A CONTRIBUTION TO THE STUDY OF TYPHOID FE

VER IN CHILDREN.

BY H. N. REad, m. d., BROOKLYN, N. Y.

Read before the Medical Society of the County of Kings.

The behavior of typhoid fever in children offers some points of difference from its course in adults. Though essentially an eruptive fever, typhoid does not attack children more frequently than it does adults, as is the case in scarlatina and rubeola; nor does it prevail indiscriminately as does variola among children and grown people alike. It is oftenest seen in adult life, the proportion of young children suffering with it being about one in four to those of older growth. This being the experience of the best known authorities, though in my own practice the percentage has been somewhat greater, between one-third and onefourth.

Typhoid fever presents another rather anomalous trait, in that although one attack protects the system from another, yet the disease is not contagious at all. It is on the whole rather an exceptional disorder though belonging undoubtedly to the exanthematous group of fevers. The idea of this fever being contagious seems to have lasted much longer in this country, if we are to judge by the Board of Health laws of different cities, than in Europe. The early editions of both Vogel and Stewer, published in 1870 and 1871, state emphatically that typhus abdominalis, which is the German name for our typhoid fever, is not contagious. The old editions of West, Hillier, Ellis, and other English authors, say the same thing.

No satisfactory reason has been yet assigned why more adults than children are attacked by typhoid fever; nor is it known why more males than females suffer from it, though most authorities think this latter statement erroneous. However, all agree that more cases are reported as occurring in males than in females, and this, strange to say, holds good as regards children also. It seems probable, however, that as more cases are reported in the future and larger tables are prepared, this discrepancy will disappear, at least in children.

In reporting my cases I have limited the returns to children under ten years of age. Cases have been reported as occurring in children as young as two weeks only (Vogel, Day, Eustace Smith). The youngest case which has come under my observation has been in a child four and

a half months old. Under two years of age the disease is rare, and increases in frequency from this up to ten years. The whole number of my reported cases is twenty-two, occurring during a period of about five or six years, the ages of the patients ranging, as said, between four and a half months and ten years. Of the whole number. there were thirteen boys and nine girls. Seven cases of the fever were clearly imported to the city, the patients being taken sick with the disease within a week or ten days after coming home from various health resorts. Two other cases were probably imported. The remainder undoubtedly originated here. Of the seven cases clearly imported I forgot to mention that two were brought home sick. Of the two doubtful cases I may remark, that the repeated trips back and forth from home to the country, so that it was difficult to fix the responsibility on the exact place of origin.

children had made

The greatest length of duration of the fever was forty-two days, a delicate little boy, aged four years. The shortest duration of the fever was seventeen days, a female infant four and a half months of age. The child died on the seventeenth day of her illness. The highest recorded temperature in my cases occurred in a healthy girl of eight years of age, in whom the thermometer registered 1064° during the second week. The fever lasted over four weeks in this case, recovery taking place. One death occurred in the twenty-two cases, a female, aged four and a half months, making the percentage of deaths rather more than four and one-half per cent. The average duration of the fever in the twenty-two cases was about twenty-five days. Diarrhea was present in every one of my cases; fourteen exhibiting it from the commencement of the sickness, and the others showing it later on. Accompanying this also was tympanites, present without exception in every case, as was also gurgling, and tenderness on pressure in the right iliac fossa. The characteristic eruption was found in sixteen cases, more than two-thirds of the whole. It appeared in different degrees of intensity, from a few rose-colored spots on the belly and chest, to a thick, dark red, papular rash, so extensive as to give rise to doubts as to whether the case was not one of measles. This was in a girl aged three years. This was a most interesting case, the whole family, nurse maid, child, and mother, being successively stricken down with typhoid fever on their return from the country. The nurse was sick when she reached home, the child was taken sick within a week after her return, and the mother about three weeks after. In all three cases the eruption was very extensive, especially so in the child and

mother, and all three cases were very severe in character. Recovery took place in all. The fever lasted four weeks in the child, and the temperature repeatedly rose to 105° F.

The eruption was noticed rather earlier in the disease than is usual in adults in all my cases (this being a point of difference in the two classes of cases), appearing generally by the end of the first week, or in some cases on the fifth and sixth day. It is generally agreed that the rash does not make its appearance as often in children as in those of maturer years, though I believe it is oftener present than some authors state— Wood, Henoch. The eruption came out in successive crops in my cases till the end of the third week. The "tache cerebrale," of Trousseau, was obtained in all the cases, but, as is well known, this symptom possesses no diagnostic value.

Epistaxis occurred in three cases, something over thirteen per cent. The profuse hemorrhages which sometimes occur from this source following a sudden fall in temperature I have never observed. Neither have I seen in my cases the severe and sometimes fatal hemorrhages from the bowels which not infrequently complicate the fever in adults. All authorities state that this is rare in young children, though cases sometimes occur. Slight hemorrhage was observed in four of my cases. The lesion of the small intestine which is characteristic of typhoid fever, is much less severe in the young than in the adult, the ulcerative process being less deep and extensive, and the liability to loss of blood therefore is much lessened. When bleeding to any extent takes place, it is apt to be followed by fatal collapse. Earle, of Chicago, and Henoch, both report a case of this kind, the former in an infant twenty-two months old, and the latter in a girl ten years of age, and both fatal within a short time. No cases of perforation of the gut, adhesion, or of peritonitis, took place among my cases.

The disturbances of the digestive system which occurred in all my cases were limited to those usually seen in typhoid fever, loss of appetite, nausea, thirst, etc. Excessive irritability of the stomach was seen in only two cases. The cerebral symptoms of the fever were seen to a greater or less degree in all my patients. The very marked brain disturbances so often seen in grown people are rare in children. Very active delirium lasting for some days was seen by me only twice. One case, a boy, age four years, was taken while at dinner with violent vomiting and diarrhea. As he was previously quite well, he was supposed to have eaten something which disagreed with him. I saw him in

the evening of the day he was taken, found the diarrhea and vomiting still continuing, and also found that active delirium had supervened. He screamed, raved, and was very violent. This condition of active delirium continued, more or less controlled by medicines, for nearly twelve days. He then became dull and stupid and nearly comatose, neither moving nor speaking for three or four days. He finally made a slow recovery, the fever lasting four weeks. The convalescence was very tedious. The case was at first thought to be one of tubercular meningitis. The other case of acute delirium was in a girl, age seven years, and lasted nearly six days with brief interruptions. (Dr. William Wallace detailed a case of his to me, that of a child of three years of age, who was seized in a manner similar to the first case described above.' The child continued delirious, and died comatose in a day or two. Meningitis was supposed to have been the cause of death till the autopsy revealed the characteristic lesions of typhoid fever.) These cases are rare, but the possibility of their occurrence must not be overlooked. Four of my cases presented the low form of delirium with the heavy, stupid condition of the mind.

The circulatory symptoms were not marked in any of my cases. The respiratory system was involved in seven cases, nearly one-third of the whole. Four of these seven were cases of pneumonia of the hypostatic kind, and developed late in the sickness. The other three were cases of catarrhal bronchitis. One fatal case on my list, was one in which the fever was complicated with bronchitis.

Convalescence in young children and infants is usually more rapid than in adults. In my cases convalescence took place in the average number in about three or four weeks.

Sequelæ were noticed in only three cases, two of which showed albumen in the urine, and one necrosis of the tibia. All recovered.

Treatment. The treatment adopted in all my cases was limited to the attainment of two objects, viz., to keep the fever within the safety limit if possible, and to support the strength of the patient. As long as the temperature was kept under 103° F., a little medication was used; if it went beyond this point, febrifuges were given p. r. n. Antifebrin and antipyrin were used to some extent, but my chief reliance has been on the cool sponging of the surface of the body with water at about 85° to 90°F. To the water a little bay rum or alcohol was added. The sponging process was repeated every second or third hour. In the very high temperatures, 105° F. and over, the antifebrin and antipyrin were

very satisfactory in their action. Stimulants were used in all my cases, generally commencing at the beginning of the third week, in some cases earlier. As is well known their employment demands close watching, and they should not be given too early. Opiates and astringents were not used, Milk was the principal article of diet in every case, and indeed the only one for the first two weeks of the fever. To this was added the beef peptonoids, meat juice and beaten egg from time to time, and gradually farinaceous foods.

In conclusion, I present the following points, which seem to be established from this series of cases:

First.-Typhoid fever attacks young children only about one-third or one-fourth as often as it does adults.

girls.

Second. As far as known, it attacks boys more frequently than

Third. The prognosis is better in young children than in grown people, the percentage of deaths being from two to six in the hundred, while in the adult the death rate is from eight to twenty per cent., according to the authority quoted, differing in different places and epidemics. Murchison, of London, whose fever reports are probably the most extensive, gives the mortality in the London hospitals through a series of years as 15.6 per cent. Hutchinson, quoted from Pepper's System of Medicine, gives the mortality at the Pennsylvania Hospital, during a period of twenty years, as 19.5 per cent. Liebermeister states the mortality at Basle through a long period, to have been from 27.3 to 8.2 per cent., the difference being due to the treatment.

Fourth. The treatment best adapted for typhoid fever in children is that which keeps the temperature within reasonable limits without attempting to force it down too far, and supports the strength of the patient until the disease is spent and the fever has left. Any procedure which has neither of these two objects in view is unnecessary and harmful, and it is far better not to treat the disease at all than to treat it too much. The more powerful depressants, aconite, veratrum viride, gelseminum, etc., are contra-indicated. The ordinary diffusible stimulants, ammonia, nitrous ether, etc., and the usual heart tonics, quinine, digitalis, etc., are not needed, and therefore may do harm. The best febrifuge is the cool sponging with water at 85° to 90°, assisted, when the fever rises to 104°, by the antipyrin or phenacetine. Alcohol in some of its various forms is the best stimulant. best diet.

Milk is the