CASES OF 
CHICKAMAUGA TYPHOID 
TREATED AT 
The Maine General Hospital, 
BY 
CHAS. D. SMITH, M. D., OF PORTLAND, 
Physician to the Maine General Hospital, CASES OF CHICKAMAUGA TYPHOID TREATED 
AT THE MAINE GENERAL HOSPITAL. 
A PAPER 
HEAD BEFORE THE 
Maine Medical Association, 
JUNE 7, 1899, 
BY 
CHAS. D. SMITH, M. D., OF PORTLAND, 
Physician to the Maine General Hospital. 
PORTLAND: 
STEPHEN BERRY, PRINTER. 
1899.  
GTses of @i ickamauga Typhoid Treated at the 
JMaine (2erjeral j^ospital. 
The object sought by this paper is to place on record the 
clinical experience derived from an association with certain 
cases of typhoid occurring among the men of our Maine Regi- 
ment of Volunteers during August and September of 1898. 
Such experience from the management of any considerable num- 
ber of these cases came only to physicians in the army service, 
or to those who occupied hospital positions in localities favor- 
able for their reception, and while to the physician who began 
his practice in the sixties, or before, these cases would perhaps 
have exhibited little that was unique or unusual, yet because 
they presented an extreme type of typhoid not usually met 
with by the younger generation in domestic practice, it has 
seemed to the writer that there is an obligation upon those of 
us who had any unusual opportunities for observation, to util- 
ize them and their results for general information. No attempt 
will be made to give a detailed description of cases ; that would 
be the least useful method of presenting the conclusions drawn. 
Although in number the cases were comparatively few, there 
ample opportunity of studying them by approved clinical 
lods and under the most favorable circumstances which a 
organization affords. 
has been made to make a statement of conditions, 
inical aspect of the cases as they came to the hospital and 
inclusions drawn from a study of the daily bedside notes 
e nurses, which have been used in the preparation of the 4 
paper, supplemented by numerous private memoranda made by 
the writer at his daily visits. 
From August 19, 1898, to January 3, 1899, fifty-four volun- 
teers who had been in camp at Chickamauga were received 
and treated for various ailments, the direct results of their 
military service. Of this number forty-two proved to be ty- 
phoid. Seventeen of them were under the care of my colleague, 
Dr. Addison S. Thayer, in a ward already organized and equipped 
for the usual hospital work. The remaining twenty-five were 
under my own care in a ward never before used, and although 
hurriedly arranged in the face of a sudden call, yet most 
admirably organized and furnished, and put in complete working 
order within twenty-four hours. 
This ward was in charge by day of a specially employed corps 
of four graduate nurses, with assistants from the regular hos- 
pital force. Night service was supplied from the under-gradu- 
ates of the training school. One, and sometimes two, male 
nurse or wrard master was on duty in each ward, as special 
service was required. 
The first hospital train reached Portland August 19th, bring- 
* 
ing twenty-four. This was followed August 26th, by another 
in charge of Assistant Surgeon G. M. Elliot, contributing 
sixteen; the others, to the number of fourteen, came in from 
time to time from the camp at Augusta or their homes. 
The hospital care of these cases began with almost no definite 
information of their previous histories. Exhausted by a long 
railway journey, with minds weakened and dulled by disease, 
the men themselves contributed practically nothing of value 
bearing upon their illness prior to leaving Chickamauga. 
In some instances, diagnosis was unmistakable; in others it 
was worked out only after several days of careful watching and 
study. 
The first attention every man received was to be given some- 
thing in the way of nourishment; milk, hot bouillon or broth 
were eagerly received, as well as water, for, almost without ex- 
ception, they were ravenously hungry and complained of exces- 5 
sive thirst. As rapidly as possible, the most serious cases 
receiving the emergency attentions at once, they were given 
much needed baths, supplied with clean clothing, and assigned 
to the several attendants. Twenty of the cases were apparently 
in the active stage of the second or third week ; four proved 
later to have been in the invasive stage, and the remaining 
eighteen were in various stages of convalescence. 
Their conditions when admitted varied greatly ; most of them 
were able, with assistance, to manage to some degree their own 
movements. Six were in a condition of profound collapse. Of 
this number but one recovered ; the others died in from thirty- 
six hours to five days after admission. Several were in stupor, 
so helpless that fecal and urinary discharges were involuntary, 
and many of these cases were having from five to ten discharges 
daily. The initial task of making them fit for reception and 
examination was no slight one. 
All were emaciated, and gastro-intestinal disturbances were 
common even in the non-typhoids. Diarrhoea was general. 
Many of my patients were markedly deaf, and complained of 
intense headaches and nausea. 
All who were conscious called incessantly for water and food, 
and complained bitterly of the refusal to allow them to select, 
in both quality and quantity, their own diet lists. Nor was 
this confined to the convalescent typhoids, of whom it would 
have been expected. As soon as possible began the work of 
diagnosis, so that the question of care and treatment might be, 
as speedily as possible, systematized aud put in operation. 
In the greater number of cases, typhoid was plain. In some 
diagnosis was delayed. Doubtful cases, in my ward, were sub- 
mitted to the Widal test, and many specimens of blood were 
stained and examined in a fruitless quest for malarial organisms. 
In every doubtful case, a positive reaction to the Widal test 
was later verified by the fully developed clinical features of 
typical typhoid. Two cases, in which there was reasonable sus- 
picion of malarial infection from symptoms, and, so far as we 
could gather information, from the rather vague descriptions of 6 
the patients themselves, are still not clearly defined in nature 
as I have reviewed them. 
Typhoid was unmistakably present in one, but while present- 
ing the general temperature wave as a whole, there seemed to 
be periodic variations, accompanied by slight chillness, sweating 
and aggravation of the nervous symptoms. Repeated examina- 
tion of a considerable number of bTood slips was entirely nega- 
tive, and as no other physical evidences of malaria were present, 
I believe the case to have been only an erratic typhoid. The 
other was one of much perplexity. The blood at no time re- 
sponded to Widal’s test, but, on two occasions following a chill, 
examination revealed the presence of several pigmented red cor- 
puscles, an absence of leucocytosis and the blood counts showed a 
fall to 3,000,000, with moderate loss of haemoglobin. The tem- 
perature chart was not that of typhoid nor malaria. It would 
rise rapidly to 104° or 105°, following a marked chill; with tem- 
perature came nervous apprehension, then delirium much like 
that of delirium tremens, a delirium of fear. During the first 
ten days these attacks made their appearance at intervals of 
about 72 hours and quinine had no permanent influence in lessen- 
ing their recurrence; then temperature would drop, retaining 
a level of 100° or 100° and a fraction. For three months these 
attacks occurred at gradually increasing intervals, and were still 
occasionally experienced at the date of his discharge—Jan. 3, 
1899. 
If these attacks were typhoidal relapses, the fact of their 
number and the periodicity of their occurrence is extraordinary. 
It should in all fairness be stated that the later fecal dis- 
charges just before the patient left the hospital were typhoidal 
in character, appearance and odor. 
But few hours’ experience was needed to demonstrate that 
we were dealing not only with typhoid infection in men so de- 
bilitated as to have almost no resistant power, but that it was 
a typhoid of an exceptionally virulent type, erratic in its 
behavior and sudden in its changes. If I were to note one par- 
ticular in which these cases differed from the disease as we 7 
have become familiar with it, I should say it was in the pre- 
cipitancy with which unfavorable conditions, especially collapse 
and persistent high temperature, manifested themselves, render- 
ing the usual anticipation of symptoms and conditions a matter 
of such uncertainty as to create grave apprehension in cases 
seemingly mild. 
I do not think that the gravity of the individual cases was 
under-estimated, but certainly we were unable, from the meagre 
information obtainable of personal histories, or pre-disposing 
causes, to justly estimate the extent to which individual resist- 
ance had been undermined. It is possible that the grouping of 
a number of severe cases of unusual virulencp and our ignorance 
of their previous histories created a distrust of all of them ; cer- 
tainly, after the experiences of the first ten days, one would 
have been justified in a readiness to accept almost anything as 
a part of the apparent programme. 
Nervous disturbance was pronounced in all the cases, and the 
circulatory, digestive and nervous systems were peculiarly sus- 
ceptible to apparently trivial influences. 
Often, without the slightest warning, patients would seem to 
lose their hold and the whole nervous mechanism become upset. 
In the milder type nervous disturbance was manifested by ex- 
cessive irritability, apprehension and marked mental depression. 
In the severer cases, delirium came on early (in some it was 
present on admission) and was maniacal in character, necessi- 
tating the use of confining straps. Stupor was usually profound 
and coma-vigil a constant and marked feature. 
The onset of one case was by profound stupor; the patient 
lying for four days Avith mahogany-colored flush upon the 
cheeks, half open eyes, insensible to his surroundings or the 
attentions of the nurse, as though narcotized. During this 
time the temperature remained at 99°. On the morning of the 
fifth day, it shot up rapidly, reaching 104° by night, delirium of 
violent type accompanying the fever in a few hours after its 
height had been attained. This patient was never conscious 
after the first day of admission, when his heaviness was begin- ning; he died in convulsions as though from heat stroke, which 
indeed it was, eight days from his arrival; rose spots appeared 
abundantly the morning of his death. I saw no better example 
of the possible malignancy of this fever than in this case. I 
have had other patients show the same tendency, and it always 
presages an explosion of some kind. 
A low nervous condition, incapable of improvement, charac- 
terized a few cases, who, judging from information derived 
from their friends or fellow patients, were alcoholics. The de- 
lirium of these cases was especially exhausting, persisting night 
and day, and sleep was difficult to obtain. 
The circulatory were not unusual for typhoid. 
The dicrotic pulse and lowered arterial tension were common 
early and were persistent. The circulation was feeble in most 
cases, and exertion, sometimes even the unavoidable movement 
of the patient by the nurse, easily induced lividity of the lips 
and face, and clammy feeling of feet and hands was noticeable, 
especially in the first few hours after admission, before the sus- 
taining effects of stimulation were apparent. As a rule, condi- 
tions were markedly asthenic. The heart muscle became easily 
and quickly exhausted, especially in the severe cases ; and 
tendency to cardiac failure, in spite of most judicious stimula- 
tion, was frequent. 
As a rule, the heart responded readily to any of the various 
stimulants, but was incapable of long-sustained action. 
It was a common experience to make the morning round as 
I did, usually before 9 o’clock, and to receive favorable reports 
of quiet nights, circulations good and temperatures moderate, 
and again at 11 o’clock to find several, with little or no warning 
in a condition requiring the most active stimulation and assid- 
uous attention to avert threatened collapse. 
The symptomatology dependent upon the digestive system 
was variable except as to diarrhoea, which was, with one excep- 
tion, a constant and troublesome feature of all the cases, in most 
of them frequent and so profuse as to be exhausting. 
There seemed to be little doubt that this had been aggravated 9 
by indiscretions in diet at Camp Thomas before infection, and 
by the misdirected attention of sympathetic friends on the way 
homeward, and at the station on their arrival. 
During the first few days this condition entailed a tremen- 
dous amount of labor upon the nurses, and it was no uncommon 
experience to have calls for urgent attention coming from eight 
or ten patients at the same time. 
Such a condition became a most serious matter by reason of 
its interference with anything like a continued contact of the 
discharges with disinfectants for any considerable period of 
time, and made such disinfection, as well as that of the persons 
of the patients and hands of the attendants, uncertain. It is, 
however, a remarkable fact that notwithstanding the extent of 
intestinal ulceration which must have existed, the records of 
the cases do not show, in all the forty-two, a single case of 
haemorrhage from the bowels. 
The temperature record was not remarkable for any number 
of extremes. A sudden rise to 107° in one case, just before 
death, being the highest, and 95° the lowest, recorded. The 
average height of rise was l03°-j— 
It was noticeable, however, that changes were apt to be 
extreme, from what would usually be regarded as trivial causes. 
One patient, and not a very sick one either, having begun 
convalescence, showed a temperature curve rising from 97° in 
the morning to 100.2° at night, reaching 101.8° the next after- 
noon. On the third morning it was 100°. On the evening of 
the same day 95°. During the next two days there was a steady 
rise to 100.6°, with only a slight remission of .6° ; then a drop in 
one day to 96.4° ; then a sharp rise, extending through thirty-six 
hours, until the morning temperature stood at 103.6°, and that 
of the evening on the same day at 98.2°. Temperatures were 
taken at varying intervals, from every two hours to twice daily, 
according to the nature, of the case. 
This oscillation was not an unusual phenomenon at the be' 
ginning of convalescence, which in most of the cases was estab- 
lished more by crisis than lysis. As the time approached when 10 
the morning decline might be anticipated, we learned to expect 
a sudden drop or a rapid decline, attended by much prostration, 
pallor and profuse sweating, the temperature zigzagging about 
the normal sometimes for a week, until it settled at a point a 
little below, usually remaining subnormal for several days, 
until the normal line was attained and kept. 
With such symptoms one naturally looked for haemorrhage, 
but in every case this was excluded by repeated high enemata 
of boiled water to see if any blood could be washed out, but 
none ever appeared. 
During the first week or two after admission, sudden rises 
every second or third day disturbed us not a little, until we 
were satisfied that this variation was peculiar to the type of 
the disease or to some coincident condition undetermined, and 
learned to confidently await the drop to its average, which rarely 
failed to come. 
Some of the charts showed strikingly this up and down vari- 
ation in the regular line of progress. 
Temperatures which began to rise in the third week usually 
did so abruptly, and persisted, rapidly destroying the vitality 
of the cardio-inhibitory and respiratory centers, death coming 
from exhaustion after violent delirium. 
For example, a temperature which had been running at 
103° each evening, would remain the same during the night, be 
a little higher the next morning, reach 104°-j- by noon, and per- 
sist, in spite of all antipyretic measures, until the end came, ris- 
ing rapidly just before death. In the face of this burning out 
of tissues, stimulation to degenerating heart muscle was utterly 
ineffectual. 
These patients gave one the impression of cases of profound 
sepsis, and when the conditions jnst outlined were established, 
the prognosis was regarded as hopeless, although some of the 
men of extraordinary vitality made a brave and successful 
fight for life. 
The complications noted were two cases of severe epistaxis, 
one necessitating frequent plugging. One of extreme jaundice, 11 
without obstruction, regarded as a rare complication, with but 
slight liver tenderness, doubtless due to direct influence of the 
typhoid toxin upon the liver cells. 
Bronchitis, marked in most of the cases, in two amounting 
to bronchorrhoea. 
There were four cases of pseudo-membranous pharyngitis, 
shown by cultures to be due to staphylococcus infection. This 
is considered as usually a fatal complication. Three of these 
cases recovered; the death of the fourth can be so easily attrib- 
uted to other conditions that it is difficult to estimate its influ- 
ence upon the fatal issue. 
There were five cases of bed sores, all existing upon admis- 
sion, in one case upon both elbows. 
There were several cases of boils upon the buttocks, lips and 
about the nostrils. 
One case of orchitis, non specific in character, occurred in the 
second week of convalescence. 
Two cases of acute nephritis, both with marked hsematuria, 
one with suppression. 
One case of parotiditis, occurring two days before death in 
one of the collapse cases, undoubtedly by direct infection. 
Blood examination upon this patient showed it to be swarming 
with actively motile bacilli. 
There was one case of marked purpura, and purpuric discol- 
oration of the lower extremities was observed in several of the 
cases of low type. 
Sequelae noted included one case of rectal abscess, which was 
drained and packed and healed without difficulty. 
One case of pleural effusion coming late in convalescence. 
A notable feature of several cases was the prolongation, far 
into the stage of convalescence, of the mental disturbance, de- 
lusions and hallucinations persisting for weeks. 
Of the forty-two cases of typhoid, nine resulted fatally, a per 
centage of 21 3/7. This excessively high rate, although only 
2 3/7 higher than Murchison’s record (Osier), is easily under- 
stood by an examination of the condition of these men when 12 
admitted, and the length of time they were under treatment in 
the Hospital. Four never rallied from the collapse in which 
they were when taken from the train. One of them died with- 
in thirty-six hours, two within forty-eight hours and one within 
three days after being received. This latter had typhoid septi- 
caemia. One died of exhaustion from delirium and high tem- 
perature in forty-eight hours. Another in stupor when admitted 
died on the eighth day, from the same cause. Another on the 
fifth day after admission, with mania. One with typhoid septi- 
caemia on the seventh day, after having rallied a little from col- 
lapse, and one of suppression of urine on the seventeenth day. 
Eliminating seven cases which were practically moribund on 
admission, but two died with whom we had a fair chance of 
work. A mortality of 5.7 per cent. 
ISTo particular system or special plan of treatment was adopt, 
ed. Indeed, there was such a diversity of demands upon thera- 
peutic resources, the result of the erratic nature of the cases, 
that their management was essentially an anticipation of condi- 
tions and emergencies. Comparatively little reliance was placed 
upon antipyretic drugs. 
Temperature was controlled by a wide variation of hydrother- 
apy, from simple sponge bathing with cold, tepid or hot water 
to the full immersion in the tub. 
The latter procedure, after fair trial, seemed to be inadvisable 
by reason of the marked tendency to depression, and it was 
abandoned for sponging or packing. One of my own patients, 
a boy of 19, with a maximum temperature of 103°, could bear 
nothing but rapid sponging with water at 100°. Cold spong- 
ing or packing induced a dangerous tendency to collapse. 
The most satisfactory application of water in my own ward 
was, first packing in hot, wet towels, to get as much hot blood to 
the surface as possible, then the application of towels wrung 
out in cooler water, gradually reducing its temperature, in some 
cases where well borne, although these were few, to about 50°. 
These applications were made first to the lower then to the 
upper extremities, and lastly to the trunk. Usually cold water 13 
packs or the ice cap to the head were employed, always the 
latter in the badly delirious cases. By this alternate hot and 
cold packing, and the promotion of evaporation by fanning, the 
temperature would often fall 2°, sometimes more. 
The most marked effect of hydrotherapy was in its quieting 
influence upon nervous irritability. 
Nearly every case needed stimulation. Life was prolonged 
in several of the fatal cases, and saved, I am confident in some 
others, by the assistance of alcohol, strychnia and digitalis, which 
were the agents most employed. Their usefulness in a system of 
stimulation for the conditions of typhoid, as their effects were 
noted, seemed to be, for continuous effect, strychnia, especially 
in the alcoholics ; brandy alone, or with strychnia for quick 
stimulation ; whiskey or strychnia, or both, for non-alcoholics ; 
and digitalis as an adjuvant to the other three. 
Atropine was most useful at times, as a powerful stimulant to 
the respiratoi’y center, utilized when circulation was feeble and 
respiration shallow and irregular, usually in combination with 
the other stimulants ; in sudden emergencies alone, or with 
brandy. 
Nitro-glycerine found a useful field as a conserver of cardiac 
energy by relieving peripheral resistance, when blood pressure 
was so high and arterial tension so marked as to impose addi- 
tional burdens upon the heart muscle. 
So far as possible, all medication was by the hypodermatic 
method ; later in convalescence stimulants and other drugs were 
given by the mouth. 
Few drugs are free from some objectional features, and while 
in general terms strychnia is to he regarded as a stimulant pos- 
sessing a maximum of good and a minimum of poor qualities 
when judiciously employed, one criticism may he made upon its 
action in the cases under consideration. It was used freely, and 
I believe intelligently, always with due regard to the danger 
of over stimulation, yet I am confident that in some of the oases 
requiring frequent and persistent support, where alcohol was 
inadmissible, and where, because it gave better and more last- 14 
ing results than digitalis, strychnia was demanded; it had a 
bad effect upon temperature, aggravating the tendency to exces- 
sive heat production. One of the normal physiologic attributes 
of this alkaloid is to increase the body temperature, and one 
was often confronted by a situation where stimulation was im- 
perative, yet where it was no less desirable to check heat pro- 
duction and augment its loss. It was clearly a choice of evils, 
for the stimulation was almost sure to produce the very condi- 
tion which gave rise to its necessity, and to steer clear was often 
a perplexing problem. 
Attempts at intestinal antisepsis by drugs was for the most 
part disappointing ; indeed, so far as the typhoid organism is 
concerned, it amounts to practically nothing. So far as gastric 
and intestinal flatulence could be controlled, a choice was made 
of salol, B. naphthol with bismuth, bisulphite of sodium, carbolic 
acid and turpentine, the latter by mouth or enemata. 
This condition, frequently so distressing, was mitigated to a 
considerable degree by predigesting milk, or excluding it from 
the diet altogether. 
Subgallate of bismuth and sulpho-carbolate of zinc were es- 
pecially efficacious in checking diarrhoea. 
Of all these agents for checking or preventing intestinal 
fermentation, my preference was decidedly for turpentine, an 
old, but by no means obsolete remedy. Warm water lavage of 
the large intestine was practiced freely and with excellent 
results. It removed easily, expeditiously, and, to the patient, 
comfortably, putrefactive products, and so lessened reabsorption, 
and when any considerable quantity of water could be retained 
it had a good effect upon renal and hepatic action. 
The dietary consisted largely of milk in various forms, supple- 
mented by broths, barley water and. egg albumin, following a 
general plan of using concentrated proteid foods, having a min- 
imum of residue, and in such quantities at each feeding as 
would insure the digestion of most, if not all, of it in the 
stomach. 
Water was given freely, as well as iced claret, and the car- bonated waters were especially useful in allaying thirst, and 
relieving nausea and gastric irritability. 
Disinfection was carried out by the use of calcium chloride, 
carbolic acid, bichloride of mercury and formalin. 
Any efficient disinfection depends less upon the particular 
agents or methods chosen from several efficient ones, than upon 
intelligent and thorough application of the one selected. 
When obliged, as we were at first, to curtail the time during 
which stools could be kept in contact with the disinfectant, an 
endeavor was made to compensate for loss of time, by thorough 
mixing with stronger solutions and frequent and liberal flushing 
of the hopper, so as to ensure each time, so far as possible, re- 
moval of the material out of the soil pipes to beyond the house 
system. 
The rules for personal hygiene of the nurses were most in- 
sistant, and to a faithful observance of them is to be attributed 
in large measure their immunity in the presence of an unusual 
amount of infection. 
During the first week after their arrival on the hospital trains 
the morale of the men was exceedingly bad and greatly aggra- 
vated the ordinary difficulties of caring for such cases. After 
that, as a result of the patient, yet no less firm and determined 
management of the women nurses, they were brought under 
control, and showed a vast change for the better, most of them 
becoming tractable, appreciative and anxious to help in the 
work of lightening the labor of their attendants, which at times 
had been almost to the limit of endurance. I cannot express 
too strongly my appreciation of the faithful, unselfish and de- 
voted work of the young women who cared for these cases. 
Their attention was unremitting, no labor was too exacting and 
no task too repulsive for their ready and cheerful service by 
day and by night. If ever the value of skilled nursing by 
trained hands was apparent it was shown in these fever wards. 
Those of us who met these cases with the resources of a gen- 
eral hospital at our command, wonder what could have been 
the experience of our professional friends in the field. 16 
I hope I shall never be obliged to look again upon what I 
saw on that hospital train of August 26tli. If one wondered 
at the management that allowed some of the cases to leave a 
hospital, and to be transported in midsummer upon a crowded, 
dirty, poorly supplied hospital train hundreds of miles, he could 
not fail also to admire the courage and appreciate the trials of 
the surgeon in charge, who succeeded in bringing his men 
through with so little loss of life.