51 Trans. Path. Soc. Lond., vol. xiii.
52 Archiv. gén. de Méd., 1868, quoted by Murchison.
During convalescence, especially in cases in which there has been much mental disturbance during the febrile period, the intellect may be weak, and continues so in some cases even after recovery in other respects is complete; but it is rarely permanently impaired. Insanity may also occur during the convalescence or after recovery, but it is usually under these circumstances amenable to treatment. In some cases the moral sense appears to be weakened after an attack, as in the case reported by Nathan Smith, in which a young man of previously good habits developed thieving propensities after his recovery.
Hyperæsthesia of the skin exists, according to Murchison, in about 5 per cent. of the cases, and may occur at any stage of the disease. It is chiefly observed in the abdomen and lower extremities, and is more frequently met with in women and children than in adult males. In a case which was partially under my care during the past summer the slightest touch made the patient, a boy of fifteen years, cry out with pain, and the administration of an enema gave him excruciating agony. Occasionally, the tenderness over the abdomen is so great that it is sometimes difficult to distinguish it from that due to peritonitis, except by the coexistence of hyperæsthesia in other parts of the body. It is very often associated with spinal tenderness, and sometimes with other spinal symptoms. Murchison does not regard it as a formidable symptom.
Cutaneous anæsthesia may also occur, but it is certainly less common in the earlier stages than hyperæsthesia. Rilliet and Barthez look upon it as of grave diagnostic import when it occurs in children.
Muscular tremor is also a common symptom of typhoid fever. A little tremulousness of the tongue when protruded may often be detected before the close of the first week. A little later the hands will be observed to tremble when held up, and still later twitching of the tendons at the wrist may be appreciable while the pulse is being felt. When muttering delirium supervenes this subsultus tendinum becomes constant, and extends to other parts of the body. The hands of the patient are frequently then in constant motion, either picking at the bed-clothes—a very unfavorable symptom—or moving in an objectless manner through the air. This condition presents many points of resemblance to that often seen in delirium tremens, and is said to come on earlier and to be more marked in those who are addicted to the abuse of alcoholic liquors. Hiccough is occasionally observed toward the close of grave cases, and is justly regarded as a bad symptom.
Spasmodic contraction of various groups of muscles is occasionally observed in severe cases, but is less frequent than muscular tremor, and in my experience is generally met with in the earliest period of the disease. The muscles of the extremities, especially those of the legs, are oftenest affected, but I have known the head as rigidly retracted as in tubercular meningitis, and have seen cases in which strabismus has been an early symptom. Murchison has had patients under his care who have suffered from constriction of the pharynx to such an extent that they could not swallow. He also reports cases in which trismus and spasm of the glottis have been present. General convulsions are not common, but occasionally do occur. Although a very grave symptom, they are not invariably fatal. Recovery took place in one of two cases which came under my own observation, and in four of the six recorded by Murchison. They are not always associated with an albuminous condition of the urine. In neither of my cases was there albuminuria, and in only one of the four of Murchison's cases in which the urine was examined was it present. In one of my cases—the fatal one—the convulsions seemed to have been induced by giving the patient improper food; in the other no cause could be discovered.
Ringing or buzzing noises in the ears are present in the early stage of the disease in a large proportion of the cases, and may sometimes persist until the disease is well advanced. Usually, however, after a few days they subside and give place to deafness. This is a very common symptom, and may either affect both ears or be limited to one. In the former case it is probably generally due to the blunted perceptions of the patient, although in a few instances it may be caused, as suggested by Trousseau, by inflammation of the Eustachian tube. When only one ear is affected the deafness is of more serious import, as it is then dependent upon the presence of local inflammation, which may possibly extend to the meninges. It is, as a rule, most marked in the severest cases. Unless there has been a local inflammation it is not followed by permanent impairment of the hearing. It has even been regarded by some observers as a favorable symptom, but this opinion does not appear to rest upon a more substantial basis than the observation of Louis, that the most profound deafness adds nothing to the gravity of the prognosis.
Imperfect or perverted vision occasionally occurs in the course of typhoid fever. In a case which was recently under my care, and which has already been referred to in another connection, there was double vision associated with strabismus. Sometimes haziness of vision, and sometimes even visual illusions, are observed. Bartlett and Murchison have often known intolerance of light present in cases characterized by active febrile excitement. As a general rule, the pupils are widely dilated and the conjunctiva pearly white—a condition which is in marked contrast with what is seen in typhus fever. When, however, stupor supervenes in bad cases, the pupils are frequently as much contracted and the conjunctivæ as much injected as in the latter disease. In a few cases unequal dilatation of the pupils has been noticed. Trousseau was accustomed in his clinical lectures to call attention to the frequency with which sloughing of the cornea occurred in the condition known as coma vigil, in which the patient lies with his eyes wide open. He attributed this accident to the fact that the eye in this condition is not kept constantly moist by the occasional closure of the eyelids, and hence, as its innervation is also impaired, is especially prone to take on ulcerative inflammation. In other cases there is a free secretion of viscid matter, which often glues the eyelids together.
The sense of taste is often lost or perverted. This is partly due to impaired innervation of the tongue and palate, and partly to the thick deposits which usually cover the mucous membrane of these organs.