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

by Unknown

⁵⁴ Cited by Murchison.

Perforation is, fortunately, not a frequent accident in typhoid fever. It was the cause of death in 20 only of 250 fatal cases collected by Hoffmann. It occurred, according to Liebermeister, in only 26 cases, 3 of which ended in recovery, in more than 2000 cases observed at the hospital at Basle. Murchison observed it 48 times in 1580 cases, Griesinger 14 times in 118 cases, and Flint twice in 73 cases. Murchison found that in a total of 1721 autopsies, the details of which were collected from various sources, it was the cause of death in 196, or 11.38 per cent. It would appear to be rather more common on the continent of Europe than in England or in this country. Perforation is much more frequently met with in men than in women. The patients were men in 15 of 21 of Liebermeister's cases, in 51 of 73 of Murchison's, and in 72 of 106 cases collected by Näcke. It is rarer in children than in adults. Rilliet, Barthez, and Taupin met with it only three times in 232 children under treatment. Murchison has, however, had a fatal case in a child of five years of age. It is also not common after forty years of age, but does occasionally occur, although the contrary has been asserted.

Perforation is most likely to happen during or after the third week of the disease, but it has been met with as early as the eighth day, as in a case reported by Peacock. On the other hand, in three cases cited by Morin⁵⁵ it did not occur until the seventy-second, seventy-sixth, and one hundred and tenth day, respectively. Instances are on record in which it has taken place after the patient was supposed to be thoroughly convalescent and had returned to his occupation. When it occurs early it is due to the separation of a slough. After the middle or end of the third week it is probably always the result of the extension of the ulcerative process to the peritoneal coat. In a large proportion of cases the perforation has been preceded by symptoms of great gravity, such as severe diarrhoea, great tympany and tenderness of the abdomen, and intestinal hemorrhage, but in a certain number of instances the cases in which it has occurred have been of a mild character, the patient in many of them not considering himself sick enough to take to his bed or even to abstain from his daily labor. After death the perforating ulcer has been found to be the only one.

⁵⁵ Quoted by Murchison.

The most frequent causes of perforation are the irritation arising from indigestible and unsuitable food, distension of the bowels by feces or gas, vomiting, and movements on the part of the patient. Liebermeister calls attention to the frequency with which ascarides are found in the intestines of those who die of perforation, and is inclined to think they may have something to do with causing it. Morin⁵⁶ reports a case in which the perforation appeared to be caused by the administration of an enema.

⁵⁶ Quoted by Murchison.

For our knowledge of the changes in the composition of the urine we are largely indebted to Parkes and certain German observers. As the disease generally begins insidiously, the condition of the urine before the attack and during the first two or three days has not been ascertained with certainty. During the latter part of the first week the amount of water is greatly diminished, occasionally falling to one-fourth or one-sixth of the usual quantity. In the second and third weeks it increases, and at the end of the fourth week may again be normal. The amount may, however, vary from day to day, but its variations do not stand in close relation to those of the febrile heat; that is, the thermometer may mark one day 104°, and the next day 100°, while the amount of urine remains the same. Still, when the temperature begins to fall permanently it increases at once, or, according to Thierfelder, two or three days after. The specific gravity is usually high in almost all cases in which the urine is scanty, and may be as high 1038. With the establishment of convalescence the specific gravity often diminishes before the water begins to increase. In other words, the lessening of the solids of the urine frequently takes place prior to the increase of the water.

The reaction of the urine is very acid in the beginning, but the acidity is not due to an increased secretion of acid, but simply to concentration. Later it may become alkaline, and even ammoniacal. The color of the urine is darker than in health during the early part of the febrile period. This is due partly to concentration, and partly to increased disintegration of the blood-corpuscles, which is a consequence of the fever.

The quantity of urea is augmented during the fever, and especially during the first week, when the water and chlorides of sodium are most diminished. As a general rule, the higher the temperature the greater the amount of urea. It may, however, be very much diminished during the presence of inflammatory complications. On the other hand, it is not affected by diarrhoea. Uric acid is uniformly increased, the amount of increase being relatively greater than that of the urea; it is often doubled, and sometimes the increase is even more than this. This increase takes place, according to Zimmer, up to the fourteenth day. It diminishes after this, and during convalescence may fall below the normal amount. Copious deposits of urates may occur at any time in the course of the disease. The chloride of sodium is usually diminished in amount. This diminution is partly due to a less amount of this salt being taken with the food, and partly to the fact that large quantities of it pass away with the stools. As the diminution cannot always be fully accounted for in this way, it would appear that it is also stored up in the body during the fever. In cases in which sweating and purging are absent the sulphuric acid is increased in amount. The phosphoric acid is at first slightly diminished, but later undergoes an increase. The hippuric acid is also diminished.

Parkes found albumen in the urine in 7 out of 21 cases. In 5 of these it was temporary, and entirely disappeared before the patients left the hospital. Becquerel found it in 8 out of 38 cases, Andral in only 4 out of 34 cases. Griesinger found it commonly, though it was usually temporary. He met with only four or five cases in which it was never present. Kerchensteiner found albumen in a fourth part of the severe cases. Brattler noticed it in 9 out of 23 cases. I have very frequently found it myself, but it has always been in my cases a temporary phenomenon. Desquamative nephritis may occur occasionally in the course of typhoid fever, and give rise to the appearance of a large amount of albumen in the urine, and also occasionally of blood. Renal epithelia and casts are sometimes seen in cases in which there is albuminuria, but usually soon disappear. Zimmermann asserts that in all but very slight cases casts may be found even when no albumen can be detected. The statement is probably too general, but there is no doubt of the occasional presence of casts under these circumstances. Bladder epithelia and pus-cells are seen in a few cases in small quantities, but decided cystitis is rare, unless it has ensued upon retention of urine. Sugar has not been found except in the urine of diabetic patients, who may have happened to contract typhoid fever. In these patients the sugar diminishes, and is sometimes wholly absent during the continuance of the fever. Leucin and tyrosin have been found by Frerichs, but at present no observations have been made as to the frequency or import of their occurrence.