The ordinary temperature-curve may be quite changed by the presence of com plicating inflammations, especially of the lungs. Moderate fever is not always an indication of the mild character of the disease. Death from hemorrhage or in flammation may occur in apparently mild cases.
A sudden fall of temperature toward the end of the second or during the third week is of serious moment, as it usually indicates either haemorrhage or perfora tion.
Cases of apyretic typhoid have from time to time been reported in which the temperature has never risen above the normal standard, and in some there has been a decline as low as to 95°.
Cases occasionally occur in which the temperature in the fourth, fifth, or even sixth week pursues a most irregular course. They are often marked by rig ors, with rapid elevations, sometimes as high as 105° or 106°, followed by equally rapid descents, often to below normal.
Such pyuemic curves may occur when there is no formation of pus to account for them, and not infrequently such pa tients make a complete recovery. The sudden exacerbations of fever are prob ably due to the absorption of septic matter through the ulcerated surface of Pet'er's patches.
During the stage of convalescence moderate rises of temperature may fol low indiscretions in diet. overexertion, or excitement, such as might be caused by the visits of friends.
In occasional cases a moderate eleva tion of 100° or 101° may be maintained long after the symptoms of fever have passed away. This is sometimes due to exhaustion, to deficient elimination, and to anaemia.
The Circulatory System.—The pulse in typhoid fever is slow in comparison with the temperature. It does not usu ally rise higher than 100 during the first week and part of the second week. It is then soft, compressible, and dicrotic. In the third week it may become small and rapid. Slight movements in the bed will, in most cases, produce increased frequency of the pulse. A sudden rise during the course of the disease is often an indication of a complicating inflam mation or hemorrhage. During con valescence occasionally the pulse tinues rapid, and the writer has observed in one case its rapidity to be maintained for months.
Bradycardia (slow pulse), sometimes as slow as 30 per minute, is observed in some cases. This appears to be charac
teristic of certain epidemics.
In the milder form of the disease the heart may maintain its force throughout, but usually the apex-beat becomes ceptibly weakened, and the volume of the first sound of the heart lessened in the latter stages of the disease. This weakening of the heart is due to degen eration of the myocardium. Occasion ally a systolic bruit is noticed, and some times in convalescence oedema of the limbs may result from weakening of the cardiac walls from anaemia, or from venous obstruction.
Enclocarditis and pericarditis are rare complications of typhoid fever. Venous thrombosis, however, is not unusual, oc curring more often in the veins of the lower extremities.
This takes place late in the disease or during convalescence, and is very often attributed by the patient to some un usual exertion.
Among the 215 soldiers suffering from typhoid fever admitted to the Pennsyl vania Hospital, there were 30 cases, or almost 14 per cent., of phlegmasia dolcns, or milk-leg. In IS of these 30 eases the left leg was affected alone in three, the right alone in two, and both in 13, the latter generally beginning on the left side when not appearing simultaneously in both. The greater tendency of this complication to occur in soldier patients may possibly be attributed to relaxa tion with distension of the venous sys tern in the legs, due to marching, thus predisposing them to the disease. The primary factor in the etiology of the dis ease is a thrombosis of the veins, and not a phlebitis or periplilebitis. J. M. Da Costa (Boston Med. and Surg. Jour., Mar. 23, '99).
The heart should always be carefully watched during the course or the fever, so that, as soon as dilatation commences, as shown by an accentuated pulmonary second sound in association with altera tion of the first sound and displacement outward of the apex-beat, the hypo dermic injection of strychnine should be started. For its success it should be em ployed early, and not called in only where cardiac dilatation is well marked. Strychnine thus given is far superior to digitalis and strophanthus by the mouth. H. D. Itolleston (Treatment, Oct.; New York Med. Jour., Dee. 27, 1902).