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It is scarcely necessary to add that a local inflammation or a
traumatic cause may give rise to symptoms simulating those of
simple continued fever, and that the diagnosis of this disease must
be uncertain until these conditions have been positively ascertained
to be absent, or, if present, until they have been proved to be
complications, and not the causes of the disease.

PROGNOSIS.—The prognosis of this disease, as it is met with in this

country, is favorable. Indeed, when uncomplicated it may be said to
end invariably in recovery, except in the aged and feeble, in whom,
when it occurs during the great heat of the summer season, it is apt
to assume the asthenic form, and to be accompanied by symptoms
of a grave character. The ardent continued fever of the tropics, on
the other hand, not infrequently terminates fatally, or may leave the
sufferer from it a chronic invalid for life, which is frequently
shortened by obscure cerebral or meningeal changes, which give rise
to irritability, impaired memory, epilepsy, headache, mania, partial or
complete paraplegia, or blindness.19
19
Sir Joseph Fayrer, K.C.S.I., M.D., F.R.S., Brit. Med. Jour., April 29, 1881, p. 607.

ANATOMICAL LESIONS.—Death so rarely occurs in this latitude from

simple continued fever that the opportunities for making post-
mortem examinations do not often occur. There are, however, a
sufficient number of such examinations on record to show that the
disease gives rise to no specific lesions. According to Murchison and
Martin,20 inspection in fatal cases of ardent continued fever usually
reveals the presence of great congestion of all the internal organs
and of the sinuses of the brain and pia mater, of an increased
amount of intracranial fluid, and occasionally of an effusion into the
abdominal cavity, and more rarely into the thoracic cavity.
20
The Influence of Tropical Climates on European Constitutions, by James Ranald
Martin, F.R.S., London, 1856.
TREATMENT.—In the milder forms of the disease little or no treatment
is required—a fact which seems to have been recognized and acted
upon long ago, since Strother remarks that the cure of it is so easy
that physicians are seldom consulted about such patients. An emetic
when the attack has been caused by excesses of the table, and
there is reason to believe that there is undigested food in the
stomach, a purgative when constipation exists, and cooling drinks,
the effervescing draught or some other saline diaphoretic, are
usually the only remedies that are called for. In cases in which the
febrile action is more intense and prolonged, in addition to the use
of these remedies an effort should be made to reduce the heat of
the skin and the frequency of the pulse by sponging with cold water
and by the administration of digitalis and aconite. The headache
which is often a distressing symptom may usually be relieved by the
application of evaporating lotions, and restlessness quieted by the
bromides. Subsequently, quinia may be given with advantage. The
patient should be restricted to liquid diet during the continuance of
fever.

In the asthenic form quinia and the mineral acids, nutritious food,
and very frequently alcoholic stimulants, must be given from the
beginning. In the treatment of the ardent continued fever of the
tropics the cold affusion or the cold bath, with quinia, would appear
to be indicated, but Morehead and other Indian physicians advise
the use of evacuants with copious and repeated venesections,
cupping, and leeches, aided by tartar emetic, till all local
determination and the chief urgent symptoms are removed; and
Murchison expresses the belief, founded on his own observations,
that life is often sacrificed by adopting less active measures.
 TYPHOID FEVER.

BY JAMES H. HUTCHINSON, M.D.

DEFINITION.—An endemic infectious fever, usually lasting between

three and four weeks, and associated with constant lesions of the
solitary and agminate glands of the ileum, and with enlargement of
the spleen and mesenteric glands. Its invasion is usually gradual and
often insidious. Sometimes the only symptoms present in the
beginning are a feeling of lassitude, some gastric derangement, and
a slight elevation of temperature; at others there are slight rigors or
chilly sensations, headache, epistaxis, diarrhoea, and pain in the
abdomen. The principal symptoms of the fully-formed disease are a
febrile movement possessing certain characters, headache passing
into delirium and stupor, diarrhoea associated with ochrey-yellow
stools, tympanites, pain and gurgling in the right iliac fossa, a red
and furred tongue, which later often becomes dry, brown, and
fissured; a frequent pulse; an eruption of rose-colored spots,
occurring about the seventh or eighth day, slightly elevated above
the surface, disappearing under pressure, and coming out in
successive crops, each spot lasting about three days; prostration not
marked in the beginning, but rapidly increasing; and occasionally
deafness, sweats, and intestinal hemorrhages. When recovery takes
place, the convalescence is usually tedious, and may sometimes be
protracted by the occurrence of one or more relapses.

SYNONYMS.—The following are a few of the many names which have

been given to the disease at different times. Most of them have
ceased to be applied to it, and only three or four of them are at
present in general use: Febris Mesenterica, 1696; Slow Nervous
Fever, 1735; Febricula or Little Fever, 1740; Typhus Nervosus, 1760;
Miliary Fever, 1760; Typhus Mitior, 1769; Synochus, 1769; Common
Continued Fever, 1816; Gastro-Enterite, 1816; Entero-Mesenteric
Fever, 1820; Abdominal and Darm Typhus, 1820; Typhus Fever of
New England, 1824; Dothienterie, 1826; Enterite-folliculeuse, 1835;
Infantile Remittent Fever, 1836; Enterite Septicémique, 1841;
Mucous Fever, 1844; Enteric Fever, 1846; Intestinal Fever, 1856;
Ileo-Typhus, 1857; Pythogenic Fever, 1858; Mountain Fever, 1870.

NAME.—It has been objected to the name "typhoid fever" as a

designation for this disease that it tends to perpetuate among the
laity the mistaken impression that typhoid fever is only a modified
typhus fever, and also that the word typhoid has been generally
applied to a condition of system which is common to a great many
different diseases, and which is not of necessity present in this. In
spite of these objections, and although it must be admitted that they
are not without force, I prefer to retain the name typhoid fever, and
for the following reasons: 1st. It was the name given to the disease
by Louis, to whom we owe the first full and accurate description of
it. 2d. It is the name by which it is best known to the profession, not
only in this country but abroad. 3d. No other name has been
proposed for it which is not quite as much open to criticism. Thus
the term enteric fever, originally suggested by the late George B.
Wood, and adopted by the London College of Physicians in its
Nomenclature of Diseases, is objectionable because it brings into
undue prominence the intestinal lesions and implies that they are
the cause of the fever. The same objection may be urged against the
name "intestinal fever," proposed by Budd. The name "pythogenic
fever" rests upon a theory of the disease which has never been
proven, and is regarded by most observers as untenable. Under
these circumstances even the influence of its distinguished proposer,
the late Dr. Murchison, has been insufficient to secure its adoption
by the profession at large.
HISTORY.—Certain passages in the writings of Hippocrates have been
appealed to by Murchison and other physicians in support of the
opinion that typhoid fever was a disease of at least occasional
occurrence in ancient times; but, although from the nature of its
causes it is probable that it has occurred in all ages and wherever
men have congregated in towns and villages, the descriptions given
by the Father of Medicine in the passages alluded to are not
sufficiently full to render it at all certain that typhoid fever had ever
come under his observation. Indeed, there is no author of an earlier
date than Spigelius1 whose writings furnish any positive evidence
that he ever met with the disease. Spigelius, however, in spite of the
doubt thrown upon his observation by Hirsch,2 would seem to have
had opportunities for examining the bodies of those who had died of
it, since he gives an account of several autopsies, in which he says
that the small intestine was inflamed and that that part of it next to
the cæcum and colon was frequently sphacelated. Panarolus3 also
says that the intestines had the appearance of being cauterized
("apparebant tanquam exusta") in some cases observed by him in
Rome a little later in the same century. Willis4 would certainly appear
to have been familiar with two forms of fever, which, from the
description he gives of them, could have been nothing else but
typhoid and typhus fevers. Sydenham5 also described a fever in
which the prominent symptoms were diarrhoea, vomiting, delirium, a
tendency to coma, and epistaxis, and which was distinguishable
from the febris pestilens by the absence of a petechial eruption.
Baglivi6 of Rome in the latter part of the seventeenth century
described the hæmitritæus of previous writers under the title of
febris mesenterica, and maintained that it was always accompanied
by and dependent on inflammation of the intestines and
enlargement of the mesenteric glands. A similar observation was
made soon after by Hoffmann,7 and by Lancisi8 in 1718. The latter
seems to have fully recognized the characteristics of the eruption,
for he says that it consisted of "elevated papules which disappeared
completely on pressure." In 1759, Huxham described, under the title
"slow, nervous fever," a disease which there can be no doubt was
typhoid fever. He moreover pointed out very clearly the distinctions
between this disease and another to which he gave the name of
"putrid, malignant, petechial fever," and which was unquestionably
typhus. Sir Richard Manningham9 also described typhoid fever under
the title of "febricula, or little fever." In the preface of his work he
calls attention to its insidious origin, and to the fact that its gravity
was often underrated at its commencement, "till, at length, more
conspicuous and very terrible symptoms arise, and then the
Physician is sent for in the greatest hurry, and happy for the Patient
if the Symptoms, which are most obvious, do not, at this Time,
mislead the Physician to the Neglect of the little latent Fever, the
true Cause of these violent Symptoms." About the same time
Morgagni10 described certain post-mortem examinations in which the
lesions of the intestines were evidently those of typhoid fever. Other
authors, whose works bear evidence that they were familiar with the
symptoms or lesions of typhoid fever, are Riedel, Roederer and
Wagler, Stoll, Rutty, Sarcone, Pepe, Fasano, Mayer, Wrenholt, Sutton,
Bateman, Muir, Edmonstone, Prost, Petit and Serres, Cruveilhier,
Lerminier, and Andral.
1
De Febre Semitertiana, Frankf., 1624; Op. Om., Amsterdam, 1745. Quoted by
Murchison.

2
Handbuch der Historisch-Geographischen Pathologie, von Dr. August Hirsch,
Stuttgart, 1881.

3
Observat. Med. Pentecostæ; Romæ, 1652. Quoted by Murchison.

4
Dr. Willis's Practice of Physick, translated by Samuel Pordage, London, 1684.

5
The Works of Thomas Sydenham, M.D., on Acute and Chronic Diseases, with a
Variety of Annotations by George Wallis, M.D., London, 1788.

6
Opera Omnia Medico-practica et Anatomica, Paris, 1788.

7
Opera Omnia Physico-Medico, 1699. Quoted by Murchison.

8
Opera Omnia, Geneva, 1718.
 9
The Symptoms, Nature, etc. of the Febricula or Little Fever, London, 1746.

10
Quoted by Hirsch.

To Bretonneau11 of Tours appears to belong the credit of having first

distinctly pointed out the association between certain symptoms and
the lesions of the solitary and agminated glands of the ileum. He
regarded the disease of the intestinal glands as inflammatory, and
therefore gave to it the name "dothienenterie" or "dothienenterite"
(from [Greek: dothiên], a tumor, and [Greek: enteron], intestine),
but, unlike Prost, fully recognized the fact that there was no
necessary relation between the extent of the intestinal lesions and
the gravity of the febrile symptoms. Hirsch, however, claims this
honor for Pommer, whose little work on Sporadic Typhus he thinks
has not received the consideration its merits deserve. Louis, to
whom for his careful study of typhoid fever we owe a large debt of
gratitude, was also fully aware of the lesions of the intestinal glands
which occur in this disease.
11
Quoted by Trousseau, Archives Générales, 1826.

The progress in pathology which observers were making was

temporarily impeded about this time by the fact that while typhoid
fever was of frequent occurrence in Paris, typhus fever was
comparatively rarely met with and had not been epidemic there for
several years. Bretonneau, Louis,12 Chomel, and indeed the greater
number of contemporary French physicians, therefore fell into the
error of supposing that the fever which was then common in
England was identical with that which they were describing, while
the English physicians of the period, with but few exceptions,
contended with equal strenuousness that there was but one form of
continued fever, and that this was very seldom associated with
disease of the intestines. In the second edition of his work Louis
abandoned his former opinion, and admitted that the typhus fever of
the English was a very different disease from that which formed the
subject of his treatise; but the confusion which existed in England in
regard to this disease was not completely dispelled until the
appearance in 1849 and the following two years of several papers on
this subject by Sir William Jenner,13 in which it was conclusively
demonstrated that typhoid and typhus fevers were separate and
distinct diseases. In Germany, however, the non-identity of these
diseases was recognized as early as 1810. Murchison says that the
names by which they are still generally known in that country,
typhus exanthematicus and typhus abdominalis, were given to them
not long after.
12
Researches Anatomiques, Pathologiques et Therapeutiques sur la Maladie connue
sur les Noms de gastro-entente, etc., par P. C. A. Louis, Paris, 1829.

13
Med. Chir. Trans., vol. xxxiii.; Edinburgh Monthly Jour. of Med. Sci., vols. ix. and x.,
1849-50; and Med. Times, vols. xx., xxi., xxii., xxxiii., 1849-51.

The contributions made by American physicians to the knowledge of

typhoid fever have been both numerous and important. In 1824 it
was described by Nathan Smith14 under the name of typhus fever of
New England, and in 1833, E. Hale, Jr.,15 of Boston, published in the
Medical Magazine for December an account of three dissections of
persons considered by him to have died of the disease. In reference
to these cases, Bartlett16 says that if the diagnosis could be looked
upon as certain and positive they would constitute the first published
examples of intestinal lesion in New England. In February, 1835,
William S. Gerhard of Philadelphia, who was then under the
impression that the two diseases were identical, reported two cases
under the name of typhus fever, the symptoms and post-mortem
appearances of which he showed differed in no respect from those
he had been accustomed to see in the cases of typhoid fever he had
observed with Louis during his studies in Paris. The year after
Gerhard had, however, the opportunity of observing an epidemic of
true typhus fever, and was at once struck with the difference
between the symptoms of the cases which then fell under his care
and of those he had seen in Paris. In an admirable paper which
appeared in the numbers of the American Journal of the Medical
Sciences for February and August, 1837, he points out very clearly
the differential diagnosis between the two diseases. He particularly
insisted on the marked difference between the petechial eruption of
typhus and the rose-colored eruption of typhoid fever. He showed
that the latter disease was invariably associated with enlargement
and ulceration of Peyer's patches and with enlargement of the
mesenteric glands, and that these conditions were never presented
in the former. He also fully recognized the fact that typhus fever was
eminently contagious, while, on the other hand, he was fully aware
that typhoid fever was not contagious under ordinary circumstances,
"although in some epidemics," he says, "we have strong reason to
believe it becomes so." The appearance of this paper marks an
epoch in the history of typhoid fever. Murchison, when speaking of it,
says that to Gerhard, and Pennock (who was associated with
Gerhard in his observations) certainly belongs the credit of first
clearly establishing the most important points of distinction between
this disease and typhus fever, and M. Valleix alludes to it in terms
equally complimentary. It is undoubtedly owing to it, more than to
any other cause, that the differential diagnosis of these two diseases
was perfectly understood by the great body of the profession in this
country long before the question of the relation which they bore to
each other was definitely settled in Great Britain,17 or even in France.
14
Medical and Surgical Memoirs, Baltimore, 1831.

15
Observations on the Typhoid Fever of New England, Boston, 1839.

16
The History, Diagnosis, and Treatment of the Fevers of the United States, 1842.

17
The honor of having first clearly pointed out the distinguishing characters of typhoid
and typhus fevers has been recently claimed for Sir William Jenner, but, as we have
seen above, his papers on this subject were not published until thirteen years after
that of Gerhard.

Bartlett gave in the Medical Magazine, June, 1835, a short account

of the entero-mesenteric alterations in five cases of unequivocal
typhoid fever, which alterations, he said, corresponded exactly to
those described by Louis. In the same year, James Jackson, Jr., of
Boston, published an account of the intestinal lesions observed by
him in cases during the years 1830, 1833, and 1834; and again in a
Report of Typhoid Fever, communicated to the Massachusetts
Medical Society in June, 1838, says that the alterations of Peyer's
patches had been noticed at the Massachusetts General Hospital
previous to 1833 in cases which were carefully examined. In 1840,
Shattuck of Boston published in the American Medical Examiner an
account of some cases of typhoid and typhus fever which he had
observed at the London Fever Hospital during the previous year. In
this paper, which had been already communicated to the Medical
Society of Observation of Paris, and which had unquestionably
exerted a marked influence upon medical thought there, he pointed
out very fully the distinguishing characteristics of each disease. In
1842, Dr. Bartlett issued the first edition of his work on The History,
Diagnosis, and Treatment of the Fevers of the United States, which
contains very full descriptions of both of these diseases, and of the
means by which they may be distinguished from each other. Since
then there have been numerous additions in this country to the
literature of typhoid fever, among the most important of which may
be mentioned the chapter on the disease in the respective works on
The Practice of Medicine by Professors Wood and Flint, the article on
typho-malarial fever in the Transactions of the International Medical
Congress of 1876, and the article in the work on The Continued
Fevers, by James C. Wilson. Abroad, the medical press has been no
less active. Within the last twenty or thirty years Jaccoud and
Trousseau in France, Liebermeister and Hirsch in Germany, and
Tweedie and Cayley in England, have all made important additions to
our knowledge of the disease. To the late Dr. Murchison18 of London,
however, is justly due the honor of having produced the best treatise
on typhoid fever in any language, and the writer cheerfully
acknowledges that he has drawn largely upon it for the material of
the present article.
18
A Treatise on Continued Fevers, London, 1873.
GEOGRAPHICAL DISTRIBUTION.—Although it will be generally admitted
that the conditions of civilization favor the occurrence and extension
of typhoid fever, yet there is abundant evidence that they are not
absolutely necessary to its production, as there is no country,
whether civilized or not, of the diseases of which we have any
knowledge, in which it has not occasionally made its appearance,
being met with in every variety of climate. It is endemic in North
America, attacking alike the inhabitants of Greenland and British
America and those of Mexico. In our own country it prevails from
time to time in every State of the Union, committing its ravages as
well among the rocks and hills of New England as in the more fertile
valleys of the West and South. In many of the newly-settled portions
of our country malarial fevers are, as is well known, exceedingly rife.
In proportion, however, as towns and cities spring up, and as the
land is properly drained, they diminish in frequency, and are
gradually replaced, to a certain extent at least, by typhoid fever; but
the influences which produced them retain for a long time enough of
power to stamp their impress upon all other diseases. In large
portions of the Western and Southern States typhoid fever is
therefore rarely uncomplicated, and is much more likely to assume
the form which will be fully described later as typho-malarial fever.

Typhoid fever has also occurred frequently in Central America and

the West India Islands. It has prevailed from time to time in the
states of South America, and occasionally assumed in some of them
—as, for instance, Brazil and Chili—an epidemic form.

Typhoid fever is endemic in the British Isles, but, according to

Murchison, is most common in England, more common in Ireland
than in Scotland, and in Scotland more common on the west than on
the east coast. It also exists as an endemic disease in every country
of the continent of Europe, from Sweden and Norway on the north
to Turkey on the south, and in some of them—as, for instance,
France and Germany—would seem to be of much more frequent
occurrence than in this country, or even in England. Medical
literature is also not deficient in evidence that it has prevailed at
various times in all the different countries of Asia and Africa and in
Australia. Morehead asserted in the first edition of his Clinical
Researches on Diseases in India that India enjoyed an absolute
immunity from typhoid fever, but in the second edition of this work
he acknowledged that a larger experience had led him to change his
opinion on this point. Moreover, the writings of Annesley, Twining,
and other Indian authors furnish convincing proof that the disease is
by no means unknown in that country. Indeed, even the relative
immunity from it which it has been claimed that tropical and
subtropical countries possess has been found, upon a fuller study of
the diseases of these countries, not to exist to anything like the
degree that was formerly supposed.

The occasional occurrence of typhoid fever in islands separated from

the main land by a considerable distance—as, for instance, the
island of Norfolk,19 which is situated in the Pacific Ocean four
hundred miles west of South America—is an interesting fact, and
one which, with the present limits to our knowledge on the subject,
it is impossible to explain satisfactorily.
19
Metcalfe, Brit. Med. Jour., Nov., 1880.

The ETIOLOGY of typhoid fever may be considered under the heads of

—1, predisposing, 2, exciting causes.

1. PREDISPOSING CAUSES.—All observers agree that the predisposition to

typhoid fever is greater in childhood and early adult life than after
thirty years of age. Thus, Murchison states that during twenty-three
years nearly one-half the admissions to the London Fever Hospital
were of patients between fifteen and twenty-five years of age, and
that in more than a fourth, the patients were under fifteen years. On
the other hand, in less than a seventh were they over thirty, and in
only one in seventy-one did their ages exceed fifty. Taking these
facts in connection with the circumstance that the entire population
of England and Wales in 1861 was 12,481,323 persons under thirty
years of age and 7,584,901 above thirty, it follows, he says, that
persons under thirty are more than four times as liable to enteric
fever as persons over thirty. Jackson found that the average age of
the patients in two hundred and ninety-one cases observed at the
Massachusetts General Hospital was a little over twenty-two years,
the average age in the fatal cases being somewhat greater than in
those in which recovery took place. Liebermeister, from an analysis
of a large number of cases treated at the hospital in Basle, has
arrived at the same conclusion. No age, however, enjoys a complete
immunity from the disease. Manzini20 has recorded a case in which
lesions of Peyer's patches similar to those of typhoid fever were
found in a seventh-month foetus which died within half an hour after
its birth. Cases are also on record in which death has occurred from
this disease in the first few weeks of life. I have myself observed
several cases in young children at the Children's Hospital in
Philadelphia. The probability is, that it is of even more frequent
occurrence in children than is generally supposed, as this class of
patients is not often admitted into general hospitals, and as from the
absence of some of its characteristic symptoms when it occurs in the
very young the nature of the disease is often unrecognized.
20
Quoted by Murchison.

On the other hand, the disease occurs not infrequently in advanced

life: 83 cases out of 5911 were observed at the London Fever
Hospital in persons over fifty, 27 in persons over sixty, and in 2 the
age was seventy-five. In a case recorded by D'Arcy the age of the
patient was eighty-six, and in one reported by Hamernyk it was
ninety.21 Bartlett long ago contended that the disease was not so rare
as was generally supposed among people over forty years of age;
and there is really no good reason to believe that the susceptibility
to the causes of the disease in an unprotected person diminishes
with advancing years, the immunity from this disease which elderly
people appear to enjoy being probably due to the fact that, as the
disease is not uncommon in early life, they are in many instances
protected by having already passed through an attack.
 21
Quoted by Murchison.

The mean age of the male patients treated at the London Fever
Hospital was slightly in excess of that of the female, but in the cases
analyzed by Jackson the reverse of this was observed.

The statistics of all general hospitals, with very few exceptions, show
a greater or less preponderance of males over females among the
typhoid fever patients treated in them. According to Murchison, of
5988 cases admitted into the London Fever Hospital during twenty-
three years, 3001 were males and 2987 were females. Of 891 cases
admitted into the Glasgow Infirmary during twelve years, 527 were
males and 364 females. Liebermeister states that 1297 male typhoid
patients and 751 female were treated in the hospital at Basle from
1865 to 1870. Occasionally, the difference is even greater than is
indicated by these figures. Thus, of 138 cases observed by Louis, all
but 32 occurred in males. When, however, we consider that the
proportion of men who apply for admission to hospitals when sick is
much larger than that of women, we should hesitate before
accepting these statistics as proof that the former are more liable to
be attacked by typhoid fever than the latter. Indeed, the opinion
which Murchison expresses is generally accepted as correct by
authors, that neither sex is more likely than the other to contract the
disease. Liebermeister asserts that pregnant and puerperal women
and those who are nursing infants enjoy a relative immunity. On the
other hand, Nathan Smith says that while the sexes are equally
liable to it, more women are cut off by it than men, in consequence
of its appearance during pregnancy or soon after parturition.

It was long ago pointed out by certain French observers that

newcomers are much more liable to be attacked by typhoid fever
than persons who have lived for some time in an infected locality. In
129 cases examined with reference to this point by Louis, the
patients in 73 had not resided in Paris more than ten months, and in
102 not more than twenty months. Bartlett noticed that during an
epidemic in Lowell which he had the opportunity of observing the
disease attacked the recent residents in much larger proportion than
the old. Liebermeister also calls attention to this peculiarity of the
disease. Murchison's experience in reference to this point has been
somewhat similar, for he found upon examination of the records of
the London Fever Hospital that 21.84 per cent. of the patients
admitted there for typhoid fever had been residents of London for
less than two years. Almost all of these patients came, he says, from
the provinces of England, and were in good health and comfortable
circumstances at the date of their arrival in London and for some
time after. Moreover, a large proportion of them were first attacked
within a few weeks after changing their residence from one part of
London to another. He also refers to instances in which successive
visitors at the same house at intervals of months, or even years,
have been seized shortly after their arrival with typhoid fever or with
diarrhoea, from which the ordinary occupants were exempt. These
facts indicate with sufficient clearness that habitual exposure to the
causes of the disease confers, to a certain extent at least, an
immunity from their effects, just as it does in the various forms of
disease arising from malaria. It is not unlikely, as has been
suggested by Wilson,22 that one of the causes of the frequency of
typhoid fever in the early autumn in our American cities among well-
to-do people is to be formed in the circumstance that during an
absence of two months or more in the mountains or by the sea they
have to some extent lost the immunity acquired by habitual
exposure to sewer emanations, and return to the atmosphere of the
city unprotected.
22
The occurrence of typhoid fever in the early fall among persons who have spent the
summer out of town is, however, susceptible of another explanation. In many
instances they have returned to houses which have been not only unoccupied, but
closed, during several months, and which, in consequence of the more or less
complete evaporation of the water in the traps of the drain-pipes, have been
thoroughly permeated by sewer gas.

There is no evidence that any particular occupation acts as a

predisposing cause of typhoid fever. Among the 621 patients treated
at the Pennsylvania Hospital during the last ten years, were
representatives of every branch of industry, and the same fact has
been observed at every general hospital, not only in this country, but
abroad. There is also no reason to believe that the station in life of
itself exerts much influence in predisposing to the disease. The rich
suffer equally with the poor. It would appear, indeed, that since the
recent general introduction of ill-ventilated water-closets and
stationary washstands into the houses of the better classes the
liability of the former to suffer from the disease is greater than that
of the latter.

Persons recovering from an illness or in an infirm condition of health

do not appear to be more liable than others to be attacked by
typhoid fever. Among the many patients who have fallen under my
care only a very few were in ill-health at the time of their seizure.
The same fact has been noticed by Murchison and other observers.
Indeed, Liebermeister goes so far as to say that typhoid fever
attacks by preference strong and healthy persons, while it avoids
those suffering with chronic ailments. That this latter class of
patients enjoys no immunity from the disease when exposed to its
causes is shown by a fact which he himself records. During his
service at the hospital at Basle from 1865 to 1871 several of the
patients in the medical and surgical wards were attacked by typhoid
fever, the cases being especially numerous in two rooms which were
situated one directly over the other. Upon investigation it was found
that a wooden pipe which extended from the sewer to the roof ran
by both of these rooms. The sewer at the point where this pipe ran
into it was of faulty construction, and was turned at a right angle, so
that the refuse matter collected there. Since this source of infection
was made known repeated cleansings, washings, and disinfections
have been followed by satisfactory improvement, and Liebermeister
believes that if the sewer were entirely altered the infection would
disappear.

It would seem only natural that intemperance, by diminishing the

powers of resistance in the individual, would increase his liability to
contract typhoid fever, but there is no proof that it does so. Few of
the patients who have come under my care were intemperate, and
still fewer were broken down by this cause. There is also no
evidence that grief, fear, or any other depressing emotion is a
predisposing cause of the disease, and the same may be said of
bodily fatigue and overcrowding. On the other hand, much
importance has been attached by writers to idiosyncrasy as a
predisposing cause of typhoid fever. What the peculiarities of
constitution are which increase the liability to the disease are not
definitely known, but there can be no question that it occurs much
more frequently, and is much more fatal, in some families than in
others.

Typhoid fever occurs with the greatest frequency in this country, as

it does with very few exceptions elsewhere, during the latter half of
summer and the early part of autumn. Indeed, its greater prevalence
at this season than at other times has given to it the name of
"autumnal" and "fall fever," by which it is popularly known in many
sections of this country as well as of England. On the other hand,
the disease is usually at its minimum in May and June. The number
of cases, however, does not usually immediately diminish upon the
onset of cold weather. On the contrary, R. D. Cleemann,23 from a
comparison of the mortality returns of Philadelphia for a period of
ten years, observed that after diminishing in November they not
infrequently underwent a marked increase in December. Of 621
cases treated at the Pennsylvania Hospital during the last ten years,
89 were admitted during spring, 259 during summer, 182 during
autumn, and 91 during winter. Of 5988 cases treated at the London
Fever Hospital,24 759 were admitted in the spring, 1490 in summer,
2461 in autumn, and 1278 in winter. Of the whole number, 27.7 per
cent. were admitted in the two months of October and November,
and in April and May only 7.3 per cent. Hirsch25 has published
statistics which do not differ materially from these. He also mentions
the interesting fact that in Rio Janeiro the maximum of the disease
occurs in the months from March to June, or, in other words, in the
season which in that latitude corresponds to our autumn. There are,
however, some exceptions to the general rule of the greater
prevalence of the disease during the autumn. Bartlett, who was
aware of its greater frequency at that time, refers to an extensive
and fatal epidemic which occurred in the city of Lowell in
Massachusetts during the winter and early spring; and similar
visitations have been observed in other places.
23
Transactions of the College of Physicians of Philadelphia, 3d S. vol. iii.

24
Murchison.

25
Handbuch der Historisch-Geographischen Pathologie, Stuttgart, 1881.

Most authors agree with the statement made by Murchison, that

typhoid fever is unusually prevalent after summers remarkable for
their dryness and high temperature, and that it is unusually rare in
summers and autumns which are wet and cold. Certainly, the
severest epidemic of the disease which has been observed in
Philadelphia in several years occurred in the year 1876, during and
after a summer of exceptionally high temperature, and one
characterized by a decidedly diminished rainfall. Still, there can be
no question that the increased prevalence of the disease at this time
was due, in part at least, to the crowded condition of the city
consequent upon the Centennial Exhibition. In 1872, although the
mean of the summer temperature was slightly higher than that of
1876, the disease did not prevail in an epidemic form. This may be
explained by the fact that the rainfall of the summer months of this
year was decidedly greater than the average. Hirsch, however,
attaches much less importance to temperature as a factor in the
production of typhoid fever than most other authors. He says that he
has found, from a comparison of a large number of epidemics, that
the disease occurs almost as often in cool as in hot summers, in cold
as in warm autumns, and in mild as in severe winters. Murchison,
moreover, admits that mere dryness of the atmosphere is not
conducive to an increase of typhoid fever. On the contrary, he says,
warm, damp weather, when drains are most offensive, is often
followed by an outbreak of the disease.

The relation which temperature and moisture bear to the causation

of typhoid fever is therefore not definitely ascertained. It is certain,
however, that the largest number of cases does not occur at the
period of the greatest heat, but is usually not observed until from six
weeks to two months afterward, and the minimum is not reached
until about the same length of time after that of the most intense
cold. This difference in time Murchison explains by the hypothesis
that the cause of the disease is exaggerated or only called into
action by the protracted heat of summer and autumn, and that it
requires the protracted cold of winter and spring to impair its activity
or to destroy it. On the other hand, Liebermeister, who believes that
the breeding-places of typhoid fever lie deep in the earth, holds that
the time is consumed in the penetration of the changes of
temperature to the place where the typhoid poison is elaborated, in
the development of the poison without the human body, and in the
period of incubation. In some places the maximum of the disease is
observed earlier in the year than in others. In Berlin, for instance,
the largest number of fatal cases occurs in October, while in Munich
it does not occur until February. This depends, he thinks, upon the
difference in the distance beneath the earth's surface of these
breeding-places in different localities, and the deeper they are the
longer, he says, will it be before they are affected by the heat of
summer or the cold of winter, since the changes of the temperature
of the air are followed by corresponding changes in the temperature
of the earth more and more slowly the deeper we go beneath the
surface.

Buhl and Pettenkofer have, as the result of a series of observations

carried on in Munich over a number of years, reached the conclusion
that an intimate relation exists between the variations in the degree
of prevalence of typhoid fever and the rise and fall of water in the
soil. When the springs were low they found that there was a marked
increase in the number of cases; when, on the other hand, they
were high, there was just as decided a diminution. Out of this fact
they have evolved the theory that the cause of typhoid fever lies
deep in the soil, and has the power of multiplying itself there, and
that this property is very much increased when the water-level sinks,
and the upper layers of the earth are consequently exposed to the
air. It is, on the contrary, diminished when the water-level rises and
the earth is again saturated with moisture. It is unquestionably true,
as has already been stated, that it is principally after hot and dry
weather, when the springs are of course low, that typhoid fever is
most prevalent, and that it very frequently subsides after the
occurrence of very heavy rains; but it is not necessary to adopt the
theory of Buhl and Pettenkofer to explain these facts. It seems quite
as probable that the increased prevalence of the disease after dry
weather is due, as suggested by Buchanan and Liebermeister, to the
greater amount of solid matter which is then suspended in the water
of the springs. A larger proportion of the germs of the disease, if
there should be any present in the soil, will therefore be contained in
any given quantity of the drinking-water. The theory fails to account,
as pointed out by Murchison, for the connection which is frequently
observed between defective house-drainage and outbreaks of
typhoid fever, occurring irrespectively of any variations in the subsoil
water. And, moreover, outbreaks of the disease have occurred under
precisely opposite circumstances, as the outbreak at Terling in 1867,
recorded by Thorne,26 which was coincident with a rise in the subsoil
water after drought.
26
Quoted by Murchison.

It is believed in many parts of our country that there is an

antagonism between typhoid fever and the various forms of malarial
fever, and it is unquestionably true that in many districts in which
the latter were formerly prevalent they have ceased to be frequent,
and have been replaced apparently by the former. In the cultivation
of the soil the causes of malarial fever disappear, or at least become
less potent. On the other hand, the increase of population and the
neglect of all sanitary laws in the building of towns, and the