ABRUPT ONSET IN TYPHOID 
FEVER. 
BY 
WILLIAM PEPPER, M.D., LL.t)., 
AND 
ALFRED STENGEL, M.D., 
11 j' ■ . \ ■■ i, ' ■ 
OF1 PHILADELPHIA. 
FROM 
THE PHILADELPHIA MEDICAL JOURNAL, 
1898. ■ [Reprinted from The Philadelphia Medical Journal, January 8,1898.] 
ABRUPT ONSET IN TYPHOID FEVER. 
By WILLIAM PEPPER, M.D., LED., 
Professor of the Theory and Practice of Medicine, and of Clinical Medicine, 
University of Pennsylvania, 
AND 
ALFRED STENGEL, M.D., 
Instructor in Clinical Medicine, University of Pennsylvania. 
Though it must be recognized, as Liebermeister 
taught, that there is no single symptom which may be 
regarded as pathognomonic of typhoid fever, the diag- 
nosis of this disease rarely causes great difficulty after 
the expiration of the first several days. At the onset, 
however, it is extremely difficult to determine positively 
whether the attack is one of typhoid fever or some other 
infectious or inflammatory disease. It is universally 
taught and is a fact that the invasion in the majority of 
cases is insidious; but we have met with so many 
instances of abrupt onset, in the last few years, that it 
has seemed wise to present the notes of a few of these 
and to call attention to this mode of invasion. In sev- 
eral cases we have permitted ourselves to be too sanguine 
regarding the nature of the case under observation, and 
have for a time been misled. Authorities for the most 
part, though stating that the onset is usually insidious, 
do not specifically call attention to the nature of the 
invasion in the exceptional cases. Only Moore {Text- 
Book of the Eruptive and Continuous Fevers, 1892) states: 
“ Of iate years the classical insidious onset of enteric fever 
has in many instances given place to a more abrupt and ve- 
hement advance, characterized by decided rigors, violent 
headache and rapid rise of temperature. This at least has 
been our experience in Dublin during and since the epidemic 
of 1889. In a word, the whole course of the disease has be- 
come more tvphus-like than formerly.” 2 
While we have met with few cases in which the sever- 
ity of the onset was such as would justify the suspicion 
of typhus fever, in general Moore’s experience coincides 
exactly with our own. We now present a few histories 
of cases met with in late years which will serve to illus- 
trate the nature of the cases we have in mind. 
Case I.—Miss B. A., aged 18, spent the summer at Atlantic 
City. She had not been as strong as usual, and on November 
15th had a sharp attack of what seemed gastro-enteric ca- 
tarrh. There was moderate fever, occasional vomiting, soon 
allayed, diarrhea which proved quite severe, and obstinate 
and considerable abdominal pain. Under strict rest, rigid 
diet, and simple remedies the symptoms disappeared, but she 
remained so weak and pale as to suggest an attack of influ- 
enza with gastro-intestinal symptoms. By December 3d she 
had improved considerably and went to an afternoon enter- 
tainment; the next morning she had a slight chill followed 
by intense headache, fever, which rapidly rose and the fol- 
lowing day reached 104.2° and slight cough, but with no 
symptoms of intestinal irritation. On December 7th the 
temperature reached 105.2°. There was enlargement of the 
spleen and intense Widal’s reaction, slight albuminuria and 
a marked Ehrlich reaction. Eruption did not appear until 
December 9th, after which it became abundant and wide- 
spread. The headache continued violent for several days; 
the bowels were constipated until the 11th day. when slight 
and easily controlled looseness developed. Delirium was 
unusually slight. The temperature reached 105° several 
times, but on the whole was easily controlled by repeated cool 
sponging. Altogether the course of the case, after the unusu- 
ally abrupt onset, with very early albuminuria and Widal’s 
reaction, presented no special peculiarity or gravity. 
Case ll.—Mrs. B. 8., aged 24, the mother of two children, 
the youngest 8 months old, has been under our observation 
for some years past. Before her marriage she had pro- 
nounced chlorosis, the hemoglobin at one time falling to 15 
per cent. (Fleischl). Since her marriage she has been more 
vigorous, but still remains chlorotic. Of late she has been as 
well as usual, though weak. After an exertion on a Saturday 
afternoon, when she walked very quickly or ran to her sis- 
ter’s house at some distance, carrying her child in her arras, 
she was almost prostrated and soon was seized with a chill, 
which was quite severe and was followed by violent nausea 
and vomiting. Everything was regurgitated from her stomach 
and she could not even retain small sips of water. Her tem- 
perature rose to 104° or 105°. (We did not see her at this time.) 
During the night diarrhea began and continued for the next 3 
three days without interruption, despite the administration 
of powerful diarrhea-mixtures, most of which, however, were 
promptly regurgitated. When we first saw her, four days 
after the onset, there was marked tenderness in the epigas- 
trium, without any distention of the abdomen. The tongue 
was furred and the patient complained of headache and pain 
in the limbs. Subsequently the case proved a typical in- 
stance of mild typhoid fever, though the duration has been 
exceptionally long. (She still has considerable fever at the 
present time, six weeks after the beginning.) For the first 
three weeks the appetite was completely absent, but during 
the last three weeks she has been exceedingly hungry. 
Case 111.—J. S., aged 30 years, was suddenly seized 
with chills followed by rapid elevation of temperature to 
103° or 104°, violent general pains, vomiting, and purging. 
His strength declined rapidly and when admitted to the 
hospital he was prostrated. The abdomen was swollen and 
tympanitic. The spleen seemed enlarged, though it could 
not be felt; the temperature continued high. The diarrhea 
could not be checked, though it was not excessive. Examin- 
ation of the lungs showed only a slight bronchitis ; the heart- 
sounds were sharp, but the heart was not enlarged and there 
were no murmurs. The patient’s strength was quickly 
exhausted and he died five days after the commencement of 
the disease. His friends were closely questioned and they 
asserted that he had been absolutely well until the day 
of onset. The autopsy showed enlargement of Peyer’s 
patches, with beginning ulceration in a few. The mesenteric 
glands were enlarged and on section grayish pink and 
rather edematous. The spleen was decidedly enlarged, soft, 
and easily friable. Bacteriologic examination discovered 
typhoid bacilli. 
Case IV.—J. A., aged 27, an employd in the Post-office, 
summoned one of the writers to his home, where he was 
found abed. He stated that a day or two previously he had 
taken cold after a distinct exposure. His face was flushed, 
his eyes considerably injected, the lids swollen, and he com- 
plained of sore throat. The tonsils were enlarged and slight 
whiteness of the follicles was observed. There was some 
cough and scattered bronchial rales. The temperature was 
100° and the pulse 96. The appetite was impaired, though 
he still had desire for food. The following day the symp- 
toms were much the same. He had slept but little during 
the night, complaining of aching in his limbs, with some 
occipital headache. An antipyretic mixture had not 
affected the temperature. There was now considerable ten- 
derness in the epigastrium. During the next few days 
scarcely any change was observed. The temperature re- 
mained persistently elevated to about the same point. The 
appearance of the patient was that of one suffering with an 4 
acute sthenic disease; his eyes were bright, his facial ex- 
pression alert. Gradually, however, he assumed a different 
appearance and afterwards became dull and apathetic. He 
was positive that he had been absolutely well up to the time 
of his exposure and acute coryza. The further history of 
the case was that of a typical and mild typhoid fever. 
Case Y.—L. H., a young man aged 24, left Denver for his 
home in Philadelphia. During the first night of his journey 
he felt a draft and the next day was suffering with a 
coryza and sore throat. On his arrival in Philadelphia one 
of the writers was called to see him. He then had a tem- 
perature of 101.4°, a pulse of 80, and complained of soreness 
of throat and coryza, with slight cough. The tonsils were 
red and somewhat enlarged. The conjunctive were deeply 
injected and the eyelids swollen. The mucous membrane 
of his nose was swollen and breathing through the nose was 
difficult. There were scattered bronchial rales and cough. 
The patient was ordered to bed and the next day was found 
in the same condition. At this time he was more carefully 
examined and it was learned that he had been perfectly well 
until the exposure and cold developed. It was also found 
that he had moderate tenderness in the epigastrium. His 
bowels were constipated; there was no enlargement of the 
spleen. During the next several days his condition was 
unchanged. The fever continued at about the same height. 
The face, eyes, and mucous membranes remained suffused. 
After one week’s duration the continuance of the condition, 
the complete loss of appetite, the slowness of his pulse and 
beginning enlargement of the spleen, indicated probable 
typhoid fever, and within a few days several questionable 
spots were detected and Widal’s test gave a positive reac- 
tion. After this the disease progressed regularly as a typical 
instance of typhoid fever. 
Case YL—C. W., aged 25, a medical student, began to feel 
badly on Friday afternoon. He had had a little headache 
for several days, but was not conscious of having had fever. 
On Friday, the day of apparent onset, the temperature sud- 
denly rose, with chilliness, but no distinct chill. The ther- 
mometer registered between 103° and 104° and he complained 
of great soreness of the throat, of universal pains, and had 
some cough and bronchial rales. Three days later he was 
admitted to the hospital and during that day his temperature 
varied from 103° to 105.4°. The pulse was slow, registering 104 
at the maximum and 84 at the minimum. Subsequently the 
history was that of an ordinary typhoid fever, with marked 
tonsillitis, some pharyngeal ulceration and annoying bron- 
chitis among the pronounced symptoms of the first two 
weeks. 
Case Vll.—Miss D., aged 28, a trained nurse, was attending 
a case, when on the 12th of February she took a bad cold. 5 
That evening her temperature rose to 101° and she felt very 
badly. She abandoned the case at once and went home. 
The next day her temperature reached 104° and she com- 
plained of much soreness of throat, coryza, and cough. The 
physician first summoned believed that she was suffering 
with influenza. The temperature continued, however, at 
unusual height and was unaffected by antipyretics. She had 
never presented bleeding of the nose and was constipated. 
There was some tenderness over the epigastrium. Her ap- 
petite was completely absent from the first. Subsequently 
the case presented features of an ordinary case of typhoid 
fever. 
The foregoing histories serve to show that of the in- 
stances marked by abrupt onset there are two partic- 
ular types: One in which the preliminary symptoms 
are gastro-intestinal in character, the other marked by 
manifest indications of acute infection, with inflamma- 
tory lesions of the throat, nose and bronchial tubes. 
The former we may designate a gastro-intestinal form, 
the latter catarrhal. 
The Gastro-Intestinal Form.—In this variety we 
have found among the conspicuous symptoms vomiting 
epigastric pain, purgation, and high fever. The vomit- 
ing has been in most cases the primary symptom, unless 
there were vague discomfort preceding it and of such 
slight moment that it had almost escaped the attention 
of the patient. The stomach becomes completely unre- 
tentive, and even when no attempt has been made to 
take food, retching continues and small quantities of 
thin mucous liquid are regurgitated. At the same time 
the patient complains of more or less marked tender- 
ness in the epigastrium. There is not usually pain, 
except on pressure, and the tenderness is rather sharply 
localized to the stomach. Soon after the onset of vomit- 
ing, or in other cases some hours later, diarrhea sets in 
and takes the form of more or less pronounced serous 
purging. The two symptoms, vomiting and purging, 
continue for a day or two or several days and reduce 
the patient’s vitality greatly. During the same time the 6 
temperature rises rapidly and reaches an elevation of 
103° or 105°, not rarely the latter. After the prelimin- 
ary gastro-intestinal symptoms have somewhat subsided, 
the temperature declines and the case progresses with- 
out necessarily presenting marked or peculiar features. 
In one of the instances (Case II) here recorded we 
were surprised at the unusual mildness of the subse- 
quent course of the disease, when the violence of the 
onset and the previous unsatisfactory condition of the 
patient’s health were taken into consideration. In 
several instances a complete remission of the symp- 
toms occurred after the preliminary attack, suggesting 
an atypical and abortive attack of great violence, fol- 
lowed by a regular and typical attack. 
Catarrhal Form. —Cases of this description begin 
very much as do some forms of influenza, and we have 
been greatly puzzled during the first week to reach a 
satisfactory diagnosis. As a rule there is chilliness or 
a distinct chill at the beginning and after some definite 
exposure; then follow redness and swelling of the mu- 
cous membranes of the pharynx and tonsils, pain on 
pressure beneath the angle of the jaw and on swallow- 
ing, more or less coryza, swelling and injection of the 
conjunctives, and bronchitis. The temperature rises 
rather abruptly and may become as high as 104°, 
though more frequently it falls short of this. The 
patients complain of pain in head and in the limbs, 
backache, and wretchedness. The most annoying symp- 
tom, perhaps, is the “ bursting headache.” The pulse 
rises in frequency, but it is not in keeping with the 
temperature. The patient loses his appetite almost 
completely, although we have met with exceptions to 
this rule. The tongue is slightly furred, and there is 
nearly always localized tenderness in the epigastrium. 
The patient, as a rule, states that he had been absolutely 
well until the initial chill, but in some cases there is a 7 
history of a slight indisposition for several days, or even 
weeks. The catarrhal symptoms continue for some 
time after the symptoms of typhoid have developed, 
and the further course of the disease shows no peculiar 
characteristics. 
It will be recognized that both of these types of onset 
differ greatly from the classic invasion, and the diffi- 
culty of diagnosis must be apparent. If, as Leube 
states, the temperature has been observed from the 
beginning, and is regularly ascending or continuous, the 
pulse is increased, but not in proportion to the tem- 
perature, the spleen is enlarged within the first week, 
and roseolous spots appear in the second week, the diag- 
nosis can be made without reservation. But, unfor- 
tunately, we are always called upon to make a diagno- 
sis before a week has elapsed, and will not be ourselves 
satisfied at so long a delay in reaching a conclusion. It 
must, of course, be admitted that many cases present 
themselves in which it would be unwarranted to make 
a positive diagnosis before the expiration of a week, 
even when the symptoms have been regular in devel- 
opment. In such cases, we can only say that the 
clinical course is like that of typhoid fever, though the 
further development of the disease may show that the 
nature of the disease is something quite different. It 
would be more hazardous, however, to assert that the 
disease is certainly not typhoid, when the evolution of 
the symptoms is not gradual and progressive, and it is 
our present purpose to call attention to the fact that 
such atypical onset is frequent. There is, naturally, a 
strong temptation to exclude typhoid fever absolutely, 
when the onset is abrupt or violent. It has been so 
long and so universally taught that the invasion of the 
disease is insidious, and authors have so regularly neg- 
lected to call attention to the character of onset in the 
exceptional cases, when admitting that insidious onset 8 
is usual only, and not invariable, that we feel it 
necessary to call attention with emphasis to the kind of 
cases we are reporting. It. may be well to allude par- 
ticularly to some of the symptoms that may aid in 
reaching a diagnosis. 
The temperature in the cases marked by abrupt on- 
sets is, of course, an unsatisfactory guide. It rises 
with as great a suddenness as does that in influenza, 
tonsillitis, typhus fever, and other infections, and may 
reach the point of hyperpyrexia in a few hours. It fur- 
nishes no ground for diagnosis in these cases, and, in 
passing, we may remark that the gradual ascent of tem- 
perature, so often described as characteristic of typhoid 
fever, is very frequently wanting in typical cases. 
The pulse is a far more certain indication. In typical 
cases it increases as the temperature rises, but not with 
equal pace. Very often the rate is below 100 or 90 
during the first two weeks, though the temperature 
reaches 103° or 104°. In atypical cases the pulse may 
be proportionately rapid from the first, but this has been 
quite unusual in our experience, excepting in the in- 
stances marked by pronounced nausea, vomiting, and 
diarrhea, or when recognized complications have con- 
tributed to accelerate the pulse. Two striking instances 
have been recently under our care in which the early 
rapidity of the pulse was of assistance in excluding 
typhoid fever. Each of these cases began abruptly,with 
symptoms quite like those narrated under the heading 
“Catarrhal Form.” The fever remained at from 102° to 
103.5° in spite of antypyretic remedies, the general ap- 
pearance of the patient was highly suggestive, the appe- 
tite was wholly wanting for several days, the spleen was 
certainly enlarged in one and doubtfully so in the other; 
in one there was a history of ill health for two or three 
weeks prior to the onset. In each, however, the pulse 
was quite rapid; disproportionately so, in fact. In one 9 
the diagnosis was further complicated by the fact that 
two bacteriologists reported that the blood caused ag- 
glutination of typhoid bacilli in cultures, though neither 
observer found the motility of the bacilli destroyed. In 
neither case was there special epigastric tenderness. 
The further history of these cases excluded typhoid 
fever. 
Loss of appetite is a symptom of some importance. 
It has seemed to us especially so in the case of children. 
It is true that anorexia is a common symptom in many 
diseases, but there are few conditions in which it is so 
pronounced and unremitting as in typhoid fever. In 
the cases marked by sudden onset the anorexia con- 
tinues without change, after the pronounced symptoms 
of onset have ameliorated. In the case of other dis- 
eases beginning with like symptoms, the appetite, as a 
rule, improves as soon as the general symptoms subside. 
Epigastric tenderness is a frequent symptom in the 
early days of typhoid fever, and one that is commonly 
ignored in descriptions of the disease. We mention it 
here particularly because we have seen cases in which 
this symptom was marked and had been regarded as 
important in excluding typhoid fever. 
Splenic enlargement, if detected early in a case, has 
always considerable weight in leading to a diagnosis. 
Its frequent occurrence in other infections, however, 
deprives it of great value, and its absence (to physical 
examination) is very common. 
The eruption of typhoid fever is an unreliable indi- 
cation. A diagnosis resting mainly upon this is an 
unsound structure. The spots are frequently atypical, 
and not rarely similar eruptions occur in other diseases. 
Typical roseolas are, of course, of some value. 
The examination of the blood by the ordinary meth- 
ods may occasionally aid the diagnostician. Pro- 
nounced deficiency in the number of leukocytes (leuko- 10 
penia) would aid somewhat, though it would not 
exclude influenza. The examination of the blood with 
regard to its action on typhoid cultures (Widal’s meth- 
od) is of the greatest importance, but is unreliable at 
the onset and for several days thereafter. In doubtful 
cases persisting for some days this test usually settles 
the diagnosis. 
Examination of the stools and urine for bacilli may 
at times be useful in the later stages of the disease, but 
has not been shown to possess particular merit in the 
beginning. 
Finally, we would repeat that typhoid fever cannot 
be excluded in cases of sudden fever, marked by decided 
symptoms of gastro-intestinal or catarrhal type; and 
that a disproportionate slowness of the pulse, pro- 
nounced and persistent anorexia, epigastric tenderness, 
and splenic enlargement are symptoms of importance as 
indicating possible or probable typhoid fever. The Philadelphia Medical Journal 
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