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Maps, plates, charts, etc., may be filmed at different reduction ratios. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right end top to bottom, as many frames as required. The following diagrams illustrate the method: Les cartes, planches, tableaux, etc., peuvent dtre film6s 6 des taux de reduction diffdrents. Lorsque le document est trop grand pour dtre reproduit en un seul clich6, il est film6 6 partir de Tangle sup6rieur gauche, de gauche d droite, et de haut en bas, en prenant le nombre d'images ndcessaire. Les diagrammes suivants illustrent la mdthode. 1 2 3 1 2 3 4 5 6 ^^HA^-i^^^uMJ^f Y}^ CHILLS IN TYPHOID FEVEH. BY W. W. FORD, M.D., &;^,JJ.=P, ff. Fellow in Pathology, McGill UnivcMity, Montreal. Reprinted from the Montreal Medical Journal, July, 1900. « • • • « . I [ • •• . :• :.. jtji d •• t« •• •. ••••..1 ■•• -.v....:*. . • •• ..: • : CHILLS IN TYl'liOli) i'EVKR. ItY W. \V. Kuiti), MA)., I'li.l)., Fellow ill I'iitlioloxy, McCiill UniviTsity, Alonlival. 'J'lio atlcntiun oi" clinicians has been particularly called williin recent years to tiio occurrence ol' extreme rigoi-s associatctl with typhoid fever, either in the regular course of the disease or in some of its more serious coiHidications. In Southern ktitudes, especially, where the presence of chills in various fevers is apt to be ascribed to the growth in the blood of the malarial parasites, the exhibition of rigors in typhoid fever is usually considered to l)e due to a combination of intermittent and en- teric fever, and the suspicion always exists that the sudden rise and fall in temperature is not due to the typhoid lesions but to the plasmodium malaria). A number of cases of the combination of malaria and typhoid have been i-oported in the Medical and Surgical History of the War of the Rebellion, where the soldiere stationed in southern camps under unhy- gienic conditions contracted both diseases. For a number of years the occurrence of these two diseases in combination was a .subject for groat dispute, and the question was only finally settled after the outbreak of the Spanisl- -American war, when soldiers returning from the Philli- pines were found to have large numbers of malarial parasites in the circulating blood, and to have as well the clinical symptoms of typhoid fever, including n positive Widal reaction, which persisted after the dis- appearance of the parasites from the blood after the administration of quinine. The follownng case which occurred in the Medical Wards of tho'ohns Hopkins Hospital in the sorviee of T)r. Osier, which by his permission is here reported, represents a combination of symptoms which for the period of the entire stay of the patient in the hospital was looked upon with suspicion as being a combination of typhoid and malaria, but which during life to all apparent observations was absolutely negative for malaria and which at autopsy showed positive evidence of the lesion? of typhoid fever. Oare : Daniel Ryan, aet. 40, white, painter by occupation, admitted to the John? Hopkins Hospital, March .^th, 1890. complaining of stomach trouble and rheumatism. Family history negative for constitu- tional diseases. Personal History : Smallpox at 10 during the Chicago epidemic, no history of malaria at any time ; rheumatism at 22, beginning in the 5528;2 2 joints of both fuct which were swollen and piiiiiful, tciulei- to tho touch. Both knot'8 wore then involvctl, then hips, hands and shouldord. No reason could be given to account I'or tho attack, lias used lead in paint- ing for (lie [)ji.st 15 years, but lias had no attacks of le'ad colic. Liips ; initial Icvsion at ^0, secondary eruption on i'aco, mucous patches in niDiilh and throat; no rheumatic pains and no loss of hair. Was treated for this at Hot Springs, Arkansas, and has had no symptoms since the secondary eruption. Contracted gonorrlicra at 23, treated with injections and since then has had a strii'lure. Is in the liabit of drinking two or three glasses of whiskey daily for periods of several weeks at a time, after which ho will total'.y abstain fir a corresponding period, lias never been in the hahit of drinking to excess and has not used tobacco excpt for occasional chewing. Hiis usually been a healthy vigorous man u|) to the time of his present illness. PnKSENT Illness : Patient stated that his first trouble began about two months l)eforo admission, wlien ho noticed that he was fev- erish, held his head ii]) with difficulty, lost his appetite, liad severe frontal headache. This has been practically persistent since on- set of trouble. He was dizzy at times. ITis arms and hands felt as if they were asleep. He had sensations of numbness throughout the whole body. No epistaxis. At ll.is time patient began to have a series of chills which came on Avhenever he was exposed to cold and at in- definite times of [he day. These chills wore severe shaking rigors, and wero followed by heavy sweats. Patient also had night sweats. For several weeks he has had a dry cough, at first painless but later, nccom- panicd by painful sensations in different parts of the body ; expectora- tion considerable, but not blood stained. Has been feverisli at times since onset of disease and is constantly thirsty. No appetite, eating folloAved by nausea and vomiting. During this period has had definite attacks of rheumatism in knees, shoulders, elbows and bands, one knee especially involved, the other not swollen or painful. Soon after the onset of these symptoms, patient entered tin:' Charity Hos])ital, Savanah, Oeorgia, where he was treated for syphilis. Patient remained here for about a month when he left because he thoiight the mercury and iodides which ho took upsot his stomach. He was some- what improved, however, and went to Richmond, Virginia, where he worked at the Soldiers Home. At this time the chills, followed by fever and sweating, became a very marked symptom of his disease and at Richmond he was treated for malaria and took large doses of quinine. He felt wepk, had no appetite and was frequently feverish, had pains in different parts of the body and was utterlv unfit for any active exertion. He remained in Richmond for several weeks and then came to Baltimore and was admitted to the Johns Hopkins Hospital. 8 Oil (jiu'stioiiii)",', patient stal'-d lliat lie liad had an acuto attack of rluMiinatipm (?) in the riglit log and kni'o which camo on abruptly two weeks before admission. Ifc gave no history of attacks similar to gall stone colic and no history of attacks of jaundice at any time. IJowels were irregular, nnich constipated ; appetite very poor. Patient has not oaten a good meal for over two montlis, is able to retain only soft eggs and milk. ^lieturition normal. f'oNniTKiv ON' Admission- : (Vnnple.xion sallow; eoiijiinctivfp faintly yellow ; no cyanosis or dyspnu>a ; lips and mucous membranes of good colour ; patient looks decidedly sick, is dull and slow-minded, but an- ewers questions rationally. Tcjiigue is slightly coatwl, breath very oU'en- sive ; a few greyish spots on the posterior wall of the pharynx ; no nlcers on membrane. Pulse slightly dicrotic, large volume, low ten- sion. Patient has a distinctly typhoidal appearance. Lux(iS : A few line rales at the end of ins[)iration in both upper lobes. Heart sounds clear ; abdominal examination negative. Liver not enlarged ; spleen not i)ali)able. Abdomen soft and full, lympanitic on percussion, but not distended, no tenderness and no foreign mass to be felt ; no rose spots. The right leg is much enlarged, the tissues of the calf being swollen and indurated, the sui)erlicial temperature is ele^'.ited, there is consider- able tenderness on palpation. About the middle of the calf is a ridge- like swelling, hard and sensitive, just below the line of the popliteal vein. Jn the popliteal space the tissues are swollen, cedematoiui and tender, there is much induration over the course of the popliteal artery and vein. The whole leg is swollen and oedematous pitting on pressure the circumference of right calf measuring 4 c.n. greater than the left. Co u USE or Disease : The patient's temperatm-e on admission was 103-|,°. It rose immediately to 10i° and then to lOa-l^", when the patient had a hard shaking chill. It dropped again to 103 and ro?e to 105, and at this time the patient was covered by a most profuse per- s])iration. His temperature now gradually fell to 101''|i„. During the night the i)atient\s temperature was very irregular and fell from 102"{io at 8 o'clock tlie day of admission, to normal at 10 o'clock and to 97 by the afternoon of the v«eeond day. During this time the pationt looked considerably upset, the sweating was profuse, rendering a constant change of garments necessaiy. There was no increase of the slight yellow tinge of the skin and con- junctiva; which had been noticed on admission and no pain in any part of the body. The spleen could not be felt, the liver was not enlarged, there was no tenderness over the gall bladder. The swelling and ten- derness in the popliteal space had not increased, and if anything was slightly less than on the previous day. . ■ ^ 1 : :.:!. :i,^-^,..iA^^^^j Tlic Icucoc-yte count wjis 7300 on March 5tli, the day of adniissioii, and 7500 on tJie Gtli. Fresli specimens of blood exaiiiincd repeatedly for malarial parasites were absolutely negative, oven though they \vc.re taken before, during and after the chills. The examination of the sputum was likewise negative. The diiferential blood count on Miircli 7th, showed a great increase of polynuclcar leucocytes, over 90% being of this variety. During the afternoon of the second day the patient had a very hard eliaking chill, lasting for nearly an hour ; his temperature rose rapidly from i)7 to 10:;i"|io, after which it iluctuated for a degree or two for about four hours, when it reached J 01, and the patient had another severe shaking chill. Jioth chills were followed by the same profuse sweating as waa noticed on the previous day. His temperature now dropped from 104 at 10 p.m. to 102 at 'i p.m. and to 9()"|io at 1 p.m. For the next few days patient's condition renuiined jiractically un- changed. He continued to have slight irregular elevations of tempera- ture, but no shaking cliills and no attacks of profuse sweating. The diagnosis of the convalescent stage of typhoid fever with thrombosis of the popliteal vein was made provisionally l)y Dr. Osier. On the 1th day the patient had a severe pain in the left side of the chest and on auscultation there was a well marked friction rulj in this area. Tlie blood gave a ])ositive Widal reaction in dilutions of 1 — 10 and 1 — 50. This reaction was always given by the blood ot the piitient from entry througiiout his entire illness. On a numl>er of occasions the reaction in dilutions of 1 — 100 was very rapid and perfectly charac- teristic. On the 5th day the patient had another severe shaking chill, the tem- perature rising from 98 to lOl'iio and to 102'''|io, after which for half the night it remained at this point, then suddenly dropped, reaching 95° the following aftenio(m, a fall of nearly 7^° in It hours. This chill was accompanied as well by profuse sweating and great constitu- tional discomfort. The Urine was turbid with a trace of albumin and a good many pus cells. Cultures gave a pm-e growth of typhoid bacilli, the organisms being typical, giving positive reactions on culture media and with the blood of patients suifering from typhoid fever. The administration of urotropine was begun a few days after admission with the result that after its administration the number of colonies from a given qu.^ntity of urine, gradually diminished, but at no time was the urine free from the typhoid bacilli. The blood examination during this period was quite interesting. Al- though fresh specimens were examined constantly, both by day and night, and during and between the chills, there never was the slightest evidence of tlio prcsonci! of any of tiio parasites of malarial fever al- thoiijjli tlic recurrence of the chills and their in-egidar type led to tlie Mispicidu thill we were (h-aliii^f with a ease of a'stivd-iiiiturnnal malarial fever, and altlioiifjh the pntient had heen exposed to the dilferent forms of malaria wliile living' in southern countries. The leucocyte counts were ^^enerally hetwecn 7000 and 8000 with llie hcf^inninj? of the cliill. Durinfj the height of the fever the leucocytes would rise to IT.OOO or iS.OOO. and frequently to ;K),000, the increase ' l)eing entirely duo to tlu; polymorphonuclear elements. Practically every ri^'or was accompanied by such a leucocytosis. 'V\w red hlood count was ;{,:)!)(;,()()(), tile ha'mo^lohin (;."■)%. The ])hysical condition of the patient changwl hut little, the friction riil> nn the leftside increased and ilie pain in this re;,non hecauie more marked ; the s])lcen hccame palpable, very low down, the border round and soft, the area of s|)lenic dulness much increased. The patient de- veloped no rose spots and no jaundice and had no other sympt,()ms of ly|>hoid fever. The induration and swelling' in the ri^dit calf in the l>opliteal space vapidly diinitiishcd and the patient was able to mov(^ his le<; with considerable freedom. It was Dr. Osier's opinion that we were dealinjr with a case of typhoid fever with thronil)osis. On the 8th day at 10 p.m.. the jiatient's ti'mpei'atnre wiiich had been I02"|,n, di'0[)])ed suddenly to 100, and he Wixs attacked by a most vinlent i'i,U()r. llie temperaturo rose immediately to 105'|,o, and fell in live minutes to 9G^|,„, a drop of 9°. With this smlden fall there were most profonnd discomfort and general prostration ; the temperature remained subnormal for only two hours, after wliicli it rose to 91)"|,„. It fluctu- ated about the normal for the next two days. Blood cultures were now taken both anfcrobically and a-robically with negative results, but as wo have said, the typhoid bacilli remained in the urine and the Widal re- action was positive. On the 11th day the patient had another chill with a sudden rise of temperature and fall to 2° below normal, and now for several dayS the patient's condition remained practically unchanged, lie had chills irre- gularly and unexpectedly at different times of the day and night, they were not, however, so violent in character nor accompanied by such great prostration ; between the chills the temperature became per- sistently subnormal and remained so up to the day of his death. The patient's ])hysical condition rapidly deteriorated, weakness be- came more marked, mental condition decidedly unfavorable, he an- swered questions rationally, though it \vas wuii great difficulty he could be got to answer at all. Emaciation was profound, appetite completely lost without vomiting ; there was no increase of the slight .iaundice noticed on admission, in fact at times this jaundice seemed to disappear. 6 The hlnod contlitiDii wm not chuiiged, tho leucocytes rciimiiiing normal between tho rigors. At this time a curious attack of respiratory distrosa was noticed l)y the attendants, and the patient became very dilHcult to iiiaiirge ; ho constantly c()iii|)laine(l of great pain l(>cato4l in the chest or abdomen, and was marke hero reported may he allied to sneh eases, hut it presents as wet) a nnmher of other interest inj; features. The rifjors were in all instances very severe. The rise and fall of tenii)era- tnre was most abrupt, each fluctuation heinj; accompanied hy severe shakinp: chills and ])rofuse sweatiufr. Tn one instance the temperature fell in five minutes froiti lO.".! to Ofi.2, a dro]) of over dejjrees. Such pronounced ripors arc seen only in two conditions practically malarial fever and scpticannia. The presence of malaria was ruled out both by tl;>' constant failure to find the parasite in the blood and tlie lack of any lesions at autopsy associated with this disease. Wo are thus forced to conclude that we were dealin;,^ with a case of typhoid fever in which chills marked the whole course of the disease or with a ease of typhoid septicaMuia. It is (piiie ])rohal)le that wo were dealin;:,' willi both. The patient constantly stated that his illness began with chills, fever and sweating and ;.is treatment for malaria at this time testifies to the conectness of lliis statement. His synn)toms while iu the hospital were rdl characteristic of sepliciemla and not of an ordinary attack of typhoid. We should th'is be led to conclude that the patient originally had a mild attack of typhoid fever with a few ulcei's in the intestine. The typhoid bacilli remained in the spleen and bladder, developing and multiplying and gave rise eventually to a condition of septicicmia with the typhoid and colon Ijacilli as the infecting agents. This general in- fection was the direct cause of death. Aside from the chills, one's attention was called particularly to several other symptoms which were unusual in typhoid. The Jaundick noticed on admission never totally disappeared. After death the body turned to a deep saffron yellow, as intense a grade of icterus being pre^sent as in oljs.tructive jaundice. No obstruction to the flow of bile could be elicited at autopsy and no catarrh of the finer bile passages. The jaundice was thus Immatoijenoxis in origin, belonging to that obscure group which is exciting so much attention from pathologists at present. TiiK ]iLOOD showed a normal white count at all times except during the rigors when the leucocytes rose to 2"),000 and 30,000. This high leucocyte coimt was itself quite contrary to all observations on the blood of malarial patients and suggested the infectious origin of the chills. The Pleurisy, the advent of which was unassociatcd with, a rigor f persisted from the tiiiio of its ai)poflrance to the deatli of the patient. At autopsy tliere wore plastic adhesions between the pleura, the lung and the (liaphi'agni at the point where the pain was felt and the liiles heard during life. 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