Typhoid bacilli occur in the blood with much greater frequency and during a much longer time through the course of the disease than was formerly supposed. The conditions which favor their pres ence, why they are found at times in mild cases and are absent in more severe ones, are questions which must yet be solved. That cultures from the blood in typhoid fever have very definite clinical importance, especially where the \Vidal reaction is delayed, as is so often the case, is evident. From personal experi ence, the use of considerable amounts of blood, diluting very largely in liquid media, and, on account of the use of the latter, especial care to avoid contamina tion are the points of chief importance. R. I. Cole (Johns Hopkins IIosp. Bull., July, 1901).
Sometimes, when there is extreme weakness in the latter stages of the dis ease, hard masses may form in the rec tum of a chalky appearance, the evacua tion of which causes great exhaustion.
Sometimes assistance is necessary to their removal.
Hmmorrhage from the bowels oc curred in from 3 to 5 per cent. of all cases collected by Flint, and in 99 out of 2000 cases observed in Munich. It usually occurs at the end of the second or during the third week. It is a ous, but not necessarily fatal, symptom.
About two-thirds of the cases terminate favorably.
According to Wilson, modern statistics give a mortality of from 30 to 50 per cent. in which the patients die either from exhaustion or from subsequent per foration and peritonitis. In some cases the haemorrhage is, for a few days, slight in amount, and then the blood may be poured out in large quantities. In others, again, a severe haemorrhage may come on suddenly and unexpectedly. Sometimes small quantities of blood may be evacu ated daily without the occurrence of any great loss. A severe and even fatal haemorrhage may take place after the dis appearance of the fever, apparently from the breaking down of the cicatricial tis sue.
The general symptoms of hmmorrhage are fall in temperature, increased rapidity and weakness of the pulse, and a cold and clammy condition of the skin.
In some cases the symptoms are pres ent some time before the blood is evacu ated.
In addition to the symptoms already mentioned, delirium ceases and con sciousness may be regained after the loss of a large quantity of blood. Faintness and extreme prostration precede a fatal result.
In cases which rally the temperature rises and the symptoms of collapse grad ually disappear. A diagnosis of con cealed hemorrhage is made by noting the symptoms already described and by mak ing a careful physical examination of the abdomen. Dullness on percussion, with a feeling of more or less resistance, will be found in some cases over the right iliac region and sometimes extends along the ascending colon. Intestinal haemor
rhage may be part of a general condition, and ulceration into a. vessel may have taken place.
or less swelling of the abdomen from the accumulation of gas is usually present. It does not, as a rule, give rise to grave symptoms. Meteorism arises from two principal causes: the increased fermentation which takes place in the intestinal contents and the paralysis of the muscular coat resulting from toxaemia. The presence of a large quantity of gas depresses the heart's action and favors the occurrence of perforation and haemorrhage. Meteor ism is, no doubt, increased in some cases by the administration of too much food.
Pain is present in a small number of cases. Intestinal ulceration and subse quent peritonitis may give rise to very severe pain. Tenderness on pressure in the right iliac fossa is frequently noticed. It may be most marked near the um bilicus and is occasionally found over the whole surface of the abdomen. The amount of tenderness is apt to be greater in nervous patients. Gurgling from pressure over the right iliac fossa is often present, but is found in many other con ditions as well as in typhoid fever.
Perforation and Peritonitis. — The ulceration of Pet'er's patches, which usu- , ally extends to the muscular coat, is sometimes continued through the peri toneum. An opening is made through which the gas, liquid, and solid contents of the intestine pass out into the peri toneal cavity. The patient is usually seized with sudden and severe pain in the umbilical region, which subsides only after the administration of morphine.
Study of pain as a symptom in 500 cases. About two-fifths of the patients are free from pain or tenderness, rather less than one-fifth have tenderness only, and pain is present at some time in about two-fifths of the cases, but dur ing the course only in about one-third.
Pain due to some condition other than the specific bowel-lesions was present in about 14 per cent. of all cases and in about two-fifths of the patients having pain during the course. It occurred with hmmorrhage or perforation in about 5 per cent. of all cases, and in about 15 per cent. of the cases in which there was pain during the course. It was most constantly present with per foration, when it was usually sudden in onset, severe in character, and paroxys mal in occurrence. The pain of perfora tion was most closely simulated by that occurring in some cases of Inemorrhage, that from phlebitis, and that of un known origin. In about two-fifths of all cases with pain during the course no cause could be found. Should this occur with other abdominal symptoms the condition may much resemble perfora tion. Thomas SlcCrae (N. Y. Med. Jour., May 4, 1901).