TYPHOID FEVER IN 
THE YOUNG 
BY 
A. JACOBI, M.D., LL.D., 
New York. 
From 
PEDIATRICS. 
Vol. VIII. No. 12. TYPHOID FEVER IN THE YOUNG.* 
By A. Jacobi, M.D., LL.D., 
Clinical Professor, Columbia University, 
New York. 
THE literature of the typhoid fever of infancy and childhood 
is very copious; that of the last twenty years is not 
exactly worthless; indeed, a number of magazine articles 
are quite valuable. But they do not compare with the 
very first publications on the subject which appeared at a time 
when typhoid fever had not long been recognized as an inde- 
pendent morbid .entity. Amongst those which should be read 
today, in order to gather almost everything connected with the 
subject, with the exception of the Diazo and Widal tests, are 
Taupin, in the Jour, des Conn. med. et Chirurg. of 1839, who 
explains the apparent infrequency of typhoid fever in the 
young by the mildness of most cases; F. Rilliet, De la fievre 
typhoide chez les enfants, Paris, 1840; the article on the 
subject in Rilliet and Barthez’s great Handbook in 1853 ; Louis 
and Andral in 1841; a paper of A. Baginsky in Virchow’s 
Arch. Vol. 49; of Henoch in the Charite Ann. Vol. 11, 1877; 
the thesis of Georges Montmoullin, 1885 (Observations sur 
la fievre typhoide de I’enfance), and the article of C. Gerhardt 
in the second volume of his great “ Handbuch,” in 1877. The 
most meritorious of all the contributions to the knowledge of 
our subject, however, is the little book of Edmund Friedrich, 
Der Abdominal Typhus der Kinder, Dresden, 1856. My 
advice to all modem and future writers on any topic connected 
♦ Read October 25, 1899, before the New York State Medical Association. PEDIATRICS. 
2 
with the question of typhoid in children is to first consult the 
102 pages of that monograph, which is apt to teach the often 
forgotten lesson that medicine is not of today nor of yesterday; 
that there have been great and good men worth knowing, before 
we were born, and that the history of our science and art is 
sadly neglected amongst us. 
Infection and Contagion.—The opportunities for infection 
or for contagion are the same for the young and for the old. 
The bacillus has been found active though it had been dry for 
months; in the soil and in clothing after one or two months. 
Into water and into the soil it is introduced with typhoid dis- 
charges which carry contagion though they have been in con- 
tact with putrid material. This experience explains isolated 
cases and those attributable to the influence of sewers and 
privies, and the transmission through the atmosphere. Flies 
have been charged with carrying the poison. Infected water 
that is used for drinking or for washing the bottles and cases 
in which milk is kept, is responsible for hundreds of epidem- 
ics. Contagion from patient to patient in a hospital or in a 
tenement, by bedding, by the hands of the attendant, by the 
use of the same unwashed thermometer for the typhoid and 
non-typhoid are surely either possibilities or facts. The fetus 
and newly born may obtain their typhoids through the blood 
of the mothers; contagion through the milk of the mother is 
not improbable, though in most of such instances the suspicion 
may be directed to other sources of the malady. Small infants 
have a great advantage in this that their typhoids are not fre- 
quently attended with characteristic stools, and that for this 
reason a hospital case is not so dangerous to its neighbors; 
that they are not roaming about the floors where older children 
pick up infection, and that the water they drink or eat is almost 
always boiled. The latter fact alone explains the relative 
absence of typhoid fever from the first year of life. 
SYMPTOMATOLOGY. 
Temperature.—The severity of the illness need not corre- 
spond with the body temperature. A girl of 9 years, whose 
case is reported by Gerloczy, in D. Med. Wock., No. 15, 1892, 
had unconsciousness, diarrhea, very frequent pulse, universal 
hyperesthesia, roseola, abscesses, and bronchial catarrh, and got 
well after thirty-nine days. During all this time there was no PEDIATRICS. 
3 
increase of her body temperature. It appears that very severe 
cases of typhoid fever, when exhibiting bad cerebral symptoms 
are liable to have low temperatures on account of the thorough 
sepsis prevailing. If so, the prognosis is very bad. 
Belei Medvei (Intern. Klin. Rundschau, 1891, No. 35 and 
36) observed a girl of 12 years that was taken sick with severe 
headache, restlessness, chill, pain in neck, unconsciousness, 
miosis, unequal pupils, rapid respiration, and a temperature 
for four days from 36.8° to 37.50 C. Then the temperature 
rose and the typhoid symptoms of spleen and cecum, and 
diarrhea made their appearance. 
This absence of high temperature does not astonish those 
who see a good deal of sepsis and of sickness complicated with 
weak heart. Temperature and danger need not correspond. 
The very feeble are not as a rule subject to high temperatures 
any more than the very old; and quite often the worst cases 
of sepsis are those which exhibit low temperatures. That is a 
fact best known to those who see much diphtheria or much 
puerperal fever. 
Observations of high temperatures previous to the appear- 
ance and recognition of the Symptoms are not frequent. While 
an adult would be about his work, the infant or child is seldom 
considered sick enough to claim attention and attendance. 
That is why chilliness and chills are readily overlooked; indeed, 
the latter are not marked as a rule in any illness of the young. 
The rise of the temperature in the typhoid of the young is mostly 
gradual ; it is high in the second stage with slight remissions 
and gradually falls toward the end of the disease. This rule, if 
it can be called so, is, however, subject to many exceptions. 
The temperature of small infants may be very irregular, is in 
many cases rather low and uniform, in others high with few 
and short remissions. Irregularities, moreover, often depend 
on complications. After all, neither those are always right 
who consider the typhoid of the nursling and infant as a uni- 
formly severe disease, like Baginsky and Roemheld, nor those 
who make light of it. The degree of individual infection, and 
the nature of the epidemic are factors that have to be considered. 
Complications which disturb the regularity of the tempera- 
ture curves, are, for instance, otitis, which is quite frequent. 
In connection with it we should not forget that the otitis media 
of the infant need not terminate in perforation of the drum 4 
PEDIATRICS. 
membrane; for the pharyngeal end of the Eustachian tube is 
so large a funnel at that early age as to permit the discharge 
of pus from the middle ear. An occasional complication is 
scarlatina; in the last two years malaria was a more frequent 
complication of typhoid than I have ever known it to be. 
Suppurating arthritis, diphtheria of the throat or of the vulva, 
both bacillary and streptococcic, are detrimental in the same 
way. Constipation is also an occasional cause of the rise of 
temperature; the regular visiting hours 6f hospitals, even 
without clandestine feeding, are apt to increase temperatures. 
Now and then there are two regular daily curves. That is 
another reason why the rectal temperature should be taken at 
least four times in twenty-four hours. 
Digestive Organs.—The condition of the lips, the tongue 
and the mouth may depend on previous catarrh, angina, or the 
presence of adenoids; otherwise on the severity of the typhoid, 
and exhibits the same surface changes of the epithelium and 
mucous membranes that are observed in the adult. The lips 
are frequently dry, the tongue mostly moist, its epithelium 
accumulated in the centre, the edges red, or the whole tongue 
red and dry, covered with dry epithelial scabs, torn or ulcer- 
ated. Large ulcerations are mainly noticed during uncon- 
sciousness, smaller ones may be quite numerous on the hard 
and soft palate in every severe case. There is no herpes. 
The throat shows angina, the tonsils are swollen, in exceptional 
cases covered with a pseudomembrane which once, in a boy of 
9 years, continued through the whole length of the esophagus 
to below the cardia. In bad cases of older children, or in the 
few that occur in the nursling when the mouth is kept open 
because of narrowness in the naso-pharynx, of indolence 
or unconsciousness, thrush is met with as it is in the worst 
cases of adult typhoid, or in moribund phthisis. Stomacace is 
less frequent, noma still less so; the latter is observed only 
toward the end of the illness, or during apparent convalescence. 
Fortunately, during nearly fifty years, I met with half a dozen 
cases only, one in a baby of 8 months, one in a girl of n 
years, all fatal. Baginsky, however, reports a case of noma 
that recovered. It may be added that noma is not quite so 
frequent after typhoid fever as after some other infectious dis- 
eases, prominent amongst which is measles, where I have seen 
at least a dozen instances. Parotitis may terminate in per- PEDIATRICS. 
5 
foration, either outward or through the external ear. An 
abscess of the submaxillary gland I have seen in few cases 
only. Otitis media is an occasional complication originating 
in pharyngeal changes. The appetite is proportionate to the 
fever, the dry mouth and the degree of unconsciousness; dur- 
ing convalescence the hunger is great and conducive to dan- 
gerous mistakes in diet. Vomiting is noticed in bad cases, 
and is caused by the condition of the digestive mucous mem- 
brane, occasionally by meningitis, and sometimes by accom- 
panying or consecutive nephritis. 
Diarrhea is a frequent symptom in typhoid fever, either 
before its apparent outbreak, or in the first week, or at a later 
period. It appears to be of a catarrhal nature, induced prob- 
ably by the presence of bacilli and their toxins. In the later 
periods of the disease it certainly depends on the presence of 
ulcerations. But to expect diarrhea as a common symptom is 
a mistake occasioned by the statements of many European 
books. In the other hemisphere diarrhea appears to be more 
general than with us. I think we miss it in one-half of our 
cases. 
Even the assumption that where there are ulcerations 
there must be diarrhea is not founded on uniform facts. In 
ward 28 of Bellevue, in 1877, I had a girl of 11 years that was 
under close observation during her typhoid fever for several 
weeks. The case was one of unusual severity—spleen, lungs, 
skin and nervous system yielding the usual symptoms; there 
was no diarrhea at any time. She died with the symptoms of 
perforation. Perforation caused by one of the typhoid ulcera- 
tions was found at the autopsy. Nor is this the only case of 
the same description in my experience. In the Proceedings of 
the Pathological Society, twenty-five years ago, there is men- 
tioned the case of a man who died in my service in Mount 
Sinai, also with perforation of an ulcerating intestine, with no 
previous looseness of the bowels. 
Constipation is not an uncommon symptom in the begin- 
ning of typhoid fever of the young, though diarrhea may 
develop toward the end of the first or during the second week, 
while on the other hand, diarrhea may be observed among the 
prodromi or in the first week, and be replaced by constipation. 
Almost in all cases of typhoid, in the young and in the 
old, intestinal ulcerations are common. But exceptions to this 
rule are met with. 6 
PEDIATRICS. 
S. Flexner and N. M, Harris (Bull, Johns Hopkins Hospi- 
tal, December, 1897), detail the case of a man of 68 years who 
had typhoid fever with bacilli in many organs, but no intestinal 
lesions; A. G. Nichols and C. B. Keenan {Montreal M. Jour., 
January, 1898) one with positive Widal test, and tumefied 
spleen and mesenteric lymph nodes, and no intestinal lesions; 
E. Hodenpyl, one that died on the seventeenth day of illness 
with ulcerations in the large intestine, but none in the small. 
This absence of intestinal lesions is rare indeed in the adult; 
in the young, mainly in the very young, it seems to be less 
rare. As a rule, it may be stated that the intestinal tract 
suffers more in advanced age, the blood more in the early. 
According to Bryant {Brit. Med. Journal, 1899, 1., p. 766) 
fifteen cases of typhoid fever are known to have exhibited no 
intestinal lesions. His case was that of a boy of 1 year and 9 
months; it occurred in a family in which there were other 
cases of typhoid fever. There was a characteristic fever curve, 
diarrhea, tympanites, tumefaction of the spleen, and a positive 
Widal reaction. At the autopsy there were pure cultures 
of bacilli in the enlarged mesenteric glands, but no intestinal 
ulceration. 
In one of his autopsies Henoch found but one Peyer’s 
plaque that was slightly swelled. 
In N- V. Med. Journal of July 29th, A. J. Hartigan, 
assistant in the Bender Laboratory of Albany, N. Y., reports 
two cases of typhoid infection without any intestinal lesions. 
Of the older literature of such instances he quotes Louis, more 
than half a century ago, and Litten, Moore, and Church 
between 1880 and 1882. He then continues: “The bacterio- 
logical era in the investigation of these forms begins with 
Banti, in 1887. In his case death took place on the twenty- 
eighth day of the disease. No intestinal lesions were found 
but the spleen and mesenteric glands were swollen; in them 
bacilli morphologically similar to the bacillus typhosus were 
found.” He quotes seventeen authors, and adds his own cases, 
without however mentioning Hodenpyl. 
It should, however, be stated that the statistics of intes- 
tinal ulcerations with perforation are not conclusive; many 
are observed in private practice, not counted, not reported, 
and forgotten. Now and then, again, a case is reported as a 
curiosity without reference to the number of cases observed PEDIATRICS. 
7 
and other important points. Barrier met with two perfora- 
tions in 24 cases, a very unusual proportion. 
Montmoullin reports seven cases in which perforation was 
diagnosticated, three of which recovered—a proportion of 
spontaneous recoveries able to arouse the jealousy of any 
operator. 
Barrier and Bouchut made long ago similar observations 
on the adult, so that they concluded that the anatomical altera- 
tions of the intestine may be absent. Chiari (Z. f. Heilk., 
1897) while finding lesions in the stomach, and bacilli in 
different organs, and septic symptoms, found no intestinal 
lesions. In nineteen collected cases, while the Widal test was 
positive, the same absence of intestinal lesions was marked. 
So the latter is not conclusive. The last case of the same 
nature was published by A. Me. Phedran in the October issue 
of the Philad. Monthly Med. Journal (1899). 
Gurgling in the ileo-cecal region, both with and without 
pressure, is common in intestinal catarrh, both infectious and 
non-infectious; that is why, under ordinary circumstances, it 
should not be held to be characteristic of typhoid fever. It 
would be more so, if complicated with constipation, and with 
some of the more frequent symptoms of typhoid fever. 
Incontinence of the sphincter ani, when met with is not so 
much the local result of the infection as of unconsciousness; 
when it occurs during convalescence, it depends on hyper- 
peristalsis, mostly combined with colic. 
Tympanites is usually very moderate, for extensive peritoni- 
tis is very uncommon, except with perforation. Sensitiveness 
of the abdomen is frequent, without the diagnosis of local 
peritonitis being always within easy reach. This latter form 
is, however, quite frequent, for in the autopsies of children, or 
of adults who died of other diseases, local discolorations and 
thickenings, of a grayish white, or yellow color, are often 
found on the peritoneal layer of the intestine, above, near or 
below the cecum. They are the results of previous local peri- 
tonitis corresponding with the locality of ulcerations during 
typhoidjfever, or any of the forms of enteritis in former years. 
Unexpected perforations of the intestine, occurring in ad- 
vanced years, during apparently perfect health, are the final 
results of such local peritonitis. 
Hemorrhages in the very young are exceptional, and 8 
PEDIATRICS. 
mostly mild in children of more than four years. I have seen 
it more than a dozen times. In a girl of ten years, the loss of 
blood was such, there being several hemorrhages in the course 
of the third week, that I attributed the supervening heart fail- 
ure to exhaustion only. Both the number and severity of the 
hemorrhages appear to depend on the character of the epidemic 
or on the season. In the very young, I sometimes saw no 
tinge of blood in five years, and in a single season eight years 
ago, I met with two, not fatal, cases of hemorrhage, in girls 
of five and seven years. This very autumn I have seen four 
cases of typhoid fever in children of from five to nine years, in 
which mild hemorrhages occurred. Of Henoch’s nine intesti- 
nal hemorrhages, five were quite mild. 
Circulatory Organs.—The organs of circulation are not 
affected to the same extent as in adults. The average heart of 
the young is stronger, and less diseased. Endo- and pericar- 
ditis, embolisms and thromboses are rarer than in advanced 
age, except in very bad and protracted cases, in which the 
myocardium was deteriorated by the bacillary toxin. For the 
same reason complete adynamia is not so frequent at least in 
the first week or weeks. During increasing inanition, how- 
ever, the circulation is impaired, as best shown by the coldness 
of the feet. The gums bleed but rarely, the nose not so often 
in infants, and the very young, as in older children. The 
pulse, mainly during the first two weeks, except in the small 
infant, where it is liable to be feeble and frequent, is either in 
correspondence with respiration and temperature, or frequently 
slower and quite strong. When it becomes feeble and fre- 
quent, with or without intermissions, it impairs the progno- 
sis, and demands persistent stimulation. It is rarely dicrotic. 
When it is in this weak condition, the heart sounds are no 
longer distinct; they are muffled, one or the other splits in two, 
and an apex murmur becomes audible. This should not be 
taken as merely functional; the myocardial weakness which 
occasions it is toxic and organic, and may remain a permanent 
lesion. 
Spleen.—The irregular respiration of nervous, or fright- 
ened infants and children, their tympanitic colon, and high 
diaphragm, possible exudation injleft pleura or lung, and the 
struggle against examination, whether painful or not, render PEDIATRICS. 
9 
the diagnosis of the condition of the spleen difficult. In per- 
haps one-half of the cases it is, however, successful. Percus- 
sion succeeds less than palpation, which may reveal the lower 
edge of the spleen. It is rarely felt before the end of the first 
week, about the time when roseola appears; earlier, however, 
when the fever is unusually high. When it diminishes rapidly 
in the middle of the third week, the prognosis is good; if not, 
there will be a relapse. When a relapse takes place, the spleen 
which was greatly reduced in size, is liable to swell 'very rap- 
idly. Permanence of this swelling of the spleen, however, is 
much rarer after typhoid, than after severe malarial fevers, and 
abscesses are quite exceptional. 
The Respiratory Organs.—The nasal mucous membrane 
is dry, covered with thin crusts, and irritated like the lips, 
which are in a similar condition. Epistaxis is not infrequent 
in older children. Together with pharyngitis there may be a 
catarrhal laryngitis. This, and the dryness of the mucous 
membrane cause hoarseness and cough. Edema of the glottis, 
which is fortunately rare, causes dyspnea and strangulation. 
Superficial and deep ulceration of the trachea or larynx, and 
perichondritis are exceptional, but I have met the necessity of 
performing tracheotomy in such cases twice. One was the 
case of a girl of seven, in which scarification of the interior of 
the larynx was unsuccessful—the child was saved by the oper- 
ation. The other tracheotomy was made during convales- 
cence on a boy of ten years, because of an abscess developing 
over and behind the manubrium sterni. He died after many 
weeks of pyemia, the main source of which was found about 
the lowest rings of the trachea, and the mediastinal lymph- 
nodes. Bronchial catarrh is frequent, without much cough, as 
long as the respiration is shallow; with cough on deep inspira- 
tion; catarrhal pneumonia is not rare, and mostly bilateral; 
croupous pneumonia is also apt to be bilateral. The more fre- 
quent form of pneumonia, however, in the protracted cases of 
feeble patients, is hypostatic, with a tendency to become bilat- 
eral at once, and to extend. Pulmonary gangrene is excep- 
tional, but should be feared in every ca.se of infectious broncho- 
pneumonia, complicated with a weak heart. 
Pleuritis is comparatively rare, purulent in exceptional 
cases only, sometimes sanguinolent, though there be no com- 
plication with tuberculosis. 10 
PEDIATRICS. 
Complications with diphtheria of the bacillary variety 
(nasal, pharyngeal, or laryngeal), are not common. When 
they occur during the prevalence of a diphtheria epidemic, 
they are grave accidents. 
Urinary Organs.—The urine is mostly of a high color, 
contains in the beginning much urea and uric acid, less chlo- 
rides than normal, indican sometimes, albumin frequently at 
an early period and more so during the height of the disease, 
renal epithelia, blood, thin granular casts, and occasional 
bacilli. The renal irritation* exhibited by the microscopic 
appearance is that which is usual in most infectious diseases, 
and is due to the effect of the toxin while being eliminated 
through the kidneys. Symptoms connected with this elimina- 
tion need not be very marked and need not lead to nephritis. 
Still, the latter may follow. Even pyuria has been found, for 
instance, by G. Blumer, in children, one of 13 and one of 10 
years (Johns Hopkins Rep., Vol. V). 
Retention of urine is rare in children, but occurs when there 
is coma or much peritonitis. In that case, and whenever it is 
important to secure urine for examination, catheterization should 
be resorted to. It is more easily performed in the young than 
in the adult and more readily in boys than in girls. Under 
ordinary circumstances, when the catheter is not employed for 
some reason or other a big ball of absorbent cotton will collect 
urine enough for the usual examination of the urine. Polyuria 
is seen during convalescence when much water is drunk. In 
that period dropsical effusions may be observed with or with- 
out albumin; it should also not be forgotten that salicylic acid 
or antipyrin when employed may cause edema; and, further, 
that there may be nephritis without albuminuria. The Diazo 
test is mostly positive towards the end of the first week, 
and remains so until the middle of the third, sometimes very 
much longer. At all events, however, its absence is no proof 
against the presence of typhoid fever. Roemheld missed it 
altogether in many cases. 
The observations made by Lafleur and others, that the urine 
voided after cold bathing exhibits a high degree of toxicity, 
would rather speak in favor of that treatment; for the more 
toxic the urine and dangerous to the laboratory animal, the 
less toxin there is left in the patient. Elimination, as speedily 
as possible, is what should be aimed at. And whatever diuretic PEDIATRICS. 
11 
effect there is in cold bathing, as in other remedies, is welcom 
as long as the condition of the patient permits it. How rarely 
that is so, will be seen in the remarks I have to make on thera- 
peutics. 
Skin.—The tendency of the skin is to be dry; that is why 
chronic eruptions are liable to disappear during the illness and 
to return when recovery is complete. This dryness is also the 
cause of the transverse fissures under the knee which Koebner 
explains by the co-operation of the lifeless epidermis, the 
vigorous growth of the extremities and the flexed posture of 
the knee; it also causes the extensive desquamation before and 
during convalescence. 
The characteristic roseola exhibits the same peculiarities 
that are noticed in the adult; it is absent in perhaps 20 per 
cent. Morse collected 671 cases, in 406 of which it was present; 
Henoch found it 362 times in 381 cases. It is not uncommon 
in the very young. I found a few spots on the epigastrium of 
a newly born that died on the sixteenth day of its life; Ger- 
hardt (Handb. Vol. 11, p. 373) met with roseola (and a tume- 
fied spleen) in a baby of three weeks. It may appear as late 
as the eleventh, even the fifteenth or seventeenth day, is 
mostly not so copious as it is in the adult, and occurs prefer- 
ably on the chest and abdomen, but also on the back and on the 
extremities. When the temperature is high at an early date, 
roseola may appear early, on the third or on the fourth day, 
and new crops may occur afterwards. In relapses it is more 
frequently missed than in the primary attack, but a new crop 
in the fourth week means a relapse. Petechiae are not frequent 
but do occur in children of more than seven or eight years, 
also in the very young; when complicated with extensive pur- 
puric extravasation they are ominous. 
Miliaria is sometimes observed when there is exceptional 
perspiration; and erythema during the height of the disease 
when there is much intestinal disorder and coma as the result 
of direct toxic, or of auto-infection. Eczema is the result of 
uncleanliness only; gangrene, abscesses, furuncles, and pustules 
are frequent ocurrences, but in the later periods of the disease 
only. 
In bad cases, and mainly when the hygiene of the skin 
was neglected, abscesses will appear in it and in the subcuta- 
neous tissue, preferably on the head, face and chest. Slight 12 
PEDIATRICS. 
irritations are sufficient to act as proximate causes. A child 
of two years developed the first abscess on the epigastrium in 
consequence of a subcutaneous injection of quinin. More 
followed, mainly on the hands, fingers, and feet, more than 
sixty were incised in the course of a few weeks, until, finally, 
recovery set in. 
In a child of two years I saw copious hemorrhages about 
the ear, groins, and neck with consecutive gangrene; in a boy 
of nine, extensive destruction of the skin over more than one- 
half of the abdomen; in both cases with final recovery. 
The desquamation of typhoid fever may be quite copious 
and resemble that of measles or even of scarlatina. On the 
other hand, some of the eruption of the two latter may resem- 
ble the roseola of typhoid fever. That is why the diagnosis 
may become difficult, particularly as there are cases of which I 
have seen some, in which the latter and one of the former may 
be contemporaneous. Thus Cosgrave {Brit. Med. Jour., Jan. 
16, 1897), reports five cases in which scarlet and typhoid fever 
were coincie nt without seeming to increase the degree of 
danger. Both started at the same time. 
From George M. Gould’s American Year Book, 1898, p. 
625, I quote Amitrano, who reports a case of typhoid fever 
developing in convalescence a scarlatiniform eruption with 
fever which was followed by desquamation. After this fever 
had subsided marked meningeal symptoms appeared for a few 
days. These disappeared, and after desquamation was com- 
plete a second intense erythema appeared, which was also 
followed by desquamation after which recovery ensued. 
Bones. —The bones suffer in different ways. The charac- 
teristic increase of growth after infectious fevers is mostly ob- 
served in scarlet, and in typhoid fevers. Epiphyseal and general 
pain about the extremities is frequent in typhoid fever, and 
some degree of epiphysitis is common, in consequence of this 
irritation. Periostitis and osteomyelitis have been observed, 
and bacilli have been found in the latter. Before the advent of 
the bacillus, I lost a child of four years with osteomyelitis of 
the right femur, in spite of early operation. Such cases are 
fortunately not frequent, but it appears they occur in from one 
to two per cent, of all typhoid fevers. Chondritis is still more 
infrequent, with less serious results. PEDIATRICS. 
13 
Nervous System.— The nervous system of the young is be- 
lieved not to be affected by typhoid fever, as it is in the adult. 
There are cases in which the general condition of the patient 
appears to be unusually good, compared with the toxic nature 
of the whole process, and with the height of the temperature. 
In many instances I concluded, from nothing but the apparent 
comfort and ease of the patient, when the high temperature 
would have suggested the presence of severe subjective symp- 
toms, that everything but typhoid fever could be excluded. 
The same holds good of that in adults. In them ambulant 
cases are by no means rare, and those in bed often demand 
permission to get up, expressing the most complete satisfaction 
with their condition, while their temperature ranges at or 
above 104. Other children are apathetic, or somnolent, or 
peevish, and restless. The “typhoid state ” should not by 
itself be taken as a symptom of typhoid fever. It may be ab- 
sent altogether, and is found now and then when there is no 
typhoid. Headache is frequently complained of, or is be- 
trayed by vertical wrinkling. Hearing may be bad, the con- 
junctiva injected and the cornea cloudy under the influence of 
the toxic disturbance of the trifacial nerve. Grinding of the 
teeth, sopor, or delirium, and vehement screams resembling 
those of meningitis, are occasionally met with. Such symp- 
toms, though ever so severe, need not correspond with the 
elevation of the temperature at all; the latter may be rather 
low, while the intoxication is quite pronounced. Not every 
case of seeming cerebral or meningeal symptoms should be 
attributed to cerebral affection only; still, contractures, or 
convulsive movements may occur when there is an effusion 
from the pia mater. Such complications of genuine menin- 
gitis with typhoid fever certainly occur, and not only after 
the eighth or tenth year when gradually the typhoid fever in 
the young resembles more and more that of advanced age. 
Kernig’s symptom may be employed to clear up the diagnosis 
of genuine meningitis. 
Some of the symptoms common to both may be explained 
differently. Vomiting may be due to the toxic degeneration of 
the cerebral substance, or to meningitis, or to the abnormal 
condition of the stomach, or even of the pharynx, or to 
nephritis. Coma or delirium I have seen in typhoid, in 
meningitis, also in cinchonism, and under the influence of 
salicylic acid. PEDIATRICS. 
14 
As a consecutive symptom aphasia was found twenty 
times by Henoch; half a dozen times I have seen it in the 
course of many years; with the exception of one that suddenly 
died, probably of myocardial degeneration, all of them got 
well. Polyneuritis is not rare. In severe epidemics it is fre- 
quently seen, usually with a favorable termination. It is due 
to tissue alterations, occasioned by the influence of the bacillary 
toxin. Hemiplegia is rarely observed; a case of “cerebellar 
ataxia ”in a boy of seven, which terminated in recovery, was 
reported by Luigi Concetti, in La Pediatria, No. 8, 1898. 
Paraplegia is more frequent, and still more so is local 
paralysis, under the influence either of the toxin, or of a 
hemorrhage, or of an embolus. Amongst them are paralysis 
of the glottis, which necessitated a tracheotomy in a case of 
Rehn’s, and of the abducens (which I have seen in quite a num- 
ber of cases, most of which were obstinate, some permanent) 
and of the accommodation muscles of the eye. Paralysis of the 
sphincter of the bladder is not infrequent. 
Psychical disturbances are seen as the sequelae of every 
infectious fever, mainly scarlatina and typhoid. Four such 
cases were reported by S. S. Adams to the American Pediatric 
Society in 1896. They may result from inanition, or from the 
parenchymatous tissue changes caused by the toxin, or from 
meningitis. Mania and melancholia are the two forms mostly 
met with. Not all of them terminate favorably. Two of my early 
cases died in lunatic asylums in rather advanced years. The 
motor disturbances not paralytic, which follow typhoid, par- 
ticularly chorea, have all got well in my recollection, a few 
only with relapses. It struck me that post-typhoid chorea was 
less subject to recurrences than other forms. 
I now give the particulars of two sets of observations, 
which will prove that the symptoms, course and complications 
of the typhoid fever of the young may greatly differ from one 
another, or from any average description of its nosology. One 
I published in the Arch. Ped., March, 1885. 
The number of typhoid fever cases treated in the Child- 
ren’s Pavilion of Bellevue Hospital, from October, 1882, to 
September, 1884, was25. Of these 11 were males, 14 females; 
17 ran a single course, 5 had relapses, 3 were sick over a 
period of from four to six weeks, without permitting the sec- 
ond attack co be distinguished from the first by an alleviation PEDIATRICS. 
15 
of the symptoms. In seven cases a distinct chill was men- 
tioned as ushering in the illness; in half a dozen more several 
attacks of chilliness were noticed. The ages of the patients 
ranged from 2 to 14 years, the average 9. Pain in the ileo- 
cecal region was complained of in fourteen cases, diarrhea was 
noticed in fifteen, bloody stools not amounting to hemorrhages 
in three; in three constipation was mentioned as a notable 
fact; in the first week of six epistaxis was observed. Tume- 
faction of the spleen was noted in sixteen; roseola was observed 
in fourteen cases. Its first appearance was noticed between 
the fifth and seventh day; it lasted from five to ten days. Pre- 
monitory symptoms were reported in nine cases; in four they 
lasted two weeks. They consisted in lassitude, loss of appe- 
tite, change of temper, and in some few cases diarrhea set in a 
week before the initiating chill or chilliness. Five of my cases 
died; one remained stupid and hard of hearing for sometime, 
but recovered. 
Contrary to my experience, as expressed in a lecture on 
typhoid fever (Medical Record, Nos, 17 and 18, 1879), in which 
I claimed a mild type and a low mortality for the typhoid 
fever of infancy and early childhood, this Bellevue service of 
mine had a mortality of 20 percent.—similar to that of CEster- 
len, who estimated it at 22 per cent., and Friedrich, who re- 
ported 23 per cent., in children under five years of age. 
In 1882 and 1883 we had a bad epidemic of typhoid 
amongst all classes and ages. The guests of summer hotels and 
boarding houses imported hundreds of cases, and the whole 
population suffered in consequence, infants and half-grown 
children as much as the rest, and the mortality all over the 
city was high. The hospitals have always more than their 
share, however, and their statistics must necessarily be errone- 
ous. Errors are occasioned by the fact that with us at least 
hospitals do not contain the average cases, but as a rule those 
only who fare badly and promise badly. A poor family will 
nurse their children, while they require but little care; 
only that one which is seriously ill, and gives a great deal of 
trouble and a bad prognosis is sent to the hospital. Of that 
class, many will die. That is why the mortality of a hospital 
does not indicate the general character of the epidemic. That 
is also why the general practitioner, singly or collectively, is 
the better judge and statistician. He sees all the cases in a 16 
PEDIATRICS. 
family, those remaining- at home, and those sent to a hospital; 
sees the mild and the severe cases, and counts those who sur- 
vive. Six cases in a family, one of which is sent to and dies 
in the hospital, may give the family practitioner a mortality of 
16, the hospital attendant one of 100 percent. 
Another series of observations was published by F. Sbrana 
{Arch, de Mdd. des Enf., Jan. 1899). He reports on seventy- 
two cases of typhoid children, from 16 months to 8 years old, 
whom he observed in Tunis; 7 5 per cent, of all cases occurring 
in that sub-tropical city were in children; in one family there 
were four, in another three cases. Why there should be 
a prevalence of cases in children, is perhaps best explained by 
Jeannel’s report made to the fourth French Congress of Inter- 
national Medicine, in 1898. He observed an epidemic of ty- 
phoid fever, in which the communication may have occurred 
through the dust of the street into which the typhoid dejec- 
tions were thrown. The principal and first sufferers were 
children who were playing in the street, and not very particu- 
lar as to what they carried to their mouths. Both their size and 
their habits I counted many years ago and repeatedly since, 
amongst the causes of the frequency with which follicular 
angina, and also diphtheria are observed amongst the young. 
The premonitory symptoms of the majority of cases con- 
sisted in anorexia, with headache, vomiting and constipation; 
the run of temperatures was quite irregular. In 50 per cent, 
there was epistaxis in the beginning; diarrhea began at a later 
period of the disease. Gurgling in the ileo-cecal region was 
not observed in patients less than three years old, and was 
altogether not common. Roseola was noticed in one-third of 
the cases, the spleen was enlarged in every one after the fifth 
or sixth day. There was no intestinal hemorrhage, and the 
fever disappeared by lysis. There was a furfuraceous desqua- 
mation in four cases; the mortality was 11 per cent. 
There were many complications; suppurating parotitis in 
two; peritonitis from perforation, one; purulent pleuritis, one, 
with considerable dilatation of the stomach during convales- 
cence ; aphasia in five; orchitis of the left side without suppu- 
ration, one; and meningitis, three; two of the last terminated 
fatally. All these cases looked very much like cerebro-spinal 
meningitis; still there was the tumefied spleen, and no herpes. 
In other cases there were milder cerebral symptoms, such as PEDIATRICS. 
17 
dysphagia, partial convulsions, aphasia, and inequality of the 
pupils, without strabismus, or vomiting. 
Friedleben placed the greatest frequency of typhoid 
in childhood between the sth and Bth year, Griesinger be- 
tween the sth and nth, Loeschner and Friedrich between the 
sth aud 9th, Rilliet and Barthez between the 9th and 14th, 
Barrier between the sth and 15th year, and Fauconnet between 
the 10th and 20th year. A few other figures contained with the 
above in Gerhardfs Handbuch, Vol. 11., are as follows: Mur- 
chison noticed that 20 per cent, of all the inmates of the fever 
hospital were less than 15 years, Von Franque collected all the 
typhoid cases of the province of Nassau, and found 2,021 of 
11,028 to be less than 10 years, Gaultier gathered many French 
statistics, and reported 31 per cent, below 15 years. In a 
small town Baginsky counted sixteen cases under 10 years out 
of a total of 50, Rosenthal 28 in 115, Schaedler 11 in 144. 
AGE, MORTALITY. 
Holt (Textbook, p. x,oo8) quotes 970 cases from eight 
authors; 8 per cent, were under 5, 42 per cent, from 5 to 10, 50 
from 10 to 15 years old. Montmoullin (These de Paris, 1885) 
reported fifteen cases under two out of a total of 295 under 15 
years. Schavoir in Stamford, Conn., collected 406 cases of all 
periods of life; of these 68 were under 5 years, 72 between 5 
and 10 years. Morse reports 284 cases in the Boston City 
Hospital; 3 were under 5 years, 77 from the fifth to tenth, and 
204 from the tenth to the fifteenth year. He also concluded 
that typhoid is unusual in infancy, because the Widal reaction 
was negative in two cases of simple diarrhea, forty-five cases of 
fermental diarrhea, and three of ileo-colitis, with the exception 
of one whose mother had typhoid fever years before. It will 
be seen, however, that in none of these cases the diagnosis of 
typhoid fever was made or suggested. As there was no 
typhoid, there was no Widal. 
All these figures and results are in confirmation of the 
earliest observations. Griesinger for instance wrote in 1857 
( Virch. Handb., 11., 2, 124): ‘ ‘Typhoid fever is very rare in the 
earliest infancy; it is only from the second to the third year 
that the disposition becomes greater; after that time it grows 
rapidly, so that typhoid fever is quite frequent amongst us. ” 
(Germany). Bouchut denies the occurrence of typhoid in the 18 
PEDIATRICS. 
newly born. According to him it occurs first between the 
first and second year. 
There are, however, well observed cases of typhoid fever 
in the newly born. Gerhardt quotes Charcellay who saw it in 
a child of eight days; Bednar, five days; Necker, thirteen 
days, and reports a case of his own at three weeks. I had a 
case, the mother having typhoid fever when the child was 
born. In the latter I diagnosticated the disease on the ninth 
day. There were a few spots on the epigastrium on the six- 
teenth day, a large and soft spleen, and Peyer’s plaques swol- 
len and rather soft, not yet ulcerated. The infant died on the 
sixteenth day of her life. C. P. McNabe (New York Medical 
Journal, Feb. 19th, 1898), observed typhoid fever, complicated 
with whooping cough and pneumonia in a baby a few weeks 
old. 
The possibility of the transmission of typhoid fever to the 
fetus is beyond any doubt. Clinical experience proves such a 
transmission for typhoid fever, malaria, measles, scarlatina, 
variola and syphilis; also in erysipelas, relapsing fever, tuber- 
culosis and sepsis. In young sheep anthrax was found as early 
as 1882; chicken cholera and glanders are transmitted in the 
same way. But it is possible that the epithelium of the 
placenta is a frequent barrier, and the suggestion of Malvoz’s 
that the transmission of an infectious disease from the mother 
to the fetus takes place only when the villous epithelium is 
injured, I have always considered to be correct. He empha- 
sizes the fact that of twins one may be affected while the other 
goes free. All these points are discussed by W. Fordyce in 
the Brit. M. [our. of Feb. 19, 1898. The typhoid fever of the 
mother may destroy the fetus, may allow it to be born alive 
but weak, or alive and vigorous. Which of these results 
occurs depends on the amount of bacillary toxin trans- 
mitted or on circumstances unknown to us in an individual 
case. But the facts are firmly established. The fetal intes- 
tine was found diseased by Manzoni in 1841, Cnarcellay in the 
the same year, Weiss in 1862. Bacilli were found in the fetus 
by Reher and Neuhaus in 1886; in the blood by Eberth in 
.1893; and the same results were obtained by Freund, Levy, 
Ernst, and Durck. Other good observations were made on the 
living child. The Widal test was found positive in a healthy 
infant 7 weeks old, that was born when the mother was in the PEDIATRICS. 
19 
third week of typhoid fever, by Crozier Griffith {Med. News, 
May 15, 1897); and by Mosse {Progres MM., March 13, 1897) in a 
newly born, whose mother had typhoid fever when in the 
sixth month of her pregnancy, and whose milk and placental 
blood gave the same positive reaction. Perhaps the case of Lan- 
douzy’s will also prove the possibility of transmission though 
not through the placenta (Soc. de Biol. Nov. 6, 1897). A 
healthy baby showed a positive Widal test, while the woman 
had typhoid three months after confinement. As the baby had 
no other symptoms of typhoid fever, it is fair to suggest or 
to believe that transmission to a sufficient degree took place 
through her milk. 
The transmission of typhoid bacilli into the fetus is demon- 
strated by a case reported by Etienne (Gaz. hebdom., 1896, 
No. 16). A woman of 18 years expelled on the twenty-ninth 
day of her typhoid fever a fetus in the fifth month of utero- 
gestation. In its blood taken from the right heart, the spleen, 
the liver and the placenta were typhoid bacilli, but no changes 
in the other organs. It appears that the death of the fetus 
resulted from the toxin which acted so rapidly that the organs 
had no time to participate in the process. 
If, however, typhoid fever has been found by some in the 
fetus, in the newly born, in the nursling, there are those who 
never saw it at that age, and therefore are inclined to deny its 
occurrence. 
In the Arch. Ped., 1895, p. 916, Dr. W. P. Northrup speaks 
of the results of 2,000 autopsies in children under 5 years. Not 
one presented the lesions of typhoid fever. He also quotes 
Dr. N. Page of the Children’s Hospital in Philadelphia, who 
says: “I have had from six to ten typhoid cases in children in 
the house constantly since I came on duty here, but not one of 
them was under 6 years.” Dr. Ch. G. Kerley observed not a 
single case of typhoid fever among 1,326 children, 85 per cent, 
of whom were under 2 years, and 95 per cent, under 5 years of 
age; nor was a single typhoid lesion found in 410 autopsies. 
He adds that there was no case in the three years following his 
observations, under his successor in office. 
Again, however, Steffen reports on 148 cases of typhoid 
in the young; 2 were less than 1 year, 26 from the third to the 
sixth, 34 between 6 and 9 years. Of Wolberg’s 277 cases, 
however, the majority were as usual from 6 to 12 years old. 20 
PEDIATRICS. 
Henoch reports on 9 cases below 2 years, 59 from 3 to 5, and 
187 from sto 10 years, with a mortality of 12 per cent. He 
also reports of the finding- of typhoid ulcerations 14 times in 26 
autopsies. Ashby and Wright declare typhoid fever to be 
“not common under 3 years,” while Rilliet and Taupin as 
early as 1840 pronounced it to be “not at all rare.” About 
the same time Billard published his experience. According to 
him typhoid fever was rare in the first year, increased slowly 
toward the fifth, and was quite frequent between the fifth and 
fifteenth. 
Maria Rivoire described an epidemic which reigned in 
Marseilles in 1896 and 1897 (Thlse de Montpellier, 1898). In 
and after May of 1897 there were 105 cases among children, of 
whom 21 died—2o per cent.; in 1896 43 cases with 15 deaths— 
-31 percent. Of 1270 cases collected during those two years 
there were: 
Below 5 years 26, 6 deaths—23 per cent. 
Between 5 and 10 years 59, 13 deaths—22 
per cent. 
“ 10 
“ 15 
i ( 
102, 24 
“ —23-5 
( t 
“ i5 
“ 20 
i i 
289, 42 
“ —14-5 
( i 
“ 20 
“ 25 
t t 
347, 63 
“ —18.5 
i i 
“ 25 
“ 3° 
i ( 
262, 54 
“ —20-5 
i i 
“ 3° 
“ 40 
( I 
i45, 25 
“ —17 
4 i 
“ 40 
“ 5° 
€ i 
3°, 7 
“ —23 
a 
Above 50 years 10, 
no deaths. 
According to these figures the largest mortality occurred 
between the tenth and fifteenth year; the mortality of children 
below 5 or below 10 years equaled that of adults between the 
fortieth and fiftieth year. 
H. Curschmann (.Not linage I, Spec. Pathol, u. Therap. III.) 
reports on 451 children (250 male and 201 female) observed with 
typhoid fever in the Hamburg Hospital between 1886 and 
1887. Of these, seven were 2; nine were 3; sixteen, 4; 
eighteen, 5; thirteen, 6; twenty-two, 7; twenty-seven, 8; 
forty-four, 9; fifty, 10; fifty, 11; sixty, 12; seventy-one, 13; 
and sixty-four, 14 years old. 
Of Brouardel’s 16,036 cases observed between 1880 and 
1889, 36 were 1 year and under, 1041 under 5, 1,265 from 6 to 
10, and 1,386 from 11 to 15 years old. 
According to an excellent report, published by Dr. I. 
Rudisch, in the Mount Sinai Hospital reports (1899), on 974 PEDIATRICS 
21 
cases of typhoid fever, which occurred from 1883 to 1898, 124 
occurred in children below ten years, and 90 between the 
eleventh and fifteenth; a total of 2x4 cases. Of these one was 
six, another ten months of age. There were altogether below 
five years 37 cases, six of which died = 16.21 per cent., and 87 
between the sixth and tenth, 7 of which died = 8.75 per cent. 
The exact figures for the first year were 5 cases with 3 deaths, for 
the second 6 with no death, the third 5 with no death, the 
fourth 10 with 1 death, the fifth 11 with 2 deaths, the sixth 16 
with 2, the seventh 20 with 1, the eighth 11 with no death, the 
ninth 24 with 3, the tenth x 6 with 1, and from the eleventh to 
the fifteentht 90 cases with 9 deaths. 
One of the principal points made by Dr. Northrup is that 
the ulcerations claimed for typhoid fever are not characteristic 
at all; that, indeed, they are found in common intestinal dis- 
eases of non-infectious nature. That is what Hervieux con- 
tended thirty years ago, when he said that follicular swellings 
and superficial ulcerations in the intestines, and swelling of the 
mesenteric lymph nodes were found without any specificity in 
the morbid process. 
This observation, and the assumption of uniformity in the 
nature of these ulcerations, was indeed the reason why in 
France for a long time the terms typhoid fever and dothien- 
enterite were synonymous. But as early as 1877 C. Gerhardt 
emphasized the fact that the peculiar typhoid (“markige”) 
infiltration and the formation of scurfs, which are mentioned 
now and then are distinctively different from the ulcerations 
of follicular or other enteritis. It is true, however, that in 
many cases there is a difference between the young and the 
adult. The changes in the plaques of the former are more 
hyperplastic (they are not so in enteritis), of the adult more 
necrobiotic. Nowadays the presence of the bacillus typhosus 
in and about doubtful ulcerations would furnish another posi- 
tive diagnostic sign. 
DIAGNOSIS. 
It is determined by the symptoms enumerated above, and 
while it is mostly easy in the adult, becomes more difficult in 
the very young. I choose to take it for granted that in doubtful 
cases the diagnosis of dentition and worms is nowadays con- 
fined to a certain class of illiterate women and obsequious prac- 22 
PEDIATRICS. 
titioners only; but the differential diagnosis of typhoid in the 
very young from a catarrhal fever, or influenza, or glandular 
fever, even from an intestinal auto-infection may remain diffi- 
cult through many days—even for the skilled and thinking. 
The fever curve is very apt to be irregular, mainly in enfeebled 
children and in the presence of one of the many complications. 
There are even some cases in which the disease sets in sud- 
denly with a high temperature; there are those, however, in 
which a high temperature is apt to be deceptive, for I believe 
with A. Fairbam [Jour. Am. Med. Ass., April 12, 1897) that 
the first symptoms may be overlooked for many a day. A 
cerebral pneumonia may exist half a week or more without 
being recognized, until the development of the disease and 
careful examination clears up the diagnosis. Influenza may 
assume the characteristics of typhoid to a certain extent. 
Meningitis may be recognized, if by no other symptoms, by 
means of a lumbar puncture and examination of the cerebro- 
spinal fluid. Altogether a rather slow pulse when not in pro- 
portion to the height of the temperature, the condition of the 
tongue, the swelling of the spleen, and the presence of roseola 
render the diagnosis secure even without the Diazo and Widal 
tests. In other instances, however, we arrive at a result by 
exclusion only. There is hardly a single clinical symptom 
which alone proves the presence of typhoid fever; the simul- 
taneous presence of many is a more perfect guide. The diazo 
test is nearly conclusive when tuberculosis and pneumonia may 
be excluded; it may be expected to be positive in 90 per cent, 
of all the cases between the end of the first and the middle of 
the third week. The greatest difficulty is met with in those 
infants that yield few or no local symptoms except those of a 
septic infection only. Lymph nodes are sometimes found 
tumefied; their swelling in the inguinal region, however, from 
other causes is so frequent that, when found alone it should 
not count. The presence of herpes should generally be taken 
as proof of the absence of typhoid fever. The presence of the 
bacillus in the discharges would be the best symptom if we 
commanded a readier practical method for its discovery, pro- 
vided there be other symptoms which make the case suspicious 
of being typhoid fever. 
Much is naturally made of the presence of bacilli in the 
discharges of doubtful cases, and quite often the diagnosis had PEDIATRICS* 
23 
to depend on it. To what extent is that justified? There may 
be cases in which I should utterly refuse to accept the diagnosis 
of typhoid fever unless there be some one or more adjuvant 
symptoms, for the same reason that makes me refuse the diag- 
nosis of diphtheria when there is nothing but the presence of 
Klebs-Loefiler bacilli, or that of tuberculosis when bacilli are 
deposited on some mucous membrane. 
PROGNOSIS. 
The character and the mortality of typhoid fever are 
apt to vary according to seasons and epidemics. Bagin- 
sky places the mortality at 9 per cent., Montmoullin at 
8.8, Steffen at 6.7, Henoch at 7.5, Wollberg at 4.7. In hospi- 
tals it is liable to be greater than in general practice for the 
reason that as a rule bad cases only are sent to public institu- 
tions. Still, in the Children’s Hospital of Philadelphia, there 
were 137 cases, three of whom died (2.66 per cent.); in the 
Boston City Hospital, the mortality in 284 children, under 15 
years, was 6 percent., while amongst 3,396 adults it was 13.5 
per cent., and Holt collects 2,623 children with a mortality of 
5.4 per cent. On the other hand, of Schavoir’s {New York 
Medical Record, 1895) 192 patients (mostly in private prac- 
tice), under 15 years, 2 died = 1 per cent. 
Nurslings,and the very young, also those approaching ado- 
lescence, are more endangered than those in the intermediate 
years, according to”Roca (Ann. de Policlin. de Bordeaux, 1897), 
and Roemheld (Jahrh. f Kinderh,, Vol. 48). High continu- 
ous temperatures are not always fatal, though they be compli- 
cated with a frequent pulse, nor are petechiae absolutely 
ominous. A moderately slow pulse, and the occurrence of 
marked remissions are favorable, particularly when the fever 
is not terminated within three weeks. This continuation be- 
yond the usual time is quite common in the very young, and 
when the case is apparently mild. A speedy recovery may be 
expected when the spleen gets smaller about the sixteenth or 
seventeenth day; if it remains large, the case will go on. Com- 
plications of any kind, pneumonia, meningitis, previous heart 
diseases, with feeble peripheral circulation (cold feet), 
laryngeal edema, hepatic or splenic abscesses add to the dan- 
ger ; that with malaria is not very dangerous provided it be 
recognized at an early time. Some of these complications are 24 
PEDIATRICS. 
frequently called sequelae; but as they share in the microbic 
etiology of the disease, they should be considered here. To 
this class belong erysipelas (mostly facial), otitis media, hem- 
atomata, which are sometimes very large and destructive to 
the implicated or superjacent cutis, arthritis, furunculosis, 
abscesses of all kinds, and occasionally an anemic dropsy, not 
attended with an affection of the kidney, the occurrence of 
which was noted by Griesinger nearly half a century ago. 
Relapses are by no means rare, either after complete 
apyrexia, or with a moderate amount of remission about the end 
of the third week, or without any or much change in the tem- 
perature. They come after apparently mild, or after severe 
cases, without or with errors in hygiene or diet; when there 
was apyrexia, they were mostly of a shorter duration than when 
the fever remain continuous, or exhibited a slight remission 
only. 
TREATMENT 
The food should be liquid. My invariable rule is, 
with adults also, to insist upon that demand until apyrexia 
has lasted ten days. The patient should be encouraged 
to drink water frequently; the admixture of from eight to 
twelve drops of dilute hydrochloric acid to a tumbler full of 
water, or sweetened water, is a pleasant and disinfectant 
drink. Of albuminoids, peptones, and “ peptonoids,” and of 
beef-juice, only a certain quantity is digested or absorbed; the 
good that is to come from them is not from swallowing, but 
from digesting. The lips and tongue should be kept clean. 
Older children will wash and gargle. When the tongue is red 
and dry, and fissured, one or two daily applications may be 
made with a clean camel-hair brush, of a one or two per cent, 
solution of nitrate of silver. The nose should be kept clean, 
washed out with normal salt solution in urgent cases. To 
guard against hypostasis of the lungs and the cord, the posture 
in bed should be changed from time to time. 
A purgative dose of calomel in the very beginning will act 
beneficially; not so after the second half of the first week when 
diarrhea and hemorrhages may be caused by it. Constipation 
requires warm water enemata daily; diarrhea, frequent irriga- 
tions with water of from 95 to ioo° F. When the discharges 
are offensive, thymol, or permanganate of potassium may be PEDIATRICS. 
25 
added in a proportion of i: 3,000-4,000. Internally, bismuth, 
sulpho-carbolate of zinc, salol, naphthalin are indicated. Bron- 
chial catarrh demands no special treatment in most cases; if 
the secretion is viscid, and dyspnea present from that cause, 
camphor is serviceable. Collapse requires strong stimulants, 
by mouth and sub-cutaneously; diluted alcohol, camphor in 
sweet almond oil 1 -.4, and the salicylate or benzoate of sodium 
and caffein, soluble in two parts of water, answer best for that 
purpose. Insomnia, great excitement, and consecutive psy- 
choses may require chloral hydrate. When the heart is feeble, 
croton chloral should be selected instead. When these symp- 
toms are accompanied with heat of the head, cold applications 
to the head, ice water, ice bags are soothing. The head 
should, under such circumstances, be kept as high as comfort 
permits. Sopor or coma should be treated with cold affusions, 
while the body is submerged in water of 90 or 95 degrees. 
Is it desirable to resort to antipyretic treatment ? If so, in 
what class of cases, mild, medium or grave ? This latter clas- 
sification, however, should not exist, for the apparently mild 
case may turn out to be a grave one. Or is it desirable to allow 
high temperatures to persist? 
The vis medicatrix naturae has been eulogized in infec- 
tious fevers. However, the wholesome influence of intense 
body heat on bacteria and toxins has become very doubtful, 
and good observers, like Flugge deny the new gospel of the 
increase of phagocytosis by high temperatures absolutely. Nor 
is the disintegration of tissues by heat alone successfully con- 
tradicted. Thus, after all, we need not enjoy the presence of 
high temperatures as a blessing, disguised or undisguised, and 
should reduce them. This much is certain, that the comfort 
of the patient is enhanced, and grave nervous symptoms alle- 
viated, when the hot, dry skin becomes cooler and moist in pro- 
portion to the reduction of the general temperature. 
Which are the means by which we can effectually obtain it? 
The number of antifebrile medicaments has grown immeasur- 
ably ; the cautious practitioner will do well, however, not to 
embark in the dark sea of unknown territories, guided 
by nothing but the flashlight advertisements of the drug 
manufacturer. Some of the new remedies are actual dangers. 
Acetanilid is a poison like all anilins; it changes hematin into 
methemoglobin, and thus causes the cyanosis that is so fre- 26 
PEDIATRICS. 
quently noticed. Antipyrin is perhaps the safest; sodium 
salicylate annoys the stomach and the kidneys, which are very 
liable to suffer from the typhoid toxin alone. Quinine acts 
well during- intermissions and remissions, not however when 
high temperatures are continuous. The cardiac stimulants— 
digitalis, strophanthus, spartein, camphor, alcohol—which 
improve the general and cutaneous circulation, and thereby 
the radiation of heat from the skin, are mighty weapons in the 
hands of the intelligent medical adviser, who moreover need 
not limit himself to the few remedies I mentioned. 
All of these remedies, however, do not exhaust our 
resources; indeed they are only of minor importance. Without 
knowing all of it the old poet exclaimed “ hudor ariston,” the 
water is the best. Cold water and warm water are our most 
reliable and at the same time the safest antipyretics. Stress 
should be laid on the latter title, because many of the very 
apostles of hydrotherapy, perhaps influenced by shaky phago- 
cytosis and toxin theories, belittle it in comparison with the 
nerve stimulating powers of water. Now, cold bathing is 
frequently contraindicated; it is not borne when the heart is 
feeble from whatsoever cause; for instance, long duration of 
the disease, complications with pneumonia, peritonitis, or 
hemorrhages, previous bad health, or, in the adult, excesses. 
No stimulant given before or during the procedure is cer- 
tain to counteract the paralyzing effect on the peripheral 
circulation. When after a cold bath the feet remain cold and 
the pulse small, the bath was contraindicated, and did harm. 
The patients in public hospitals are quite often of a low 
vitality, and feel the cold bath as a shock; at all events, 
most of those who arrive in the hospital after a week or two 
have passed the time when the cold bath might have done 
good. Of this nature is the latest experience of I. Rudisch 
in the Mount Sinai Hospital (Mt. S. Rep., Vol., 1899). He 
says: “The Brand treatment reduced the mortality a little 
over 2 per cent. This reduction occurred in the cases which 
had been sick two weeks or longer, outside the hospital. Since 
the introduction of the Brand treatment there has been an 
increase in the number of cases of pneumonia and phlebitis, 
and a decrease of those of furunculosis and nephritis. 
Relapses have increased 2.5 percent. The death rate in the 
relapse cases before and since the introduction of the Brand PEDIATRICS. 
27 
treatment is practically the same. It has not reduced the 
number of complicated cases as a whole, but has decreased the 
number of deaths from toxemia in the causation of the mor- 
tality of typhoid fever.” 
This does not speak well for the indiscriminate use of 
cold water for hospital patients. 
The dangers of cold bathing are not encountered in warm 
bathing. This is not the place to prove for the thousandth 
time that a bath of 950 or 90° F. when of sufficient, even when 
of short duration, will reduce a temperature of 104° or 106°. 
It is simply a fact. Such a bath may easily be given every 
three or five hours; even apparently mild cases should have 
two or three daily, from the beginning to the end of the illnesss. 
They reduce the temperature, the accompanying frictions 
stimulate the cutaneous and general circulation, the general 
condition is improved, the so-called typhoid state relieved, and 
relapses become less frequent. Warm bathing should be the 
principal treatment of all typhoid fevers, not to the exclusion, 
however, of occasional medication calculated to have similar 
effects. The combination of frequent and protracted bathing 
with proper medication will always remain appropriate, though 
our resources should, as we expect, be increased by sero- 
theraphy. The searching for it, and the frequent insufficiency 
of medication in skilful or unskilled hands, both by thoughtful 
or routine practitioners, have caused us too often to neglect 
our most active helps. Even where serotherapy has scored 
its most deserved laurels, for instance, in diphtheria, the 
almost boastful limitation to the use of antitoxin, to the exclu- 
sion of other internal and external treatment, is a mistake. 
What is to be treated is not the bacillus, but the organism 
invaded by the bacillus; and the clinician should know that 
bacteriology is an indispensable aid to clinical medicine, but 
not clinical medicine itself. Thus, when we shall find an anti- 
toxin for the typhoid bacillus, we shall still require adjuvant 
treatment for the typhoid man, woman and child. PEDIATRICS 
DILLON BROWN. PiD < 
MiwroßA 
Devoted to the Study of 
Disease in Children. 
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