TYPHOID FEVER. Antony 1 describes an interesting observation concerning the etiology of typhoid fever. Two regiments which were lodged in the same barracks were served from the same water-supply. In one regiment there was a number of cases of typhoid fever, while in the other none occurred. The explanation of this proved to be that in one regiment the water was drunk without boiling, while the soldiers in the other regiment for months had taken nothing but tea-the water, of course, having been boiled. In discussion Chantemesse suggested that the occurrence of typhoid fever in only a part of a series of persons apparently exposed to the disease might be explained by the fact that, by their presence, other micro-organisms favor infection with the typhoid bacillus. Certain persons contract typhoid fever without drinking water which is definitely infected. This he attributes to the fact that typhoid bacilli are taken into the intestine frequently or remain there for a long time without being able to produce disease, but if water infected with other organisms is drunk, the presence of these other organisms is sufficient to precipitate a typhoid infection. [The view that preliminary intestinal infection of various parts predisposes to typhoid infection seems likely from certain observations, and may indeed be a factor of great importance. It would be interesting to investigate this subject experimentally were animal infection more certainly established for this disease.] F. S. Crum,2 in studying the mortality of typhoid fever in 24 American cities, emphasizes the unpleasant fact that throughout this country typhoid fever mortality is exceedingly high. It is noteworthy, however, that there has been a marked reduction in the death-rate during the last 10 years in most of the cities, New Orleans alone showing an increased mortality. The reduction in the mortality in Newark from 99 per 100,000 to as low as 14 per 100,000, is very instructive, since the city water-supply was altered just at the time that that reduction occurred. Securing water from a high, thinly settled district at a distance was coincident with a drop within 2 years from 99 per 100,000 to 22 per 100,000. A similar improvement in Chicago was also coincident with an improvement in the death-list from typhoid. [In considering statistics it is always to be remembered that diagnosis has become more accurate. Many fatal cases of typhoid were formerly classed as malaria. This mistake is far less frequent now. On the other hand, however, it must be acknowledged that the milder cases that are now recognized, and that tend to lower mortality, were not correctly diagnosed in former times.] 3 Genersich reports an epidemic of typhoid fever in a Hungarian town in which 209 cases occurred, 28 of which were fatal. The drinking-water used by these people was taken from two cisterns, and a bacteriologic examination of the water showed the presence of the typhoid bacillus. 1 Gaz. des Hộp., July 7, 1899. 2 Med. Rec., Aug. 12, 1899. 3 Centralbl. f. Bakt. Parasit. u. Infect. Krankh., 1900, Nos. 7 and 8. C. C. Hubbard1 describes an epidemic of typhoid fever which occurred in Worthville, N. C., a village of about 350 inhabitants. There were 63 certain cases and a number of others which were doubtful. Infection in about half the cases apparently occurred from one well, and the epidemic came on at a time of the year when water was very low and when a number of the wells of the village had gone dry. The death-rate was about 10%. P. E. Archinard 2 notes that earlier clinicians in New Orleans considered typhoid fever uncommon, but that the disease is now frequently seen. He believes that this is due to actual increase in the disease, because, chiefly, of increase in population, the bad drainage obtaining in the city, and especially the prevalent custom of using rain-water for domestic purposes. J. C. Tresh and E. R. Walter 3 describe an outbreak of typhoid fever which was probably due to infection from eating cockles, since the water-supply seemed to be uninfected and there was no evidence of infection of the milk-supply. The sewage arrangements were good and there was no pollution of the soil, so that these factors seemed to be excluded, and the cockles seemed to be the cause, since practically all those who were attacked had eaten them, and they were obtained from a source which was polluted by sewage. Almost all of those who were taken ill were recent arrivals in the place where the outbreak occurred. W. H. Park 4 reports his discovery of the typhoid bacillus in the feces in 40% of 104 cases. One epidemic of typhoid fever which he reports was due to contamination of ice; another was the result of eating raw cockles, the water in which the latter had grown having been infected by sewage. He believes that it is possible to immunize against typhoid fever by injecting serum from an immunized horse or by injecting agar cultures of the typhoid bacillus which have been heated up to 55° C. or to which % carbolic acid has been added. The Widal reaction, he finds, occurs in about 95% of cases. If it is found in a dilution of 1:10, higher dilutions should be investigated. C. A. Cameron 5 describes a series of small epidemics of typhoid fever due to infection from the milk which was served to all the people who became ill. It was learned that cases of typhoid fever had occurred at the dairy from which the milk was supplied, and the woman who had nursed the patient with typhoid fever also attended to the business of the dairy. As a result there were in one institution 32 cases of typhoid, in another 6, in another 4, in another 14; besides this, there was a series of cases in private houses which had been supplied from the same dairy. V. C. Vaughan 6 contributes a paper upon typhoid fever as it appeared among the soldiers in the war between the United States and Spain. Vaughan's paper is the result of an investigation by the Government Board, of which he was a member. He notes first that 1 Med. News, Dec. 30, 1899. 3 Brit. Med. Jour., Dec. 16, 1899. Dublin J. M. Sc., Nov., 1899. 2 Phila. Med. Jour., Mar. 31, 1900. the army surgeons' diagnosis of typhoid fever was in many cases very unreliable. Most cases of fever were diagnosed malaria; but so far as can be determined, malaria was rare among the troops, while typhoid fever was extremely common. The infection in the camps was brought by soldiers from their homes. One fact that is considered of great importance in having caused the spread of the disease is that in many instances the surgeons unwisely suppressed the diagnosis in order to prevent alarm. The disease did not come from drinking-water, since residents of nearby towns used the same water and did not become infected, while the soldiers did. The general infection was believed to have been due chiefly to the method of depositing excrements in pits. The disease was believed to have been carried by flies. There was no evidence of infection through milk. The Board of Investigation insists that it is of the utmost importance to sterilize completely all fecal matter, and recommends for future use a galvanized iron trough, which should contain a saturated solution of milk of lime and should be emptied daily by odorless excavation. Each company should have such a trough. The Board also insists that medical officers of the army should have special training in military hygiene. The mortality from typhoid is said to have been between 4% and 7%. Considering the effect of changing the location of the camp, the Board decided that mere change in location, even if the sick are left behind, does not rid the camp of typhoid. It is necessary to disinfect the belongings of the camp. If, however, the move be made before there is wide-spread infection, the disease may disappear. A sea voyage lasting some days or more seems to be of decided use in ridding the command of typhoid fever, though this did not seem to be of marked effect if there was already a wide-spread infection among the men. H. Peck1 discusses 206 cases of typhoid fever which he has investigated in connection with the question of sick-room infection. He decides that in 28 of these cases the patient probably received the infection in the sick-room, and considers that such a manner of infection is much more common than is usually believed, and that the danger of such infection should be recognized and guarded against. Infection in the sick-room is particularly likely to occur in the small houses of the poor, where people are crowded together. [We can confirm the author's views from our own experience, and have become impressed with the opinion that the profession does not sufficiently recognize the danger of infection in the sick-room. The friends of patients are allowed to become careless through the well-meant assurances of the physician that typhoid fever is not contagious. This statement, without explanation of its limitations, naturally leads to carelessness.] Pathology.-R. Lepine and B. Lyonnet 2 report some experiments concerning typhoid infection in the dog. They first fed the animal on bouillon cultures of typhoid fever, without the production of any lesions or. of agglutinative power in the blood-serum. The injection of virulent cultures into the intestine, and ligation of the intestine above 1 Brit. Med. Jour., Sept. 2, 1899. 2 Rev. de méd., Aug. 9, 1899. and below the site of injection, caused no result except enlargement of the mesenteric glands. Afterward a loop of intestine was isolated by Thiery's method, and bacilli were injected into the isolated loop. This induced marked agglutinative action of the blood-serum, peritonitis, and intestinal lesions resembling those seen in man; bacilli were recovered from the mesenteric glands. Injection of cultures into the mesenteric vein resulted as follows: The bacilli were found in the spleen 8 times,. in 1 case the result was doubtful, in 1 case negative; 8 positive results were obtained from the examination of the liver, only 2 positive results from the kidneys, 1 positive and 1 doubtful from the lung, 3 negative and 1 positive from the heart blood. Injections of cultures underneath the intestinal peritoneum resulted in finding typhoid bacilli in the spleen regularly; in 5 out of 7 experiments it was found in the liver and 3 out of 5 times in the bone-marrow, and not in any instance in the kidney. Injection of bacilli into a vein of the larger circulation was done 7 times and produced some appearance of general infection in all cases. Injections into the trachea caused death in 2 cases, probably from toxemia; in 3 cases there was typical red hepatization of the lungs, but there was no fever, and the animals probably died from toxemia. W. Ophüls 1 describes a case of typhoid infection without intestinal lesions which occurred in a man of 24 who was admitted to the hospital in a semiconscious condition. The diazo and Widal reactions were positive. The patient died a week later. The necropsy showed enlargement and softening of the spleen and lymph-glands, necroses in the liver, and multiple hemorrhages in the mucous membranes of the genito-urinary tract; bacteriologic examination showed in the spleen large numbers of bacilli which had the characteristics of typhoid bacilli. Ophüls believes that in a certain number of these cases which are apparently without intestinal lesions infection has taken place in the usual way, through the intestinal mucous membrane, but there has been no ulceration of Peyer's patches and the swelling has disappeared. As proof of this, he notes that often in even those cases there is evident irritation of the intestines, and that in many instances death takes place late in the disease when the lesions of the intestines might have disappeared entirely if they had not ulcerated. [The existence of diarrhea and other signs of intestinal irritation in typhoid fever by no means proves that there has been any lesion in the intestine. There is little doubt that the diarrhea is often due far more to the general toxemia than to the local lesions.] A. McPhedran 2 describes a case which ran the usual course of typhoid fever and presented positive Widal and diazo tests. Death occurred about 40 days after admission to the hospital. The intestines were found free from lesions except inflammation and small hemorrhages, but cultures from the spleen showed the presence of the typhoid bacillus. It was evidently a case of typhoid without lesions of the intestines. A. J. Lartigau 3 describes 2 cases of typhoid fever with multiple 1 1N. Y. Med. Jour., May 12, 1900. 2 Canadian Jour. of M. and S., Oct., 1899. 3 Boston M. and S. Jour., Sept. 7, 1899. ulcerations of the vulva and vagina from which the typhoid bacillus was isolated. The fact that the ulcers were multiple suggested strongly that the origin was in minute bacillary emboli. [We have seen 1 case with similar lesions of the vulva. The ulcers were deep and irregular, and in the assured absence of any form of venereal infection, were regarded as probably due to the existing typhoid infection. They occurred early in the disease when the patient's general condition and circulation were little affected. Unfortunately, no cultures were obtained.] Symptomatology.-W. H. Thomson 1 reports his experience with. 368 cases of typhoid fever-a 10 years' experience. The mortality was 6.8%; but if the deaths which occurred during the first week are excluded, the fatalities were but 3%. Diarrhea was relatively rare, while constipation was common, the infrequency of diarrhea being attributed to the fact that meat-broths were but little used in the diet; Thomson believes that such foods easily produce diarrhea through undergoing fermentation. Tympanites was seen in 20%, and was a bad sign. Hemorrhage occurred in 7.3%; the best treatment was hypodermoclysis of from 8 to 12 ounces of normal salt solution. There were 4 cases of perforation, 2 of which were successfully operated upon. Delirium was rare. Peripheral neuritis was seen 24 times. It was attributed to the foot-drop resulting from the prolonged relaxation of the leg muscles. Phlebitis occurred 7 times and cutaneous abscesses 29 times; the latter appeared in epidemic form in 1894 and were thought to be due to infection from bathing in Croton water. There were 15% of relapses. In one fatal case intestinal lesions were absent, but there was a severe pelvic myositis, which was thought to be typhoidal. In treatment Thomson uses a mercurial purge every third night for 2 weeks, and gives milk exclusively up to the fourth week. He believes that pepsin and bismuth have great value in improving digestion and thus preventing inflammations of the mouth, throat, middle ear, and parotid glands. A. A. Smith 2 reports a series of 104 cases of typhoid fever seen in Bellevue Hospital. There was a history of marked alcoholism in 15% to 20%, chilly feelings were noted in about 50%, diarrhea was present in the same percentage, epistaxis in about 41%, characteristic spots could not be observed in 20%, enlarged spleen was absent in 20 cases, the Widal reaction was absent in 10 cases and present in 49, the diazo reaction was present in 44 and absent in 15. There were 8 relapses and 10 deaths. In 5 cases the plasmodium of malaria was seen in the blood during convalescence. In 1 case the intestine was aspirated for the relief of tympanites; peritonitis occurred and the patient died. In 3 cases death was due to exhaustion, in 2 to perforation, in 1 to edema of the glottis, and in 2 to hypertrophy. H. E. Belcher 3 reports a case of typhoid fever which began on July 25th, and in which there was a continuous high temperature until Sep 1 Med. Rec., Nov. 11, 1899. 2 Med. News, Dec. 9, 1899. 3 Brit. Med. Jour., April 7, 1900. |