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The “typhoid state” revisited
SPECIAL ARTICLE
The “Typhoid State” Revisited
ABRAHAM Boston,
VERGHESE,
The “typhoid state” occurs classically with typhoid and typhus fevers but is also seen in other infectious diseases. Clinical descriptions of this state as “muttering delirium” or “coma vigil” refer to the peculiar preoccupied nature of the stupor. Picking at the bedclothes and at imaginary objects (carphology and floccillation) are characteristic, as is muscular twitching (subsultus tendinum). There is strong evidence that the death of Falstaff in Shakespeare’s Henry V is a vivid description of the typhoid state.
M.D.
Massachusetts
Many classic clinical descriptions in medicine are in danger of being forgotten; the diseases they depict are either uncommon or diagnosed and treated before advanced signs develop. Modern textbooks have abandoned some clinical descriptions that are only of historical interest. One such entity is the “typhoid state.” A recent patient with the acquired immune deficiency syndrome and overwhelming mycobacterial infection demonstrated the clinical appearance of the typhoid state and the need to be reminded of this clinical diagnosis. The typhoid state is best defined as a febrile state of semiconsciousness accompanied by a curious “muttering” delirium. It derives its name from its association with typhoid fever [l] but is seen in other infections. Osler [2] said of the typhoid state (in his writings on typhoid fever): It is, as a rule, a quiet delirium, though there are cases in which the patient is very noisy and constantly tries to get out of bed, and, unless carefully watched, may escape. The patient does not often become maniacal. . . . The eyes may be open, but he is oblivious to all surrounding circumstances and neither knows nor can indicate his wants. The urine and faeces are passed involuntarily. In this pseudo-wakeful state, or coma vigil as it is called, the eyes are open and the patient is constantly muttering. The lips and tongue are tremulous; there is twitching of the fingers and wrists-subsultus tendinum and carphologia. He picks at the bedclothes or grasps at invisible objects. These are among the most serious symptoms of the disease, and always indicate danger.
The incidence of the typhoid state, during the course of typhoid From the Division of Infectious Diseases, Boston University, and the Veterans Administration Medical center, Boston, Massachusetts. Requests for reprints should be addressed to Dr. Abraham Verghese, R103 Research Building, Veterans Administration Medical Center, 150 South Huntington Avenue, Boston, Massachusetts 02 130. Manuscript accepted November 29, 1984.
370
September
1985
The American
Journal
fever in tropical countries, is about 50 percent [3]. Transient parkinsonism, acute psychosis, and catatonic schizophrenia can occur, in addition to delirium and coma [4]. Neurologic manifestations are
only slightly less common in Western series [5,6]. Typhus can produce a similar appearance: this is evident in George Cheever Shattuck’s [7] description of the typhoid state in his treatise
on tropical medicine:
of Medicine
Volume
79
“TYPHOID
This stage (of nervous excitement) is followed by that of nervous depression in which there is quiet delirium, apathy, somnolence, or coma. This is the ‘typhoid state,’ a condition that develops not only in typhoid, but also in typhus fever. When the typhoid state is fully developed, the semi-comatose patient lies helplessly upon his back. The eyes and mouth remain open, there is twitching of the muscles of the jaw, of the arms and of the hands and the fingers pick aimlessly at the bed clothes. The eyes are sunken, the nose is thin, the face and ears are dusky, the limbs are cold, and the respiration is rapid and shallow. There is incontinence of urine and feces. Recovery is possible even when the outlook appears hopeless. &vi/l’s System of Clinical Medicine [l] (a classic British textbook that advocated a “system” of medicine based on the presenting symptoms or signs as branching points) corroborates these descriptions and states that it is met with frequently “especially towards the end” in typhoid and typhus, smallpox, severe eryisipelas, septicemia, tuberculous meningitis, encephalitis, lobar pneumonia, acute miliary tuberculosis, acute glanders, acute anthrax, cerebral malaria, yellow fever, and plague. &will’s also defines these unfamiliar terms: subsultus tendinum, muscular twitching% carphology, picking at the bed clothes; floccillation (floccus = wool), picking at imaginary objects. (Carphology and floccillation are often used interchangeably.) In the death of Falstaff, Shakespeare’s description of the febrile illness takes the medical reader’s breath away. There is more to this than simple virtuosity of prose or cadence. Mistress Quickly provides us with this example of her medical literacy (as she brings Falstaff’s friends gathered at the Boar’s Head Tavern these tragic tidings) [8] : As ever you come of women, come in quickly to Sir John: Ah, poor heart! He is so shaken of a burning quotidian tertian, that it is most lamentable to behold. Sweet men, come to him. act ii, scene 1 The use of the terms quotidian and tertian speaks to the familiarity of these words to Elizabethean tongue and to the prevalence of malaria and other febrile maladies. (Her coupling the two terms into “quotidian tertian” is the comic touch of Shakespeare; her need to impress on Falstaff’s friends the gravity of the situation prompts this neologism.) Having sprung the news of Falstaff’s impending death on his unwitting audience (who, after Henry IVParts I and II, could not have enough of the lecherous, corpulent Sir John), Shakespeare creates a tantalizing delay. Another scene intervenes before Mistress Quickly returns to her timeless description of the death scene [9] :
STATE”
REVISITED-VERGHESE
Nay, sure, he’s not in hell: he’s in Arthur’s bosom, if ever man went to Arthur’s bosom. ‘A made a finer end, and went away an it had been any christom child; ‘a parted ev’n just between twelve and one, ev’n at the turning o’ the tide; for after I saw him fumble with the sheets, and play with flowers, and smile upon his fingers’ end, I know that there was but one way; for his nose was as-sharp as a pen, and ‘a babbl’d of green fields. ‘How now, Sir John!’ quoth I ‘What, man, be o’ good cheer.’ So ‘a cried out “God, God, God!” three or four times. Now I tried to comfort him, bid him ‘a should not think of God: I hop’d there was no need to trouble himself with any such thoughts yet. So ‘a bade me lay more clothes on his feet; I put my hand into the bed and felt them, and they were cold as any stone; then I felt to his knees, and so upward and upward, and all was cold act ii, scene 3 as any stone. Readers must make their own judgment as to whether or not this was the typhoid state. This was probably a scene many in the audience had seen played in their own lives. (It is even possible that Shakespeare himself succumbed to typhoid [lo], the River Avon being wont to spill over into Stratford-upon-Avon as it swelled, bringing with it raging epidemics.) To skeptics, one can only point to the “fumbling at the sheets” (floccillation), the “playing with the flowers” (carphology), and the “babbl’d of green fields” (muttering delirium?) as being astute observations of clinical medicine that are unlikely to be pure imagination (even one as lively as the Bard’s!). The “nose as sharp as a pen” could have been a metaphor for the Hippocratic facies. Indeed, it has been suggested that Shakespeare was well versed in the Father of Medicine’s texts (the term carphologia was coined by Hippocrates) [ 1 I], and Hippocrates may have been a source for some of Shakespeare’s other vivid death scenes (the death of Hamlet’s father, the death of Gloucester). In the modern era, when many past scourges have been tamed, and the physician is challenged not only by disease, but also by the wealth of scientific knowledge that needs to be retained, one is well advised to remember Shattuck’s admonition: “We think we are too busy to read an old book, but when we do so, we find that the masters knew their art, though the young student of today knows more science” [ 121. New diseases appear and old clinical signs are rekindled; doubtless, new clinical descriptions will be made by astute observers, leaving a legacy of theirown. By the end of Mistress Quickly’s narration, it is evident that Falstaff has weakened. Circulatory failure, a familiar enemy, moves in, and finally “all was cold as any stone.” Sir John is dead: Old, cold, wither’d,
September 1995
The
and of intolerable
American Journal of Medicine
entrails.
Volume
79
371
“TYPHOID
STATE”
REVISITED-VERGHESE
REFERENCES 1.
2. 3.
4. 5.
372
McMath T: Profound toxemia of infective origin (synonym: the typhoid state). In: Warner EC, ed. Savill’s system of clinical medicine, 14th ed, 1964. Madras: Orient Longmans, 1964; 662-664. Osler W: The principles and practice of medicine. New York: D. Appleton, 1892; 25. Osuntokun BO, Bademosi 0, Ogunremi K, et al: Neuropsychiatric manifestations of typhoid fever in 959 patients. Arch Neurol 1972; 27: 7-13. Breakey WR, Kala AK: Typhoid catatonia responsive to ECT. Br Med J 1977; 2: 357-359. Huckstep RL: Typhoid fever and other Salmonella infections. Edinburgh: E & S Livingstone, 1962; 181.
September
1985
The American
Journal
of Medicine
6. 7. 8. 9. 10. 11. 12.
Volume
79
Stuart BN. Pullen RL. Typhoid: clinical analysis of 360 cases. Arch Intern Med 1946; 78: 629-66 1. Shattuck GC: Diseases of the tropics. New York: AppletonCentury-Crofts, 1951; 247. Campbell OJ: The living Shakespeare. New York: Macmillan, 1958; 479. Ibid. 482. Simpson RR: Shakespeare and medicine. Edinburgh: E 8 S Livingstone, 1959; 57. Bucknill JC: The Medical knowledge of Shakespeare. London: Longman, 1860; 166. Shattuck FC: The science and art of medicine in some of their aspects. Boston Med Surg J 1907; 157: 63-67.
The “Typhoid State” Revisited
ABRAHAM Boston,
VERGHESE,
The “typhoid state” occurs classically with typhoid and typhus fevers but is also seen in other infectious diseases. Clinical descriptions of this state as “muttering delirium” or “coma vigil” refer to the peculiar preoccupied nature of the stupor. Picking at the bedclothes and at imaginary objects (carphology and floccillation) are characteristic, as is muscular twitching (subsultus tendinum). There is strong evidence that the death of Falstaff in Shakespeare’s Henry V is a vivid description of the typhoid state.
M.D.
Massachusetts
Many classic clinical descriptions in medicine are in danger of being forgotten; the diseases they depict are either uncommon or diagnosed and treated before advanced signs develop. Modern textbooks have abandoned some clinical descriptions that are only of historical interest. One such entity is the “typhoid state.” A recent patient with the acquired immune deficiency syndrome and overwhelming mycobacterial infection demonstrated the clinical appearance of the typhoid state and the need to be reminded of this clinical diagnosis. The typhoid state is best defined as a febrile state of semiconsciousness accompanied by a curious “muttering” delirium. It derives its name from its association with typhoid fever [l] but is seen in other infections. Osler [2] said of the typhoid state (in his writings on typhoid fever): It is, as a rule, a quiet delirium, though there are cases in which the patient is very noisy and constantly tries to get out of bed, and, unless carefully watched, may escape. The patient does not often become maniacal. . . . The eyes may be open, but he is oblivious to all surrounding circumstances and neither knows nor can indicate his wants. The urine and faeces are passed involuntarily. In this pseudo-wakeful state, or coma vigil as it is called, the eyes are open and the patient is constantly muttering. The lips and tongue are tremulous; there is twitching of the fingers and wrists-subsultus tendinum and carphologia. He picks at the bedclothes or grasps at invisible objects. These are among the most serious symptoms of the disease, and always indicate danger.
The incidence of the typhoid state, during the course of typhoid From the Division of Infectious Diseases, Boston University, and the Veterans Administration Medical center, Boston, Massachusetts. Requests for reprints should be addressed to Dr. Abraham Verghese, R103 Research Building, Veterans Administration Medical Center, 150 South Huntington Avenue, Boston, Massachusetts 02 130. Manuscript accepted November 29, 1984.
370
September
1985
The American
Journal
fever in tropical countries, is about 50 percent [3]. Transient parkinsonism, acute psychosis, and catatonic schizophrenia can occur, in addition to delirium and coma [4]. Neurologic manifestations are
only slightly less common in Western series [5,6]. Typhus can produce a similar appearance: this is evident in George Cheever Shattuck’s [7] description of the typhoid state in his treatise
on tropical medicine:
of Medicine
Volume
79
“TYPHOID
This stage (of nervous excitement) is followed by that of nervous depression in which there is quiet delirium, apathy, somnolence, or coma. This is the ‘typhoid state,’ a condition that develops not only in typhoid, but also in typhus fever. When the typhoid state is fully developed, the semi-comatose patient lies helplessly upon his back. The eyes and mouth remain open, there is twitching of the muscles of the jaw, of the arms and of the hands and the fingers pick aimlessly at the bed clothes. The eyes are sunken, the nose is thin, the face and ears are dusky, the limbs are cold, and the respiration is rapid and shallow. There is incontinence of urine and feces. Recovery is possible even when the outlook appears hopeless. &vi/l’s System of Clinical Medicine [l] (a classic British textbook that advocated a “system” of medicine based on the presenting symptoms or signs as branching points) corroborates these descriptions and states that it is met with frequently “especially towards the end” in typhoid and typhus, smallpox, severe eryisipelas, septicemia, tuberculous meningitis, encephalitis, lobar pneumonia, acute miliary tuberculosis, acute glanders, acute anthrax, cerebral malaria, yellow fever, and plague. &will’s also defines these unfamiliar terms: subsultus tendinum, muscular twitching% carphology, picking at the bed clothes; floccillation (floccus = wool), picking at imaginary objects. (Carphology and floccillation are often used interchangeably.) In the death of Falstaff, Shakespeare’s description of the febrile illness takes the medical reader’s breath away. There is more to this than simple virtuosity of prose or cadence. Mistress Quickly provides us with this example of her medical literacy (as she brings Falstaff’s friends gathered at the Boar’s Head Tavern these tragic tidings) [8] : As ever you come of women, come in quickly to Sir John: Ah, poor heart! He is so shaken of a burning quotidian tertian, that it is most lamentable to behold. Sweet men, come to him. act ii, scene 1 The use of the terms quotidian and tertian speaks to the familiarity of these words to Elizabethean tongue and to the prevalence of malaria and other febrile maladies. (Her coupling the two terms into “quotidian tertian” is the comic touch of Shakespeare; her need to impress on Falstaff’s friends the gravity of the situation prompts this neologism.) Having sprung the news of Falstaff’s impending death on his unwitting audience (who, after Henry IVParts I and II, could not have enough of the lecherous, corpulent Sir John), Shakespeare creates a tantalizing delay. Another scene intervenes before Mistress Quickly returns to her timeless description of the death scene [9] :
STATE”
REVISITED-VERGHESE
Nay, sure, he’s not in hell: he’s in Arthur’s bosom, if ever man went to Arthur’s bosom. ‘A made a finer end, and went away an it had been any christom child; ‘a parted ev’n just between twelve and one, ev’n at the turning o’ the tide; for after I saw him fumble with the sheets, and play with flowers, and smile upon his fingers’ end, I know that there was but one way; for his nose was as-sharp as a pen, and ‘a babbl’d of green fields. ‘How now, Sir John!’ quoth I ‘What, man, be o’ good cheer.’ So ‘a cried out “God, God, God!” three or four times. Now I tried to comfort him, bid him ‘a should not think of God: I hop’d there was no need to trouble himself with any such thoughts yet. So ‘a bade me lay more clothes on his feet; I put my hand into the bed and felt them, and they were cold as any stone; then I felt to his knees, and so upward and upward, and all was cold act ii, scene 3 as any stone. Readers must make their own judgment as to whether or not this was the typhoid state. This was probably a scene many in the audience had seen played in their own lives. (It is even possible that Shakespeare himself succumbed to typhoid [lo], the River Avon being wont to spill over into Stratford-upon-Avon as it swelled, bringing with it raging epidemics.) To skeptics, one can only point to the “fumbling at the sheets” (floccillation), the “playing with the flowers” (carphology), and the “babbl’d of green fields” (muttering delirium?) as being astute observations of clinical medicine that are unlikely to be pure imagination (even one as lively as the Bard’s!). The “nose as sharp as a pen” could have been a metaphor for the Hippocratic facies. Indeed, it has been suggested that Shakespeare was well versed in the Father of Medicine’s texts (the term carphologia was coined by Hippocrates) [ 1 I], and Hippocrates may have been a source for some of Shakespeare’s other vivid death scenes (the death of Hamlet’s father, the death of Gloucester). In the modern era, when many past scourges have been tamed, and the physician is challenged not only by disease, but also by the wealth of scientific knowledge that needs to be retained, one is well advised to remember Shattuck’s admonition: “We think we are too busy to read an old book, but when we do so, we find that the masters knew their art, though the young student of today knows more science” [ 121. New diseases appear and old clinical signs are rekindled; doubtless, new clinical descriptions will be made by astute observers, leaving a legacy of theirown. By the end of Mistress Quickly’s narration, it is evident that Falstaff has weakened. Circulatory failure, a familiar enemy, moves in, and finally “all was cold as any stone.” Sir John is dead: Old, cold, wither’d,
September 1995
The
and of intolerable
American Journal of Medicine
entrails.
Volume
79
371
“TYPHOID
STATE”
REVISITED-VERGHESE
REFERENCES 1.
2. 3.
4. 5.
372
McMath T: Profound toxemia of infective origin (synonym: the typhoid state). In: Warner EC, ed. Savill’s system of clinical medicine, 14th ed, 1964. Madras: Orient Longmans, 1964; 662-664. Osler W: The principles and practice of medicine. New York: D. Appleton, 1892; 25. Osuntokun BO, Bademosi 0, Ogunremi K, et al: Neuropsychiatric manifestations of typhoid fever in 959 patients. Arch Neurol 1972; 27: 7-13. Breakey WR, Kala AK: Typhoid catatonia responsive to ECT. Br Med J 1977; 2: 357-359. Huckstep RL: Typhoid fever and other Salmonella infections. Edinburgh: E & S Livingstone, 1962; 181.
September
1985
The American
Journal
of Medicine
6. 7. 8. 9. 10. 11. 12.
Volume
79
Stuart BN. Pullen RL. Typhoid: clinical analysis of 360 cases. Arch Intern Med 1946; 78: 629-66 1. Shattuck GC: Diseases of the tropics. New York: AppletonCentury-Crofts, 1951; 247. Campbell OJ: The living Shakespeare. New York: Macmillan, 1958; 479. Ibid. 482. Simpson RR: Shakespeare and medicine. Edinburgh: E 8 S Livingstone, 1959; 57. Bucknill JC: The Medical knowledge of Shakespeare. London: Longman, 1860; 166. Shattuck FC: The science and art of medicine in some of their aspects. Boston Med Surg J 1907; 157: 63-67.