In many cases, when the prostration is extreme, the urine is passed involuntarily, but in some of these cases the incontinence of the urine is only apparent, and is really the result of over-distension of the bladder. This is a condition which is very apt to be overlooked, and I have known paralysis of the bladder to result in consequence of this neglect, and to continue sometimes after convalescence has been established.
COMPLICATIONS AND SEQUELÆ.—Although cerebral symptoms are among the commonest manifestations of the disturbing effects produced in the economy by the typhoid fever poison, they are almost always independent of inflammation of the brain and its membranes. In a few cases, however, the lesions of meningitis have been found after death. In some of these it has come on without assignable cause, in others it has been the consequence of pyæmia, of tubercles, or of the extension of inflammation from the petrous portion of the temporal bone. Occasionally, during convalescence, some impairment of the intellect is observed. This may consist in simply some loss of memory or childishness of manner. At other times delusions of a mild form are present, or else the patient is liable to attacks of acute mania, sometimes violent, coming on suddenly and without fever. In a few instances the moral sense seems to have been perverted, as in the case reported by Dr. Nathan Smith, already referred to, in which a young man of previously good character developed a propensity to steal after his attack. Recovery with the re-establishment of the physical health almost occurs in these cases. Murchison says he knows of no case in which this condition has been permanent. On the other hand, Dr. C. M. Campbell,57 who had the opportunity of observing an attack of typhoid fever among some insane patients at the Durham County Asylum, reports that the mental state was in no case injuriously affected by the disease, but, on the contrary, underwent a marked improvement in several of the cases. Indeed, in two of the cases, in which the prognosis had become very unfavorable, mental recovery began during the attack of fever.
57 The Journal of Mental Science, July, 1882.
Paralysis, muscular tremors, and chorea are also occasionally observed after attacks of typhoid fever. According to Murchison, paralysis does not supervene until several weeks after the commencement of convalescence. It may last for several weeks or months, but recovery in the majority of instances eventually takes place. According to Nothnägel,58 the most common form is paraplegia, but it may also take the form of hemiplegia, strabismus, paralysis of the portio dura, motor paralysis of individual spinal nerves, such as the ulnar or peroneal, or local anæsthesia. On the other hand, neuralgias and disturbances of sensation are not common sequelæ of typhoid fever.
58 Cited by Murchison. See also article by Paget, St. Bartholomew's Hospital Report, vol. xii.
Degeneration of the muscular tissue of the heart is probably present in some degree in every case of typhoid fever, being, of course, most marked in the severest cases. There would seem, however, to be no special tendency to disease of its valves or membranes. Arterial thrombosis or embolism, giving rise to gangrene of the part supplied by the obstructed artery, is of occasional occurrence. Patry,59 Hayem,60 Trousseau,61 and others report or refer to several cases in which gangrene of the leg, hand, or cheek was observed, and among others a case in which sphacelus depending upon obstruction of the carotid artery, the result, as Patry thought, of arteritis, commenced in the left ear, and extended from there to the forehead and cheek.62 A. Martin63 reports the case of a woman who expelled from the vagina a fetid-smelling structure of cylindrical form, which proved to be the cervix of the uterus, with the upper part of the vagina, and in whom menstruation was not re-established until after the performance of an operation. Spillmann64 has also called attention to the occurrence of gangrene of the vagina and vulva in cases of typhoid fever. This complication is generally met with toward the end of the febrile period.
59 Archives générales de Médicine, 1863, vol. i. pp. 129-549.
60 Loc. cit.
61 Clinique médicale.
62 Since the above was written Barié has called attention in the Revue de Médicine, Jan. and Feb., 1884, to the frequency with which acute inflammation of the arteries occurs as a sequel of typhoid fever. The author, whose investigations were limited to the larger arteries, found that the vessels generally implicated are in the order of their frequency, the posterior tibial, the femoral, and the dorsal artery of the foot. The affection is usually unilateral, appears during convalescence or when the patient leaves his bed, and occurs just as often after light as after severe cases. He distinguishes two varieties: 1, acute obliterating arteritis, and, 2, acute parietal arteritis. The first variety is characterized by embryonal infiltration of all the tissues, by disappearance of the smoothness of the intima, which becomes uneven and granular, and by the formation of a secondary thrombus, and almost invariably terminates in dry gangrene. The second is merely an inflammation without such a clot, and always terminates in recovery without gangrene.