August 12: Eruption of innumerable, almost confluent, sudamina; subsultus tendinum, irregular unequal pulse, secessus involuntarii.
August 14: At the morning visit the patient appeared somewhat better and answered readily several questions; yet the following night he was seized with convulsions, and the next day, August 15, we found him with head retracted, lips and face cyanotic, and thorax prominent and motionless; in other words, in a state of almost complete asphyxia, as a result of the tetanic contractions of the thoracic muscles (an actual paroxysm of tetanus). In spite of immediate inhalations of chloroform and sinapisms to the extremities and thorax, he died on August 15, at 10
Autopsy*-The bronchi filled with froth. On the anterior surface of the heart, one ecchymotic spot. No intestinal lesions. The spleen was enlarged to about three times its normal size, was extremely soft, dark in color, and when examined microscopically, showed an enormous number of pigmented organisms of different kinds.
We have detailed examples of mild infections with typhoid symptoms on dd. 74, 75, 79.
* Here given in abstract.
Some writers differentiate an adynamic form of typhoid pernicious. These cases are characterized by subnormal temperatures, associated with the continuance of the severe prostration. The apathy of the patient is especially striking. He lies devoid of intelligence, with wide open eyes, giving either no or an unintelligible random answer to questions, occasionally laughing idiotically. He is often too weak to sit up, and if the limbs are elevated, they fall back lifeless. Swallowing is difficult.
Icterus, severe anemia, leukocytosis, and hemoglobinuria are often present (Kelsch and Kiener). The pulse is extremely small and weak. The adynamia occurs most frequently in persons who have become severely anemic on account of preceding malarial disease. This form, therefore, is most commonly observed late in the fever period; in other words, in the months of September and October. The symptom complex is ordinarily annexed to that previously described for typhoid pernicious, and may last several days and then gradually give way to a long convalescence. If a renewal of the fever occurs during the adynamia, it aggravates the prognosis (Kelsch and Kiener).
In the following we present a case of Kelsch and Kiener's, which shows to what degree of anemia this condition may advance:
B., soldier in the Third Zouaves. Had two years' service in Algeria. Acquired intermittent fever after returning, in August, 1874, from a detachment in the forest, near Jemmapes. The fever, first tertian, then quotidian, finally irregular, resisted treatment; the patient was, therefore, removed on September 27 to the hospital at Philippeville. He left the hospital on October 26 in a very anemic condition after receiving permission to return to France to recuperate. Before going on board, homeward bound, he had, on August 29, a severe attack, beginning with fainting, and from this he fell into a half comatose condition. This was still continuing when he was brought to the hospital on October 30.
On admission: Stupor; no answers could be gotten to questions. Patient stared vacantly before him, mumbling to himself, and repeating always the same word. The face was expressionless, extremely pale, grayish or somewhat yellowish. The spleen was enlarged. Quinin sulphate, 1.0.
October 31: Stupor less marked, yet continued severe adynamia. During the night, involuntary passage of urine. Temperature, 38.2°. Blood examination: Erythrocytes, 1,090,400; leukocytes, 2585. In the microscopic field, a few melaniferous leukocytes.*
November 1: Patient has again fallen into a half comatose condition; does not answer when spoken to. The look is vacant, the eyes wide open. Occasionally an idiotic laugh. Involuntary urination. No stool. Temperature, morning, 38°; pulse, 100 and weak. Evening, 37.2°; pulse, 84. Blood examination: Erythrocytes, 931,540; leukocytes, 1980; a few pigmented cells.
* Malarial parasites had not been discovered.
November 2: Patient slept during the night. The sensorium is more active, the patient answering, though slowly. The memory is cloudy; the expression of the face is that of a lost, feeble minded character. The tongue is pale and moist. No stool; involuntary urination. Temperature, morning, 35.8°; pulse, 84; evening, 36°. Blood examination: Erythrocytes, 779,260; leukocytes, 3290; no pigment found.
November 3: Remarkable improvement; the memory has returned, and the patient is able to give information as to the beginning of the disease. Voluntary urination; the urine concentrated, but contains no albumin. Weakness marked, color of the face cachectic, continued hypothermia. Blood examination: Erythrocytes, 668,714; leukocytes, 2820; no pigment.
The following days gradual improvement. Patient gained constantly in strength. The temperature varied between 35.6° and 38.8°.
From November 8 the blood finding improved: Erythrocytes, 1,022,438; leukocytes, 2350; here and there a melaniferous cell.
November 13: Blood examination: Erythrocytes, 1,610,502; leukocytes, 3055. Slow convalescence.
As already mentioned, Kelsch and Kiener had in the adynamic forms a mortality of 25 per cent.
Death takes place in the hypothermic collapse, with an outbreak of sweating, in a faint with coma, or in convulsions.
Convalescence is usually protracted and tedious. The edema of the legs may continue a long time as a result of the anemia and heart weakness. Moreover, thromboses and gangrene are sometimes seen.