cases was there any history of family tendency to nervous affections nor any personal history of past convulsions or other affections that might be responsible for an epileptic attack. Dide believes that the toxemia of the disease probably causes the epilepsy. [Undoubtedly severe illness of various sorts may be the exciting cause of epilepsy; may initiate attacks in individuals who are predisposed, or may convert a petit mal or nocturnal epilepsy into a severer type.] E. W. Pressly, among infrequent sequels of typhoid fever, records a case in which there was purpura associated with swelling of the joints, and in which recovery occurred; another case of purpura of very great severity in which there was hemorrhage into the skin and from many mucous membranes, and resulted in death 14 days after the appearance of the purpuric symptoms; a case of dry gangrene of the leg, the cause of which is not stated; a case in which sudden crossed paralysis occurred during convalescence, this being followed by symptoms of chronic hydrocephalus which were greatly improved by lumbar puncture; and additional cases in which the interesting observation was made that goiters present in each case disappeared rapidly after the occurrence of the typhoid fever. J. M. DaCosta 2 observed 30 cases of phlegmasia dolens in the 215 cases of typhoid fever seen among the soldiers treated at the Pennsylvania Hospital, and in 135 additional cases this complication appeared after the fever had run its course; in the total number of cases there were 13% that showed the complication. The explanation of this frequency could not be found. It was thought possible that excessive marching had led to it; but it was found that most of the patients had been in camp. He believes the condition is primarily a thrombosis, and not a phlebitis, since there is no pain in very many of the cases in the early part of the attack, and no other evidence of inflammation. He has seen but one death from this cause in his experience; this was due to pulmonary embolism. Heger describes a case in which there were the usual symptoms of typhoid fever and the positive Widal reaction; but tubercle-bacilli appeared in the sputum and the patient died with signs of acute miliary tuberculosis. The latter was found at autopsy, the lungs presenting tubercular pneumonia, and the liver, kidneys, and ileum showing numerous miliary tubercles. But while there were no typhoid ulcers in the intestine, cultures from the spleen showed typhoid bacilli. [This case is of interest in connection with the one quoted from Meigs's communication, vide supra.] A. A. Eshner reports a case of typhoid fever in a tuberculous subject who also presented evidences of syphilis; and mentions another case in which death occurred soon after an attack of typhoid fever which had been followed by lobar pneumonia, and in which at the postmortem there were also lesions of chronic tuberculosis. Both cases seemed to be instances of triple infection. 5 H. Fischer reports an observation which he made some time ago of coincident typhoid fever and trichinosis. This occurred in a young butcher who had eaten infected meat. The most prominent symptoms were those of typhoid fever; the autopsy showed the lesions of 1 Phila. Med. Jour., June 24, 1899. 2 Boston M. and S. Jour., Mar. 23, 1899. typhoid in the intestines. Operation upon a bedsore had shown during life trichinæ in the tissue removed, and they were also found in many of the muscles after death. N. Senn,' in writing of the invasion of Porto Rico and of typhoid fever in that campaign, says that at the time of writing there were 250 cases at Ponce and 145 at Guayama, in almost every instance the disease having been contracted before the patient left the United States. It was usually mild in character. In one case there was a metastatic abscess of the submaxillary gland, which is a rare complication; and in another case death was caused by progressive gangrene of the penis. Breton reports a case of typhoid orchitis which resulted in suppuration and required removal of the testicle. A bacillus resembling the typhoid bacillus was found in the pus, but this was not absolutely differentiated. [This complication is rarely reported; but we have seen 3 cases within the past year, all of them in soldiers; in 1 there was suppuration, necessitating removal of the testicle.] COMBINED TYPHOID AND MALARIAL INFECTION. 3 I. P. Lyon reports a case of combined typhoid and malarial infection which occurred in a man of 48, who had had repeated attacks of malaria some months before. These had been only imperfectly treated, and the patient had not recovered health between the attacks, so that malaria probably remained present. He was admitted on Jan. 5, 1898, with a history of daily chills since Dec. 18, 1897. At the time of admission he had the appearance of typhoid fever, but febrile paroxysms occurred twice in the 48 hours after admission. The course of the fever was characteristic, the Widal reaction was positive, and the leukocytes were reduced. He entered upon convalescence, but 9 days later developed febrile paroxysms and showed tertian parasites in his blood. Quinin was given at once upon their discovery, and after 3 paroxysms the disease was controlled and the patient left the hospital cured. A study of the 29 other certain cases of combined infection reported is given; and Lyon decides that the American conception of "typhomalaria" is erroneous, and that the French have given the correct description of this disease. The course in the cases studied was of average severity and often grave. Only one or two cases recorded were mild; the mortality was 33.3%. Complications frequently occurred. The typhoid picture usually dominated the scene. The malarial manifestations appeared at different periods, often being present at the onset of the disease, sometimes occurring during its course, but frequently being seen only in convalescence. In some cases they were present at the onset, disappeared entirely during the course, and reappeared during convalescence, the typhoid fever seeming temporarily to overcome the malaria. Quinin was usually given; and it is probable that had it not been for the treatment, the malarial symptoms would have continued to complicate the picture of the typhoid. Abdominal symptoms were marked in most of the cases, contrary to the usual American teaching; but bilious symptoms were not especially prominent. The most marked difference between the French descriptions and those 1 Jour. Am. Med. Assoc., Sept. 10, 1898. 2 Jour. des Prat., Sept. 3, 1898. 3 Am. Jour. Med. Sci., Jan., 1899. given by Americans is that the latter state that the disease is mild, while French writers consider it severe. The latter is undoubtedly the proper conception. Lyon believes that combination of the diseases is not uncommon in our Southern States; but he does not think that the cases that have often been described as such have in most instances been true examples of this combination. J. M. DaCosta' reports 10 cases of typhoid fever verified by the Widal test in which malarial plasmodia were found at some stage of the disease, usually during convalescence. The author especially notes the fact that the occurrence of the chills and other manifestations of malaria appear late, and sometimes only during a relapse. The tertian parasite was usually found; in some the estivoautumnal was present. C. F. Craig reports the case of a physician who had a combined typhoid and quartan malarial infection. The distinctive symptoms of typhoid, including the Widal test, were all present. About 3 weeks after the onset of the disease, however, when defervescence seemed to be progressing satisfactorily, he had repeated chills, and examination of the blood showed quartan parasites. The chills reappeared after intervals of 72 hours. After grave illness the patient recovered, the malaria being controlled by quinin. A. Stengel states that he has seen 2 cases of typhoid fever in which the tertian variety of the plasmodium was found during convalescence. M. Goltman observed a case in a boy of 14, which began with chill and polyuria. On the following day another chill occurred and intracorpuscular malarial organisms were found in the blood. Quinin was given up to the production of cinchonism, but the fever persisted and rose-spots appeared. Soon after, however, the temperature became subnormal and remained at that point for 3 weeks, when entire recovery occurred. It seemed, therefore, to be an irregular form of typhoid fever preceded by malarial infection. T. F. Raven describes as malarial enteric fever a case that progressed through a course of what was thought to be typhoid fever, and toward the beginning of convalescence had a severe chill of typical malarial character, with a temperature of 105° F. There was a recurrence on the next day, and after the administration of quinin the attack ceased for a week, when there was another recurrence; but after the second administration of quinin the affection disappeared entirely. Diagnosis.-R. Kraus and W. Seng, in studying the mechanism of agglutination, have investigated the theory that the bacteria are carried down mechanically by the precipitate. They made suspensions of India-ink, cinnabar, and other substances in bouillon, and found that when alcohol, sodium hydrate, and other substances causing precipitation were added, the substance suspended was agglutinated and carried down in the same way as bacteria are by the addition of a specific serum. They believe, therefore, that agglutination is due to the mechanical action of precipitation, the specific agglutinating substance forming the precipitate in the case of a specific reaction and carrying the bacteria down with the precipitate. Phila. Med. Jour., May 6, 1899. 5 Brit. Med. Jour., July 2, 1898. * Ibid., June 17, 1899. * Med. Rec., Sept. 17, 1898. 6 Wien. klin. Woch., Jan. 5, 1899. G. H. Weaver1 has studied the effect of the use of cultures of varying degrees of virulence in carrying out the Widal reaction. Of 4 cultures of different degrees of virulence he found in every instance that the best reaction was obtained with the least virulent culture. In 30 cases no positive reactions were obtained. Thirty-two cases of typhoid fever were examined: in 30 the fresh serum was used, and this method gave 27 positive results and 3 doubtful; the latter patients all died, and 2 of them showed the lesions of typhoid fever only, while 1 was also tuberculous. In all of these cases but one examination was made. In 2 of them the dried-blood method had given negative results. The dried-blood method was used in 29 cases, with only 19 positive results, 8 doubtful, and 2 negative. In 1 of these cases, in which a positive result was obtained, postmortem showed both tuberculous and typhoid lesions. Weaver considers the dried-blood test much less accurate than that with fresh serum. 2 McWeeney describes a method which he uses in carrying out the Widal test in cases which do not present a satisfactorily distinct reaction. He allows the typhoid bacillus to grow in a hanging drop of broth which contains about 1% of the suspected serum. The preparation is kept at 37° C., and examined after 4 hours, when, if the case be typhoid, it is said the bacilli will be found to have grown into chains that later become twisted, while motility is entirely absent. If the serum is not typhoidal, the bacilli are separate and normal in motility. W. Leube states that a dilution of 1:10 or 1:15 in carrying out the Widal reaction for typhoid fever is insufficient. A positive result is of value only when the dilution has been as great as 1:30 or 1:50. Under such circumstances a positive reaction makes the diagnosis of typhoid very probable. 3 4 Kessel and Mann report the conclusions at which they arrived from a study of the Widal reaction in typhoid fever. They think that it is a reaction of immunity; but that it is not quantitatively in direct relation to the degree of immunity, and that the agglutinins are not the true immunizing substances. It is not absolutely pathognomonic of typhoid fever. They had positive reactions in 2 cases of croupous pneumonia during the course of the disease; but the reaction disappeared after recovery. They also report 2 cases of typhoid in which the reaction did not occur. The reaction was usually in direct proportion to the amount of relative slowing of the pulse, but showed no relation to any other symptoms, excepting that there was an inverse relation between the duration of the fever and the strength of reaction. There seemed, therefore, to be some correspondence between the strength of the reaction and a satisfactory prognosis. Twenty cases were examined after they had had typhoid fever. In those who had had the disease within 1 year, 64.5% of reactions were positive; in 11 cases which had had the typhoid fever between 2 and 5 years previously, 72.7% were positive. Positive reaction occurred in 4 cases that had typhoid fever 5, 10, 15, and 21 years before, respectively. They think, however, that if an individual is ill and shows a strong Widal reaction, this is valuable in diagnosis, and is to be 2 Dublin Jour. Med. Sci., Sept., 1898. 1 Med. News, Dec. 10, 1898. 3 Sitzungsbericht phys. med. Gesellsch. z. Würzburg, 1898. Münch. med. Woch., May 2, 1899. attributed to the present illness, and not to the former attack. They believe that it is the most valuable sign that we have of typhoid fever in children. Three nurslings whose mothers recently had typhoid fever gave no reaction, while the mothers did. The mother's milk gave a reaction in one case in a dilution of 1:1; in the second case in a dilution of 1:12; in the third case in a dilution of 1:50. In the latter case the reaction occurred with greater dilution of the milk than of the blood. The agglutinins did not seem to be transferred to the infants through the milk, since the blood of the child did not react in a dilution even as slight as 1 : 1. Schabad,' as a result of his large experience with the Widal reaction, decides that when carefully carried out by an expert, it is a valuable diagnostic sign. He considers that marked or moderate reaction when using a dilution of 150 indicates typhoid fever. A negative microscopic reaction he believes excludes the disease. He thinks that the duration of the reaction is directly related to the severity of the disease; the intensity of the reaction less so. He notes that the serum from bullæ may be used instead of blood-serum. Examination of the urine for the reaction does not give reliable results. Tarchetti, in studying the prognostic value of the serum-reaction in typhoid fever, was unable to confirm Courmont's statement that the intensity of the reaction and the mildness of the disease were in direct relation to each other. This was not the fact in a number of instances in his work; and he notes as one especial complication of such a method of prognosis the occurrence of a relapse which makes the reaction more pronounced, even though the disease at the same time becomes more severe. J. M. Anders and J. McFarland3 give the results of the Widal test as carried out in the cases of 230 soldiers, using the dried-blood method. All were believed to have typhoid fever, and 219 gave positive reactions; 10 gave no reactions when repeatedly tested up to the time of return of normal temperature, though there were 3 of these cases in which the diagnosis was somewhat doubtful. Of the 219 giving positive reactions, 128 gave reaction before the appearance of rose-spots. Eight of them gave no reaction as late as the twenty-eighth day, and 2 gave none even up to the twenty-eighth day. 4 A. C. Abbott reported that in the past 20 months there had been collected in the city laboratories (Board of Health) of Philadelphia the records of Widal reactions carried out in 4154 cases, and that the error had been but 2.8%. R. C. Cabot and F. L. Lowell have made studies of serum-diagnosis in dispensary-work. They insist that the test can readily be done in outpatient work. In 204 cases of typhoid fever the results were negative in all. Positive reactions were obtained in 39 cases that had passed through typhoid fever within 1 to 18 months before the examination. Quantitative tests were made in a number of instances; in 1 case it was found that a positive reaction was obtained with a dilution of 1:1000. 2 Gaz. degli Ospedali, No. 133, 1898. Ibid., Feb. 25, 1899. Medicinskoje Obosrenje, 1898. |