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In the cases, of which this was one, all occurring at the same time in patients who had been in the hospital for a fortnight suffering from quite ordinary diseases, it is certain that the disease was contracted during their stay in hospital. They are interesting on this account of interest especially from the fact that, presenting almost identical symptoms of very varying intensity, one of them was due, not to typhoid, but to paratyphoid infection. It seems highly probable that further investigations will show that not only paratyphoid, but other bacilli, may be responsible for varieties of cases of what clinically seem all to be typhoid fever.
The discovery of paratyphoid fever, differing as it does but little from an ordinary case of typhoid fever-except in the mildness of the symptoms and the far less liability to a fatal issue is obviously a decided step in the disintegration of the idea of all cases of what is clinically typhoid being due to a single cause. It is possible--even probable-that we shall progress still further in this work of disintegration, but meanwhile it is certain that we must abandon the idea of typhoid fever being a purely intestinal disease, and must regard it as toxæmia, or a modified form of septicemia, in which the organism which is the actual cause of the disease passes from the local and primary seat of infection into the blood, and produces there the toxins which give rise to the various symptoms. These symptoms will depend (1) upon the intensity of the poison, (2) upon the special conditions of the invaded organism, (3) upon the particular part of the body upon which the disease chiefly spends itself. A certain number of our patients die within a few days from the onset of the disease, from an extreme dose of poison, just as occurs occasionally in every zymotic disease, often before local manifestations of the malady have had time to manifest themselves. Of such a nature was the case of John M., aged thirty, who came under my care on February 9 of last year, and died on the 23rd. It was noted on admission, though he had been ill for only a very few days, that he was very ill; he lay on his back in a restless, asthenic manner, with flushed face, respirations about 36, and a running dicrotic pulse of
about 130; his tongue was dry, furred, and cracked; the abdomen was distended, but moved a little, and was not rigid; some diarrhoea was present, but was not excessive. He gradually sank into a profoundly asthenic state, was very restless, listless, and feeble; both lungs became congested, but no pneumonia or other complication occurred; the spleen could not be felt, and there were no spots to be seen. No improvement of any kind occurred, and he died, as stated, fourteen days after admission. It was quite clear that in this case no local mischief was responsible for the patient's death. One felt that never from the first moment he was seen could any hope be entertained of his recovery, and though he was watched and treated with the utmost solicitude, and freely stimulated by brandy and subcutaneous injections of strychnine, no improvement took place. He died from the huge dose of poison. According to Curschmann, this case represents a well-marked type of the disease, and one in which the prognosis is always hopeless. Death occurs even in such cases before the specific intestinal lesions are marked, and may take place as early as at the end of the first week, while it is rarely postponed longer than the end of the second.
In marked contrast with a case of this description is that of a girl, Annie E., aged twenty, who was admitted on the 31st of August, and left cured on the 10th of October. There was no doubt about the nature of the disease. The Widal reaction was positive, and she manifested in the slightest possible manner all the classical symptoms of the disease, with the exception only of the non-presence of spots. Her temperature never exceeded 100.6, and the pulse, though rising to 110, was always regular and good in quality. She never gave us the slightest anxiety, but, with the possibility of perforation always in view, was treated with the same care as though she had been gravely ill. The contrast between these two cases the one so gravely ill that one felt sure at first sight that there could be no hope of recovery, and the other so slightly ill as never to be the source of anxiety was most marked, and affords a strong proof, if proof were needed, that it is not the poison, but its amount, which is the danger to our patients.
Variations in the type of the disease are further afforded by those cases in which particular systems, such as the respiratory or nervous systems, are affected. The affections of the respiratory organs may occur in any portion of the respiratory tract, and may be distinguished into those which are due to typhoid infection, and those which are complications of the disease. Epistaxis occurs usually early in the disease, and is of no special moment; but if it occurs at a later period of the febrile stage, may be a source of danger.
Affections of the larynx and trachea are of much greater moment, and, when occurring by themselves or in association with bronchitis, often very seriously endanger the life of the patient. They sometimes occur as complications of the disease, and at others as direct evidence of the influence of the typhoid bacilli which have been found to exist in the laryngeal lymph follicles (by Schultz). Such a case was that of Jessie P., a woman of thirty-seven, who was admitted into the hospital suffering from typhoid on November 8, 1902, and did not leave the hospital until twenty-two weeks later, when, though the typhoid fever had long been cured, she still remained the victim of bronchial catarrh and difficulties of breathing, associated with the laryngeal changes. She was suffering markedly from bronchitis at the time of admission, with some tendency to asthenia. The ordinary typhoid symptoms improved rapidly, and caused no anxiety until at the end of the fourth week she was said to be greatly improved, and, as far as the ordinary typhoid condition was concerned, convalescent; but in the fifth week her condition got worse; her chief symptoms now were dyspnoea and stridulous breathing; her lungs were resonant throughout, but were blocked with ronchi; respirations were hurried; her pulse was 142; the temperature never exceeded 100. During the next week her general condition improved, but her cough remained about the same, with the expectoration of a good deal of frothy mucus. In the seventh and eighth weeks her condition remained much the same. The typhoid symptoms had disappeared, but there was a good deal of dyspnoea from the bronchitis, and stridor from the laryngeal inflammation.
At this time a small ulcer was found at the base of the arytenoid cartilage in the inter-arytenoid space. She progressed pretty well under treatment until the fourteenth week, when the respiratory embarrassment suddenly became more marked, and a laryngoscopic examination revealed a small discharging abscess situated at the base of the right arytenoid cartilage. This discharged copiously, and was evidently the pointing of deep burrowing pus. There was also some œdema of the glottis, with an intense reddening. The patient, who had been allowed up, was sent to bed again, and early in the fifteenth week was discovered one evening unconscious, blue, and apparently moribund. The house physician performed immediate tracheotomy with his penknife, and, thanks to his determination and persistence, after four and a half hours of apparently hopeless artificial respirations, the patient came round. She improved gradually and slowly, and was able to leave the hospital seven weeks later very greatly improved in general health, but still suffering somewhat from bronchitis. These laryngeal complications, which are commonly due to direct local infection, are very alarming and often fatal, but I have come across very few of them in my own personal experience.
The larger bronchi are often affected in typhoid, usually, if not always, as complications of the disease; but the bronchial glands are often found on post mortem examination to be swollen and to present evidence of the presence of the bacillus of Eberth.
Catarrh of the medium-sized and smaller bronchial tubes is almost a constant symptom in enteric. Murchison used to say-and Broadbent has repeated-that fever steadily increasing for a week, without local inflammation, may, with a few exceptions-notably influenza--be set down as typhoid; and I am very confident that there are no symptoms of early typhoid so constant or so suggestive of a typhoid infection as catarrh of the smaller bronchial tubes, when associated with the peculiar rise of temperature characteristic of the disease.
Curschmann is of opinion that, from the constancy of its -occurrence and the peculiarities of its symptoms and course,
it can be definitely looked upon as a specific typhoid symptom, and may be attributed directly to the action of toxins or of the bacilli. It occurs usually in the lower lobes, and sometimes may extend to the whole of both lungs. It is not unusually attended with cough or much, if any, expectoration.
Lobar pneumonia is, if it occurs, almost invariably a complication, and not a symptom, of the disease; but bronchopneumonia occurs with greater frequency, and, though it is usually a complication, it may sometimes be of a specific typhoid character.
Finkler and others have said that the presence of the bacillus of Eberth is the exciting cause of this form of inflammation-it is a very dangerous complication of the disease, and death occurs in the majority of cases. The following case illustrates not only a marked type of the disease from which the patient recovered, but also demonstrates in most pointed manner the value of oxygen in promoting
Alfred B., aged thirty-four, was admitted to the hospital, suffering from well-marked typhoid, on the 18th of March last year, and left it cured on the 30th of May. The ordinary typhoid symptoms gave no trouble, but in the third week his lungs became blocked with rhonchi, and his breathing hurried, shallow, and frequent. His face was cyanosed, his pulse was 130, his temperature oscillating between 100 and 103 degrees. It was noted that he was very asthenic, and he exhibited subsultus, and delirium of a low type,. and that there was congestion of the bases of both lungs; and improvement seemed hopeless, but, thanks again to theenergy of the house physician and nurses, for a whole fortnight oxygen was administered at hourly intervals, and digitalis and strychnine were given subcutaneously every fourhours. Life was maintained at a very low ebb and with great difficulty until the sixth week, when his lungs began to improve, but the asthenia was so marked that it was not until the eighth week that strychnine injections could be omitted, and he began to make decided progress, which was uninterrupted until his discharge from the hospital.