HEMORRHAGIC TYPHOID FEVER; 
TREATMENT AND A REVIEW OF THE TABU- 
LATION OF SEVENTEEN CASES. 
Clinical Lecture delivered at the Philadelphia Hospital, February 17, 
1891. 
BY 
ROLAND G. CURTIN, M.D. 
Reprinted from the Philadelphia Hospital Reports for 1892. HEMORRHAGIC TYPHOID FEVER; TREATMENT AND 
A REVIEW OF THE TABULATION OF 
SEVENTEEN CASES. 
The young man whom I bring before you this morning you 
will observe is extremely anaemic. He is fifteen years of age and 
a native of Ireland. Before his present illness his general health 
had always been good. He has been sick four weeks, the last two 
of which have been spent in this hospital. During the first week 
of his illness he had considerable nosebleed and looseness of the 
bowels, and had a history of having had several hemorrhages from 
the bowels. His mother informed the resident physician that 
with one of these hemorrhages he lost " over a basinful of blood." 
The patient was very pallid when admitted to the hospital; his 
lips and conjunctivae were very pale, and his eyes were dull and 
heavy. His heart was weak and his pulse was very rapid, and his 
chest was found to be filled with bronchial rales. 
When first admitted to the hospital his temperature was 99f° F., 
but it soon rose to 104° F.; his tongue was dry and cracked; he slept 
most of the time, and when aroused he was quite ill and stupid. 
The second day after his admission, at the commencement of the 
third week of his illness, he had what is called a tarry stool. The 
hemorrhage probably accounted for the low temperature of ad- 
mission, which is often the first symptom. There was nothing 
abnormal found in his urine. On the 16th, yesterday, his blood 
was examined, and 3,325,000 red corpuscles were found to the 
cubic' millimetre. You know the normal is 5,000,000, showing 
that the number of corpuscles was but a little over half the normal 
quantity. His temperature is now sub-normal, which might be 
another symptom of hemorrhage, as he has already had several. 
This lowered temperature is not from hemorrhage, as the other 2 
HEMORRHAGIC TYPHOID FEVER. 
symptoms show that it is due to commencing convalescence; and 
you will find that at this stage the temperature usually falls below 
the normal point. After the loss of blood the temperature went 
up again, and this was probably due to the reaction which usually 
takes place after the loss of a large quantity of blood combined 
with the feverish state, which would take place in a healthy body. 
I stated to you that early in the third week, just after admission, 
he had a " tarry stool,"-that is, of darkgrumous blood; when a 
hemorrhage takes place the juices of the intestines alter the blood, 
and if it remains in the bowel long enough it becomes partially 
digested, which causes the dark, tar-like color. If the stool should 
be of this color, it would be likely to escape observation; how- 
ever, the nurse should be warned to be on the lookout. If the 
hemorrhage is large and the bowels are loose, it may not come 
away at all, or only a little changed. It might then be of a venous 
or arterial color. 
I have brought the patient before you more particularly to speak 
on the treatment of hemorrhage in typhoid fever. During the 
hemorrhage it would be dangerous to bring a patient from the 
ward into this clinic. A hemorrhage of the bowels usually takes 
place sometime before it appears in the stool, so that often the 
hemorrhage has stopped before it is discovered. You can imagine 
how a patient might have a small hemorrhage in the small 
intestine to-day, and if there was a constipated condition of the 
bowels, the blood might remain there and not be discharged 
for two or three days. So you must not think, when you see 
blood coming from the bowels, that the patient is having a hem- 
orrhage then, for he may be safely over it. When this boy came 
into the hospital he was probably over his hemorrhage, or it was 
in his bowel. On admission his temperature was quite low, his 
face was pale, and there was scarcely any color in his lips; and 
even now, when I pull down the lower eyelid, I find the con- 
junctivae and lips very pale indeed. This anaemia is largely 
due to loss of blood; first, by profuse epistaxis, and later by ex- 
treme intestinal hemorrhage. Typhoid-fever poison also has a 
tendency to poison the blood and cause an anaemic condition. 
What does intestinal hemorrhage come from ? It is usually from 
an ulcerated condition of the bowels; probably a slough is thrown 
off* from an ulcerating intestinal gland, a blood-vessel opened, and 
a hemorrhage produced. Sometimes in typhoid fever we have HEMORRHAGIC TYPHOID FEVER. 
3 
persons who are particularly prone to hemorrhage owing to the 
peculiar condition of the blood; they are called " bleeders," or, 
speaking more scientifically, they are said to have a hemorrhagic 
diathesis; it is also called hemophilia and hematophilia. The fact 
that this young man has had both epistaxis and bowel hemor- 
rhage, goes to show, therefore, that he has an unusual tendency to 
bleed. 
I recollect seeing a child who had typhoid fever some years ago. 
About the middle of the second week she began to bleed from her 
bowels and bladder, from her stomach, her lungs, her vagina, and 
her eyes and ears. This showed that the blood was in such a 
condition that it was oozing out of all the mucous membranes. 
In these cases, with hemorrhage from all the mucous surfaces, the 
fault is in the blood, not a result of ulceration. In typhoid fever 
usually hemorrhages occur during the third week, at this time the 
glands are opened by the ulcerating process, and break down and 
open the blood-vessels. 
In a case of typhoid fever, how shall we determine that blood is 
being poured out into the intestines ? First, by the temperature; 
sometimes by closely watching the temperature, which in large 
hemorrhages will suddenly fall. In all cases we should view a 
sudden drop in the temperature as a serious symptom. Secondly, 
by the constitutional effects. If the fall in temperature should be 
associated with great sudden prostration, muscular and cutaneous 
relaxation, hebetude, pallor, sunken features, in other words, a 
tendency to a state of collapse, the picture is quite complete. We 
will suppose that a diagnosis of intestinal hemorrhage has been 
made ; what measures shall be used to arrest the bleeding ? 
Ergot internally and hypodermically administered will generally 
stop the hemorrhage, but it must not be entirely depended upon, 
for the blood-vessel may be too large for the ergot to stop the 
bleeding; and, again, active peristalsis may prevent this mild 
remedy from arresting the hemorrhage. The patient should be 
kept quiet, and should not under any circumstances be allowed 
to turn from side to side or to rise up in bed. The next im- 
portant step is to give him a remedy which would check peri- 
stalsis and keep the bowels at rest. You could use opium or 
some of its preparation, such as deodorized tincture of opium, 
if it seems best, or to act better than morphia given internally or 
hypodermically. If the patient is nauseated, you perhaps cannot 4 
HEMORRHAGIC TYPHOID FEVER. 
give it by the mouth, then you may give it hypodermically or by the 
bowel. There are astringents that can be used with good effect, 
as acetate of lead, gallic acid, and sulphuric acid. These are some 
of the remedies that are usually given for this complication of 
enteric fever. The best remedy is ergot or ergotin. 
As some patients cannot stand the pain it is likely to produce 
when given hypodermically, and as ergot given by the mouth some- 
times causes vomiting, and as the ergotin as well as the ergot may 
have a serious influence, no remedies should be given or continued 
that are liable to produce retching or vomiting. If the hemor- 
rhage does not stop, I have found sulphuric acid or oil of erigeron 
to be good hemostatics in these cases. These may be given if 
they do not nauseate the patients. I give the erigeron in the form 
of a capsule or cachet with magnesium carbonate. The magnesia 
absorbs and dilutes the erigeron, and in that way you avoid the 
bad taste and irritation to the stomach. Oil of turpentine in- 
ternally often acts beneficially in these cases. You can apply it 
also externally, not as a hot stupe, for the warmth is not desirable, 
but by a flannel cloth sprinkled with the oil. 
In some extreme cases I have seen the bleeding stopped almost 
at once upon the hypodermic injection of ergotin. When you give 
this injection, you will find that the patient often suffers much pain 
in the point of puncture. Sometimes the shock to the nerves 
does more good in stopping the bleeding than the action of the 
ergotin itself. In the case of the little girl I spoke of as bleed- 
ing from all mucous surfaces, I told her mother that with so much 
oozing from the stomach it would be impossible to save her, and 
it would only be a question of a few hours that she could live. 
Her mother went into the room crying, and the little girl said, 
" Mamma, did the doctor say I was going to die ?" The mother 
threw her arms about the child and wept. The child said, 
" Mamma, I am not going to die." Remarkable to relate, the 
bleeding stopped inside of two hours, and the child got well. It 
was not medication, it was simply the shock to the nerves caused 
by the mother's grief which stanched the flow of blood. 
There is an external application that can be tried in bad cases- 
that of ice to the abdomen. If you have a hemorrhage of the 
bowels, the patient is very often in a state of collapse, when, of 
course, it is not a good thing to apply cold to the abdomen, 
but it is sometimes justifiable when everything else fails. An- HEMORRHAGIC TYPHOID FEVER. 
5 
other way that ice has been applied is by placing small pieces of 
ice in the lower end of the intestines, which brings the cold in 
close contact with the lovfer part of the abdomen. The hemor- 
rhage comes on usually unexpectedly, and, if you are thrown on 
your own resources, it is very important to act promptly. Cold 
douches on the abdomen have been used with success or with 
great benefit in some cases, but are open to more objections from 
the actual application of force. 
I shall give you a brief summary of the treatment of hemor- 
rhagic typhoid fever, and you can see at a glance the remedies 
usually given: 
Rest and quiet; ergot internally and hypodermically ; opium ; 
acetate of lead; gallic acid; sulphuric acid, externally and in- 
ternally; oil of turpentine; oil of erigeron; ice to the abdomen; 
ice to the bowel; stimulants constantly; food given little and 
often. 
When the cases are properly treated and the blood is not seri- 
ously altered, hemorrhagic cases of typhoid fever are not often 
fatal. It is a curious circumstance how many cases of hemor- 
rhagic typhoid fever I have seen during the last six weeks. In 
the Presbyterian Hospital there have been two cases, and four in 
this hospital. It is very unusual to have so many cases in so 
short a time. 
When the hemorrhage has ceased, the most important thing is 
to try and improve the condition of the patient all you can. When 
the fever is up, it is best not to give iron, as it would not generally 
be considered good therapeutics. 
STATISTICS OF SEVENTEEN CASES OF HEMORRHAGIC TYPHOID FEVER. 
I have some statistics of interest on hemorrhage in typhoid 
fever that I have been gathering for the last twelve years. I have 
tabulated seventeen cases, the later being more thoroughly noted 
than the older ones. 
The first note is in regard to age. From thirteen to fifteen, 
two; from fifteen to twenty, three; from twenty to twenty-five, 
three; from twenty-five to thirty, five; from thirty to thirty-five, 
one; from thirty-five to forty, none; from forty to forty-five, two ; 
from forty-five to fifty, none; from fifty to fifty-five, one. 
The next note of interest is as regards sex. Thirteen were 6 
HEMORRHAGIC TYPHOID FEVER. 
males; four females. The most of the cases here tabulated were 
from a hospital in which the male patients largely predominated, 
and these would not be as many if the cases had been gleaned from 
an equal proportion of the two sexes. 
It is quite interesting to study the data in regard to hemorrhages. 
First, the day of first hemorrhage. One on the 6th, one on the 
7th, two on the 12th, one on the 13th, two on the 15th, two on the 
16th, one on the 17th, one on the 21st, one on the 23d, one on the 
26th, one on the 29th, one on the 35th, and one on the 39th. 
As to the amount of the first hemorrhage, I find that the one 
occurring on the 6th day was two or three quarts; on the 7th day 
was a case of hemorrhagic diathesis, in which blood was flowing 
from the lungs, nose, bowels, and bladder. 
Of two cases occurring on the 12th day one lost half a pint, 
and the other about the same quantity. 
The one on the 13th day lost nearly five fluidounces. 
Of the two on the 15th day one lost one ounce, and one a half 
pint. 
Of the two on the 16th day one lost six fluidounces, the other, 
two quarts. 
The one on the 17th day lost one pint. 
The one on the 21st day lost one and a half pints. 
The one on the 23d day lost an amount not noted. 
The one on the 26th day lost a half pint. 
The one on the 29th day lost two pints. 
The one on the 35th day amount not noted. 
The one on the 39th day lost one pint. 
The study of the cases having two hemorrhages is interesting. 
Case 1 had two herporrhages,-the second hemorrhage occurring 
two days after the first, the amount about one and a half pints. 
This patient fully recovered. Case No. 3 had two hemorrhages,- 
the second occurring two days after the first, the amount was one 
pint. The next case that had more than one hcfrnorrhage was No. 
10. This man had three. The amount of the different hemor- 
rhages was not noted. This patient fully recovered. No. 11 had 
two hemorrhages, and lost about three-fourths of a pint in the last 
one. No. 17 had two,-the second one occurred five days after 
the first, the loss was fully a pint. 
If we study the color of the blood, we find that in two cases it 
was bright red, in eight cases it was dark red; one showed altered HEMORRHAGIC TYPHOID FEVER. 
7 
blood and clots, and four dark red and clots. In one case the first 
hemorrhage was bright red and the second dark red. 
In three cases of the seventeen a relapse followed the hemor- 
rhage. In three- cases of the seventeen hemorrhage occurred 
after the relapse. In two cases the bleeding was not confined to 
hemorrhage from the bowels, but also, in one, there was hemor- 
rhage from all the mucous membranes, in another purpura hemor- 
rhagica was present. Twelve of the seventeen cases recovered, 
and five died. One died the second day after the hemorrhage of 
exhaustion; one died the third day after; one died in two weeks; 
two were not noted. In two of the five cases that died autopsies 
were held. In neither case was the point found from which the 
hemorrhage occurred. Seven cases were treated in their private 
homes, and ten treated in the hospital; and of the five deaths but 
two occurred among those who were treated outside of the hos- 
pital. Both of them complicated by la grippe, and one by phle- 
bitis. 
It must be remembered that sometimes patients are sent to the 
hospital upon the discovery that they have hemorrhage from the 
bowels; hence, they are more liable to die, owing to the fact that, 
first, they are severe cases, and, secondly, that transportation of 
the patients in this condition greatly endangers his life. 
In looking over these cases I find that the temperature before 
the hemorrhage in three cases was stated to be not elevated; in 
two cases elevated to a moderate degree; in one not noted. 
Of the six actually noted, the temperature was in two cases 102° 
F.; two cases, 102.3° F.; one case, 104° F.; one case, 103.4° F. 
The temperature as noted after the hemorrhage in one case, 96° 
F.; one case, 97° F.; one case, 98° F.; three cases, 99° F.; one 
case, 99.3° F.; two cases, 102° F. 
It will be seen by a study of these cases that there was usually 
a fall of temperature taking place at the time of hemorrhage, 
particularly where loss of blood was large.