Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 91

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

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About this time for a period of two days, the patient was un- able to void urine and he had to be catheterized. On April 23d the temperature rose to 100° F., and the next day to 103º F., which proved to be the beginning of a typical attack of typhoid fever. A blood culture on April 26 (the fourth day of the fever), yielded typhoid bacilli and the Widal reaction was also positive. On April 27, it was noted that the spleen was enlarged and palpa- ble. No rose spots were made out. During the illness the patient suffered greatly from the pain in the back, at times this being extremely severe. His expression of apprehension when anyone came near the bed, fearing that they might touch it and so cause him pain, was always striking. He looked very haggard and ill, and remained absolutely motionless unless he had to move; this was done with great deliberation and care and there was no doubt of the severity of the pain. Examination showed no dis- turbance of sensation in the legs; ordinary sensation, pain and temperature sense all seemed normal. The attack of fever was not very severe; the patient did well and the temperature reached normal on May 8, the 16th day of the attack or relapse. The blood count showed a slight drop, as the hæmoglobin was 80 per cent, red cells 4,460,000 and the leucocytes 6800 per cmm. The leucocyte counts throughout were between 6000 and 7000. The urine showed a specific gravity usually between 1014 and 1028; there was no albumin or sugar. A positive diazo reaction was given once. The blood pressure was low, generally between 80 and 100 mm. Hg., averaging about 90 mm. Hg.

On May 20, a plaster cast was put on with the patient in a ham- mock. A second one was applied a week later and the patient was much more comfortable. At this time he complained very little of pain and got about without much difficulty. There was no evidence of any wasting in the legs more than is usual after an attack of typhoid fever. The leg reflexes were rather active but equal on the two sides and sensation seemed perfectly normal. The X-ray plate showed the same changes in the vertebræ as be- fore. He was discharged in good condition on June 8.

On July 18, 1909, the patient was seen and found to have been improving slowly. He had not returned to his usual employment but had been doing a certain amount of light work which did not involve much exertion. He had been wearing a plaster jacket and stated that he suffered very little from pain in the back although he had felt weak. Two days before this examination he removed the plaster jacket and since then has had rather more pain. Examination of the back did not show any change in the spine but the muscles on the right side were still definitely more con- tracted than on the left. There was no kyphosis and no definite scoliosis. What pain the patient had was referred to the lumbar region but there was no tenderness on pressure over the spine. The reflexes in the legs were still much exaggerated. Four months later he was practically well.

Remarks .- One point of interest is the occurrence of a re- lapse or second attack between five and six months after the

original attack. Whether this should be termed & relapse or : second attack is difficult to decide, for there is no period vti: can be set as a dividing line between a relapse and a sxc: attack. The case here reported is much like one previos" described by the writer," in which the original attack began e June 2, the patient being convalescent in March when tx symptoms of typhoid spine appeared. He was admitted ? the hospital on July 4 of the same year for the spinal som: toms, and a week later the second attack (or relapse) typhoid fever began. In both these cases there was an is terval of months between the attacks, in which the symptoc: of spondylitis appeared. One explanation of the cause a! typhoid spondylitis is that there are local lesions in the bone t which typhoid bacilli are present. It is tempting to sugges: that this focus may have been the source of the second infectie in these cases. However, our knowledge of what determine relapses is not very satisfactory and it would be easier to re gard the second febrile attack in these two cases as a secocd attack rather than as a relapse. Besides the retention : typhoid bacilli in the body after recovery from an attack .. typhoid fever is so common (e. g. in the gall bladder) that we should not attach too much importance to such a source of re- infection.

CASE 2. Typhoid Fever in June, 1909; intestinal hemorrhay; phlebitis; recovery; discharged Aug. 14, 1909. In October, 195. neuritis of the right external popliteal nerve; spondylitis found

The patient was a white male, aged 45, whose occupation was ! worker in a factory in which he did a great deal of heavy lifting The first admission (Medical No. 24248) was on June 14, 1999. when he came complaining of cough. There was no history of arthritis and he had not used alcohol. He had always been hard worker and a heavy eater. His illness began eight days it fore admission when he received a severe wetting. For a day e: two after this he felt dizzy and had some indefinite trouble in the head; this was much worse after he spent some hours working in a hot room. There was also some headache and indefinite pains about the chest. On examination the patient was a healthy looking man with a good color. The percussion note over the lungs was rather hyperresonant and there were a few râles heart on both sides of the chest; the heart was clear. The abdomen was natural; no rose spots were found and the spleen was not felt. Four days after admission the temperature fell to normal and then rose again, at one time reaching 105° F. Definite rose spots appeared and there was slight jaundice. On June 22, about the 16th day of the illness, the patient passed blood from the bowel, but the hemorrhage was not severe, and made no change in the patient's general condition. On June 21, the 15th day of the disease, the blood culture was positive, typhoid bacilli being obtained. The course was without any special features till he be gan to get up out of bed on August 8, when he complained of some pain in the right leg, both in the popliteal space and below the knee. The leg was somewhat swollen below the knee; the skin had a shiny appearance and was quite sensitive to the touch. There was definite swelling and the circumference of the right calf was 3 cm. greater than the left. This was regarded as & mild attack of phlebitis and subsided before discharge on August 14th

For a time after leaving the hospital both legs were very weak. especially below the knees and the swelling and pain in the right leg returned after discharge. In from two to three weeks the weakness of the left leg had disappeared entirely but the right

" Loc. cit.

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IVAG DIA WeCAS that the pain and swelling in the right leg dis- peared and the patient was able to walk about without any ecial discomfort. During October the patient was seen several mes in the out-patient department. His complaint was espec- lly of dizziness and weakness, but he stated that he had not iffered from any pain. He had chronic ear trouble for which he id been treated some time before and the aurist considered that is was possibly responsible for the dizziness. The patient had ade several attempts to resume work but found that he had not fficient strength and that when he went to do any heavy lifting was apt to stagger. It was not possible to obtain the history any special strain or injury during this time and no definite dence of spondylitis could be found although the patient was beatedly examined with this in mind. There had not been any n in the back and it was difficult to test the movements of the ne as on any attempt at- bending the patient complained of ziness and was afraid of falling. In the absence of any definite aptoms suggesting spondylitis it was not thought necessary at s time to have an X-ray plate taken. During this time he : gained twenty pounds in weight and was a good deal stronger. Towards the end of October the patient began to complain of ible in the right foot. He stated that at first there was numb- 3 over the upper part of the foot and especially in the great later he had some difficulty in walking as he was unable to perly lift the foot. On October 27, it was found that he had e difficulty in walking and that the right foot dragged a little. w days later he complained of a good deal of pain in the right , and the gait was distinctly more affected. The knee jerks › present on both sides but the ankle jerk was decreased on right. He had no power of movement in the right great toe had difficulty in lifting the foot. In view of the condition he admitted to the hospital November 9. (Second admission). xamination the patient's general condition was excellent; the s and heart were clear throughout. The abdomen was nor- and the spleen was not felt. On examination of the legs it found that there was marked foot drop on the right side with ed weakness of the extensors of the right foot. Voluntary l flexion of the right foot was possible but the right great ould not be flexed or extended except that slight flexion oc- d when the other toes were moved. Passive movement of reat toe was possible in any direction. The knee jerk on the side was much more marked than on the left. Plantar re- e was normal on the left side but could not be obtained on ght side. There was no ankle or patellar clonus. The super- veins of the right leg were definitely dilated but there was ema of the feet or ankles, and well-marked pulsation was it in the dorsalis pedis artery on both sides.

: the dorsum of the right foot, from the ankle along the margin, including the right great toe and extending to the of the extensor digitorum longus, sensation to touch was affected and the response to pain and temperature stimuli ither inaccurate. Along the medial border there was an : hyperæsthesia; pain stimuli caused a marked contraction rectus femoris, almost approaching a spasm. There was phy of the calf muscles and there did not seem to be any ice in the strength of the hamstring muscles of the two he sensory disturbances cleared rapidly and disappeared by ber 25. On electrical examination it was found that with vanic current the affected nerve did not respond to stimuli; scle itself responded to a strong current, the ccc. being r than the acc. With the faradic current the nerve did pond; the muscle responded sluggishly and less so than icle on the other side.

X-ray plate by Dr. Baetjer showed a definite deposit of the left side of the spine between the articulations of the and V lumbar vertebrae, which practically obscured the

The bone was deposited on the lateral ligaments and the anterior and posterior ligaments seemed free. There was no deposit on the right side.

During this time the patient's temperature was practically nor- mal, and he was discharged much improved after being ten days in the hospital. The patient's condition improved steadily after this and in January, 1910, the signs in the right leg had prac- tically disappeared. He complained that the right leg tired more quickly than the left; this may have been due as much to the effects of the phlebitis as to the paralysis. By the beginning of March the patient seemed perfectly well. He did not make any complaint of pain in the back and the movements of the spine seemed normal except for slight limitation in the lumbar region. He had returned to work and seemed able to do this without diff- culty.

Remarks .- This case is unusual in several particulars. In the first place it shows that typhoid spondylitis may occur without any severe pain. The symptom of pain has been re- garded as the most essential one in " typhoid spine " and it is very evident in this case that but for the radiogram the diagnosis of spondylitis could not have been made. In this event the condition in the popliteal nerve would have been re- garded as a post-typhoid neuritis and the causal influence of the local process in the spine would not have been recognized. The involvement of the nerve root on the opposite side to that on which the deposit of bone occurred is seen not infrequently in cases of spondylitis.

The Nature of " Typhoid Spine."-Formerly the term was applied to a symptom picture regarded by many as being a neurosis in the majority of cases. That it may be a neurosis in some cases is quite possible but the increase in our knowledge of the organic changes which occur in " typhoid spine " speaks against this view. This is upheld by the fact that as the condi- tion was studied more carefully an increasing number of cases have been reported with evidence of definite bony changes, sup- porting more and more strongly the view that it is a spondylitis. This is analogous to the change in our views regarding spon- dylitis generally. The work of recent years has shown that many of the cases formerly regarded as lumbago, “.rheuma- tism," etc., are instances of spondylitis, probably associated with various organisms in different cases. The proportion of cases of " typhoid spine " with bony deformity or shown by the X-rays to have bony changes is comparatively large, in fact as large as could be expected. Spondylitis is of very varying de- gree in different cases and many of those which we see with other conditions-such as arthritis deformans when a spon- dylitis is part of a multiple arthritis give no positive evidence of bony changes either by deformity or by the X-rays.

In 1907 Silver ' collected 67 cases of typhoid spine of which 14 were rejected for various reasons, leaving 53 fairly definite cases. Among 51 of these in which the sex was stated only six

" Typhoid Spine; a report of a case with radiographic evidence of structural change; analysis of the reported cases; complete bibliography." The Am. J. Orthop. Surg., 1908, V, p. 194. In the same volume is an article by Myers, "Typhoid Spine with special reference to the deformity." These are two interesting and com- prehensive articles which should be read by all interested in the subject.

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JOHNS HOPKINS HOSPITAL BULLETIN.

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were females. In making this collection Silver excluded those cases in which a neurosis seemed probable. Myers found in his study that kyphosis had been noticed in 36 per cent of the cases. It seems a fair inference that in a large number of cases with an actual spondylitis this need not proceed to the extent of causing external bony change. However, the number of cases with external bony deformity, considered with the number in which radiographs show bony changes, points to the probability that the symptoms are due to a definite process in the spine or its attachments. To decide this question as far as possible the various changes which suggest definite local changes may be considered.

1. Local swelling .- This has been frequently noted and Sil- ver found it reported in 14 (26 per cent) of his collected series. Redness has been present in a few cases, tenderness in . many more, sometimes over the spine, sometimes over the adja- cent muscles. Rigidity of the spine has been quite common and may be considered to be almost invariably present.

2. Changes in the spine .- Kyphosis was noted in 15 of his series by Silver and by Myers in 20 of 56 cases (36 per cent). The descriptions of this vary considerably but it is fair to say that some degree was present in one-third of the cases. Scoliosis was noted in some cases, in nearly all of which it disappeared after an interval. Alteration of the lumbar curve is not uncommon.

3. Evidences of involvement of the nerve-roots .- These while variable, still are suggestive of organic changes. Sen- sory disturbances are common and alterations in the reflexes occur in a large proportion. In some cases the symptoms evi- dently were due to changes inside the spinal canal causing pressure on the cord. In one of the cases previously reported by the writer there was marked atrophy of the muscles of one leg. The second case here reported is of special interest in this connection.

4. Radiograms .- These have shown definite evidence of bony changes in a sufficiently large number of cases to support strongly the view that organic changes are the rule in typhoid spine. It must be remembered that many cases of spondylitis do not show any definite bony changes. Brief mention of some of the findings may be made. In the two previously re- ported by the writer there were definite deposits of new bone in the lower spine. In Silver's case there was a slight curving of the spine to the left at the juncture of the first and second lumbar vertebræ in the first plate, which had disappeared when a second plate was taken. On the left side of the spine no line of separation between the bodies of the first and second vertebra could be made out, the bone was denser than normal and there was a shadow between the transverse processes which represented a deposit of new bone. In Myers' case the skia- gram showed " a synostosis between the second and third lum- bar vertebræ with loss of height from disappearance of the intervertebral space." Halpenny 'in 1909 analysed 72 cases from the literature among which there were ten cases with

radiographic examination, in two of which no changes Re- found. Some additional cases have been reported in viz definite changes were found. Carling and King' repar : case in which the " spines of the eleventh and twelfth dese and first lumbar vertebrae were prominent." There was ts a deviation of the column to the right. The X-ray pln " showed a very dense shadow over the bodies of the niri tenth and eleventh dorsal vertebræ, extending laterally bez; their limits and expanding from above downwards to a poz an inch outside the articular processes on the right side esi rather less on the left. The right edge was rectilinear and we. defined ; the left edge was irregular and not so well dedite? below." Three weeks later " the main mass of the shadow RE less dense, whilst indications of a localisation to the cost-re: tebral articulations could be made out." Wilson ' reported ; case in which there was thinning of the intervertebral discs wit signs of necrosis in the vertebrae and many osteophytes aroc: them. In connection with these reports it is interesting : note that relatively very few cases of typhoid spine have been reported from Great Britain. Another case is reported b Godder,' in which the " X-ray of the spine shows a disease: condition of the vertebrae at the level of the last dorsal and fr. lumbar." There is no other note as to the bony changes. LE Swett's' case there was slight lumbar kyphosis and scoliosi The X-ray plate " showed a disappearance of the disc betwer the fourth and fifth lumbar vertebrae, with evidence of JET bone formation and the scoliosis beginning at this point." La a recent article Frick ' reports three cases without mentioning an X-ray examination. He discusses the whole question a: length and gives an excellent bibliography. One of his case showed the curious rhythmical contractions of the abdominal muscles which were noted in one of our earlier cases. Iz Frick's patient the contractions were synchronous with tz pulse. Potter " has reported a case in which the X-ray place showed " a very definite lesion in the intervertebral dise be tween the tenth and eleventh dorsal vertebra. The spacing between these vertebra is reducd to about one-half the size is between the others." There was an increase in the density c: the lower part of the tenth and upper part of the eleventh der- sal vertebræ.

5. Suppuration .- The occurrence of suppuration is worthy of mention. It has been pointed out that if the condition is due to the local action of typhoid bacilli, suppuration might be commonly expected, as typhoid bone lesions in general show : marked tendency to pus formation. Yet one of the prominent features of typhoid spine is the absence of suppuration. In the report of the previous cases the writer suggested that it was exceedingly probable that instances of suppuration would be reported sometime and in this connection a case reported by Myers is of interest. A diagnosis of typhoid spine had been

"Typhoid Spine; with the report of a case. Surg., Gynec. and Obst., 1909, IX, 649.

" Lancet, 1910, I, 1136.

* Lancet, 1909, II, 1279.

" Bost. M. and S. J., 1910, CLXII, 711.

$ Yale Med. J., 1909, XVI, 119.

" Interstate Med. J., 1910, XVII, 813.

10 Med. Rec., 1910, LXXVIII, 1092.

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wv nou veen on for weeks some odor was noticed and on removing the cast a granulating wound was found over and to the right of leventh and twelfth dorsal spines. The skiagram showed ostosis of the eleventh and twelfth dorsal vertebræ. Some ion arose as to whether the abscess had originated in the ; or was due to pressure of the jacket and cultures did not e the matter. While this case is suggestive it can hardly cepted as definitely proved to be an instance of suppura- associated with typhoid spondylitis. An instance reported uyot 1 is also not positive although very suggestive. This in a child who after an attack of what was regarded as ›id spine, had pain in the lumbo-sacral region. On in- 1 on both sides of the spinous processes, a large amount of vas found but no proof obtained of any bone lesion. Two later a focus of osteomyelitis in the left fibula was opened i few days later one in the right thumb. The patient re- 'ed without any deviation of the spine. However, this ot be regarded as a definite proved case.

rtain cases in which abscess formation occurred over the : spine may suggest a possible source in the bone but it is sary to remember that deep bedsores may extend down to one and suggest an origin from it. In fact the necrosis times involves the deeper tissues earlier than the skin. le absence of positive proof it is not wise to consider these amples of suppuration due primarily to processes originat- n the bones.

·eatment .- As regards prevention it is important to re- ber the influence of trauma and we should warn the nts convalescent from typhoid fever to exercise care in en- ng in any occupation which might throw strain on the ?. When the condition is established it is well to carry ctive treatment at once as by doing this we can probably the extension of the process in some cases and certainly the patient suffering. One form of treatment seems well 1 a trial, the use of vaccines as in the prevention of id fever. It is to be hoped that this will be tried in the e. The dosage should be the same as that employed in

IZ. hebd. d. sc. méd. de Bordeaux. 1906, XXVII, 9.

the anti-typhoid vaccination. In treating the established con- dition two points have especially to be kept in mind, the relief of pain and the protection of the spine, which, as Myers points out, is often structurally weak. The pain is usually lessened by immobilization of the spine as any movement causes great suffering. To secure this some form of fixation is required. Myers favors the use of a brace, pointing out that in the appli- cation of a support it is important not to fatigue the patient or injure the spine. He also draws attention to the impor- tance of avoiding anything which will compress the chest. If a jacket is applied this should be done with the patient in a recumbent position and not by the suspension method. Silver mentions the use of the plaster bed and also a gas-pipe frame. It seems important to carry out whatever is adopted as early as possible after the onset of the condition. By this we may shorten the duration of symptoms and perhaps limit the amount of spinal involvement. In the first case reported here the plaster jacket was exceedingly satisfactory and gave the patient great relief. In the first of the cases previously re- posted by the writer, the jacket failed to give any relief and increased the pain. In such cases or before some appliance can be applied the use of counter-irritation, especially the Paquelin cautery, may give relief. Large doses of sedatives often seem to be without effect on the pain and the quantity of morphia which can be given without any appreciable relief to the patient is remarkable. The fever, which is often present, sometimes diminishes as soon as fixation is carried out, if it be due to the spondylitis. In cases in which it is due to a relapse or a second attack of typhoid fever, one must be guided by the indications. It may be very difficult to carry out any systematic method of hydrotherapy and in such cases expectant treatment is the only resort.

Conclusions .- It may be regarded as established that " typhoid spine " is a spondylitis or perispondylitis with defi- nite local changes which may lead to the formation of new bone and so result in more or less fixation of the spine. Judg- ing from spondylitis generally, this permanent change is less likely to occur if the proper treatment is instituted early. Many cases of spondylitis clear without permanent changes.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 91

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189