A system of practical medicine. By American authors. Vol. 1

by Unknown

I shall now proceed to describe in detail some of the most important of the symptoms presented by the disease.

Even in the beginning of an attack of typhoid fever the face has a listless and languid expression, although the eyes are usually bright and the pupils dilated. In mild cases no further alteration of the physiognomy than this may be noticeable throughout the whole course of the disease, but in bad cases, when the typhoid condition is fully developed, the expression becomes dull and heavy. There is, however, never the general suffusion of the face seen in typhus. On the contrary, the face is often pallid, or there is at most a circumscribed flush on one or both cheeks, which is most marked during the exacerbations of fever or after the administration of food and stimulants. During convalescence the effects of the long illness are fully visible in the face.

Prostration, or loss of muscular strength, is present from the beginning in a large number of cases of typhoid fever, but is generally not so marked in the early stages as in typhus fever. It is usually most intense in grave cases, but to this rule there are numerous exceptions. It is not rare to find patients, in whom the other symptoms are severe, able to sit up in bed, and even to rise to stool, throughout the attack. Bartlett records a case in which the patient did not confine herself to bed until the occurrence of perforation, and I have had under my care a man who, supposing he was suffering only from a slight diarrhoea, performed the duties of a nurse in a military hospital until two days before his death, although the autopsy showed very extensive ulceration of the intestine. Several cases have come under my care in the second week in which patients have walked a considerable distance to make application for admission to a hospital. Generally, however, the prostration becomes extreme in the third and fourth weeks of bad cases, the patient lying helplessly on his back, and frequently slipping down in bed from sheer weakness.

Epistaxis may occur at any stage of typhoid fever, but is most common in the forming stage. Observers differ in opinion in regard to its frequency. Murchison noted it in only 15 of 58 cases, and gives it as his belief that it is more common in France than in England or this country. Flint found that it had occurred in 21 only of 73 cases, and Jenner in 5 of 15 fatal cases. On the other hand, Bartlett says that it is quite a common symptom, and Wood and Gerhard, from the frequency with which they had met with it in the beginning of the disease, were accustomed to regard its presence as of importance in a diagnostic point of view. Part of this divergence of opinion is probably due to the fact that it is usually small in amount, and therefore very apt to be overlooked. I have in many cases, after having been told there had been no epistaxis, found the evidence of it upon the fingers or bed-clothes of the patient. It may, however, be so profuse as to endanger life and render necessary the use of the tampon. Except in the latter case it is without influence upon the course of the disease.

The skin may be almost constantly dry as well as warm throughout the whole course of the fever in a small proportion of severe cases. But, on the whole, perspiration occurs with greater frequency in typhoid fever than in any other acute disease, unless it be rheumatism. It takes place most commonly at night after the evening exacerbation, or in the morning when the patient awakes from sleep, but it is not very rare to find the skin clammy at other times. The sweating is usually general, but in a few cases it is local only. When colliquative, it is frequently exhausting, and is then a grave symptom. It is sometimes prolonged into convalescence, when it is not only annoying, but in consequence of the prostration it induces may sometimes retard the restoration to health.

I have never been able to satisfy myself that any peculiar odor is given off by the skin in typhoid fever, and most observers make a similar statement. Chomel, however, asserted that the perspiration has a strong acid odor, and Bartlett agreed with Nathan Smith in thinking that typhoid fever patients exhale a peculiar odor, not pungent and ammoniacal, like that of typhus, but "of a semi-cadaverous and musty character," which is especially noticeable during the later stages of severe and fatal cases.

The eruption is one of the most characteristic symptoms of the disease. Indeed, in many cases, without it the diagnosis would be impossible. It is rarely absent in a well-developed case. Murchison says that it was noted in 4606 cases only out of 5988 admitted into the London Fever Hospital in twenty-three years, but admits that it would probably have been found in some of the others if it had been properly looked for. Wood says that he has seldom met with cases in which it was absent. It is oftener absent in children than adults—a circumstance which makes the diagnosis of the disease in the former often a matter of great difficulty. It consists of isolated rose-colored spots, slightly elevated above the surface, circular in form or nearly so, having well-defined margins, usually about a line in diameter, but sometimes varying from half a line to two and even three lines in diameter, and disappearing on pressure, to return when the pressure is removed. They are generally first observed some time between the seventh and fourteenth days, but cases are on record, especially in children, in which they are said to have appeared much earlier, and others in which they could not be discovered until the twentieth day. In the latter cases, however, it is not improbable they had really been present at an earlier period, but had escaped detection. The eruption occurs in crops at intervals of three or four days, each spot lasting from three to five days, and the whole duration of the eruption being usually from ten to twenty, and varying of course with the severity of the attack. It may continue to appear as late as the twentieth day, and in cases of relapses very much later. Spots are sometimes seen on the abdomen or elsewhere after the subsidence of fever, and whenever seen indicate that the diseased process is not at an end. They are usually scattered over the lower part of the front of the chest and the abdomen, but are also not infrequently met with upon the back, and if they are not found upon the abdomen, the patient should be gently turned upon his side and this part of his body carefully examined. When very abundant they are often also seen upon the extremities, and occasionally even upon the face. Wood has seen them abundant on the upper and inner part of the thigh, and confined to that place. When tardy in making their appearance, they may often be brought out by application of a mustard plaster or by that of heat in any form; and it is probably, therefore, owing in large measure to the warmth of the bed that they are often so fully developed upon the back. In number they may vary from two or three to several hundred. In one case Murchison counted one thousand, and in three cases which came under my care in the winter of 1881-82 the body was so thickly covered by spots of an unusually large size that when I first saw the patients I directed them to be isolated under the fear that the disease would prove to be typhus fever. When very numerous the edges of two or three of the spots may run together, giving the eruption an irregular character. No relation between the copiousness of the eruption and the severity of the disease has ever been proved to exist. While the prevailing impression, therefore, that cases in which the eruption is freely developed are apt to be of a mild character, is true in many instances, it is by no means so in all. The three cases above referred to all ran a severe course, and one of them proved fatal. The spots disappear after death, and are rarely converted into petechiæ, but in bad cases I have seen purpura spots, and even vibices, developed independently of them. Sometimes the appearance of the eruption is preceded for a day or two by a delicate scarlet rash, which Tweedie says resembles roseola and has been mistaken for scarlet fever.

Sudamina, so called from their resemblance to sweat-drops, also occur not infrequently in this disease. They are minute vesicles, often not larger than a pin's head, but sometimes two lines in diameter, and occasionally, in cases in which two or three have coalesced, much larger. They usually contain at first a clear serum, which may, however, subsequently become turbid, and when very minute must, in consequence of their transparency, be viewed obliquely to be seen. Frequently, when they cannot be distinguished by the eye, they are readily detected by the touch. They rarely occur before the twelfth day, and often not before the close of the third week. Their most usual seat is the neck, the folds of the axillæ, and the groin, but there is no part of the body except the face in which they may not occur. They are most frequently seen in those cases attended by profuse sweating, and are by no means peculiar to typhoid fever, but are met with in other diseases—as, for instance, acute rheumatism—which are attended by this symptom. They are generally followed by branny desquamation of the cuticle in the position they have occupied.

Spots of a delicate blue tint—the "taches bleuâtres" of French writers—are sometimes observed on the skin in cases of enteric fever. They must be of infrequent occurrence in this country, for, although I have looked carefully for them in every case that has come under my care, I have rarely been able to detect them. According to Murchison, "they are of an irregularly rounded form and from three to eight lines in diameter. They are not in the least elevated above the skin, nor affected by pressure, even at their first appearance. They have a uniform tint throughout their extent, and they never pass through the successive stages observed in the spots of typhus. Two or three of them are sometimes confluent. They are most common on the abdomen, back, and thighs." They are said in some cases to be distributed along the course of the small cutaneous veins, and to occur most frequently in cases which are mild. They are met with in other diseases, and usually precede in appearance the characteristic eruption of typhoid fever.

The hair is very apt to fall out after an attack of typhoid fever. The nails suffer in their nutrition in common with other parts of the body—a fact which may be recognized by the peculiar markings which are found upon them after recovery, and to which attention has been particularly drawn by Morris Longstreth in a paper in the Transactions of the College of Physicians of Philadelphia, vol. iii., 3d Series.