CLINICAL DESCRIPTION.—The invasion of the disease is usually so gradual that it is often impossible to obtain from patients exact information as to the time of the beginning of their illness. Among those who present themselves for treatment at the Pennsylvania Hospital it is not uncommon to find that many have suffered for several days, it may be as long as a week, or even longer, before taking to their beds, from vague feelings of discomfort, from headache more or less intense, aching pains in the back or limbs, or from sensations of chilliness alternating with flashes of heat. In other cases derangements of the digestive system are more prominent, such as nausea, or even vomiting, diarrhoea, or irritability of the bowels. Notwithstanding these symptoms, and the indisposition to exertion engendered by them, they have frequently continued to follow their usual avocations up to the time of their application at the hospital for admission. There is generally, however, no difficulty in recognizing at once the nature of their disease. Upon examination the pulse is found to be frequent, the respiration accelerated, the tongue furred, the skin hot and dry, and the abdomen tympanitic.
Among patients whose position in life enables them to pay greater attention to trifling symptoms than those who are compelled to seek hospital relief, opportunity is frequently afforded to the physician to study the disease at a period less remote from its commencement. The symptoms it presents when seen as early as the second day are generally of a very indefinite character. There may be a feeling of malaise, headache with a tendency to giddiness, pain in the back and limbs, a slightly coated tongue, thirst, and anorexia. The patient may complain of chilly sensations alternating with flashes of heat, but it will rarely be found that the attack has commenced with a decided chill. Diarrhoea may also be present at this time, or may not supervene until later. Even in cases in which it is absent the bowels will generally act inordinately after the administration of a gentle purgative. Occasionally, the attack begins with vomiting, but this is not, in my experience, a frequent mode of commencement. If the visit be made in the morning, the febrile symptoms will be little marked, the pulse being only slightly accelerated and the temperature being rarely more than from a half to a degree above the normal. In the evening, however, the thermometer usually indicates a greater elevation of temperature.
At subsequent visits the same symptoms are presented. It will be observed, however, that the fever is decidedly remittent in character, the evening temperature being always from a degree to a degree and a half higher than that of the morning, while the temperature of each succeeding day is a little higher than that of the day which preceded it. The patient is restless and wakeful at night, or sleep, when obtained, is unrefreshing and disturbed by dreams. He grows dull and slightly deaf, and although able to answer questions intelligently when roused, does so with an effort, and soon after lapses into his former condition. Although obviously growing weaker every day, it is sometimes difficult to get him to take to his bed. The diarrhoea continues and increases in severity; the stools become watery in character and ochrey-yellow in color; they may exceed six, or even twelve, in the twenty-four hours. Epistaxis either consisting of a few drops of blood only, or so profuse as to endanger life, may also occur during the first week. Examination of the abdomen toward the middle or close of the first week will almost always reveal the existence of tympany and of tenderness and gurgling in the right iliac fossa, and very frequently also of slight enlargement of the spleen. The urine at this stage of the disease is dense, scanty, and of high color. The tongue too will be observed to be more heavily coated than at first, and to be dryish, the fur being disposed on the middle of the dorsum of the organ, while the tip and edges are free from it and abnormally red in color. Usually, toward the close of the first week, the pulse will be found to be between 100 and 120 in frequency. It often, however, does not attain this frequency, and in some cases does not exceed 50 throughout the whole of the attack. At the same time, the thermometer generally indicates a temperature of from 102° to 104°, and in bad cases even one much higher than the latter.
These symptoms are not pathognomonic, but Murchison regards their existence in a young person as warranting the suspicion that he is suffering from this disease. About this time, however, or, to speak more accurately, usually from the seventh to the twelfth day, a new symptom occurs which is more characteristic. This is an eruption of isolated rose-colored spots, the tâches roses lenticulaires of Louis, occurring principally upon the surface of the abdomen, but not infrequently seen also upon the chest, back, limbs, and even, according to some authors, upon the face. They are round in shape, with a well-defined margin, usually about a line in diameter, but sometimes considerably larger, slightly elevated above the surface, and disappearing upon pressure, but returning when the pressure is removed. They can almost always be found at this stage of the disease if diligently sought for.
If the disease tends to run a severe course, all the symptoms become aggravated toward the end of the second week. The tongue grows dry and brown, the pulse more frequent, feeble, and markedly reduplicated in character, the diarrhoea still more severe, and the fever higher than before, with little or no tendency to remit in the morning. The nervous symptoms also come into prominence. The headache may grow more violent or may be replaced by increased dulness, which may sometimes be so decided as to render it difficult to fully rouse the patient. At other times delirium is a prominent symptom. This may only occur at night, but not infrequently is observed during the daytime as well. It is usually more active in character than that which accompanies typhus. Trembling of the tongue and of the limbs is not uncommon at this time. The urine becomes more abundant, paler, and less dense than before. Even in cases characterized by symptoms as severe as those above detailed some improvement is, however, often observed to take place between the fourteenth and twenty-first days. The morning remission becomes more decided, the evening temperature less high than that of the preceding day; the stools lessen in number, and gradually assume a more healthy appearance; the pulse diminishes in frequency and gains in force; the tongue becomes moist, and shows a tendency to throw off its fur; the trembling grows less marked; the dulness and delirium lessen; and the patient falls into a refreshing sleep. In other cases, in many of which recovery eventually takes place, there is at this time, instead of an improvement, a still further aggravation of the symptoms. The pulse becomes more feeble and frequent; the tongue is not only excessively dry and brown, but shrivelled and fissured; the lips and teeth are encrusted with sordes; the stools contain shreds of membrane, and often blood; the subsultus tendinum increases; carphololgia, or picking at the bed-clothes, occurs. The prostration becomes so extreme that the patient frequently slips down in bed from sheer weakness. The active delirium of the previous stage is replaced by the low muttering form, or the patient lies upon his back with his eyes half closed in a semi-unconscious condition, from which he is with difficulty aroused, and which may deepen into coma. Occasionally, however, the active delirium continues, and is associated with an obstinate wakefulness; the urine and feces are passed involuntarily, or, with an apparent incontinence of the former, there may be retention, which is very apt to be overlooked. If these symptoms continue for any length of time, bed-sores may form not only over the sacrum, but on other parts subject to pressure, and the patient, worn out by long-continued suffering, dies from exhaustion.
Occasionally, in the midst of these symptoms, and sometimes even in cases in which the condition is not so alarming, prostration approaching collapse, without obvious cause, suddenly supervenes. The pulse becomes a mere thread, the surface is bathed in a clammy sweat, and the temperature is found to have fallen from four to seven degrees, and in some cases even more. These symptoms almost always indicate that intestinal hemorrhage has taken place, and are followed by the discharge of blood either in the course of a few hours or not until a day or two subsequently. If the hemorrhage be moderate in amount, and does not recur, reaction usually takes place in a short time; but if, on the other hand, it is profuse or frequently repeated, death may occur, either immediately or later, as the result of the exhaustion it has induced. Very much the same set of symptoms attend the occurrence of perforation of the bowel, an accident which is also liable to happen in the course of typhoid fever, but which may generally be distinguished from intestinal hemorrhage by its being accompanied by a sharp pain in the abdomen, which is frequently so severe as to cause the patient to cry out, by its not being attended with the same reduction of temperature, and by the absence of blood in the discharges. In a day or two all doubt will be set at rest, if the case be one of perforation, by the occurrence of general peritonitis.
A fatal termination is by no means the usual result, even in cases in which the disease has assumed its worst features. Indeed, it may be said that there is no condition in typhoid fever so grave that recovery from it is impossible. Many authors would make perforation of the bowel an exception to this general rule, but there are observations on record which would seem to show that this accident is not invariably fatal. Even in cases in which the patient has lain helplessly on his back in a semi-unconscious or comatose condition, passing his discharges under him, the physician will often be gratified to find at one of his visits some evidence of improvement, trifling as it will probably be. It may be only a slight change of position, an inconsiderable fall of temperature, or a scarcely appreciable moistening of the tongue; but these changes, insignificant as they apparently are, are sufficient to indicate to the practised eye of the observant physician the approach of convalescence. Next day there will be a still further reduction of temperature, a more decided moistening of the tongue, a sensible diminution of the nervous symptoms, and a reduction in the frequency of pulse. In this condition, however, as may be readily imagined, convalescence may be retarded by numerous accidents, and life may hang trembling in the balance for several days, or even weeks, before it is fully established. It is not necessary to recount here the various steps by which a return to health is reached, as they are essentially the same as those which mark the convalescence of the less severe variety of the disease, and have already been fully referred to in the description of that form.
But even after the establishment of convalescence, and after the patient has been free from fever for several days, febrile attacks lasting for a day or two, or even longer, may occur as the consequence of very slight causes, such as undue excitement, or fatigue of any kind, or the immoderate indulgence of the appetite, which in this condition frequently needs to be restrained. These attacks are usually spoken of as recrudescences of fever, and do not differ materially from attacks of irritative fever occurring under other circumstances. They usually subside under appropriate treatment with the removal of their cause, but leave the patient somewhat weaker than they found him. In other cases, it may be a week or ten days after the fall of the temperature to the normal, and frequently at a time when all danger seems to have been passed, a true relapse of the disease occurs. In this, of course, all the symptoms of the primary attack are reproduced, including even the eruption of rose-colored spots. The temperature usually, however, attains the maximum more rapidly, and the duration of the fever is generally shorter, than that of the original attack. A second relapse is also not very uncommon, and even a third may occur. Various complications and sequelæ also occur in the course of typhoid fever, which will be referred to fully hereafter.
Another form of the disease, which it may be well to allude to briefly here before closing the general description of the disease, is the abortive form. In this variety the attack begins and runs its course up to a certain point, including often even the occurrence of the eruption, as it does in the majority of cases; but at a period which varies between the seventh and fourteenth day the symptoms suddenly subside and the patient rapidly convalesces. In some cases it may be difficult to distinguish this form from an attack of simple continued fever, and, in fact, in cases in which the eruption is absent it will be impossible, unless other cases of typhoid fever have occurred in the same house or family, or unless the patient has been unmistakably exposed to the influences under which the disease arises.
In a few cases the disease begins abruptly with a chill, intense headache, or with gastro-intestinal symptoms, which have in rare instances been so violent as to have suggested to the mind of the attending physician the possibility of corrosive poisoning. This, according to Chomel, is the most frequent mode of commencement, but his experience on this point is opposed to that of the great majority of observers.