The symptoms of obliterating arteritis are—pain, more or less sudden in its onset, directly over the course of affected vessels, and increased by pressure, by the erect position, and by walking; diminution, and then absence, of pulsation; swelling of the limb, without oedema or redness; and, later, the appearance of bluish mottling of the surface, and, more rarely, of patches of purpura; lowering of the temperature, with or without troubles of sensibility, such as formication, anæsthesia, etc., and the appearance of a hard and painful cord, due to the formation of the thrombus. In the parietal form the diminution of the pulsations is sometimes preceded by a considerable exaggeration of their amplitude, and, while the temperature on the affected side is usually lowered, it may sometimes be increased.
63 Centralblatt f. Gynakol, 1881.
64 Archives générale, Mars, 1881.
Venous thrombosis, the result of weakness of the heart's action, is more frequently observed. It occurs generally during the convalescence of cases which have run a severe course, and usually affects the veins of the lower extremities. I have seen both the femoral veins obstructed from this cause at the same time. All the cases which have come under my own observation have ended in recovery, and only 2 of 31 collected by Liebermeister terminated fatally. Death occurred in 3 of the 17 cases collected by Murchison, but in none of them was this result attributable to this complication alone. There is, however, always danger of a portion of the thrombus becoming detached and producing embolism of the pulmonary artery.
Pyæmia is said by Murchison and other authors to be an occasional complication, but it is certainly rare in this country. In the milder cases abscesses form during convalescence beneath the skin in different parts of the body. In the more severe cases pus is deposited in the joints or in the internal organs. Albert Robin65 has reported two cases in which there was suppurative joint affection. In one of these the joints of the fingers and toes, with the sheaths of the corresponding extensor tendons and both knee-joints and one shoulder-joint, were affected. In the other the left knee was filled with pus. In both cases the fever soon assumed an adynamic character.
65 Gazette de Paris, 1881.
Laryngitis may sometimes occur in the course of typhoid fever, and when it assumes the diphtheritic form and runs on to the formation of ulcers is a very serious complication of typhoid fever, as it is not infrequently accompanied by oedema of the glottis and gives rise to the necessity for tracheotomy. It is fortunately, at least in its worst forms, rare in this country. In Germany, judging from the number of cases collected by Hoffmann and Griesinger, it is of more common occurrence. The ulcers are oftener met with in some epidemics than in others. During the winter of 1860-61, which I passed in Vienna, the frequency with which they occurred was the subject of remark among those who were in attendance upon the various clinics.
I have already called attention to the frequency with which bronchitis in some form or other attends upon typhoid fever. When it invades the smaller bronchial tubes it occasionally gives rise to lobular pneumonia or to collapse of some of the lobules of the lung. Lobar pneumonia may also occur in the course of typhoid fever. It was observed 52 times in 1420 cases of typhoid fever under treatment at the Basle hospital from 1865-68. When it comes on late in the disease, especially if the patient is comatose, or even semi-conscious, it may be entirely overlooked, unless the lungs are carefully examined, as it often does not reveal itself to us by any of the ordinary symptoms. It may, however, occur early, and I have known it so prominent in the beginning of an attack that the existence of typhoid fever was not suspected. It sometimes terminates in abscess or gangrene, but is more usually followed by chronic pneumonia, which may eventually either end in recovery or lay the foundation for phthisis. Pleurisy with effusion is also not an uncommon complication. It was observed, according to Liebermeister, at the hospital at Basle 64 times in 1743 cases of fever. It is also a serious complication, as 21 of the 64 cases terminated fatally. Murchison refers to three cases in which it was followed by empyema. Other morbid conditions of the respiratory organs which may occur as complications of typhoid fever are oedema, infarction, hypostatic congestion of the lungs, emphysema, and pneumothorax. Acute miliary tuberculosis is also an occasional complication, but is oftener met with as a sequel. According to Liebermeister, the tendency to pulmonary complications has diminished since the introduction of the cold-water treatment.
Catarrhal or diphtheritic inflammation of the fauces and pharynx occurs in a large number of cases, and frequently gives rise to a great deal of difficulty in swallowing. Indeed, it has been so frequently observed in some epidemics that a few writers have regarded it as a symptom rather than a complication of the disease. Either of the varieties of inflammation may extend through the Eustachian tube to the middle ear and be the cause of deafness, which usually passes off as the inflammation subsides. Occasionally, however, the affection of the middle ear gives rise to perforation of the tympanum or to caries of the petrous portion of the temporal bone.
Murchison says he has known the symptoms of and lesions of dysentery to coexist with those of typhoid fever in several cases, and Liebermeister asserts that diphtheria of the intestinal mucous membrane is an occasional sequel to severe cases, especially when other mucous membranes are the seat of diphtheritic inflammation. In a few instances which have come under his observation it had given rise to perforation of the bowel or to gangrene of the intestinal mucous membrane.