ON THE SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER, 
AND ON THE HEPATIC COMPLICATIONS 
WITHOUT JAUNDICE. 
BY 
J. M. DaCOSTA, M.D., LL.D. (Harv.), 
OF PHILADELPHIA. 
Transactions of the Association op American Physicians. 
REPRINTED FROM THE 
1898. ON THE SIGNIFICANCE OF JAUNDICE IN TYPHOID 
FEVER, AND ON THE HEPATIC COMPLI- 
CATIONS WITHOUT JAUNDICE. 
J. M. Da COSTA, M.D., LL.D. (Hart,), 
IILADELPHIA. 
During the past winter there were in the wards at the Pennsylvania 
Hospital a number of cases of typhoid fever that presented the peculiar 
and rare symptom, jaundice. It is the object of this paper to analyze 
these cases and to inquire into the significance of jaundice when occur- 
ring in typhoid fever, at the same time that the hepatic complications in 
which jaundice does not generally happen will be passed in review. 
Case I.—A colored woman, aged eighteen years, was in the ward for a 
long time, extremely ill with typhoid fever. The course of the fever was 
marked by only moderate diarrhoea, but it was attended with very high 
temperature, the record showing temperatures of 105° and upward, and by 
nervous manifestations, especially delirium; the Widal reaction was decided. 
In this case of long-continued typhoid fever there appeared two striking 
symptoms: one was jaundice, the second was inflammation of the right 
parotid gland. 
The jaundice appeared on the eleventh day of the disease, and though 
by the thirtieth it had greatly diminished, yellowness was still perceived in 
the conjunct!vse. The jaundice was not associated with any marked change 
in the size of the liver; if there were any, it was slightly increased, for the 
percussion dulness was distinctly to be detected below the margin of the ribs; 
the organ was painful to the touch when pressure was made over its free 
border, and there was general sensitiveness of the abdomen. 
Subsequent to this state of things the right parotid gland gave evidence of 
inflammation, and became tumid and tender. The swelling at the angle of 
the jaw subsided without suppuration under local treatment with ice and 
applications of tincture of iodine, and by the thirtieth day of the disease 
there was very little to be felt of the parotid swelling, which at one time 
threatened to form an abscess. As further symptoms in the case may be 
noted nausea and vomiting, hebetude, and albuminous urine showing blood- 
cells and granular and hyaline casts, as well as pus casts and bile-stained 2 
DA COSTA, 
epithelial cells. The urine was freely passed, forty-six ounces in twenty- 
four hours, and contained one-half gramme of albumin to the litre; it 
responded readily to the tests both for biliverdin and bilirubin. On several 
occasions chills occurred, but they were not severe; the blood was examined 
for malarial organisms, with negative results, 
Jaundice persisted, though slight, for a few days more; the tenderness 
over the lower part of the liver disappeared ; the bowels were constipated ; 
the tongue was somewhat coated; the temperature was 99°. The urine, 
tested repeatedly when the jaundice was at its height, gave evidence of the 
presence of bile-pigment. The stools were never clay-colored; indeed, they 
were usually the ordinary stools of typhoid fever ; sometimes they were noted 
as brown, sometimes as yellow or greenish. No bile-pigment was detected in 
the urine on March 7th, the thirty-second day of the disease. The patient 
made a good, though slow, convalescence. 
It is worthy of note that the jaundice was associated with parotid 
swelling, which I think more than a coincidence, as it has happened in 
other instances, as we shall further on see. 
Let me now give the particulars of a case of jaundice in typhoid fever 
which came on very late in the disease, only three or four days before 
death, and grew in intensity to the fatal ending. 
Case ll.—Sarah K. 8., aged thirty years, white, was admitted February 
18,1898, with the statement that thirteen days previously she had been taken 
ill with anorexia, diarrhoea, vomiting, and epistaxis. She had not had a chill, 
headache, or cough. Upon admission her temperature was 104°, the pulse 
120, the respirations were 40 to the minute. Her cheeks were flushed, the 
pupils were large, the sclera clear, the conjunctivee of a good color. Sordes 
existed upon the teeth and lips. The tongue was dry, red at the tips and 
edges, with a brown streak in the centre. Her breath was fetid. The lungs 
were clear on percussion; there were no rales. At the apex of the heart 
was heard a blowing systolic murmur, not transmitted ; at the base, too, was 
a soft, blowing systolic murmur, which was transmitted into the carotids; 
there was no venous hum. The heart’s action was regular but rapid. The 
pulse was small in volume and dicrotic. The liver-dulness began at the sixth 
rib and extended to the costal margin; the border was not palpable. The 
spleen extended from the eighth rib in the mid-axillary line to the last rib ; 
it was not palpable, and not tender upon percussion. The abdomen was 
tympanitic, and, upon pressure, pain and gurgling were elicited in the right 
iliac fossa. Characteristic rose-spots were found on the abdominal surface. 
There were pre-tibial cedema and some pain upon pressure in the legs. 
On the following day it was noted that hebetude was marked, the facial 
expression was dull, the temperature was 102° to 103°, the pulse very weak, 
dicrotic, and compressible. The urine was straw-colored, with an abundant 
sediment; it was acid, of specific gravity 1030, and contained a trace of 
albumin, with abundant urates and granular and hyaline casts. SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
3 
The treatment was beta-naphtol, three grains every third hour; whiskey, 
a half-ounce every second hour; strychnine sulphate, one-thirtieth of a grain 
every fourth hour, and a milk diet. The surface of the body was sponged 
with cold water every third hour, when the temperature was 103° or over. 
During the next few days the bowel movements continued loose and fre- 
quent, from four to seven daily. The eruption became more profuse. The 
temperature was only kept down by systematic sponging. The splenic area 
of dulness became much increased, and some local tenderness developed; 
the tongue became dry, brown, and fissured. The Widal test of the blood 
yielded a positive reaction. The stimulant was increased to five drachms 
every two hours on the 21st, on account of the very dicrotic character of the 
pulse; but as this was better the next day the whiskey w’as decreased to four 
drachms every two hours. The hebetude continued; there was epistaxis on 
the 23d. On the 24th the pulse was noted as stronger and more regular, 
though still rapid. A systolic murmur, looked upon as hemic, persisted. 
There was marked throbbing of the carotids ; the second cardiac sound was 
distinct. She was weak and exhausted, at times delirious, though the mind 
was mostly clear. On the 25th some yellowness of the conjunctive was ob- 
served, and the urine contained bile-pigment. On the 26th it was noted that 
the skin and conjunctive were markedly jaundiced. The pulse was feeble and 
compressible. The bowels were very loose, eight movements within the last 
twenty-four hours, notwithstanding the use of opium suppositories; the dis- 
charges were thin and yellow. Dilute nitro-muriatic acid, fifteen minims, 
was given every four hours in place of the beta-naphtol, which had been 
discontinued. Oxygen inhalations were also employed, and she took 
strychnine. 
On the 28th the records state that the delirium was deepening. She was 
intensely jaundiced all over the body. The eruption was still profuse; the 
liver was not enlarged or palpable; there was no pain or soreness over it. 
The pulse was very weak; sordes were present on the teeth and tongue; the 
bowTel movements were green and yellow, and still loose. In spite of very 
free stimulation, the patient died of exhaustion during the evening. An 
autopsy was not obtained. 
In the cases that have been detailed the jaundice occurred as a late 
symptom. Jaundice may be, however, an early symptom, and even 
show itself in advance of the fever, appearing as the result of an early 
infective process in the bile-ducts. 
In a remarkable case which, so far as I know, is unique, the jaundice 
distinctly preceded the development of the typhoid fever, and occurred 
during the latter part of the period of incubation. 
Case III.—A Danish weaver was admitted into my ward at the hospital on 
January 7, 1884. He had been jaundiced for a few days without obvious 
cause. He complained of weakness and loss of appetite. His temperature 
was 99.5°, the pulse 118, The next day the yellowness of the conjunctive 4 
DA COSTA, 
and the skin was more marked; the tongue had a heavy yellow coat; the 
liver was observed to be somewhat enlarged, as was the spleen. The case 
was looked upon as one of catarrhal jaundice, and he was treated with phos- 
phate of sodium and Rochelle salts, and placed on a restricted diet. The 
jaundice slowly improved and almost passed away, but the man did not gel 
well, for, after the 19th, he was noticed to be decidedly feverish, and on the 
24th the morning temperature was 104°, and he was very weak ; his face was 
flushed; diarrhoea set in. A note made at this time states that he had all the 
appearances of beginning typhoid fever. On the 27th there was no doubt 
of the correctness of this view. The tongue was coated, with red edges and 
tips. The abdomen was tympanitic, the movements from the bowels loose 
and of typhoid character. Rose-colored spots were found on the abdomen. 
He had repeated epistaxis. 
He was treated with eight grains of quinine daily, with stimulus, with dilute 
muriatic acid, and, later, with turpentine. In the course of the case great 
restlessness, delirium, and subsultus tendinum were noted, followed by 
marked hebetude, increasing prostration, and frequent involuntary move- 
ments from the bowels. He died February 4th, from exhaustion. 
At the autopsy the liver was found to weigh four pounds, eight ounces. 
The gall-bladder contained thin, pale-colored bile; there was no evidence 
of inflammation or ulceration of its mucous membrane, or of disease of the 
bile-ducts. The hepatic cells showed a cloudy swelling; the same condition 
was noticed in the epithelium of the kidneys, which were otherwise healthy. 
The spleen weighed twenty ounces, was highly congested, and its tissues soft. 
The posterior portions of the lungs were much congested. A number of infil- 
trated and ulcerated Peyer’s patches were found in the lowest part of the 
ileum. There was also ulceration of many of the glands of the large intestine, 
and considerable swelling of the glands of the mesentery. 
it is difficult in this case to state exactly when the typhoid fever 
began, but, counting from the appearance of the eruption, which we 
know to be between the seventh and ninth days, the fever probably 
started on the 18th or 19th of January, and thus about two weeks after 
the onset of the jaundice. This, therefore, would be strictly within the 
period of incubation, and it seems reasonable to suppose that the 
typhoid infection had lighted up a catarrhal process in the gall-bladder 
and bile-ducts which antedated the intestinal affection and disappeared 
in the course of the febrile malady. The alternative suggestion is 
coincidence, which seems very unlikely. 
The case of jaundice in typhoid fever that I shall now describe was 
admitted into the Pennsylvania Hospital on January 31, 1898, the day 
on which I gave up the men’s medical ward to my colleague, Dr. Arthur 
V, Meigs, who kindly permits me to give the details of the case as it 
developed under his observation. SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
5 
Case IV.—J. S, a waiter, aged twenty-six years, was admitted into the 
hospital with the distinct statement that he had never had pneumonia, an 
affection of the liver, rheumatism, or typhoid fever. He had been ill for 
ten days previous to admission, and a week before his admission he was 
seized with a severe chill, followed by fever, sweats, and epigastric pains. 
From this time on he had a number of chills, with severe abdominal pains, 
most acute over the region of the gall-bladder, accompanied by obstinate 
constipation and vomiting. When examined on admission his temperature 
was 102.2°, the pulse 88; the skin and conjunctivEe were decidedly jaundiced ; 
the tongue was heavily coated; the abdomen rigid, not distended, but gener- 
ally painful on percussion. There was no particular tenderness in the right 
iliac fossa; the greatest tenderness was over the region of the gall-bladder, 
and pressure there caused nausea. The liver was distinctly enlarged and 
palpable. A considerable amount of urine was drawn by catheter. The man 
lay in bed with his legs flexed and with all the appearances of a local peri- 
tonitis. Poultices were applied to the abdomen without material modification 
of the symptoms. On the evening of the first day the temperature attained 
to 104.4°. It declined to 98.6° the next morning, and then passed by evening 
to 103°. On the second day after admission it had fallen early in the morn- 
ing to 99°. The patient was extremely restless, with clammy perspirations, 
the pulse was imperceptible, and he soon died. 
His case suggested an inflammatory disease within the abdomen rather 
than typhoid fever, and the symptoms were such as might have been due to 
an appendicitis at the upper part of the appendix. 
At the autopsy typical typhoid ulcers were found in the ileum and caecum, 
the mesenteric glands were swollen, the spleen was large and friable; there 
was no peritonitis. The liver was considerably enlarged; its left lobe had a 
blunt edge. There was no abscess or gross lesion in the liver. The gall- 
bladder was distended with an unhealthy-looking bile ; it contained no con- 
cretions ; its coats were not altered; it had no adhesions. There was no 
swelling or sign of inflammation in the biliary ducts. The base of the right 
lung was congested. 
It appeared at first from the symptoms that the case was one of 
cholecystitis; the nausea and vomiting, and especially the seat of pain, 
pointed to it. But the autopsy did not bear out this view, since no signs 
of inflammation of the gall-bladder were found. The distention of the 
viscus was the only thing to account for the pain; and the jaundice 
must, after all, have been the result of the blood alteration and the 
morbid condition of the liver structure. It is to be regretted that 
there are no microscopical or bacteriological examinations to record. 
In the case we have just examined the jaundice was associated with 
the occurrence of chills; indeed these formed a prominent feature of 
the morbid manifestations. They were yet more so in the following 
case, though the lesion was, I believe, a different one. The man was 6 
DA COSTA, 
shown at a clinic with great enlargement of the spleen in the course of 
typhoid fever, and the jaundice subsequently developed in the midst of 
very grave symptoms. 
Case V.—A Swedish sailor, aged twenty-three years, was admitted on 
December 6, 1897, with severe abdominal pain, that was at first over the 
whole upper part of the abdomen, but had localized itself in the left hypo- 
chondrium, extending almost to the crest of the ileum. The temperature 
was 99.6°. The bowels were moved two or three times daily ; the discharges 
were not loose. The pulse was 120, weak, and irregular; the tongue mark- 
edly coated and tremulous. The history obtained was that he had been an 
unusually healthy man who did not remember any illness except an attack 
of malaria some years ago. Eight weeks since, while at sea, he began to 
suffer with headache and weakness; subsequently was seized with fever ; was 
delirious part of the time, and altogether decidedly ill for weeks on board 
ship. He was very weak when he left the ship, but after reaching land he 
began to improve until the last few days, when he had night-sweats, abdom- 
inal cramps, and felt himself very ill. The day of admission the temperature 
rose in the evening to 104.2°; no rose-spots were found. The most marked 
feature of the case wras the extent of the splenic dulness, which was 18 cm. 
in length from the sixth rib laterally, and passed fully two fingers’-breadth 
below the costal margin. The enlarged organ could be distinctly felt, and 
was very tender on pressure; indeed, the whole splenic region was tender to 
the touch, extremely so on percussion. Bulging was visible to the eye, and 
the line of dulness was influenced by inspiration and expiration. The heart’s 
action was rapid, the second sound accentuated; there was no murmur ; 
marked pulsation existed at the supra-clavicular notch. 
He was looked upon as having typhoid fever with splenitis, and the ques- 
tion of abscess of the spleen was considered. There was some doubt whether 
we were dealing with the primary attack of the fever, prolonged by the con- 
dition of the spleen, or with a relapse ; the former view was adopted. The 
patient was placed on dilute muriatic acid, twenty minims every fourth hour, 
on milk-diet, and the ointment of iodide of mercury and lanolin, equal parts, 
with four grains of extract of belladonna, was rubbed in over the spleen. The 
blood examined microscopically showed 4,500,000 red to 6000 white corpus- 
cles. Widal’s reaction was positive. The urine was acid, of specific gravity 
1029, and contained neither sugar, nor albumin, nor casts. 
On December 9th, three days after admission, a crop of rose-spots was 
found on the abdomen. These disappeared by the 13th; his whole condi- 
tion was steadily improving and the temperature had become normal A 
note on the 16th speaks of the large size of the spleen persisting, but of the 
tenderness having gone; of the absence of tympany, of tension of the abdo- 
men, and of any signs of cardiac disease. On the 17th the temperature began 
to rise, and by the evening of the 18th it had attained to 105°; the pulse was 
148, and weak; the respirations were 40. There was a slight return of the 
splenic tenderness, but nothing marked. The blood was examined for plas- SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
7 
medium; none was found. Dark days followed, with recurring severe chills 
and temperature of 106°, with a pulse weak and 156; with hurried, shallow 
breathing and congested lungs, but with the murmur remaining vesicular. 
The first sound of the heart was indistinct, the second clearer and well 
defined. In the blood, repeatedly examined, no plasmodium was detected; 
a repetition of Widal’s test gave again the same positive result. Quinine in 
large doses produced no effect on the chills, and but little on the tempera- 
ture. A cold bath reduced it to 95°, but he did not bear the bath well. The 
temperature rose again by the next day to 105.3°, and two chills happened on 
that day. After the chills and the fever rises the patient did not sweat, but 
the skin was moist. A note of the 21st mentions yellowness of the skin and 
the conjunctive, and bile in a urine free from sugar, but slightly albumin- 
ous and containing hyaline and granular casts. There was no distention of 
the gall-bladder; the lower border of the liver could be felt, and was slightly 
tender; the organ extended just below the margin of the ribs. General 
abdominal pain existed at the upper part of the abdomen; the stools were 
not clay-colored. 
During the time of the chills and fever and at the height of the jaundice 
the treatment consisted chiefly of sixteen grains of quinine daily, and ot 
borate of sodium, ten grains every third hour, given for a time in place of 
the dilute muriatic acid, which, however, was afterward resumed; and, while 
the temperature was so high, three grains of phenacetin, with two of salol, 
were also administered with some apparent effect. For a time, too, the weak- 
ness of the circulation necessitated the free use of digitalis and of whiskey. 
The temperature, by the 21st, became normal and remained so with occa- 
sional exacerbations during convalescence. There was, however, from 
January 2d to the 10th, a post-typhoid temperature reaching 102°, without 
return of the eruption. The splenic dulness gradually decreased, and by the 
sth extended merely to the margin of the ribs; the jaundice had entirely 
disappeared by the sth, even to the urinary tests. The man left the hospital 
well on January 26th. 
It is very difficult to explain this case. As regards the spleen, there 
was no doubt of its great enlargement and tenderness, more marked 
than I have ever seen in typhoid fever, and I looked throughout the 
case for an abscess. But no positive evidence of this was ever obtained, 
and if it happened, or a purulent infarction occurred—which, as 
Murchison noticed in two cases, softened—the purulent fluid was 
absorbed or encapsulated, and no rupture took place. 
Regarding the spleen as the source of the grave symptoms, two views 
suggest themselves to account for the chills and the jaundice. One is 
that they were both pyaemic from the morbid process in the spleen, the 
jaundice being of blood origin, as it is in pyaemia. The second is that, 
considering the splenic vein as a main branch that goes to form the The lighter lines represent the Intermediate temperatures. 
Temperature Chart of Case Y, SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
9 
portal vein, infected thrombi produced a pylephlebitis, and that chills 
and jaundice, the latter certainly, resulted from the superinduced 
condition of the portal vein. The difficulty of adopting this view is 
the recovery. Still, we know that pylephlebitis may end in recovery. 
Frerichs tells us that this may happen when the pylephlebitis is not too 
extensive. In a recent operation for typhlitis Treves1 actually saw the 
morbid lesions. The liver surface was dotted over with the innumerable 
yellow specks regarded as characteristic of the disease, and the patient’s 
condition appeared hopeless, but she recovered. On the whole, I be- 
lieve that the view of the patient whose case I have been describing 
having had pylephlebitis is the correct one. 
Jaundice is of very rare occurrence in typhoid fever. Sir William 
Jenner2 states that he has never observed a case. Murchison3 has met 
with it in but four instances, and had a fifth case communicated to 
him. My friend and late colleague at the Pennsylvania Hospital, 
James H. Hutchinson, reviewing his experience in typhoid fever in an 
excellent article,4 mentions that he had not seen this complication, 
Petrina,5 during the years 1875 to 1880, met with but one case in 194 
deaths from typhoid fever. Griesinger is quoted by Liebermeister6 as 
having noted it ten times in 600 cases, and Liebermeister mentions 
that in the hospital at Basle it was observed twenty-six times in 1420 
cases, or one in about fifty-five. These figures indicate higher pro- 
portions than jaundice is generally regarded as occurring in, except 
in hot climates. Jamieson7 states that in China it is generally, perhaps 
always, present to a greater or less extent in prolonged cases, and cites 
nine cases in which it was deep. But Sorel,8 in Algeria, observed only 
six cases in 871 of typhoid fever. In cold climates jaundice in typhoid 
fever must be very rare. Huss,9 in analyzing 2294 cases of typhus ab- 
dominalis—typhoid fever—in Stockholm, does not mention an instance. 
Yet Werner,10 in St. Petersburg, speaks of having observed ten cases in 
one outbreak of typhoid fever. 
Prior to this winter I had met with but a solitary instance that I 
can recall, and it is remarkable that this paper, which contributes five 
to the scanty general number, should record four observed in the last 
1 British Medical Journal, February, 1894. 
2 On Fevers and Diphtheria. 3 Diseases of the Liver, 2d ed., 1877, p. 401. 
4 System of Practical Medicine hy American Authors, vol. i. p. 295. 
5 Prag, med. Wochenschrift, 1881, No. 41-43. 
6 Ziemssen’s Cyclopaedia of the Practice of Medicine, vol. i. 
7 Imperial Maritime Customs, China Med. Reports, 1888-95, 87th Issue, pp. 63, 67. 
s Bull, et M6m. de la Societe Med. des HSpitaux de Paris, 1889, tome vi. 3d series. 
9 Statistics and Treatment of Typhus and Typhoid Fever, etc., 1855. 
i° St. Petersburger med. Wochenschrift, 1892, p. 32. 10 
DA COSTA, 
few months, during which we have had a widespread epidemic of 
typhoid fever in Philadelphia. Where there is a complication of 
malaria, jaundice is not infrequent. Thus, in the report of so-called 
typho-malarial fever from the Seminary Hospital during the civil war, 
jaundice occurred in seven out of 64 cases, only one case of which wras 
fatal. 
As regards the time of the occurrence of the jaundice, it generally 
does not come on until the middle of or until late in the disease. In my 
own cases, omitting Case 111., where it antedated the febrile malady, it 
began in one case (Case I.) on the eleventh day; in Case 11., on the 
twenty-third day; in Case IV, it probably came on in the first week ; 
in Case V., as convalescence seemed to have been reached. In most 
of the instances on record that I have analyzed, it appeared in the 
second or third week of the disease. Still the jaundice may happen 
early, as it did in many of Jamieson’s cases.2 In one of Andral’s fatal 
cases3 it occurred on the third day; in a fatal case of Frerichs’/ on the 
fifth ; in one of Murchison’s5 that recovered, it appeared on the sixth 
day of a relapse; in one of Osier’s6 cases, also ending in recovery, on 
the fourth day of a relapse; in one of Sorel’s7 cases, not until convales- 
cence ; in McPhedran’s case,8 just before convalescence. It may go on, 
and is apt to go on, gradually deepening until death, and may—though 
this is very exceptional—become dark and intense. In cases that re- 
cover the jaundice gradually disappears with the fever; yet it may 
persist into convalescence, as in Case I. of this paper, and even remain 
after the patient is able to be about.9 
With reference to the symptoms that attend the jaundice, we do not 
find that they are constant; they are, as a rule, the symptoms of a 
severe case of typhoid fever with the usual amount of tympany and 
nervous disturbance. Delirium is apt to be present; yet I cannot say 
that it has seemed to me much aggravated by the hepatic condition, 
and there are intervals of clear mind even in the delirious patients, as 
happened in Case IV. and in Case V., in which questions are ansivered 
rationally. The temperatures are, as a rule, high, and, as the cases 
here presented prove, chills are not uncommon; nor are pulmonary 
congestions. Vomiting is a frequent but far from invariable symptom. 
1 Medical and Surgical History. Medical History, part iii. p. 805. 
2 Loc. cit. 3 Clinique Med., 1834, vol. i. 
4 Diseases of the Liver, 1858. 6 Diseases of the Liver, Case CXXXVII. 
6 Case 1., Transactions of the Association of American Physicians, vol. xii., 1897, p. 380. 
7 Societe Med. des Hopitaux, tome vi. 
s Canadian Practitioner, March, 1891. 
9 Case XXXVIII. in Murchison, Treatise on the Diseases of the Liver. SIGNIFICANCE OF JAUNDICE IN TYPHOID FEYER, 
11 
The urine almost always contains bile, and, as in grave cases of 
typhoid fever, is apt to show some albumin and granular and hyaline 
casts. Examined by Murchison,1 in two cases, for leucin and tyrosin, 
these were not found. The character of the stools is of special 
interest; they are much like the ordinary typhoid stools, or darker 
and greenish; they are very rarely clay-colored. In four of the five 
cases here reported they were not. But in one of Murchison’s2 cases in 
which jaundice happened during a relapse, the stools were noticed 
as clay-colored, and the same in Osier’s1 case in which jaundice ap- 
peared early in a relapse. There may be, as in one of Andral’s4 
cases, marked constipation. Neither the temperature nor the ]iulse has 
appeared to me to be influenced by the occurrence of the jaundice; the 
temperature remains high, the pulse rapid. In some instances profuse 
sweats occur. The liver is generally somewhat sensitive to the touch, 
especially at its lower border. In the cases I have noted it was slightly 
enlarged or of normal size. But it has been observed to be much 
reduced, as in the case reported by Sabourin ;5 in the case mentioned by 
Frerichs, the hepatic dulness was almost absent.6 
Complications attending the cases in which jaundice is met with are 
not unusual. Marked pulmonary engorgement existed in Cases IV. 
and V. detailed in this paper. In one of Andral’s7 cases the patient died 
of left-sided pneumonia on the ninth day of the disease; both lungs 
were highly congested. In a case described by Louis8 in which jaundice 
and bilious vomiting occurred, there was a purulent swelling of the 
right parotid; abscesses were found in the liver. In the first case of 
my series there was also parotid swelling, but it did not suppurate. In 
Sander’s9 case double parotitis followed, and the number of cases of com- 
bination of jaundice with parotitis in typhoid fever shows that it is more 
than coincidence. In one of Frerichs’ cases,10 too, parotitis is men- 
tioned, but it was associated with typhus rather than with typhoid, and, 
therefore, cannot be, strictly speaking, considered here. In another11 
of his cases of jaundice in undoubted typhoid, profuse epistaxis preceded 
the jaundice, as it did in Case 11. of my series. In Lannois’ case12 the 
epistaxis was marked and repeated; the jaundice was very intense, 
1 Ibid., p. 420. 2 Diseases of the Liver, Case CXXXVII. 
3 Loc. cit., p. 380. 4 Clinique Med., 1834, vol. i. p. 11. 
5 Revue de Medecine, 1882, p. 600. 
6 Observ. XVIII., Diseases of the Liver, vol. L, Sydenh. Soc. Trans., p. 215. 
7 Clinique Medicale, 1834, tome i. p. 11. 
3 Fievre Typhoide, vol. i., Observ. XVII., p. 111. 
9 Deutsche Klinik, 1861, p. 70. 10 Diseases of the Liver, p. 168. 
11 Ibid., Observ. XVIII., p. 215. 12 Revue de Med., 1895, p. 911. 
i° Diseases of the Liver, p. 168. 
is Revue de Med., 1895, p. 911. 12 
DA COSTA, 
black. Epistaxis, indeed, bears, I think, a distinct relation to the 
jaundice and its intensity. In one of Murchison’s1 cases thrombosis of 
the femoral vein happened in a patient who had become jaundiced on 
the fourteenth day of enteric fever. In Freundlich’s case2 thrombosis 
of the scrotal veins and gangrene of the left inguinal region coexisted. 
He had • also double croupous pneumonia of the lower lobes. When 
jaundice is severe and occurs early, Jamieson3 speaks of its usual asso- 
ciation with hsernoglobinuria, intestinal hemorrhage, and hfematemesis 
—indications of blood dissolution. 
Having examined into the mode of appearance of the jaundice and 
the symptoms attending it, let us inquire into its origin. Is it a jaun- 
dice of obstruction to the flow of bile, such as we know catarrhal jaun- 
dice to be, or is it due to the blood condition and the changes in the 
parenchymatous structure of the liver? In the great majority of in- 
stances, most assuredly, I think, not to the former condition. It is 
usually a blood jaundice, with more or less disorganization of the red 
corpuscles and often associated with alteration in the liver cells. In 
favor of this view we have these facts: its occurrence, as a rule, as a 
late symptom and in grave cases; the character of the stools, which are 
but little modified, and do not show any hinderance to the flow of bile • 
the general similarity to the jaundice noticed in other infective diseases 
and altered blood states, such as in pytemia. The condition of the liver 
itself does not give us much information. Yet where the organ has 
been carefully examined it has been found to show degeneration, 
granular or fatty, of the hepatic cells, that has even been likened 
by Frerichs to the state found in acute atrophy. Then in some in- 
stances we have abscess, though not in many, for I shall presently 
show that in the majority of cases abscess of the liver attendant on 
typhoid fever is not accompanied by jaundice. Further, we may have 
a pylephlebitis, with secondary changes in the hepatic tissue. However 
different, these causes may be all grouped together as non-obstructive 
jaundice—jaundice not from catarrhal obstruction of the bile-ducts. In 
a few instances this, however, does happen, and the records submitted 
in this paper prove that it is especially as a precursor to the active devel- 
opment of the enteric fever (as in Case HI. of my own cases), or in the 
early stage of a relapse, that this kind of jaundice occurs. 
Broadly speaking, then, the jaundice met with in enteric fever is due 
to the blood affection and the alterations produced by the toxins of the 
disease in the secreting cells of the liver, or to gross changes otherwise 
1 Diseases of the Liver, 2d ed., Ohserv. CXXIX., p. 420. 
3 Deutsche Archiv filr klin. Med., Bd. xxxiii., 1883, p. 318. 
3 Loc. cit,, p. 63. SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
13 
there induced, and only in exceptional instances to a catarrhal condi- 
tion of the bile-ducts. Besides this, jaundice in typhoid fever occurs from 
inflammation of the gall-bladder and the morbid changes in the bile-ducts 
that may attend the cholecystitis. But this I only mention here to enu- 
merate all the causes, as we shall presently examine this disease in detail. 
It is apparent that jaundice in typhoid fever is not always asso- 
ciated with the same lesion, and that we can no more regard it as 
significant of any one hepatic disorder than we can jaundice met with 
in the varied diseases of the liver and bile passages unconnected with 
typhoid fever. Further on, I shall endeavor to make clear in how far 
we can, with reasonable certainty, distinguish between the different 
causes of jaundice in typhoid fever; but for the present I again state 
that the most frequent cause is from the blood infection, and without 
gross organic lesion, though in a moderate proportion of cases this exists. 
Taking this general view of the subject, let us inquire into the gravity 
of the symptom. It is, indeed, a grave symptom, as may be judged 
from the following table, in which I have placed, together with my own 
cases, those in which there is sufficient detail to make them of any clinical 
value, and excluding the cases associated with perforation of the gall- 
bladder and other very marked gall-bladder lesions, which I shall speak 
of separately. 
We have thus, in 52 cases, 33 deaths and 19 recoveries. Analyzing 
further these cases, according to their probable cause, we find them thus 
grouped: 4 catarrhal; 3 pylephlebitis, of which in one (the case of 
McPhedran) there were also marked changes in the liver; 5 of chole- 
cystitis, in 2 of which (the cases of Sander and of Griesinger) there 
was most probably, too, cholangitis; 6 cases of abscess of the liver; 5 of 
acute yellow atrophy or a state closely akin to it (2 of Frerichs, 2 of 
Murchison, and 1 of Sabourin), and 29 cases in which blood infection 
and more or less of a fine parenchymatous change in the liver existed ; of 
these, 5 (Sorel’s) are not fully enough reported for us to be certain 
as to the cause of the jaundice, and, for the sake of accuracy, cannot be 
counted, leaving 24 in which the condition just mentioned was either 
proved or may be with reasonable certainty assumed to have existed. 
It would be very desirable to separate those in which there is. a mere 
blood infection, induced by the presence of the typhoid bacilli or their 
toxins in the blood, or the absorption of septic matter with or without 
infected thrombi, and leading to alterations in the blood-corpuscles, 
from those in which decided, though not gross, parenchymatous changes 
happen. But it is impossible to do so with any certainty. Moreover, there 
is no fixed line ; changes in the liver texture are soon secondarily induced. 14 
DA COSTA, 
No. 
Author. 
Reference. 
No of 
cases. 
Probable cause 
of jaundice. 
Marked associate symptoms. 
Result. 
Post-mortem appearances. 
Remarks. 
i 
Andral 
Clinique Medi- 
cate, 1834, vol. 
i. pp. 10, 616. 
2 
Blood infection 
In the first case pneumonia of left 
lung; heavy congestion of both lungs. 
In the second case jaundice very 
marked. 
Died. 
In both cases lesions of typhoid 
fever; condition of liver not 
stated in first case. In second 
nothing abnormal was seen 
in liver and biliary passages. 
2 
Louis 
Fievre Ty- 
pho'ide, 1841, 
vol. i. obs. xvii. 
p. 118, and obs. 
xxvi. p. 369. 
2 
Blood infection 
and liver ab 
scess in first 
case; blood 
infection in 
second case. 
In the flrfet case suppurating parotid 
gland ; pain in the sides and in epi- 
gastrium ; bilious vomiting ; marked 
delirium. In the second case jaun- 
dice on the twenty-fifth day of the 
disease, preceded by erysipelas of leg. 
Died. 
Typhoid fever lesions in intes- 
tines ; enlarged mesenteric 
glands; an abscess near the 
free border of the liver; six 
smaller masses (metastatic 
abscesses?) in the small and 
middle lobes ; bile passages 
healthy. In second case many 
typhoid fever ulcers; softened 
mesenteric glands; healthy 
liver and biliary ducts; dis- 
tended gall-bladder. 
3 
Frerichs 
Diseases of the 
Liver, obs. xiii., 
1858, obs. xviii. 
2 
Blood infection 
and parenchy- 
matous change 
in liver (like 
acute yellow 
atrophy). 
Great tenderness in region of liver, 
and afterward of entire abdomen ; 
thin greenish stools; bilious vomit- 
ing: chill, dyspnoea. In the second 
case chill; thin, pale stools ; violent 
epistaxis; tremor; dyspnoea; dimi- 
nution of hepatic dulness. 
Died. 
Typhoid ulcers in ileum; debris 
of disintegrated cells, oil glo- 
bules in the portions of soft- 
enedliver; liveryieldedleucin 
and tyroslnabundantly; gall- 
bladder not affected. In the 
second case liver shrivelled ; 
disiutegrat’n of hepatic cells, 
some filled with fat; mucous 
membrane of gall-bladder not 
affected : small quantities of 
whitish fluid in gall-bladder. 
4 
Sander 
Deutsch. Klin., 
1861, p. 70. 
1 
Cholecystitis 
and probably 
cholangitis. 
Jaundice appeared at end of second 
week; became very marked ; vomit- 
ing ; grayish stools; severe pain like 
bilious colic; tenderness in hepatic 
region and enlargement of liver; after 
five or six days gradual disappearance 
of the jaundice. 
Died. 
Biliary ducts were found to be 
dilated, and a large number 
of stones were in the gall- 
bladder. 
After having entered on con- 
valescence, the patient died 
in the eighth week subse- 
quent to double parotitis. 
5 
Chvostek 
Med. Chirurg. 
Rundschau, 
June, 1861, 
p. 188. 
1 
Blood infect’n; 
liver abscess. 
Laryngeal perichondritis ; deep jaun- 
dice; abscess of lung; jmeumothorax 
Died. 
Two large abscesses in liver, 
evidently pysemic and sec- 
ondary ; also abscess in left 
lung. 
Table of Fifty-two Cases of Jaundice Observed in Typhoid Fever, with Results. SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
15 
6 
Border 
Lancet,Oct. 17, 
1871. 
1 
Blood infect’n; 
liver abscess. 
Icterus on sixth day of fever in a boy 
nine years of age ; greatly increased 
after a chill on the eighth day; liver 
dulness normal; diarrhoea. 
Died. 
The liver was a mass of small 
abscesses; superficial ulcera- 
tion of Peyer’s patches. 
Had the bath treatment; 
death on seventeenth day of 
the disease. 
7 
Heitler 
Wien. med. 
Presse, 1875, 
No. 3. 
1 
Blood infect’n ; 
parenchyma- 
tous change 
in liver. 
Date of beginning of fever uncertain; 
jaundice probably about third week, 
preceding diarrhoea; stools bilious, 
subsequently yellow; no chills; urine 
albuminous, also blood and tube-casts 
in it; normal liver percussion ; in- 
creasing jaundice; delirium; coma. 
Died. 
Ulcers in ileum; lungs con 
gested; liver rather large, 
flabby, soft; brown bile in 
gall-bladder; spleen enlarged 
to four times its normal size. 
Abscess of liver discharged 
through bowel, pus and 
blood passing by the bowel 
on eighty-fourth day, after 
severe abdominal pain; com- 
plete recovery by one hun- 
dred and twentieth day. 
8 
Sidlo 
Der militar 
Arzt, Wien, 
1875, No. 23, 
p. 20. 
1 
Abscess of 
liver. 
Pain in the hepatic region on thirty- 
second day of typhoid fever; on thirty- 
fifth day jaundice ; swelling of liver; 
abscesses over right mastoid, in right 
temple, and in right axilla; tumor 
there gradually shrank; great emaci- 
ation ; gradual diminution of liver 
dulness and of jaundice. 
Recov. 
9 
Griesinger 
Infections- 
krankheiten; 
detailed also by 
Hagenmiiller, 
Theses de Paris, 
1876, No. 269. 
1 
Cholecystitis 
with probable 
cholangitis. 
Woman, aged twenty, in sixth week of 
typhoid fever, peritonitis, icterus, 
chills ; painful tumor to right of um- 
bilicus; swelling of liver; great pros- 
tration; convalescence. In eighth 
week return of tumor, with chills, 
icterus, vomiting ; got better; subse- 
quently two more relapses; the symp- 
toms disappearing under treatment 
with large doses of opium. Final re- 
covery in fifth month. 
Recov. 
The patient had previously 
had jaundice several times, 
especially at her periods. 
The case is remarkable for 
its length, the recurrence of 
the symptoms, and the final 
recovery. 
10 
Lave ran 
Case communi 
cated to Hagen- 
miiller and 
published by 
him, Theses de 
Paris, 1876, No. 
1 
Cholecystitis. 
Repeated bilious vomiting, severe pain 
in right hypochondrium, which is 
painful; icterus slight; fever reach- 
ing 40.6° C.; considerable prostration; 
no tumor mentioned. 
Rccov. 
Symptoms came on in sixth 
week, early in convales- 
cence. 
11 
Goltdammer 
Deutsch. Arch, 
f. k. Med., 1877, 
vol. xx. p. 68. 
2 
First ease most 
likely from 
blood infection 
and parenchy- 
matous change. 
Second, catar- 
rhal ; but not 
fully enough 
reported to be 
certain. 
Tenderness and swelling in hepatic 
region in one case of severe typhoid 
fever; no details given of second case 
except that the jaundice was of short 
duration and occurred in convales- 
cence. 
Recov. 
Very meagre details given. 
In both cases the bath treat- 
ment had been employed. 16 
DA COSTA, 
No. 
Author. 
Reference. 
No. of 
cases. 
Probable cause 
of jaundice. 
Marked associate symptoms. 
Result. 
Post-mortem appearances. 
Remarks, 
12 
Murchison 
Diseases of the 
Liver, 2d ed., 
1877, Cases 
CXXXVIL, 
CXXX1X. Two 
mentioned (p. 
401) without be- 
ing described. 
One case(uuder 
Rostan’s care) 
communicated 
(CXXXV1IL). 
5 
One catarrhal 
(CXXXVIL); 
one blood 
infection 
(CXXXIX.); 
in the other two 
blood in lection 
& parenchyma- 
tous changes; 
in the commu- 
nicated case 
this also most 
likely cause. 
In first case clay-colored stools; no 
hepatic tenderness: constipation ; 
jaundice occurred in a relapse ; case 
recovered. In Case CXXXIX. jaun- 
dice appeared on fourteenth day asso- 
ciated with albuminuria, subsequent 
thrombosis, jaundice passed away ; 
death from gradual exhausion. In 
two cases no particulars. In commu- 
nicated case jaundice persisted dur- 
ing convalescence. 
3 died. 
2 recov. 
In two cases liver found to be 
small, and its secreting cells 
loaded with oil. 
13 
Petrina 
Prag. med. 
Wochen., 1881, 
Nos. 41-43. 
4 
Case I. Blood 
infection, pyle- 
phlebitis with 
thrombi, mili- 
ary abscesses 
in liver. 
Case II. Blood 
infection, prob 
able parenchy- 
matous change 
in liver. 
Case III Prob- 
able parenchy- 
matous change. 
Severe typhoid case; jaundice ap- 
peared thirteenth or fourteenth day 
of disease, not preceded by chill, and 
gradually increased, becoming very 
deep; fever high (highest 40.6° C.), 
with marked morning remissions 
and evening exacerbations; profuse 
sweating; moderate meteorism; liver 
enlarged and sensitive, left lobe espe- 
cially ; stools yellowish-brown or 
brown; profuse diarrhoea toward 
end; bile-pigment but no albumin 
or sugar in urine. 
Icterus eighteenth day of disease ; re- 
peated chills; marked fluctuation 
between morning and evening tem- 
perature ; liver enlarged ; whole re- 
gion sensitive; vomiting and epi- 
gastric pain ; profuse sweats; no albu- 
min in urine ; ascites; congested 
lungs, cedema of lungs. 
Jaundice on fifteenth day, preceded by 
chill on thirteenth ; abdomen sensi- 
tive, especially liver region over left 
lobe; liver increased in size ; urine 
contains bile-pigment, no albumin ; 
chills recur. Patient left the hospital 
improving, but still jaundiced ; the 
liver and spleen were still swollen 
after nearly four weeks. 
3 died. 
1 recov. 
Fresh and old cicatrizing le- 
sions in Peyer’s patches; lungs 
congested; liver very large, 
full of yellow points, which 
are found to be miliary ab- 
scesses ; granular and fatty 
changes in hepatic cells; 
thrombosis of some of the 
finer portal veins; dark bile 
in gall-bladder; spleen large; 
in pancreas a few yellow 
foci; lungs congested. 
. 
No autopsy. The marked gas- 
tric symptoms and the oc- 
currence of ascites are re- 
markable features of this 
case, which was probably 
one of pylephlebitis. 
Though not specifically 
stated, it is likely that this 
patient recovered. SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
17 
Case IV. Chole- 
Jaundice on second day of a typhoid 
Cicatrized Beyer’s patches; 
cystitis, with 
fever relapse; jaundice preceded by 
thickening of mucous coat of 
cholangitis ; 
chills; liver enlarges, becomes ten- 
gall-bladder; peritoneal ad- 
interstitial 
der on pressure; bilious stools, sub- 
hesions between stomach and 
r 
hepatitis. 
sequently yellow ; repeated chills; 
liver; liver small, surface 
L 
apparent recovery, except slight 
jaundice and enlarged liver remain- 
ing. Returns to hospital, a little over 
a month after leaving it, with (edema 
of lower extremities; yellowish, liquid 
stools; urine full of bile-pigment; 
general dropsy develops, with hydro- 
thorax and ascites, and abdomen is 
tapped; dies of oedema of the lung 
granular; biliary ducts in 
liver filled with brownish-yel- 
low masses, some containing 
spear-shaped concretions, 
others fibrinous coagula; 
some of the smaller bile-ducts 
have undergone obliteration 
with increase of connective 
tissue; this process also spread 
after a lingering illness. 
to Glisson’s capsule, and led 
to atrophy of the liver ; thus 
interstitial hepatitis had oc- 
curred following inflamma- 
tion of gall-bladder and bile- 
ducts ; cholelithiasis acce- 
dens is also recorded. 
14 
Sabouriu 
R.jvae de Med., 
1 
Parenchyma- 
Man, twenty-nine years of age; deep 
Died. 
In intestines ordinary typhoid 
1882, p. 600. 
tous change 
jaundice preceded by epistaxis; time 
fever lesions ; heavy conges- 
(acute yellow 
of appearance of jaundice uncertain; 
meteorism, diarrhoea, delirium, albu- 
tion of lungs; liver dimin- 
atrophy). 
ished in size in a state of acute 
minous urine, intestinal hemorrhage; 
average temperature 39° to 40.6° C.; 
pain on pressure in right iliac fossa 
atrophy with fatty degenera- 
tion of the hepatic cells; gall- 
bladder contained a small 
and right hypochondrium. 
amount of almost healthy- 
looking bile. 
This case is not free from 
15 
Stedman 
Med. and Snrg. 
1 
Parenchyma- 
Jaundice, probably early in second 
Died. 
Liver enlarged and of nutmeg 
Rep., Boston 
tous change 
week; tenderness in right hypochon- 
appearance; Beyer’s patches 
doubt as one of typhoid 
City Hospital, 
in liver. 
drium; no epistaxis, nausea, or vomit- 
swollen, not ulcerated; spleen 
fever. Death occurred on 
■3d ser., 1882. 
ing; urine, besides bile-pigment, con- 
tains a trace of albumin ; diarrhoea, 
hypostatic congestion of lungs; high- 
softer but small; kidneys en- 
larged and in a state of cloudy 
swelling. 
the eighteenth day, and 
Beyer’s patches should then 
have shown ulceration. 
est temperature recorded 102°. 
Death in middle of fifth 
16 
Freundlich 
Deutsch. Arch. 
1 
Blood in feet’n ; 
Jaundice early in fifth week of typhoid 
Died. 
Anatomical lesions of enteric 
f. klin. Med., 
pyaemia. 
fever, in which thrombosis of the scro- 
fever in intestines; double 
croupous pneumonia of lower 
week. 
1883, Bd.xxxiii. 
tal veins followed by gangrene there 
p. 318. 
and in the inguinal region had arisen; 
repeated chills; in the progress of the 
case persistent albuminuria and in- 
lobes ; condition of liver not 
stated. 
testinal hemorrhages. 
Very doubtful case, in which 
at end of the second week 
17 
Mathieu 
Revue de Med., 
July, 1886, 
vol. vi. p. 633. 
temperature became 38° C. 
Was it abortive typhoid fol- 
lowed by a relapse ? 18 
DA COSTA, 
No. 
Author. 
Reference. 
No. of 
cases. 
Probable cause 
of jaundice. 
Marked associate symptoms. 
Result. 
Post-mortem appearances. 
Remarks. 
18 
Sorel 
Bull, et Mem. 
de la Soc. Med. 
des Hopit. de 
Paris. 1889, vol. 
vi. 3d ser., p. 
6 
Cannot judge 
from slight 
description. 
Four cases happened at beginning of 
the malady, two of which were fatal; 
one case jaundice shortly before 
death ; one in convalescence. In one 
case, p. 239, epistaxis was frequent. 
3 died. 
3 recov. 
No particulars given, except 
that in one case in which 
there had been also bloody 
urine, the liver was said to 
have been altered. 
19 
Romberg 
Berlin, klin. 
Wochenschrilt, 
March, 1890. 
1 
Blood infect’n ; 
thrombosis of 
vena porta, 
and small liver 
abscesses. 
Intestinal hemorrhage; albuminous 
urine ; chill on twenty-fourth day of 
the disease; next day jaundice; 
brownish or yellow soft stools, sensi- 
tive abdomen, increased liver dulness 
and tenderness in hepatic region; 
fever with irregular remissions; 
icterus became intense; repeated 
chills. Death on thirty-first day of 
disease. 
Died. 
Many typhoid ulcers, for the 
most part in the process of 
healing; phlegmonous sup- 
puration in mesentery near 
ctecum ; thrombi in ileocsecal 
vein and its branches; liver 
markedly enlarged and full 
of small abscesses, especially 
of left lobe ; masses of staphy- 
lococci in thrombi in portal 
veins. 
At autopsy, diffuse pylephle- 
bitis and chronic purulent 
peritonitis found; in the mes- 
entery a small abscess appar- 
ently originating in a mesen- 
teric gland. 
20 
McPhedran 
Canadian Prac- 
titioner, March, 
1891. 
1 
Blood infection 
and parenchy- 
matous change 
(diffuse pyle- 
phlebitis). 
Symptoms came on, in a man, as con- 
valescence was about to set in ; tem- 
perature became irregular; recurring 
chills with sweating; jaundice; in- 
crease. of liver dulness. Subsequently 
signs of chronic peritonitis. 
Died. 
21 
Jamieson 
Imperial 
Maritime Cus- 
toms, China 
Med. Reports, 
1888-95, 37th 
issue, pp. 63,67. 
9 
Blood infection 
with probable 
parenchyma- 
tous change. 
Jaundice appeared in one case on the 
fifth day, in one on the eighth, in 
three on the tenth, and one respec- 
tively on the eleventh, fourteenth, 
seventeenth, and forty-fourth days; 
deep jaundice in all, and symptom 
not of gradual onset. 
4 died. 
5 recov. 
Four of the five cases in 
which jaundice appeared 
before the eleventh day 
proved fatal. Severe intesti- 
nal hemorrhage occurred in 
three of the fatal cases. 
22 
Lannois 
Rev. de Med., 
1895, p. 911. 
1 
Parenchyma- 
tous change; 
cholecystitis. 
Icterus began toward third week of 
severe typhoid fever; at first light, it 
became very intense, black; liver 
greatly enlarged, marked meteorism, 
intense pulmonary congestion. Death 
eleven days after appearance of icte- 
rus ; not long before, a superficial ab- 
scess appeared on back of hand, and 
one on the internal surface of the leg 
on the same side. 
Died. 
Many Peyer’s patches involv- 
ed. Enormous liver,weighing 
3000 grammes, yellow and 
fatty; gall-bladder greatly 
distended,containing, besides 
a clear liquid, flocculent mu- 
co-pus ; superficial erosions in 
membrane; biliary passages, 
no ulceration or abscesses. 
This was a very marked case 
of suppurative cholecystitis. SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
19 
23 
Osier 
j Transactions 
I of Association 
of American 
Physicians, 
1S97. 
2 
Catarrhal in 
first case; 
blood infection 
(with paren- 
chymatous 
change ?) in 
second. 
In the first case nausea and vomiting 
came on early in a relapse of typhoid 
fever, of which the original attack 
was one of moderate severity ; jaun- 
dice appeared fourth day of relapse; 
no enlargement of liver; tenderness 
on deep pressure in front of tenth 
rib ; nausea and vomiting prominent 
symptoms; profuse sweats ; clay-col- 
ored stools : temperature range from 
102° to 103.5°. In second case severe 
attack of typhoid fever ; jaundice at 
end of second week; jaundice be- 
came of considerable intensity; mete- 
orism; abdomen not tender; liver 
dulness not decreased; marked de- 
lirium ; nystagmus: temperature, 
which had been high (105°), dropped 
to 97.2°. 
1 recov. 
1 died, 
In the second case the pa- 
tient died on the sixteenth 
day. It was remarkable 
that, notwithstanding a fail- 
ing temperature for four 
days, the pulse was of good 
volume. 
21 
Da Costa 
Present paper. 
' 
5 
1 catarrhal; 
1 pylephlebitis; 
3 parenchyma- 
tous changes 
in liver with 
blood infect’n. 
Detailed in present paper. Jaundice 
marked in all. 
3 died. 
2 recov. 
All were severe cases of 
typhoid fever. DA COSTA, 
Looking at the results, according to the best-ascertained cause of the 
jaundice, we note in the four catarrhal cases three recoveries and one 
death, this being the catarrhal case of my series, which, however, died 
a considerable time after the disappearance of the jaundice. In the 
three cases of we find one recovery and two deaths; in 
the five cases of cholecystitis with jaundice there were two recoveries 
and three deaths; in six cases of abscess of the liver, one recovery and 
five deaths; of the five cases of yellow atrophy all died. 
The most common of the ordinary and lighter changes in the liver 
structure consists in a cloudy swelling, with granular degeneration in 
the hepatic cells. But Handford,1 while mentioning that both paren- 
chymatous and interstitial changes are frequently found, regards as the 
most constant and, perhaps, the most important of these, interstitial 
hepatitis. This may, as a sequence, lead to atrophic cirrhosis, as in a 
case reported by Bourdillon.a The little opaque areas of destroyed 
liver-cells, that were formerly described as lymphoid nodules, and are 
not uncommon, do not, so far as is known, give rise to any symptoms 
pointing to the necrotic change. 
The question may arise whether the jaundice may not be due to some 
agent employed in the treatment. But it has been observed under the 
most diversified, including the cold bath, treatment.3 Werner,4 who 
is an advocate of the use of chloroform in typhoid fever, states that he 
observed jaundice in four cases, very light in three, without swelling or 
tenderness of the liver, and stopped the remedy. But in six other 
cases treated with chloroform later, also in boys under fifteen years of 
age, notwithstanding the longer use of the remedy, jaundice did not 
occur. 
Jaundice in typhoid fever happens most often at the age at which 
typhoid fever usually happens. But Petrina0 reports a case in a 
woman aged fifty-six years; Burder,6 one in a boy aged nine years. 
Ido not know of a single instance in early childhood. As regards 
sex, many more cases have been met with in men than in women. 
The main object of this paper is the consideration of the clinical sig- 
nificance of jaundice in typhoid fever, and this has now been done. 
But it would be incomplete without inquiring into the frequency with 
which jaundice is absent, though hepatic complications exist, and with- 
1 Hepatitis in Enteric Fever. Trans. Path. See. London, 1889. 
2 La Semaine Medicale, September 30, 1891. 
s Goltdammer mentions two such cases. Deutsch. Arch. f. k. Med., 1877, Bd. xx. p. 68. 
4 St. Petersburger med. Wochenschrift, 1892, p. 32. 
6 Prager med. Wochenschrift, 1881, Nos. 41 and 43. 
6 Lancet, October 17,1874, p. 552. SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
21 
out a consideration of the character of these complications. Of the 
relative importance of these, we may get a fair idea by examining 
Holscher’s statistics in 2000 fatal cases of typhoid fever at the Patho- 
logical Institute of Munich.1* Among 227 involving the liver and 
gall-bladder, there were 208 of disease of the liver structure; 12 cases 
of abscess; 3of acute yellow atrophy; 1 of amyloid degeneration of 
the liver; sof diphtheritic processes in the gall-bladder and suppura- 
tion, including one of perforation of the gall-bladder; 3of oedema of 
the gall-bladder; while 22 in addition are classed simply as icterus, 
without being linked to any organic disease. 
The ordinary parenchymatous alterations, that are presumably repre- 
sented by the 203 in the numbers just quoted, are not to be recognized 
during life, and force themselves on our attention only in the few in- 
stances in which they are attended with jaundice ; the very great majority 
of the changes in the liver structure in typhoid fever give rise, indeed, 
to no symptoms. Leaving for separate consideration diseases of the 
gall-bladder, abscess of the liver is the affection which most often 
manifests itself. Yet it cannot be said that abscess of the liver in 
typhoid is often met with. Holscher’s statistics have just been 
quoted. Romberg mentions 677 cases with 88 deaths, among which 
there was but one liver abscess; it was associated with suppurative 
pylephlebitis. Schultz2 analyzed 3686 cases with 362 deaths, without 
a single instance of hepatic abscess. 
As regards abscess of the liver, I have collected twenty-two cases in 
which the association with typhoid fever seemed beyond doubt, and 
which admit of more or less complete clinical analysis. Others that 
have been reported I have rejected as very uncertain, as the combina- 
tion with typhoid fever is not proved. Bouillaud’s case, mentioned by 
Andral,3 which has been questioned, I have included. Of the 22 cases, 
7 only had jaundice; in 3it is specifically mentioned as not present, and 
in 12 it is not mentioned at all, making 15 cases out of 22 in which jaun- 
dice may be fairly presumed to have been absent. Thus jaundice is not 
a symptom to be depended on in the diagnosis of abscess of the liver in 
typhoid fever. More important are chills, violent, prolonged, and re- 
peated, as in Barth’s1 case, and generally preceding the jaundice, should 
this happen, as in Romberg’s case; great variations in temperature, as 
in Case I. of Petrina; profuse sweating and sensitiveness in the region 
1 Mtlnchener med. Wochenschrift, January, 1891, Nos. 3 and 4. 
2 Observations made at the Hamburg Hospital, quoted by Romberg, loc. cit. 
3 Clinique Med., 3d edition, 1834, vol. i. p. 616. 
4 Bull, de la Soc. Anat., 1853, p. 80. 22 
DA COSTA, 
of the liver. The liver may or may not he swollen ; in Goltclammer’s 
case it was swollen. In Gerhard’s1 case the right hypochondrium was 
prominent, and tender on pressure, and fluctuation was detected over the 
right lobe of the liver. As further symptoms pointing to abscess of the 
liver, should there be any hepatic manifestations, are abscesses in other 
parts of the body, as in the parotid (Louis’s case), in the perichondrium 
of the larynx (Chvostek’s case), over the mastoid region (Sidlo’s case). 
At times hepatic symptoms are wholly wanting, and the abscess is only 
found at the autopsy. 
All the symptoms mentioned may also happen in pylephlebitis, 
except the rarest, fluctuation; especially the repeated chills, the pain 
and tenderness in the hepatic region, the high irregular temperature; 
and I know no way of distinguishing pylephlebitis from abscess, with 
which, indeed, it is generally classed, unless by the progress of the 
case, in which enlargement of the subcutaneous abdominal veins and 
collections of fluid in the peritoneum may be observed in addition. 
But the latter signs occur to a decided extent only where there is also 
marked thrombosis in the portal veins or its main branches, as in a 
case of Lannois,2 and there is apt to be painful enlargement of the 
spleen as well as of the liver. I think jaundice, most probably pysemic 
and from infected thrombi, is apt to happen among the symptoms of 
pylephlebitis with greater frequency than in abscess of the liver not 
associated with this, and to become deeper; but it is far from invari- 
able. It was absent in the case of Asch and of Bernhard,3 an instance 
of pylephlebitis from suppurating glands in the mesentery, and where 
there was a purulent thrombosis of the mesenteric veins and the venae 
portae were full of pus. 
Viewed in its clinical bearings, we find abscess of the liver in typhoid 
fever under these conditions; as metastatic abscess, due to a pyaemic 
infection from other parts of the body, as the consequence of pylephle- 
bitis, which is nearly always caused by an infection from typhoid lesions 
in the intestine, or from suppurating mesenteric glands and a resulting 
infective thrombosis; or, as owing to typhoid ulceration in the biliary 
passages and secondary suppuration. The first of these causes is illus- 
trated by most of the cases in the table, notably by those of Louis, 
of Chvostek, of Sidlo, of Dunin,1 of Barth.5 To the second category 
belong the cases of Lannois, of Osier, of Romberg, of Gerhard,6 of 
1 Medical News, July 24, 1886. 2 Revue de Medecine, 1895, p. 913. 
3 Berlin, kiln. Wochenschrift, 1882, xiv. p. 772, and Jahrb. fiir Kinderheilkunde, N. F., 1886, 
Bd. xxv. 
4 Deutsch. Arch. f. k. Med., 1886, Bd. xxxix. p. 379. 
5 Bullet, de la Societe Anat., 1853, p. 80. 6 Loc. cit. SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
23 
Tiingel,1 in which pus from a suppurating lymphatic gland near the 
caecum broke into a root of the superior mesenteric vein ; of Buckling2 
with a similar history; of Asch and Bernhard,3 where there was also a 
suppurating mesenteric gland. Cases belonging to the third group are 
the rarest. A very striking one is mentioned by Klebs,4 in which a 
suppurative inflammation of the bile passages within the liver hap- 
pened, and their dilatation formed abscesses filled with thick, greenish, 
muco-purulent liquid. In the pus from liver abscesses, typhoid fever 
bacilli were found by Lannois. It may be also a question whether in 
some of the cases regarded as metastatic there have not been separate 
foci of inflammation and suppuration due to the typhoid bacilli; for 
instance, in the cases in which the parotid glands, as well as the liver, 
have been implicated. 
In this connection we may discuss whether there be a form of typhoid 
fever in which liver symptoms arise, including jaundice, owing to the 
direct action of the specific micro-organisms on the liver or the bile 
channels. Mathieu5 describes, under the title of “typhus hepatique 
benin,” a case which he believes to have been of this character, and 
in which a relapse similar to a typhoid fever relapse happened, and 
Pfuhl6 cites nine cases that came on after swimming repeatedly in a 
swimming school in the infected Elbe water at Altona near Hamburg, 
and all of which had fever and jaundice, I have analyzed these cases, 
and do not find their clinical history closely corresponding to typhoid 
fever. They all recovered, and are spoken of as due to mixed infec- 
tion. Mathieu’s case also recovered; and, as these cases happened 
before the introduction of the Widal test, we must remain in doubt as 
to their nature. I had at the Pennsylvania Hospital last year a case 
of jaundice in a colored woman (Case No. 2775), with fever, violent 
epistaxis, hebetude, diarrhoea, and albuminous urine, in which the 
Widal test gave positive reactions. She had been suffering with fever 
for two weeks, and it preceded the jaundice. The case proved fatal 
in the third week of the disease, and seemed to be an undoubted one of 
typhoid fever with hepatic complication. At the autopsy no lesion 
was found in the intestinal glands. The mesenteric glands were here 
and there enlarged, and one appeared as if it had pressed upon the 
choledoch duct; the gall-bladder was much distended, and its mucous 
coat inflamed; the liver was small and in a high state of fatty degen- 
1 Thierfelder, Ziemssen’s Handb., Bd. viii. p. 84. 
2 S() Falle von Leberabscess, Berlin, 1868. 3 Loc. cit. 
4 Handbuch der pathol. Anat. 5 Revue de Med., July, 1886. 
6 Deutsch. milit. arztl. Zeitsch., 1898, vol. xvii. pp. 9, 10. 24 
DA COSTA, 
eration; the spleen was small; the kidneys large, with signs of inter- 
stitial nephritis. Unfortunately, through a misunderstanding, no cul- 
tures were made from the liver and gall-bladder, as had been intended, 
and, notwithstanding the positive character of the Widal test, I hesitate 
greatly to bring forward the case as one of hepatic typhoid without 
intestinal lesion ; it may have been one of acute yellow atrophy, of which 
it presented also many of the synrptoms. 
More common in typhoid fever than diseases of the liver itself are 
the diseases of the bile passages. We know through recent researches 
how frequent is their infection, especially the gall-bladder infection, 
with the typhoid bacilli. Chiari1 reports the results of autopsies in 
twenty-two patients, and only in three was the bacillus absent from the 
gall-bladder. In twelve cases there was inflammation of the mucosa 
alone; in one the whole wall was affected, causing peritonitis.2 In the 
discussion that followed a valuable paper by Mason,3 on “ Gall- 
bladder Infection in Typhoid Fever,” Councilman stated that he had 
found the typhoid bacillus in nearly every case. Gilbert and Girode4 
demonstrated the presence of the typhoid bacillus in suppurative chole- 
cystitis. Dupre5 got pure cultures of typhoid bacilli from the gall- 
bladder of a patient operated on for gallstones six months after typhoid 
fever; in another case, in a man who died about the fifteenth day of 
typhoid fever, although the gall-bladder presented no obvious patho- 
logical changes, pure cultures of Eberth’s bacillus were obtained. 
Not only do these gall-bladder infections happen in the course of 
typhoid fever in association with the characteristic intestinal lesions of 
the disease, but they have been observed when these were absent. Cases 
of the kind are reported by Guarnieri6 and in most interesting papers by 
Osier7 and by Cushing.8 Mark Richardson’s9 case, in which there was no 
distinct history of typhoid fever, but in which the typhoid bacillus was 
found in the fluid obtained from the distended gall-bladder by operation, 
is another case in point. It is quite as likely that the infection of the 
gall-bladder occurs in these instances through the typhoid bacilli in the 
blood as by direct infection from the continuous intestine. Further, 
great interest is attached to these gall-bladder infections in typhoid 
1 Eleventh Intern. Med. Congress, Zeitschr. f. Heilkunde, 1894, Bd. xv. S. 199. 
2 Case described, Prager med. Wochenschrift, 1893, No. 22. 
a Transactions Assoc. American Physicians, 1897. 
* Mem. de la Soc. de Biologie, 1890 and 1893. 6 Infections Biliaires, 1891. 
6 Contrib. alia patog. della infez. biliari.; also, Baumgarten’s Jahresbericht, 1892, S. 284. 
Trans. Assoc. American Physicians, 1897. 
8 Bulletin of the Johns Hopkins Hospital, vol. ix. No. 86, 
9 Boston Medical and Surgical Journal, December 16,1897. SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
25 
fever from the now established fact that they lead to the formation of 
gallstones; as, on the other hand, gallstones seem to invite the bacillary 
infection to the gall-bladder. The association with gallstones is curi- 
ously illustrated in a case by Chantemesse,1 in which living typhoid 
bacilli were found in a gallstone removed by operation eight months 
after an attack of typhoid fever. Van Dungern’s2 case of bacilli found 
fourteen years and a half after typhoid fever in the pus from an abscess 
formed around the gall-bladder is unique; here, however, no stones 
were detected. The patient recovered. 
Now, from the frequency, it might almost be said constancy, with 
which infection of the gall-bladder happens in typhoid fever, it would 
be supposed that symptoms referable to it are very common. But 
it is just the reverse. In the cases of irritation or the lighter cases 
of inflammation produced by it, there are absolutely no symptoms; 
even in the more severe cases, in which obvious lesions are found, 
symptoms are often absent or, at least, not recognizable; and thus the 
majority of cases pass undiscovered and mostly unsuspected. It is only 
the very marked ones, and chiefly those in which perforation has hap- 
pened, that have been noticed. I shall attempt an analysis of such of 
the cases as have been published with sufficient fulness to give real 
information, and which seemed to me to be undoubtedly linked to 
typhoid fever, for it is astonishing in how many instances the evidence 
concerning this is most meagre. I have been greatly aided in the task 
by the courteous permission of Dr. Westcott to make use of the refer- 
ences he had prepared for the remarkable work of Dr. Keen, On the 
Surgical Complications and Sequelce of Typhoid Fever, and by the 
most efficient assistance of Dr. Woodbury. After rejecting all the 
doubtful cases, I got together and tabulated fifty-three cases of chole- 
cystitis in typhoid fever, some simple though marked, some suppurative, 
some perforative. But before analyzing these, it may be well to inquire 
in what proportion these affections have been noticed by pathologists 
irrespective of, as well as with, typhoid fever. Courvoisier3 gives us 
valuable information on this point. Of 16 cases of cholecystitis of 
catarrhal origin or with beginning suppuration, fully 5 occurred in the 
course of typhoid fever. Six cases out of 55 of empyema of the gall- 
bladder were due to infection, one of which was from typhoid; 41 were 
due to cholelithiasis. In cases of phlegmonous infiltration of the 
walls of the gall-bladder, typhoid was twice the cause, and the other 5 
1 Traite de Med., tome i. p. 764. 2 Munch, med. Wochenschrift, 1897, No. 26 
3 Casuist. Statistische Beitrage z. Path. u. Chir. der Gallenwege, Leipzig, 1890, pp. 76-94. 26 
DA COSTA, 
cases were due to cholelithiasis. Fatal result is the rule in purulent 
cholecystitis. Of 82 cases, 53 proved fatal. Among these were 10 
cases due to typhoid. In many of the cases there was no suspicion of 
cholecystitis prior to the autopsy. In cases of perforation of the gall- 
bladder, with encapsulation into the abdominal cavity, mentioned by 
Courvoisier, there were four in which no calculi existed, and which 
were due to typhoid. 
Cholecystitis in typhoid fever, when at all marked, is a grave com- 
plication, no matter what be its exact form. In 58 cases of typhoid 
cholecystitis I have collected, there were 39 deaths and 15 recoveries, 
while in 4 the result was uncertain or not stated. Of the different 
forms, the instances of perforation without operation are the most fatal; 
1 only out of 24 recovered by a discharge through the abdominal 
walls (case of Salzman); 3 recovered after operation (cases of Alexieef, 
Williams and Shield, Osier and Halsted). In suppurative chole- 
cystitis there are a number of recoveries, but also as the result of 
operation (cases of Caspersohn, Mason, Richardson, Williams and 
Shield, Osier and Halsted). In the cases of cholecystitis which are 
catarrhal, recovery is not infrequent; where there is also cholangitis 
(as in Case IV. of Petrina and in Sander’s case), the prognosis is not 
good. But Griesinger’s case, in which this complication probably 
existed, recovered. 
To proceed now with the clinical analysis of the 53 cases I have col- 
lected, to which, for some purposes, I shall add the 5 of cholecystitis 
with jaundice detailed in the table printed in this paper. Of these 58 
cases there were 22 in which perforation of the gall-bladder happened. 
In 6 of the 22 cases of perforation gallstones were found, while in 16 
they are either stated to be absent or are not mentioned ; thus gallstones 
were not encountered in more than about one-fourth of the cases of 
perforation. Suppurative cholecystitis may, from the descriptions, be 
recognized in 24 of the 58 cases; and in eight of these there was also 
perforation. In the other instances the lesion was catarrhal, with very 
slight if any suppurative change. Ulcers of the gall-bladder cannot 
be absolutely separated from suppurative cholangitis, as in nearly all 
instances some suppuration coexists. 
As regards sex, there is very little difference in the occurrence of the 
marked gall-bladder complications of typhoid fever. In 48 cases in 
which the sex is mentioned 26 were males, 22 females. The affections 
may be met with at almost any age. In 48 cases 8 were twelve years 
of age or less; 40 cases were over twelve years of age. The youngest SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
27 
case happened in a girl, aged five years (case of Alexieef4); the oldest 
in a man, aged sixty-seven years (case of Anderson2). 
The question of the diagnosis of these gall-bladder complications, and 
the possibility of telling them apart, is of great importance. It has 
been stated already that in many instances they are latent, and have 
only been discovered after death. But the knowledge of their occurrence, 
and the search for them in acute cases, will cause them to elude discovery 
less and less frequently. The marked symptoms are pain and tumor. 
Pain is almost never absent. It is epigastric, or in the right hypo- 
chon drium, and is very often referred directly to the seat of the gall- 
bladder. It may be so severe that the patient shrieks, especially when 
he moves (as in Budd’s case), or rolls in agony (Barthez and Rilliet’s 
case). It often occurs in severe paroxysms. In the great majority of 
instances it is associated with marked tenderness, which, however, is 
not apt to remain confined to the region of the gall-bladder, but to be 
found also over the whole of the right hypochondrium or right side of 
the abdomen; and the entire abdomen even may be sensitive, most 
likely then from a spreading peritonitis. On the other hand, the 
general tenderness may become localized in the region of the gall- 
bladder. In a few instances sensitiveness, without pain, is spoken of; 
in a very few, as in a case of Louis’, pain is mentioned as absent. 
Rigidity of the abdominal walls, especially on the right side, not infre- 
quently coexists. 
Tumor is of diagnostic significance as great as or even greater than 
pain, though it is not so common a symptom. It is specially men- 
tioned in 21 out of 53 cases, only, therefore, in less than one-half. 
But it is probably present in larger proportion; the typhoid state of 
the patient and the marked meteorisrn that generally exists prevent its 
detection. It occupies the seat of the gall-bladder, and is thus to be 
looked for at Mayo Robson’s3 point, namely, at the junction of the 
upper two-thirds with the lower third of a line drawn from the ninth 
rib to the umbilicus. In a number of instances it is described as 
pear-shaped and firm, also as being tender on pressure; it may be a 
mere resisting mass below the costal margin. The tumor of the gall- 
bladder may be noticed to disappear slowly, or, where perforation hap- 
pens, the disappearance may be sudden. In some instances the tumor 
swells up from time to time, as in the remarkable case of Leudet,4 in 
1 Journ. Dietskaya Med., 1896, No. 4; abstracted in the American Journal of the Medical 
Sciences, October, 1897, p. 466. 2 Medical News, August, 1896. 
8 Diseases of the Gall-bladder and Bile-ducts, 1897, p. 37. 
4 Clinique Medicale de I’Hotel Dieu de Rouen, 1874. 28 
DA COSTA, 
which a woman who left the hospital apparently well, though writh 
signs of a tumor from typhoid cholecystitis still perceptible under the 
false ribs, had markedly recurring swelling with tenderness at each 
menstrual period for six months. The tumor that is found, though 
having its origin in the lesion in the gall-bladder, may not be due to 
this viscus, strictly speaking, but, in the perforated cases, be a pus- 
cavity formed around it. The history of the case and the irregular 
shape of the swelling may lead us to suspect its cause, but there is no 
certainty in the discrimination. 
Among the less marked symptoms are jaundice, nausea and vomit- 
ing, and chills. Jaundice occurred in 17 out of 58 cases, was thus 
absent or not mentioned in 41, and only occurs, therefore, in less than 
one-third of the cases. It is not, as a rule, deep, though, after it shows 
itself, it persists. It does not occur in the cases with perforation in 
any greater proportion; 5 only out of the 23 cases of perforation had 
jaundice. Nor is it of much more frequency in the suppurative cases, 
the proportion being 6 out of 24, Indeed, its relation to the gall- 
bladder lesions in typhoid fever is uncertain and of little value in diag- 
nosis. In rare instances the jaundice is due to impaction of a gallstone, 
as in the case of Barbe,1 in which attacks of gallstone colic and steadily 
deepening chronic jaundice preceded typhoid fever; and, at the 
autopsy, besides the characteristic intestinal lesions, a perforated gall- 
bladder was found and an obstruction of the common choledoch duct 
by a stone. 
Nausea and vomiting occur as transient symptoms, though in much 
greater frequency than in the ordinary course of typhoid fever. They 
are mostly to be noticed at the beginning of the gall-bladder complica- 
tion. In Legendre’s2 case the vomiting of large quantities of green, 
bitter fluid is specially mentioned. Chills are conspicuously absent. 
I find their occurrence noted in only 3 out of 54 cases, including the 
cases in which perforation happened. Burger’s3 case began with a 
severe chill; chills happened six days before death in BuddV case, and 
happened also in one of Osier’s cases. The other symptoms are those 
of severe cases of typhoid fever. But the frequent occurrence of pul- 
monary complications, especially toward the end of the fatal cases, is 
noteworthy. In a number of instances pneumonia was the immediate 
cause of death. 
As regards the diagnosis of typhoid cholecystitis, this is impossible 
1 La France Med., 1884, ii. p. 1071. 
2 Bull, de la Societe Anatom, de Paris, 1881, p. 1893. 
3 Deutsch. Arch. f. k. Med., 1873, p. 623. 4 On Diseases of the Liver, 3d ed., 1857, p. 196. SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
29 
with any certainty, except where tumor is present, though it may be 
suspected if there be nausea and vomiting, a sense of weight, and sen- 
sitiveness over the gall-bladder. But the occurrence of tumor and of 
pain and tenderness at or near the seat of the gall-bladder make the 
diagnosis not difficult. The most likely error is confounding the 
malady with an appendicitis. As a rule, the seat of pain and tender- 
ness and swelling is different; in the one case in the right iliac fossa, 
in the other in the region of the gall-bladder. But we cannot trust 
implicitly to this; as in appendicitis, especially at its upper part, or 
where the appendix is not normally situated, the localization of the 
symptoms may be high up ; and in cholecystitis the pain and tenderness 
may not be most marked over the gall-bladder, and the swelling may 
be very difficult to define. 
An exact discrimination of the different forms of typhoid cholecystitis 
cannot be always made. They are all most likely to come on late in the 
disease, or after convalescence has been established, and all, whether 
with or without perforation, as Hagenmiiller1 has clearly established, 
are prone to be associated with local peritonitis in the neighborhood of 
the gall-bladder. Where there are abscesses in other parts of the 
body, and we can exclude pylephlebitis and hepatic abscess, a suppu- 
rative cholecystitis may be inferred, if pain and tumor be present. If 
there be a history of biliary colic and gallstone, or if this arise in the 
progress of typhoid fever or not long subsequent to it, signs of cholecys- 
titis mean suppurative cholecystitis. I think, too, though there are not 
many observations on this point, that examinations of the blood will 
help us materially. We know through the researches of Thayer that in 
typhoid fever the number of white blood-corpuscles varies but little from 
the normal standard, about 6000 per c.cm. Marked leucocytosis, if there 
be symptoms of cholecystitis, points to its being suppurative, as in 
Mason’s case and in Anderson’s case, where there was perforation. On 
the other hand, in a case of Osier’s that recovered, there was no leuco- 
cytosis, and we may infer the cholecystitis not to have been purulent. 
In laying stress on leucocytosis we must, however, exclude abscess of 
the liver, in which condition it may also exist. Yet here the local 
symptoms are different; there is less pain, no tumor over the gall-blad- 
der, and in doubtful cases I should attach much importance to the 
occurrence of chills. The analysis in this paper has proved their ex- 
treme rarity in cholecystitis of any form, whereas they are very com- 
1 De la Cholecystite dans la Fievre typhoide. Theses de Paris, 1876, No. 269 
2 Johns Hopkins Hospital Reports, yol. iv. 30 
DA COSTA, 
mon in abscess and in pylephlebitis, as is sweating. In none of these con- 
ditions can we lay much stress on the presence or absence of jaundice. 
There are cases of gall-bladder affection in typhoid fever in which there 
is mere distention with bile or a watery fluid. Case IY. of this paper 
probably belongs to these. They have been supposed, as in the case of 
Dumoulin,1 to be due to retention of bile owing to nervous disturbance 
attending the fever, analogous to the retention of urine ; or they may be 
the result of obliteration of the cystic duct, as in a case of Louis,2 where 
the bile in the distended gall-bladder had the appearance of urine, and 
the cystic duct was compressed by an enlarged lymphatic gland that 
surrounded it. No means exist of distinguishing these cases during life 
from acute cholecystitis, except it be by the absence of severe pain and 
very marked tenderness. Then it is likely that they are really in- 
stances of bacillary infection of the gall-bladder, and that the typhoid 
bacilli will be found in the fluid, only marked inflammation has not 
been induced. 
Perforation of the gall-bladder has as its chief symptoms suddenly de- 
veloped or intensified pain, collapse, and peritonitis. In some instances 
that have been reported there is also marked drop of temperature, as in 
the cases of Bouamy3 and of Bond.4 The effect on the tumor is often 
a decided lessening or a disappearance. Peritonitis, which may remain 
local, as in the case of Hawkins5 and others, develops, and may lead to 
encapsulation of the discharged contents of the gall-bladder. On the 
other hand, a subsequent general peritonitis may occur. The course 
is often a comparatively slow one, two of the reported cases, Ranvier’s6 
and Archambault’s,7 not dying until the twelfth day after the perforation. 
It is evident how very similar the symptoms are to those of intestinal 
perforation. Gall-bladder perforation can be, indeed, distinguished 
only by the seat of the pain and the previous existence of the tumor. 
Should jaundice be present it would be an additional aid in discrimina- 
tion. On the other hand, intestinal hemorrhages preceding the symp- 
toms of perforation, and rapidly developing general peritonitis, belong 
more strictly to the intestinal lesion; local peritonitis in the upper part 
of the abdomen on the right side is more characteristic of gall-bladder 
perforation, as is a slower progress of the symptoms. Fall of temperature, 
too, attending the collapse, occurs much oftener in intestinal perforation 
in typhoid fever than in gall-bladder perforation in the same disease. 
1 Gaz. Med. de Paris, 1848, p. 551. 
3 Gaz. Med. de Nantes, 1890, p. 133. 
5 Medico-Chir. Trans., vol. Ixxx. p. 138. 
7 Bull, de la Soc. Anat,, 1852, p. 90. 
2 Pievre Typhoide, vol. i. p. 201. 
* British Med. Journ., July 12,1884, p. 67. 
« Bull, de la Soc. Anat., 1864, p. 483. SIGNIFICANCE OF JAUNDICE IN TYPHOID FEVER. 
31 
The treatment of the jaundice attending these different hepatic affec- 
tions will be guided by our recognition of the probable cause. Those 
which are due to blood infection and to the finer parenchymatous changes 
in the liver cannot be reached by any special treatment, which must 
be that of the grave underlying typhoid condition. I will, however, 
point out that two of my cases recovered while taking decided doses of 
mineral acids, and this was also the result in two of Murchison’s cases. 
In abscess of the liver, as well as in pylephlebitis, large doses of qui- 
nine may be employed. In the ordinary form of cholecystitis, recovery 
has followed applications of leeches over the swelling, followed by 
poultices, as in Observation No. LXYIII. of Frerichs. Besides the 
general treatment of the typhoid state, attention must be paid to the 
character of the discharges from the bowels; when very dark and 
showing vitiated bile, small doses of mercurials should be given. Leu- 
det’s1 case got well under calomel and under frictions with belladonna. 
The suppurative cases require support, and, as soon as we are reasonably 
sure of their character, surgical interference, the admirable outcome of 
which was seen in the cases of Caspersohn,2 of Williams and Shield,3 
of Alexieef/ of Mason,5 of Osier and Halsted,6 of Mark and Maurice 
H. Richardson.7 Among the perforation cases I know of only one 
recovery without operation, the case of Salzmann,8 in which a discharge 
occurred through the abdominal wall. An operation alone promises 
success, and how well it may succeed is proved by the results of Williams 
and Shield and one of the cases of Osier and Halsted. 
1 Loe. cit. 2 Festschr. f. Fr. von Esmarch, 1893, p. 455, Kiel and Leipzig. 
3 Lancet, March 2,1896. 
4 Journ. Dietskaya Med., 1896, No. 4. Quoted in The American Journal of the Medical Sci- 
ences, October 1897, p. 466. 
5 Trans. Assoc. American Physicians, 1897. 6 Ibid. 
7 Boston Med. and Surg. Journ., December, 1897. 
8 Med. Corresp. Wiirtemh. Arztl. Verein., 1870, xl. 84.