chomel. In the latter they are harder, smoother, and more elevated. To this variety Louis has given the name of plaques dures, Chomel that of plaques gauffrées. The morbid process is also very apt to extend from the solitary follicles to the surrounding mucous membrane.
In a large number of the glands in many cases, and probably in all of them in the abortive form of the disease, the changes never advance beyond the first stage, a restoration to their normal condition taking place by colliquative softening.46 The morbid material upon which their enlargement depends breaks down into an oily débris which is gradually absorbed. This retrograde process takes place faster in the follicles than in the interfollicular tissue, and, as pigment is very apt to be deposited in the depressions thus formed, the patches acquire an appearance which has been compared to that of a recently shaven beard. This appearance is met with, however, in other diseases, and is therefore not peculiar to typhoid fever.
46 Rindfleisch, Pathological Histology, Sydenham Society Translation, vol. i. p. 441.
The description of the changes in these glands in the subsequent stages of the disease which follows is taken mainly from Rindfleisch's work on Pathological Histology.
In the stage of necrosis small portions of single Peyerian patches, varying in size from that of a lentil to from three-quarters of an inch to an inch and a quarter in diameter, assume a yellowish-white, opaque tint instead of their former reddish and translucent aspect, gradually become separated from the surrounding tissue by a sharp line of demarcation, and then pass into a state of cheesy necrosis. Here and there the same changes are observed to have taken place in the solitary glands. When once this has occurred, recovery can only take place by expulsion of the necrosed parts and consequent ulceration. Necrosis of the glands probably rarely occurs before the beginning of the second week, but it has occasionally been observed much earlier. Murchison reports cases in which he saw it as early as the first and second days. The process usually involves the mucous membrane only, but it may extend to the muscular and even to the peritoneal coats.
In the third stage the dead parts are gradually thrown off, the process of separation usually occupying several days. At first an increased degree of congestion, followed by suppuration, is observed at the edges of the sloughs, which before their complete detachment may often acquire a yellow, green, or brown color from the imbibition of bile. The ulcers which result correspond in size and form with the sloughs. They are, therefore, in the case of the agminated glands elliptical in shape, with their long diameter corresponding to the axis of the intestine. Their edges are swollen and overhanging, and their floor is generally formed by the deepest layer of the submucous connective tissue. They sometimes penetrate much more deeply, and may even extend to the peritoneal coat, and thus give rise to perforation of the bowel. The ulcers which result from sloughing of the solitary glands are, as a rule, small and round. Murchison says that ulceration may also be produced in the following way: The mucous membrane becomes softened, and one or more superficial abrasions appear on the surface of the diseased patch, which extend and unite into one large ulcer, and this ulcer proceeds to various depths through the coats of the bowel, and even to completed perforation, but Rindfleisch and other recent German writers do not allude to this process.