The second case is one suspiciously like typhoid, yet 3 successive tests of the serum were negative. The history is as follows: K. C., 31⁄2 years; had scorbutus at 18 months, at which time he was in charge of Dr. T. M. Rotch. The latter subsequently referred him to me, and I first saw him in April, 1901. His tonsils were removed in October, 1901, by Dr. Casselberry, but aside from that there is nothing noteworthy in his history until March 7th, 1902. It was first noticed on that day that he was drowsy in the afternoon; for the next few days he was bright in the morning, but drowsy every afternoon and disinclined to play; no other symptoms were noted. I first saw him on March 12th, at which time physical examination was negative, except for a tongue coated in the center, clean at the tip and edges. March 14th: Widal negative (8th day). March 17th: Blood: red, 4,640,000, white, 18,000; no plasmodium; Widal negative (11th day). Urine, no diazo. March 20th: Widal negative (14th day). March 26th: There have been no symptoms except irritability; no epistaxis, no splenic enlargement, no rose spots on abdomen or back, bowels constipated. March 28th: Feces examined by Dr. Roark showed abundant growth of the colon bacilli, no typhoid bacilli. The onset of this case, symptoms and general course, were most suspiciously like typhoid; even the subnormal temperature of convalescence is present. Yet with no splenic enlargement, no rose spots, 3 negative serum tests on the 8th, 11th and 14th days respectively, the high leucocyte count and absence of typhoid bacilli from the feces, even though not examined till the 22nd day of the course, we are scarcely justified in making a diagnosis of typhoid. The case is markedly similar to one reported by Gwynn (17) showing all the symptoms of typhoid, yet giving a negative serum reaction, the only one of his 265 cases clinically typhoid, failing to be positive in reaction. Gwynn's case was proved later to be a paracolon infection and he suggests that the possibility of the colon and paracolon bacilli causing typhoidal symptoms may explain many "negative" results in the serum test and correspondingly increase the value of the latter. I have regarded my own case as due to infection by one of the colon group. SUMMARY. The Widal serum reaction occurs in infants and children under the same conditions as in adults. It is perhaps apt to be weaker in early life. The evidence available is overwhelmingly in favor of the theory that a "positive" reaction means typhoid, regardless of symptoms and physical signs. As these symptoms and signs are often irregular or absent in early life, the reaction is especially valuable at this time, and in two ways: By detecting mild or obscure cases, and by ruling out certain intestinal cases which might be mistaken for typhoid. About 10 per cent of a limited series of intestinal infections in Chicago during the summer of 1902 were typhoids; of 127 children, throughout the city, suspiciously sick, about 20 per cent were typhoids. The serum test should be more widely used both to insure proper treatment of the individual patient, and to prevent the spread of disease. I cannot close this paper without expressing my great obligation to the staff of the Lincoln Park Sanitarium, especially to Drs. Storer, Wynekoop, and Johnson, who supplied the clinical material, and to Dr. Kierulff of the city laboratory, who has performed all the tests and lent most cordial and hearty sympathy to the work. We members of the profession in Chicago are to be congratulated on having at hand such a well equipped and well manned municipal laboratory. REFERENCES. 1. Cheadle-Lancet, 1897-II.—254. 2. Guinon & Meunier. Bull et Mem. de la Soc. des Hopitaux de Paris, 1897 (abstracted Zeitschr. f. Heilk. 1897-XVIII—471). 3. Chiari & Kraus.-Zeitschr. f. Heilk. 1897—XVIII.—471. 4. Morse. Boston Med. and Surg. Journal, January 12, 1897. Archives of Pediatrics, May, 1901. 5. Gershel. Journal American Medical Association, August 17, 1901. 6. Koplik. Archives Pediatrics, 1901-XVIII., 12-934. 7 8. Love. J. Amer. Med Assos., 1901-XXXVI., 893. 9. Berg. Med. Rec., N. Y., 1901-LIX., 441. 10. Chapin & Armend. Post-Graduate, 1901-XVI-445. II. Gillies. Montreal Med. J., 1901-XXX.-99. 12. Cushing. Johns Hopkins Reports, Vol. VIII., 385. 13. Strasser. Med. Rec., N. Y., 1901, LX.-286. 14. Bryant. British Med. J., April, 1899, 776. 15. M. A. Brown. Cincinnati Lancet Clinic, 1901, 85 N. S. 46–387. 16. Tobiesen. Zeitschr. f. Klin. Med., 1901, XLIII.—147. 17. Gwynn. Johns Hopkins Reports, Vol. VIII. 394 EAST CHICAGO AVENUE. TYPHOID FEVER IN INFANCY AND CHILDHOOD. By I. A. ABT, M. D., CHICAGO. For some years past, I have been studying in a detailed way, typhoid fever as it occurred in infants and children. The largest number of cases came under my observation in the children's ward of the Michael Reese hospital. Up to the spring of this year I had studied in a careful manner, 90 cases which were the subject of a report to the Illinois State Medical Society at its meeting held in Quincy in May, 1902. During the past summer, owing to the epidemic character of the disease and to the fact that the children who came to the Michael Reese hospital for treatment, for the most part live in the Ghetto on the west side, which has, as is well known, been the hot bed of the epidemic we have passed through, the number of cases has been increased by 110 additional, making in all a total of 200 cases. Previous to this summer, there had been no particular epidemic of the disease for a number of years. During the winter and early spring a case of typhoid was rarely encountered, whereas, during the month of June a few cases occurred, the number increased in July, and by far the largest number of cases was admitted during the months of August and September. Some of the cases admitted during the latter months were protracted ones and remained in the hospital until nearly the close of the year. A few cases suffering from the disease were admitted until December 1. THE AGE OF OCCURRENCE OF THE DISEASE. Even in recent years it has been maintained that typhoid fever in children under two years of age was of extremely uncommon occurrence. De Grassicourt (1) found only three cases in children as young as two years in 276 cases of typhoid. Vogel (2) collected 1,017 cases, only 4 of which occurred in the first year of life. Morse (3), who has rendered great service by his classical report on this subject, found no case in a child as young as two years. Holt (4) has never seen a case in a child of two years of age. It must be remembered, however, that the clinical as well as the post mortem diagnosis of typhoid fever in very young children, has been in the past impossible in many cases. The Widal reaction and the leucocyte count have been of great service in enabling us to diagnose cases which previously passed for another disease, or were not diagnosed. Chicago Medical Society, October 8, 1902. There can hardly be doubt any longer that fetal typhoid can occur. Morse (3) summarizes concerning this point, as follows: "The typhoid bacillus probably enters directly into the circulation, causing a form of general septicemia; therefore, the intestinal lesions in fetal typhoid are absent. The fetus usually dies in utero, or shortly after birth. The fetus may be born alive; if so, it is feeble and lives only for a short time. Death usually occurs in a few days. without definite symptoms. The fetus is not infected in every case." In the first ninety cases the youngest child was 8 months old. One was 17 months of age; 1 was 21 months; 5 were 2 years old; 5 were 4 years old; 7 were 5 years old; 5 were 6 years old; 6 were 7 years old; 5 were 8 years old; 7 were 9 years old; 9 were 10 years old; 7 were 11 years old; the remainder were between 12 and 14 years of age. Of the 110 added to the series, 67 were males and 43 females. Their ages ranged as follows: One, 1 year old; 2, 2 years; 13, 4 years; 9, 5 years; 9, 6 years; 5, 7 years. Of the remainder, 41 of the males were between the ages of 8 and 14 years and 29 of the females between the ages of 8 and 14. During the past season several cases of children who were two years old, or less, have come under my observation. Of these, one in particular, is of interest, because it illustrates the mild type which not a few of these cases pursued. The little fellow to whom I refer was from my private practice. He was scarcely two years old. He had frequently been ill with mild gastro intestinal derangements which usually yielded in a short time to a dietary and mild purgative treatment. The mother, who was a very intelligent woman, had treated the little patient on this plan for a week before I was called. The temperature had varied. between 101° and 103°; it was irregular in its course. The mother informed me that she did not consider that the child was suffering from one of his usual gastro intestinal infections, because the stools though they contained some mucus, showed a more perfect digestion and were less foul smelling than previously when the little patient had been ill from an ordinary intestinal derangement. Upon examination it was found that the spleen was enlarged, the patient was pale, the musculature had already become flabby, he was very restless though he did not make the impression of being severely ill. The first Widal test was incomplete, a second one after several days was positive. The decided leucoplenia-4,800 leucocytes --and the presence of an enlarged spleen confirmed the diagnosis of typhoid. The little fellow ran a short course of fever, lasting in all, about sixteen days. At the present time his temperature is normal and has been so for nearly a week. This brief history illustrates the mild type of the disease as it occurs in many of these young patients, which undoubtedly in the past has frequently been unrecognized, and which we are now beginning to more fully understand owing to improved laboratory methods which we have at our command. It would be a mistake to assume that all of the cases in young children under two years of age are of this mild type. Very recently I had the privilege of seeing a case with a fellow practitioner in an infant about twenty one months old in which the disease was well marked and resembled the severer forms which occur in adults. This infant was restless with constantly high fever, very rapid pulse and respirations, the trunk both anteriorly and posteriorly was dotted with well marked rose spots, the spleen was palpable and the prostration was extreme. The youngest patient that I have seen was only 8 months old. This was a male child. The mother and a brother of 2 years were in the hospital at the same time ill, with typhoid. The disease in the eight months old patient was ushered in by fever and vomiting. Roseola over abdomen and buttocks were distinctly present a few days after admission. The spleen was enlarged; the temperature was constantly high; the abdomen was tympanitic. The diagnosis was made by the course of the disease and positively confirmed by the Widal reaction. One case, a child twenty one months old, died. The autopsy showed the usual abdominal and intestinal findings of typhoid in young children. The solitary and agminated follicles were swollen without being ulcerated, the mesenteric glands and spleen were enlarged. This was a case in which multiple gangrene occurred, and has previously been the subject of a special report (5). PRODROMATA AND MODE OF ONSET. The majority of the children were admitted after they had been ill a number of days and for this reason accurate data as to prodomata and onset were not obtainable. In the older children prodromal symptoms were usually present. In smaller children the onset was frequently abrupt. A sudden rise of temperature was recorded in all the cases of young children; vomiting at the very beginning occurred nineteen times in our series. Convulsions are said to occur rarely; in one of our cases the onset was thus marked. Diarrhea was present ten times. Constipation was more frquent and occurred sixteen times. Headache was more frequently complained of than any other single symptom except fever. At the beginning of the disease 42 |