The prognosis is more unfavorable in a fever in which the temperature is continuously high, and in which the morning remissions are slight or wanting, than in one in which the daily fluctuations are greater, even though the temperature may reach a higher point during the evening exacerbations in the latter variety than is attained at any time in the former. Occasional remissions, even if produced by quinia or other remedies, are to be regarded as favorable omens, as they indicate that the fever tends to subside. A high morning temperature ought, therefore, to give rise to more alarm than a high evening temperature. The prognosis is grave when the morning temperature rises to 104° or is persistently above 103°. Murchison says that recovery is rare after a morning temperature of 105°. Fiedler91 saw, with a single exception, all patients die whose temperature in the morning rose to or exceeded 106.25°, while of those whose temperature in the morning rose to 105.44°, if only on one day, more than half died. Any marked deviation from the usual temperature range in the course of the fever is unfavorable. A rapid rise of temperature indicates increased danger: it may be due to the occurrence of a complication or of some other cause acting unfavorably upon the patient. A sudden and decided fall should excite even more alarm, as it is generally the consequence of a free intestinal hemorrhage. A temporary abatement of the fever, with amelioration of the other symptoms, occurring between the tenth and twentieth days, and giving rise to the hope that convalescence is about to commence, but followed by a return of the symptoms in an aggravated form, is also unfavorable. Such cases, according to Chomel, Louis, Bartlett, and Murchison, almost invariably terminate fatally.
91 Quoted by Liebermeister.
The prognosis is bad in cases in which coma or wild or violent delirium comes on early. A moderate amount of delirium, especially when it occurs only at night or upon wakening in the morning, and is readily dissipated by attracting the patient's attention, or stupor which disappears when he is thoroughly roused, is not unfavorable. Insomnia, subsultus tendinum, carphologia, slipping down in bed, incontinence of the urine or feces, and retention of urine, are all symptoms of bad omen. Rigidity of the limbs is also a bad symptom; Dr. Jackson reports six cases in which this symptom occurred, only one of which recovered. Excessive subsultus is especially unfavorable, as it is generally most marked in cases in which the ulcerations of the intestines are most extensive. Extreme deafness occurs in mild as well as severe cases; it is therefore without significance in prognosis.
In estimating the importance, in a prognostic point of view, of these various nervous symptoms, it is important to bear in mind that a degree of fever which produces no disturbance of the mental functions in a phlegmatic person will give rise to active delirium and other marked cerebral symptoms in a person of an excitable temperament.
A change in the character of the pulse and of the action of the heart is often the earliest indication of the approach of danger in typhoid fever, and both pulse and heart should therefore be carefully examined at every visit. The first change is usually a diminution in the intensity of the first sound of the heart. This is significant, as it is frequently the earliest premonition of cardiac failure, to which a large proportion of the deaths in typhoid fever is due. A pulse of 120 and over, especially if it is at the same time feeble, is also unfavorable. The important part which the frequency of the pulse plays in the prognosis is shown by the following observations made by Liebermeister at the hospital in Basle: Of 63 cases in which the pulse rose to or above 120, 40 were fatal, or nearly two-thirds. Among these 63 were 37 in which it did not rise to 140; of these, 19 were fatal, or about one-half; in 26 it rose above 140; of these, 21, or about four-fifths, were fatal. In 12 patients it rose above 150; of these, 11 died. Of those in which the pulse rose to 160, the only case that ended in recovery was that of a girl twenty-one years old suffering from an imperfectly developed typhoid. Intermittence of the pulse is unfavorable, especially, according to Hayem,92 when it occurs during the first week of the disease. In convalescence intermittence is not to be regarded as an unfavorable symptom. The prognosis is bad also in those cases in which, with excessive weakness of the pulse, there are other evidences of cardiac failure, as, for instance, congestion of the lungs, cyanosis of the surface, coldness of the extremities. A very frequent pulse is not so unfavorable in a child as in an adult, or in a person of a nervous temperament as in one of a different disposition.
92 Loc. cit.
Other unfavorable symptoms are a dry, brown tongue, excessive tympanites with great abdominal tenderness, severe diarrhoea, vomiting when it occurs late in the disease, intestinal hemorrhage, and colliquative sweats. The delusion sometimes observed in very severe cases, in which the patient declares that he is not ill, is a very bad sign, many authors, and among them Louis, asserting that they have never known recovery to take place after it has been manifested. Peritonitis is a very serious complication, whether due to perforation or to some other cause. Still, it would appear not to be invariably fatal, since recovery has occurred in cases in which all the symptoms of this complication were present.
Favorable symptoms, on the other hand, are a gradual decrease of the temperature with increasing morning remissions, moistening and cleansing of the tongue, a lessening of the delirium, and other nervous symptoms, reappearance of an intelligent expression, recognition by the patient of friends and attendants, and a diminution of the diarrhoea. A copious eruption is also regarded by many as a favorable symptom. Cases in which constipation exists generally do well. Nathan Smith never knew a patient to die whose bowels were constipated throughout the attack.
The death-rate of typhoid fever is found to vary very considerably in different years and in the different seasons of the year, as will be seen from the two following tables. Statistics as to the mortality of the disease to be reliable must therefore be based upon a large number of cases extending over a series of years.
The following table shows the number of cases admitted into the Pennsylvania Hospital during each of the twenty years ending Dec. 31, 1881, and the ratio of mortality among them: