Typhoid Fever in Infants unde:- Two Years of Age ETIOLOGY—PATHOLOGY—symptomatology, BY SAMUEL S. ADAMS, M.D. Washington, D. C ARPRINTED FROM The American Journal of Obstetrics Vol. XXXI. No. 2.I8H6. NEW YORK WILLIAM WOOD & COMPANY, PUBLISHERS 1895 TYPHOID FEVER IN INFANTS UNDER TWO YEARS OF AGE. ETIOLOGY—PATHOLOGY—SYMPTOMATOLOGY.1 If an apology is necessary for introducing the subject of typhoid fever into this Society, after the recent thorough discus- sion of the entire subject in the Medical Society of the District of Columbia, it is to be found in the fact that the disease is so rarely met with in infants, or at least is so rarely diagnosticated by the post-mortem appearances, that we feel justified in presenting it here. We have been induced to select this subject owing to a discussion of the same subject which took place in the American Pediatric Society two years ago, in which Dr. Northrup, of New York, claimed that this disease did not occur in infants, or, at least, that it had not been found in the pathological examinations made in the New York Foundling Asylum; and that “swollen Peyer’s patches and mesenteric glands and spleen in children cannot safely be interpreted like similar lesions in adults.” He further says: “ So many undefined fevers in infantile life drag along, variously diagnosticated; so many undefined cases come to autopsy, revealing swollen Peyer’s patches, swollen mesenteric lymph nodes, enlarged spleen—what shall we say of them ? The 1 Read before the Washington Obstetrical and Gynecological Society. 2 ADAMS: TYPHOID FEVER IN symptoms of typhoid and no autopsy; the autopsy of typhoid and no symptoms; bacterially no typhoid bacilli.” In the discussion which followed this paper the consensus of opinion seemed to be that typhoid did exist in infancy, and I took the ground that, though J had not been able to verify my diagnosis by the typical anatomical lesions, nevertheless I was certain that I had treated the train of symptoms which clinically characterize this disease in the adult. Previous to 1840 it was believed that infancy and early child- hood were immune against this disease. Prior to this date the disease seems to have been defined under the term “ infantile remittent fever.” There can be no question that it existed prior to this date and that the mistake was in not differentiating it from other febrile diseases, though about this date Stewart, in his work, clearly defines the disease as occurring in infancy; still even much earlier it was described by Abercrombie in a 6-months-old girl and in another 7 months old, the latter being confirmed by a necropsy. West in 1822 described the disease fully from a clinical and anatomical standpoint. Millard in 1828 reported two cases in children. Characlay in 1840 reported a child 8 days old who died ; it presented enlarge- ment of the follicles, Peyer’s patches, and mesenteric glands. Shadier narrates the case of a 7-montbs-old child whose mother died on the twenty-sixth day of typhoid fever. Five days after its mother’s death the infant sickened, and died on the eleventh day; ulceration and infiltration of Peyer’s patches, swollen mesenteric glands, and enlargement and softening of the spleen were found. Earl, of Chicago, reported a case 24 months old that had the typical symptoms of typhoid, compli- cated by intestinal hemorrhage, in which the necropsy revealed the characteristic local lesions. Numerous other cases under 2 years of age have been cited. Not only have infants contracted it from their mothers at birth, but a fetus of seven months is reported as having it. Etiology.—A tangible cause has unquestionably been found for this disease, and the specific bacillus is found in the lesion. The poison does not originate spontaneously from decomposing ani- mal or vegetable matter, but must have been transported from some infected individual. So far as infants are concerned the proof of the presence of the bacillus is still negative. Ebertli claims to have found the bacilli in the tissues of a fetus of the INFANTS UNDER TWO TEARS OF AGE. 3 twentieth week’s gestation, as well as in the intervillous spaces of the placenta, and developed cultures from them. The theory of the transformation of the germs outside of the body—that is, the transformation of the bacillus coli communis into the bacillus of Eberth—is still sub judice. Although this point has not been definitely determined, we must depend upon the experimental inoculation of animals for its settlement. Water is probably a good carrier of the disease in infancy, though milk, which readily takes up bacilli of other varieties, may be the common carrier. Pathology.—The same anatomical lesions exist in the child and in the infant that are found in the adult. It will not be long before the presence of the bacilli will be demonstrated in the lymph structures of the bowel, spleen, and other organs. Gerhart believes that the lesions in children differ from those in the adult, especially ki the beginning. The swelling of Peyer’s patches shows itself earlier, and is seen with greater frequency near the ileo-cecal valve, though it may reach higher in the small intestine. The swollen patches often project above the mucous membrane, and above them are often seen denudation and slight ulceration. From these sites the destructive processes extend. It has been suggested that this difference in the amount of destruction may be due to the character of the food of the infant, which is fluid and non-irritating. In the case which I present below, the anatomical lesions in the intestines seem to be as typi- cal as those in the adult. Clinical History.—As far as the clinical picture is concerned, there does not seem to be any marked difference in the child and adult, but in the infant there is unquestionably a difference. Restlessness is marked and the fever persists for days with only slight irritation of the gastro enteric tract. The temperature, which usually reaches a higher range than in the adult, is well borne, and it is surprising how long some infants can bear a con- tinuous high temperature. If headache is present it is not recog- nized. There is usually nothing characteristic in the appearance of the tongue. Vomiting has been observed in a few cases, but is probably due to forcing food. The appetite is uncertain, some- times voracious, at others almost entirely absent. Constipation is usually present throughout the entire course of the disease making it necessary to relieve the bowel by enemata. The typical rose spots are not always present or are seldom recog- nized. Tympany is rare. Hemorrhage from the bowel is sel- 4 ADAMS : TYPHOID FEVER IN dom seen, though some observers mention it. Peritonitis may or may not be present. The spleen, if enlarged, is seldom de- tected, and Northrup claims that it cannot be recognized unless it project below the margin of the ribs. The liver is probably unaffected. The kidneys are not affected. Epistaxis is rare. Bronchitis has been observed in a few cases, but is probably due to hypostatic congestion. Relapses occur in a fair percentage of cases. The following case is unquestionably one of typhoid fever. The diagnosis was not positively made until the necropsy. The specimen was examined and pronounced to be typhoid fever. Subsequently the report of the bacteriologist, though not con- firmatory, did not deny that it was the disease. Florence P., aged 2 years, mulatto, was admitted to the Chil- dren’s Hospital, D. C., September 19th, 1893. Previous History.—Her father has consumption, but her mother’s health is fair. Child was well until one month ago, when she was taken with diarrhea which lasted a few days. About one week ago there was another attack of diarrhea, accompanied by nausea, loss of appetite, and languor. At times the stools contained blood and mucus, but were unaccompanied by pain and straining. She has had a slight cough for several days. Present Condition—The child’s general appearance indicated severe illness, but tin emanation. bicrh temperature, and rapid pulse, with the frequent nmeo-sangui olent stools, led us to sus- pect an enteritis catarrhalis. She was placed upon milk diet; sponge baths to reduce the temperature ; and in a few days the diarrhea ceased. (See chart.) September 23d : Paralysis of extensor muscles of left hand noted. Paralysis extended gradually until the 29th, when the extensors of both hands and feet were paralyzed. September 30th : Upon returning to duty, after my vacation, I found the foregoing notes upon this case. The temperature had now gone up to 101.2°, and there was a persistent tonic contraction of flexors of both upper and lower extremities. Efforts to extend the limbs caused the child to scream, but she was so stiff that she could be rolled from side to side without discomfort. Ir- ritability was the \y mental disturbance noted. Fluid extract of ergot, gtt. iij. every three hours, was given, and by October 10th the rigidity had entirely disappeared, she was eating and INFANTS UNDER TWO YEARS OF AGE. 5 digesting well and was rapidly convalescing. Medicinal treat- ment was now discontinued. October 19th : While sitting in her carriage yesterday the patient was suddenly seized with violent jerky movements of upper extremities. She was rest- less, and the temperature was noted to be 104°. This morning September. October: October. Temperature Chart. it reached 104.6°, and plienacetin and calomel were ordered. One grain of plienacetin in two doses having reduced the tem- perature more than 7°, it was discontinued. October 20th: Temperature 102.8° and rigidity of extremities marked. Sul- phate of quinine, gr. i. by suppository, every three hours during the day. October 26th: The rigidity has disappeared and the 6 ADAMS : TYPHOID FEVER IN INFANTS UNDER TWO YEARS OF AOI temperature lias remained subnormal for twenty- four hours, so the quinine is to be stopped. October 28th : There is a recur- rence of the aggravated symptoms, so the suppo- sitories are resumed. No- vember 2d: The tempera- ture has remained high since the last report, so the suppositories are or- dered to be discontinued. November 3d : Has been in collapse since noon of the 2d, and has had six- teen profuse liquid stools, without blood. Death occurred at 2 p.m. During the last four weeks of her illness con- stipation prevailed and had to be relieved by ene- mata or mild purgatives. The irregularity of the temperature wave and the evidences of cerebro-spin- al irritation rendered the diagnosis so obscure that typhoid fever was not suspected until a few days prior to death, when the quinine was found to have little or no effect upon the hyperpyrexia. Necropsy, six hours af- terdeath.—Brain: Mark- ed congestion of entire brain, more on the right side; left hemisphere covered with a gluey Ileo-colic portion of intestine, showing thicken- ing and ulceration of solitary bodies and Peyer’s patches of ileum. Adams : typhoid fever in infants under two yeears of age. 7 substance which tilled the sulci, especially abundant around Syl- vian fissure. Heart: Normal. Lungs: Marked hypostatic con- gestion. Abdomen: Liver normal; gall bladder empty and pale; spleen enlarged, congested, and softened ; kidneys normal. Stomach: Congested and contained about a pint of grumous material, which was not examined chemically or microscopically; mesenteric glands enlarged and softened. Intestines (macro- scopic) contained a quantity of yellow, watery feces. The lower end of ileum shows thickening and ulceration of Peyer’s patches (see cut), and to a less extent of the solitary follicles. The soli- tary follicles of the cecum are also ulcerated. 1632 K STREET. MEDICAL JOURNALS PUBLISHED BY WILLIAM WOOD & COMPANY. MEDICAL RECORD. A WEEKLY JOURNAL OF MEDICINE AND SURGERY. Price, $5.00 a Year. The Medical Record has for years been the leading organ of the medical profession in America, and has gained a world wide reputation as the recog- nized medium of intercommunication between the profession throughout the world. It is intended to be in every respect a medical newspaper, and contains among its Original Articles many of the most important contributions to medical literature. The busy practitioner will find among the Therapeutic Hints and in the Clinical Department a large fund of practical matter, care- fully condensed and exceedingly interesting. 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