Typhoid Fever as we see it in 
Central New York. 
II. L. ELSNER, M. D., 
BY 
SYRACUSE. 
REPRINTED PROM 
E\>e "Netu ¥odt iJHelucal Journal 
for November 28, 1885. Reprinted from the New York Medical Journal 
for November 28, 1885. 
TYPHOID FEYER 
AS WE SEE IT IN CENTRAL NEW YORK.* 
By H. L. ELSNER, M. D., 
SYRACUSE. 
It is not the writer’s object to give you a treatise on 
typhoid fever—its pathology, symptoms, and everything 
pertaining to that disease—in the space of this essay. That 
has been done by others whose accurate and keen observa- 
tions have been given to the profession during the last 
twenty years. For the typical cases of typhoid we can find 
no better authorities than Griesinger, Liebermeister, Lebert, 
Murchison, and a score of others. All physicians who have 
been in active practice and seen a fair number of fever pa- 
tients are well aware of the fact that in central New York 
but few of their cases follow the train of symptoms laid 
down in our leading text-books on typhoid fever. The 
cases that do follow exactly the descriptions of our leading 
authorities are rather the exception than the rule. Our 
cases are without the characteristic or typical temperature- 
curve. Their symptoms do not follow each other in regu- 
lar order; in fact, their course seems different from the 
* Read before the Third Branch of the New York State Medical 
Association, June 9, 1885. A number of temperature charts were 
shown at the meeting, but, in order to save space, they are not pub- 
lished.—Editor. 2 
TYPHOID FEYER AS WE SEE IT 
cases collated. The object of this paper is to lay before 
you the result of my clinical experience with the disease 
mentioned, and to prove to you by my records that our 
cases are atypical. In central New York you will have no- 
ticed that each year our fevers show some different phase; 
that each endemic has its characteristic manifestations, 
which cause it to differ from the typhoid of the previous 
year. Some epidemics, or even isolated cases, are influ- 
enced by a large and powerful malarial element; others are 
associated with complications changing the entire course of 
the disease, or markedly modifying it. Let us look, first, 
to the prodromes of the fever as we see it. In not a few 
cases of pure typhoid we have found our patients present- 
ing, with a high temperature, following a more or less severe 
chill without having experienced a single prodromal symp- 
tom. In these cases there was no gradual rise to a higher 
temperature; but without prodromes we are at once plunged 
into a state of affairs which we would hardly expect in typi- 
cal cases before the end of the fifth or seventh day. In one 
case, seen with Dr. A. S. Edwards, the patient was taken 
suddenly, on returning from his work, with a slight chill 
and a temperature of 104° F., all symptoms warranting the 
diagnosis of typhoid. Death took place on the sixth day 
of the disease. On post-mortem examination we found the 
enlarged spleen and mesenteric glands, with the characteristic 
appearance of Peyer’s patches. These lesions at once proved 
the case to be typhoid beyond a shadow of doubt. Some 
of the cases do have the usual prodromes well marked; but 
the fact is established that, in a goodly number of our 
cases, there is an entire absence of prodromes; that in a 
few cases the gradual rise of temperature does not take 
place, but we have at once a high temperature followed by 
the characteristic rise and fall of the second week of ty- 
phoid. For the confirmation of this fact I would refer you IN CENTRAL NEW YORK. 
3 
to Charts K, 0, and P. In children we frequently find a 
prodromal stage of catarrhal symptoms showing themselves 
in catarrhal bronchitis or broncho-pneumonia. I will not 
detail the history of patient M. L., but refer you to Chart 
Q, where there was a pneumonia followed by catarrhal 
bronchitis, and finally typhoid, with alarming haemorrhage, 
on the thirtieth day of his sickness. In those cases not at 
first burdened with some complication we are safe in saying 
that violent chills are rather the exception than the rule. 
Most frequently there are sensations of cold, as “ cold shud- 
ders” or “ cold streaks.” These sensations continue usually 
during an entire day, and are accompanied with headache. 
Violent chills occur in those cases with an intermittent ten- 
dency. In most cases we have the usual malaise, change of 
disposition, and listless and disinterested manner of the pa- 
tient. Gastric disturbances are found in some cases during 
the first days of the disease, taking the place of other early 
symptoms. It is often difficult in these cases to give a posi- 
tive diagnosis, for we may be justified, if there are also diar- 
rhoea and abdominal tenderness, in diagnosticating gastro- 
enteritis, or some other abdominal disease with like symp- 
toms. In these cases the epistaxis and facial appearance of 
the patient will aid in making the diagnosis. Gastric irri- 
tability continuing into the second and third week is a 
serious and often unfavorable symptom. In 60 per cent, of 
my cases there was an early diarrhoea; 40 per cent, of the 
patients suffered from constipation. This constipation is 
often obstinate, and, before resorting to any measure di- 
rected toward its relief, we are warned by the ileo-csecal 
tenderness, and the other symptoms, that the patient has 
enteric fever. 
A small admixture of blood is sometimes found in the 
stools during the first days of the disease, while in two 
cases I have found a free discharge of blood. In the first 4 
TYPHOID FEVER AS WE SEE IT 
of these cases this bloody discharge was the symptom which 
led the patient to seek medical advice. In the second case 
there was a distinct venous haemorrhage. These early 
haemorrhages were found in cases of enteric fever with 
marked malarial symptoms. In some of our cases the diar- 
rhoea was superseded by an obstinate constipation. In not a 
single case of typhoid disease have I been unable to detect 
tenderness in the region of the ileo-caecal valve at some time 
during its course. This ileo-caecal tenderness is not influenced 
by the severity of the disease or the amount of ulceration. It 
is present in all cases of typhoid fever, however mild or severe 
the manifestations. To this point I have given the closest 
attention in the examination of my patients, and it is one 
which I can positively assert. In typhoid fever, as we see 
it, epistaxis is one of the most frequent symptoms. In some 
cases it is mild, in others of sufficient gravity to require 
surgical interference. Early profuse nose-bleed is more fre- 
quently found in the severer forms of the disease. Nose- 
bleed profuse after the tenth day is always to be regarded 
as an ominous sign. There is no characteristic appearance 
of the tongue in our forms of typhoid fever. Some of our 
cases have led to the death of the patient after severe haemor- 
rhage or perforation, with a moist tongue from the first to the 
last day of the disease. In some of the most critical cases of 
typhoid that I have seen there has been a moist, red-tipped 
tongue throughout the course of the disease. Repeatedly 
we find the dry, hard, cracked tongue, bleeding at its edges, 
with sordes on the teeth. This appearance of the tongue 
is found in the graver forms of the disease. We are more 
likely to find intestinal haemorrhage and other intestinal 
symptoms in a case with the dry tongue than with the moist 
tongue. The pulse goes hand in hand with the temperature 
during the height of the disease; after severe haemorrhage 
it is more rapid, and even dicrotic. If the temperature is IN CENTRAL NEW YORK. 
5 
high the pulse is correspondingly high. I hardly think 
that any one of us could diagnose typhoid fever from an 
examination of the pulse, as there is nothing characteristic 
in it, any more than a physician could tell the true state 
of a fever patient without the daily use of the thermome- 
ter. The roseolar eruption is usually present; only oc- 
casionally do we fail to find it; when I have failed I have 
thought that it was overlooked. In some cases the erup- 
tion is quite profuse, but in the majority it makes its 
appearance at the time and in the manner mentioned in 
the books. In most of the cases of haemorrhage I have 
noticed a fall of t<?lnperature, at some time during the 
twenty-four or thirty-six hours preceding its appearance, ex- 
ternally. Some of our patients seem to mend rapidly after a 
single haemorrhage, but, when oft-repeated and large, they 
tend to debilitate the patient, and finally death may ensue 
from exhaustion. There is nothing noteworthy in the be- 
havior of the haemorrhage, and we pass to the considera- 
tion of the question of malarial influence on our forms of 
typhoid. To me it does not seem possible that a patient 
who has typhoid germs floating in his blood can not modify 
the symptoms arising from that condition by the admixture 
of malarial poison. I have thought that our typhoids were 
markedly influenced by a malarial element, and am now 
positively convinced by clinical experience. Often we are 
called to attend patients with typhoid who have gone safely 
through all the stages of the disease, each stage marked by 
characteristic periodicity. After convalescence has com- 
menced, and our patients are doing nicely, we find them 
suddenly with severe chill, elevation of temperature, pro- 
fuse perspiration and exhaustion following. This condition, 
if not treated, is likely to recur at a corresponding hour in 
the course of a few days. Quinine, liberally administered, 
is sufficient to overcome this trouble. If you will study 6 
TYPHOID FEVER AS WE SEE IT 
the temperature-charts closely you will find that in numer- 
ous cases the temperature is higher at periods of the dis- 
ease every other day; again you will find sudden and irregu- 
lar elevations of temperature, with profuse perspiration. 
These patients have the roseolar eruption, some of them are 
accompanied with active delirium, and some have profuse 
intestinal haemorrhages. Though the typhoid germs are 
in the ascendancy, the malarial element makes a pro- 
found impression, and influences materially the symp- 
toms and course of the disease. Many of our cases begin 
with the symptoms of malarial continued fever, but before 
many days assume a typhoid type, show abdominal symp- 
toms, and are then true cases of enteric fever. To decide 
the subject of temperature-curve, I will not longer weary 
you with detailed histories of cases; but have taken a num- 
ber of cases from my daily record, and some from the hos- 
pital records, all of which have been faithfully kept, and 
appended them to this paper. I could offer many more 
charts, but they all show that we have no characteristic 
temperature-curve for typhoid fever as we see it in central 
New York. 
Are there mild cases of typhoid fever ? Does our sci- 
entific or any other treatment of these cases abort them ? 
That there have been mild cases in our midst we can not 
deny. In the mildest the patients in my experience have not 
been considered convalescent before the end of three weeks, 
and in some the convalescence has been very slow. Our 
German confreres do not deny the possibility of mild cases 
of typhoid, and Jurgensen has written an able article de- 
scribing them in Yolkmann’s “ Klinische Vortrage,” No. 
61. We can not accept the mere statements of those who 
tell us that they abort typhoid fever; if we are called to 
see a case of fever of any kind, and our efforts are rewarded 
by a fall of temperature and return to normal of the patient, 7 
INT CENTRAL NEW YORK 
we can not consider that a case of aborted typhoid. The 
accurate, skilled, and careful observer will be cautious how 
he makes a diagnosis of any fever during the first week; 
and yet some of our friends would have us believe that 
they have cured their patients before we have had time to 
make a diagnosis. 
To make the diagnosis of enteric fever we must be sat- 
isfied that there are abdominal lesions ; without these there 
can be no typhoid. During the early days when we are 
called to see these cases the symptoms are vague ; there may 
or may not have been nose-bleed ; we could not say that a 
patient had typhoid fever because he had nose-bleed and 
slight febrile disturbance, all of which disappeared after a 
day or two of most energetic and polypathic medication. 
Those who abort cases of typhoid must first satisfy us that 
they have made the proper diagnosis; must instruct us in 
the manner of making such diagnosis, by pointing out the 
features of their cases which lead them to its early recog- 
nition and ultimate abortion. 
In conclusion, I would say that it has not been my 
object in this paper to mention all the symptoms of ty- 
phoid fever; but it has been my endeavor to attempt at 
least to decide, by a careful examination of my records, a 
few points which seem to have puzzled and upset us for 
some time past in the discussion of the subject under con- 
sideration. I think I am safe in concluding that we do 
not have as a rule in our cases of typhoid fever a sche- 
matic temperature-curve, that they are markedly influ- 
enced by a malarial element, and, finally, that we are only 
justified in making the diagnosis of typhoid fever after a 
careful examination of the patient, noting each and every 
symptom, including thermometric measurements daily for 
at least seven days, the abdominal symptoms, roseola, ileo- 
cascal tenderness, epistaxis, and then, by the coupling of all 8 
TYPHOID FEVER AS WE SEE IT 
these symptoms and a careful consideration of each, a diag- 
nosis can be made. 
DISCUSSION. 
Dr. Higgins: Mr. President, I can not feel at liberty to let 
this paper pass without saying a few words and giving my tes- 
timony to the faithfulness of Dr. Eisner’s description of typhoid 
fever as we meet with it in this vicinity. And, after a practice 
of thirty-five years in an intensely malarial region, I am more 
and more impressed that we have few cases of disease of any 
character that are not to some degree influenced by malaria. 
The point he made I have often observed, of the malaria mani- 
festing itself after having passed the patient through that stage 
which I supposed placed him beyond the need of my care. In 
these cases distinct chills with marked regularity, requiring ac- 
tive and decided anti-periodic treatment for their suppression, 
were the main feature of what is often called relapse. I should 
say, however, that these cases were generally of that class that 
were allowed to go on from eight to ten days at the outset 
without active treatment, the most important period to modify 
the disease. 
I look upon the paper as one of the most valuable and inter- 
esting I have ever heard upon this type of fever, and it interests 
me greatly from the fact that in this long period to which I 
have alluded our fevers have very much changed in character. 
We do not have now, as we did thirty years ago, those positive 
characteristics that definitely settled the question as to their 
nature. We do not find even those marked and distinct cases 
of old-fashioned “fever and ague.” We find more prostration 
with a commingling of types belonging to different classes. 
Those fevers that were termed “bilious remittent” have disap- 
peared, or at least the name has, and the word “ typhoid ” has 
the ascendancy over all others. I find very little true typhoid 
fever in the vicinity in which I practice, and that, almost with- 
out exception, masked by this subtle agency. In fact, I find so 
much of this malarial character that I am very cautious how I 
use the word “typhoid,” and cases of that type often require 
many days to distinguish their true character. But with reference [IN CENTRAL NEW YORK. 
9 
to abdominal lesions, those cases that develop that form of com- 
plaint, there can of course be no question. But what I wished 
to speak of particularly were those peculiarly malarial influences 
mingling with almost every disease which comes under my no- 
tice, and that too in all seasons of the year. 
I simply arose, Mr. President, to make my acknowledgments 
to my friend, Dr. Eisner, personally, for this very able paper, it 
being so faithful a delineation of the disease as it has come un- 
der my observation, and being a subject of great public as well 
as professional interest. 
Dr. Boss: I am very much interested in the doctor’s paper; 
and while it seems that the type of typhoid fever mentioned by 
him is somewhat different from that which I am accustomed to 
see, I think, at least in half our cases, we have a comparatively 
typical run. There was another fact brought out by the doctor 
which is present in almost every case—that of roseola being 
found between the seventh and eighth days. Almost all of my 
cases have been between the eighth and twelfth days. Another 
thing: after an extremely high temperature, often running as 
liigh as 104° at the outset, and a pulse of 110 to 130 during the 
first twenty-four or forty-eight hours, the temperature will 
drop, then gradually rise, continuing as in a well-behaved case of 
typhoid fever. 
A great many patients, as we see them, have constipation— 
perhaps one third; some are so much constipated that we are 
obliged at times to remove portions of hardened faecal matter 
from the rectum with the finger; the tongue usually assumes a 
comparatively typical form. 
In regard to aborting cases, I have seen cases begin with 
every symptom of typhoid fever—epistaxis, diarrhoea, tympani- 
tes, tender abdomen, and delirium, with a gradual rise of tem- 
perature for five or six days; then suddenly, whether due to 
treatment or to the natural termination of the disease, the fever 
drops to normal, other symptoms subside, and the patient is out 
within a week or ten days. 
I had such a case not more than a month ago—that of a 
physician who resided in this city and was in the hospital here, I 
believe. He left the hospital and went into the country, where 10 
TYPHOID FEVER AS WE SEE IT 
they were having, or had recently had, typhoid fever. He came 
home to Elmira and remained a few days, intending to go to an 
adjoining town to practice. The day before his intended start 
he was taken with every symptom of beginning typhoid fever, 
lie had epistaxis, tympanites, delirium, diarrhoea, and a gradual 
rise of temperature for about five days, followed by a gradual 
abatement of all the symptoms. 
Within seven or eight days he was out and about the house. 
I have seen such cases again and again, especially when we have 
had a large number of typhoid fever patients on hand. 
Now, whether these are cases of simple fever or cases of 
aborted typhoid fever I am not prepared to say; the thought 
often comes to me that they might be, and there are good, well- 
read practitioners who believe this to be possible. 
Of course we have no authority for expecting to abort a 
case of typhoid fever; neither do I wish to be considered as ad- 
vocating such a theory. I would like to hear on this point the 
opinion of other members of the association. 
Dr. Brown: My idea of typhoid fever is somewhat different 
from that of the last speaker. I believe that typhoid fever, 
strictly speaking, is a specific poison; that it starts out as ty- 
phoid fever, and I have contended that the idea of breaking up 
typhoid fever is simply ridiculous. 
I believe when it is typhoid fever it is typhoid fever from 
the commencement; I believe that it is typhoid fever through- 
out ; I believe if it commences as typhoid fever it will run a 
course as typhoid fever, and, according to my experience in a 
large number of cases connected with a school in Pennsyl- 
vania several years ago, and published in the journals, where 
the infection was caused by drinking-water. There were sixty- 
two persons taken sick within three weeks. The shortest dura- 
tion of the fever was thirty days, and they ranged from that to 
forty and forty-five days. A large majority had haemorrhage 
from the bowels and the cases were typical cases of typhoid 
fever. There were a few persons about the building and in 
that vicinity, who did not drink the water, who did not have 
the fever, but all that drank it had the fever. It was found 
that the drinking-water that they used was from a well that IN CENTRAL NEW YORK. 
11 
was about forty feet from a privy-vault that had been used 
for ten years. We found that the contents of the privy- 
vault had backed around into the well. The water tasted 
good and had the appearance of being good water. At the 
place there was an Artesian well that was one hundred and 
forty feet deep carried into the building, but the students 
and some of the teachers liked the surface well so much bet- 
ter that they would go out from their rooms and down to this 
well to get the water because they liked it. The deep well 
was, of course, all right. I sent samples of this water to Dr. 
Lattimer, of Rochester University, and he examined it and re- 
ported that it was swarming with animalcula; and so I believe 
that the large majority of cases of typhoid are the result of 
drinking water that is contaminated by sewage and bad air, and 
that in these cases of direct infection of typhoid fever there 
is no such thing as aborting them. These cases of continued 
fever spoken of I should regard as a different disease from true 
typhoid fever. 
Dr. Bloomer.—Mr. President and Gentlemen : If this meet- 
ing had been held a year ago Dr. Chapin would probably have 
been here; and if he had been here he would have, no doubt, 
called attention to certain mental manifestations present in cases 
of typhoid fever. 
There is no doubt that about the third week of typhoid fever 
there is a mental condition short of delirium, where the patient 
is restless, apathetic, indifferent to his surroundings, when the 
question of testamentary capacity often comes up. Dr. Chapin 
related last year two cases published in the “ American Journal 
of Insanity.” 
In one of his cases the patient, fifty-eight years old, a 
farmer, lying at the point of death, called his sons to his 
bedside and discharged some obligations to the amount of 
$6,000 or $8,000. He recovered from the fever; and a year 
afterward his sons were very much surprised by his asking 
them to have this obligation discharged; and he himself was 
quite confounded when he learned that the instrument had 
already been executed. 
In another case the patient made a will in which he ignored 12 
TYPHOID FEVER AS WE SEE IT 
the heirs in the male line, and his signature bore such a striking 
resemblance to that of the lawyer who guided the pen that 
there was a contest over the will. The late Dr. Cook and Dr. 
Chapin were called in as experts, who testified that in their opin- 
ion the patient was non compos mentis, and not in a disposing 
state of mind when he made the will; but the will was, not- 
withstanding, admitted to probate because it was executed in 
due legal form; and you all know what objections lawyers raise 
to the setting aside of an instrument that is executed according 
to the legal requirements. 
Dr. Elsnek : I merely wish to say that possibly the title, as 
it appears on the programme, is a misnomer. 
The cases that I have described to you on paper have been 
seen in this county, and my experience with typhoid fever has 
been limited to this county. We consider ourselves in central 
New York, and, as I had no better name or title to give the 
paper, I gave it the title that appears on the programme. 
Now, in regard to roseola. I think that you will find, in 
looking over the temperature-chart (for I have been particular 
in marking the roseola), that it did usually occur between the 
seventh and eighth day. 
Then in regard to the abortive cases, and such cases as Dr. 
Ross mentioned. We all see them. 
We are all called to treat just such cases as the doctor has men- 
tioned. Some of the patients have active delirium at once, and 
some do not. We have a gradual rise of temperature, and, for a 
few days, imagine that we have a well-defined case of typhoid 
to treat; but our treatment is rewarded with success. Now, 
those cases can not be considered typhoid fever. One of the 
points that I wish to make in my paper is this: That we are not 
justified in making the diagnosis of typhoid fever unless we are 
sure that there are abdominal lesions. The tenderness in such 
a case may be caused by many other things. Typhoid ulcera- 
tion may cause tenderness; ulceration in the region of the valve 
may cause it, and many other diseases that are not typhoid at 
all are associated with marked abdominal disturbance, yet can 
not be considered cases of typhoid fever. If we speak of abort- IN CENTRAL NEW YORK. 
13 
ing typhoid fever, such cases must be thrown out. Wo can not 
consider those as aborting cases of typhoid. 
In regard to the mental state. I did not mention that in my 
paper, for I simply wish to impress upon your mind the leading 
symptoms of typhoid as we see it. 
Dr. Bloomer has mentioned the mental state in some cases 
between the second and third week—that apathetic condition, 
that condition when the patient does not care whether school 
keeps or not. I think the much larger proportion of our patients 
are just in that very condition at that stage of the disease. The 
patient seems to lose all interest in himself or herself, however 
solicitous ho or she may have been before; and I think there is 
a stage in typhoid, though I would not make this as a positive 
statement, at which these patients are not responsible for what 
they do, however clear they may have been during the entire 
course of the disease. I have repeatedly asked patients who 
have appeared perfectly rational throughout the entire course 
of the disease whether they remembered any facts concerning 
their sickness; much the larger proportion of them have told 
me that the time during the entire sickness seemed as if it had 
been a dream.