MEDICAL REVIEW,

VOL. XXXV.

A WEEKLY JOURNAL OF MEDICINE AND SURGERY.

ST. LOUIS, MO., MAY 29, 1897.

ORIGINAL ARTICLES

Diagnosis and Treatment of Typhoid
Fever.

BY L. C. ROYSTER, MD, SMITH MILLS, KY, Secretary, Board of U. S. Pension Surgeons, Henderson, Ky.

DEFINITION.-Typhoid or enteric fever is an acute in fectious, continued fever characterized by peculiar intestinal lesions, splenic enlargements, rose colored erup tions, diarrhea, prostration, etc. The morbid changes are chiefly found in the lower part of the ileum and up. per part of the colon and consist in a necrotic inflam. matory infiltration of the follicular structures and neighboring parts commonly called "Peyer's patches" with a catarrhal inflammation of the rest of the mucous membrane. It is due to a pathogenic micro-organism (the bacillus typhosus) which, as a rule, finds an en trance into the system by means of food and drink, par ticularly by water.

The prodromic symptoms are headache, vertigo, loss of energy, pain in the back, bronchitis, slight diarrhea, insomnia and epistaxis. (Gould-Keating).

The disease is generally considered to begin with the first elevation of temperature, which comes on by chilly feelings or a decided chill when the patient generally takes to his or her bed and the doctor is usually called or consulted. Diagnosis is the first thing to consider. We may be enabled to arrive at a positive diagnosis the first or second day, or it may be six, eight or even ten days before we can be positively certain that we have typhoid fever to deal with.

We usually take the symptoms in the following order (which often takes a week or more to complete): (1) History of prodromic stage; (2) temperature and pulse; (3) tongue, mouth; (4) headache and nervous symp. toms; (5) appetite; (6) bowels; (7) skin; (8) epistaxis; (9) bronchitis; (10) spleen, liver, kidneys; (11) physiognomy; (12) hematology.

NO. 22.

on the patient's own statements or upon the parent's or companion's statement. They may be credited or they may not, as the case and surroundings may be.

some cases.

They generally complain of having had frontal headaches for several days or weeks with a tired aching feeling in the back, shoulders and lower extremities, with dizziness when stooping or exercising, complete loss of energy, with possibly a little hacking cough in An occasional nose bleed, bowels loose especially when they eat heartily of solid food, hypercatharsis, when a purgative is given. Insomnia is marked in some cases. I have found most of the above symptoms to have existed in the majority of cases, by no means all. The onset is sometimes as sudden as in an attack of remittent.

TEMPERATURE AND PULSE.-The fever may be ushered in by a decided rigor with a temperature of 104° or 105° F., and a pulse of 120 to 140, or it may come on so insidiously as to puzzle you as to whether you have a fever or not, the mercury ranging in the neighborhood of normal in the morning, and a fraction of a degree above normal, or quite normal in the afternoon and night, with a pulse also normal or thereabouts. There are exceptions however. In the majority of cases the fever begins with an evening temperature of 100°, 101° or 102° F. on the first day, and an increase of about .5° to 1° each succeeding day for five or six days when it will reach its maximum height and remain there for six to ten days and then gradually decline or go up as the case may be favorable or unfavorable; if favorable, it will run its course in from twenty-one to twenty eight days; if unfavorable, it may last six or eight weeks.

The fever is probably never absent throughout the entire course of the disease, although there are cases recorded to the contrary. In the Boston Medical and Surgical Journal, Vol. CXXI, No. 10, Prof. F. C. Shattuck says: "It seems to me that there is absolute proof that typhoid fever may exist and even prove fatal with. out the presence of fever." James C. Wilson shares the same opinion. Strube has reported fourteen cases of typhoid fever in which the temperature was normal or subnormal. These cases occurred among the German troops beseiging Paris. (Medical News, Vol. XII, page 189).

TONGUE, LIPS, TEETH, GUMS.-The tongue is furred from the beginning, often presenting a brownish appearance with red edges. Sometimes it remains white, The prodromic stage is entirely subjective depending not unlike a malarial tongue, except it is rarely broad

and flabby as seen in a malaria, but pointed or wedge- given the credit of placing this on a scientific basis. shaped on protruding, this is a very important point in The phenomenon which is commonly spoken of as the differentiating from malaria, for when it is seen in "Widal reaction" may be briefly described as follows: typhoid fever you can almost with positive certainty ex- "Add a certain portion of blood serum from a patient clude malaria, this character of tongue is often seen in suffering from well developed typhoid fever to a bouilsome of the exanthemata, scarlet fever, measles, etc., lon culture or watery emulsion of the typhoid bacillus except the papillæ are not as prominent; sometimes and in from thirty minutes to several hours flocculi or there is a dark-brown line in the center of the tongue of clumps will have formed throughout the mixture and various shapes. You do not have the dry, parched and fallen to the bottom as a granular sediment leaving the cracked, nor the raw beef tongue until after the first overylying fluid more or less clear. A control culture week as a rule. The lips are usually dry and often of the typhoid bacillus treated in the same manner with parched, no herpes as seen in malaria. Unless scrupu the blood of a non-typhoid, sick or well, will remain lous cleanliness is enjoined sordes will accumulate on uniformly cloudy with no sediment. If a drop of the the teeth and gums, which should never occur. former mixture be transferred to a cover-glass and exHEADACHES, NERVOUS SYMPTOMS, ETC.-There is a amined microscopically the bacilli will be seen to dull, frontal headache from the beginning as a rule gather in masses and become motionless while the few often lasting throughout the disease; it is sometimes that remain free generally lose their mobility. A drop absent or not complained of, especially in children. of the latter mixture will be seen to contain very The facial expression shows an indifferent listless ap- actively mobile bacilli evenly distributed throughout pearance, a mental hebetude in some cases. There are the fluid and thts condition will be found to persist for other nervous symptoms seen in severe cases, such as hours or even days if the specimen be properly sealed wild delirium, subsultus tendinum, etc. to prevent evaporation.

"To the agent which causes this agglutination and which seems to be identical neither with the bactericidal or the immunizing substances of the immune serum Pfeiffer has given the name 'paralysin' and Gruber 'agglutinin.""

APPETITE.-The appetite in most cases is completely lost, in some few cases it is ravenous from the beginning. The abdomen is often distended with gas and tender to the touch, especially in the right iliac fossa; this symptom is invariably present amounting to severe pain in some cases, whilst in others it has to be care- Dr. Wyatt Johnston, of Montreal, independently of fully sought for, especially in young subjects. There Widal, deduced that substances such as the toxins and is often gurgling when counter pressure is made over antitoxins (analogous to the agglutinins) preserve their the head of the colon (this should not be practiced often characteristics in the dry state, the same might be true for fear of rupturing the gut). The bowels are often of the substances causing the serum reaction, he thereloose with ochery-colored stools, they are frequently fore examined specimens of dried blood from ten typi constipated, and when a cathartic is given they act too cal cases of typhoid and found the reaction to be comfreely. Bloody stools are rarely seen in the first week plete in every case. Whereas in ten cases of nonof the disease, if they are seen the blood generally typhoids there was no reaction. comes from piles or fissured rectum. The difficulty of separating the typhoid bacillus from the colon bacilli renders the microscopic examination of the feces impracticable. If this were practicable, it seems to me that the early and positive diagnosis would be settled, without the consideration of any other symptom.

SPLEEN, LIVER, KIDNEYS.-The spleen is always enlarged. The liver and kidneys are generally normal. EPISTAXIS.-Nose bleed is often seen, but rarely to an alarming extent. Bronchitis is common, especially in young persons and children.

SKIN.—The skin is almost always dry throughout the course of the disease; it is sometimes moist and even profuse sweating is seen. There are rose-colored spots developing from the fifth to the eighth day, which can almost always be found if diligently sought for, they resemble a flea bite, they are scattered over the chest and abdomen.

It is on the above line of symptoms that we have heretofore had to make our diagnosis. Recently the science of hematology or the examination of the blood has promised important results in making an early diag. nosis of typhoid fever. To Widal, of France, must be

Dr. Jerome B. Thomas, Jr., of Brooklyn, N. Y., in experimenting with both of the above tests says the Widal test is the most reliable. The reaction is sometimes found in other diseases, such as rheumatism, malaria, phthisis and old typhoids.

Johnston recently stated that he had applied the test in more than six hundred cases with perfect confidence in its reliability.

Biggs-Park, of New York, in the March number of the American Journal of the Medical Sciences, arrives at the following conclusions in regard to Widal's serum test in typhoid fever:

be

"It seems probable that a positive diagnosis may reached in 50 per cent of cases of typhoid fever and a probable diagnosis in half the remaining cases." Thus leaving 25 per cent doubtful.

Widal describes two methods of diagnosis which should be carried out concurrently:

FIRST METHOD.-Draw a few drops of blood from the end of finger, mix the separated serum with ten parts of a one to two day typhoid bouillon culture. Observe with the microscope from one-half to several hours. If large clumps of motionless bacilli gather and the areas

between are free or almost free from bacilli, the case is relegated to oblivion. To sit on the stool of do nothing, typhoid.

Second Method.-Draw about 5 c.cm. of blood from the median vein of the arm with a sterile syringe, mix c.cm. of serum with 4 c.cm. of typhoid bouillon cul ture, incubate at 37° C. for twenty four hours when the reaction will be complete, then examine, as in the first method, with the microscope.

From the foregoing it would seem that we have a very valuable means of making a positive diagnosis in typhoid fever in the majority of cases. The main objection is the tardiness in showing up the reaction, it not being obtainable sooner than the fifth or sixth day. TREATMENT.-The treatment of typhoid fever resolves into hygienic, dietetic and medicinal.

waiting for this so-called self-limited disease to run its course and kill about 25 per cent of cases, should not be longer tolerated. Especially when we have means at hand that will not only mitigate suffering and lower the death rate, but, as I believe will shorten the dura. tion and in many instances prevent complications.

The most popular lines of treatment at the present day are the antipyretic and intestinal antiseptics. The antipyretic treatment consists of means calculated to maintain the body temperature at a reasonably low de. gree. The Brand method or cold water treatment is the most popular, especially in hospital practice. While this method has been practiced for many years in Germany it remained for James B. Wilson, of Philadelphia, The sick room should be large, airy, well ventilated to give this treatment a test in this country. He began and divested of unnecessary furniture, the windows his experiments in the German Hospital, in 1890, by should be at the side of the bed and not in front or behind the patient, and abundance of fresh air should be admitted from time to time, draughts should not be allowed to blow directly on the patient -although the danger of taking cold while the fever is on is very slight. The light should be tempered and in summer the sunlight excluded in a measure, the contrast be tween night and day should be maintained as much as possible in order that the patient may sleep at night. The temperature of the room should be about 65° F.

Absolute tranquility should be insisted upon and only one or two persons allowed in the room at one time, they should not be allowed to converse or read to the patient, the patient should not be allowed to get out of bed. The bed should be comfortable and clean, a hair or cotton mattress preferred. The patient's clothing should be changed as often as necessary. The stools should be disinfected and buried as soon as discharged, and all soiled linen should be burned or boiled at a high temperature for a considerable time.

series:

SERIES.

YEAR.

NO. OF CASES. NO. OF DEATHS

PER CENT.

5

1

1890

106

4.7

2

1891

116

8

6.9

The Presbyterian Hospital reports for the same period show 288 cases treated, 31 deaths, mortality 13.8 per cent. Different methods of treatment were practiced THE DIET should be bland, digestible and nutritious. in the last two hospitals including the Brand method The nearest approach to this is good fresh cow's milk and intestinal antisepsis. I will not describe the Brand administered in small quantities frequently; they should method, as it can be found in almost any modern textnot be overfed, two to three pints in twenty-four hours book. Antipyretic drugs have no place in the treatment is an abundance during the first week or two of the dis- of typhoid fever after the first week. Phenacetin or ease after that if the patient's strength is failing you acetanilid may be cautiously given in the beginning can increase the quantity to four or six pints per diem. with benefit. Sponging the body with tepid or cold When they tire on sweet milk give them butter-milk, a water will usually be sufficient to keep the fever within little chicken broth or beef soup. Water should be bounds. The old plan of giving quinine in large doses given at frequent intervals, if necessary, the patient for its antipyretic effect should not be practiced. In should be urged to take it. Hard and indigestible food such as ordinary diet, should be interdicted. Too much stress can not be put upon the diet in typhoid fever, for without a suitable diet your medicine will avail nothing. I often tell my patients that I had rather risk my chances without any medicine and with a proper diet than with medicine and an improper diet.

fact, I believe that quinine not only should not be given to reduce fever, but should not be given at all in any stage of the disease. In other words, I believe that quinine is contraindicated in typhoid fever.

In my opinion the most prominent indication in the treatment of typhoid fever is intestinal antisepsis. That the Eberth bacillus is the prime cause of this disease is MEDICINAL TREATMENT.-The time has come when admitted by most all modern clinicians and bacteriolo the so-called expectant plan of treating this most for- gists. That the lower end of the small intestine is a midable foe of mankind, a foe that costs more than veritable hot bed for the propagation of this germ 50,000 lives annually and unnumbered days of misery which generate ptomaines and leucomaines which are and suffering, to say nothing of the expense, should be said to be the cause of the fever and the long train of

suffering from pulmonary phthisis, at a given stage, under similar circumstances, may vary greatly and yet the external symptoms be identical. The microscope then is of great value to study the nature of the expectora tion fully, not only to examine to find the bacillus of tuberculosis, but in all its bearings. It is necessary, therefore, in therapeutics, to take into consideration the many factors that go to decipher the pathologic phenomena of tuberculosis of any organ and also the history back of the existing conditions, and besides all this, the specific complications that may exist, which are, unfortunately, exceedingly common, if not gener ally predominant when the patient reaches the physician. From this point, it is obvious, that to use any organic form of treatment based on the laws of Nature (by which laws specific maladies are often cured without the intervention of man), we must place every case on its merits and imitate Nature as closely as possible.

cast reflections on any school, and far less on any man connected with the first school, nor do I wish to exalt any man or product of the latter, but I do desire to sub mit, for the consideration of this scientific body, the grounds for the existence of each and their limitations. First, as to the action of the toxins of the germ of consumption. On what ground is it possible for one to consider them useful in the prevention and cure of tu. berculosis, realizing that they constitute the essential factor (poison) of this malady in its pure form? It can be done only on the theory of immunization or vaccina. tion, and this (vaccination) depends for its success on systemic reaction to the vaccine poison before the disease it is expected to prevent or cure has progressed too far. The essential of vaccine is the toxic influence that provokes the formation of antitoxins in the system by which the body becomes immune. This is in accordance with the accepted laws of physiology and pathology. The numerous forms of developments of tuberculosis It would seem then, that tuberculin can be useful on. should be first well understood and considered fully, ly if it be capable of rendering a susceptible body im and not a general catch all course, but a specially mune against the disease which the germ of consumpadapted treatment should be applied, the specific basis tion produces, by creating a reaction of the system of which to be such an agent as is best calculated to against it, by which, during which, and on account of arrest the progress of the malady by removing the which, an antitoxin or counter poison is generated. It cause, remembering always that causal remedies in con is claimed by the highest authorities, chiefly Professors sumption are not alone of importance. Koch and Klebs, than whom no pathologists are superior, that at least some of the irritating proper ties of tuberculin may be eliminated and the agent remain an effective curative agent. Koch has just issued a new paper claiming curative properties for a new lymph when used very early. This claim of Koch and Klebs and von Ruck has been much controverted. However, it is worthy of the strictest study and investi. gation, aud the very name of the authors of it commands respect But in any event, it does seem logical that tuberculin as a curative agent must be used, at a very early hour, before there exists any appreciable damage to the tissues, at a moment indeed when not one per cent of consumptives reach the doctor. Furthermore, the fact that almost every case of consumption is a mixed infection, what can tuberculin (the essential consumption poison) do against the invasion of the germs of pus, etc.? Against these complicating microbes the very nature of this remedy proclaims its im potency! The limits of this preparation therefore, under whatever name, and no matter by whom it may be placed before the medical profession, seems to be within the boundaries defined by the beginning of the special or general pathologic effect, manifested before the beginning of the fever. Then, possibly, the inWith this brief preface, I beg to submit for your con- jections of tuberculin may act quickly enough to imsideration, that there has been in existence for some munize the individual, before the germs have sufficiently years, two distinct schools of organo-therapeutics with invaded him to cause hopeless ruin. It is obvious that, reference to tuberculosis. One claims that the products to immunize any individual against tuberculosis the (poisonous agents) of the bacillus of tuberculosis are tuberculin must be used before the disease exists, to capable of curing the disease. The other, which is any great extent, or at least before it has developed into based on the principles of sero-therapy, claims that on- conditions sufficient to produce appreciable external ly the agents produced by nature, to cure this microbic manifestations. In advanced conditions, it is reasona disease, are applicable and logical. I do not wish to ble to suppose that it can be of value only to the extent

With respect to methods of organic treatment, one must realize not only the specific effects of each, on the micro-organisms that are supposed to cause the disease, or on the complicating germs which are believed or known to exert a certain deleterious influence on the system by their presence and their poisonous products, but one must consider, also, the direct chemic and physi. ologic effects of the organic therapeutic agents used, and that of the germ products on the organization un der their influence.

The organic substances used in medicine and the poi son of the microbes which it is intended the former shall somehow nullify are both capable of great damage on the cells of the body, chiefly of the nerves and blood and have great bearing in determining the limits of organo therapy.

Organic medication, theoretically supposed to arrest the growth of micro organisms in the system, depends on natural properties to accomplish this object, and not on chemic effects of the order of an ordinary antiseptic on the life of germs. Yet, some of those organic products of life, which are used in medicine, or produced in the body by germs, are potent and may kill cells, liquefy them even, and cause death.