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, {238} 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 Spigelius[1] 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. Panarolus[3] 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. Willis[4] 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. Sydenham[5] 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. Baglivi[6] of Rome
in the latter part of the seventeenth century described the
hæmitritæus of previous writers {239} 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 Lancisi[8] 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
Manningham[9] 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 Morgagni[10] 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.
[Footnote 1: _De Febre Semitertiana_, Frankf., 1624; Op. Om.,
Amsterdam, 1745. Quoted by Murchison.]
[Footnote 2: _Handbuch der Historisch-Geographischen Pathologie_, von
Dr. August Hirsch, Stuttgart, 1881.]
[Footnote 3: _Observat. Med. Pentecostæ; Romæ_, 1652. Quoted by
Murchison.]
[Footnote 4: _Dr. Willis's Practice of Physick_, translated by Samuel
Pordage, London, 1684.]
[Footnote 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.]
[Footnote 6: _Opera Omnia Medico-practica et Anatomica_, Paris, 1788.]
[Footnote 7: _Opera Omnia Physico-Medico_, 1699. Quoted by Murchison.]
[Footnote 8: _Opera Omnia_, Geneva, 1718.]
[Footnote 9: _The Symptoms, Nature, etc. of the Febricula or Little
Fever_, London, 1746.]
[Footnote 10: Quoted by Hirsch.]
To Bretonneau[11] 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.
[Footnote 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 {240} 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.
[Footnote 12: _Researches Anatomiques, Pathologiques et Therapeutiques
sur la Maladie connue sur les Noms de gastro-entente, etc._, par P. C.
A. Louis, Paris, 1829.]
[Footnote 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 Smith[14] 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, Bartlett[16] 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 {241} 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.
[Footnote 14: _Medical and Surgical Memoirs_, Baltimore, 1831.]
[Footnote 15: _Observations on the Typhoid Fever of New England_,
Boston, 1839.]
[Footnote 16: _The History, Diagnosis, and Treatment of the Fevers of
the United States_, 1842.]
[Footnote 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. Murchison[18] 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.
[Footnote 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 {242} 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.
[Footnote 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, {243} 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. Manzini[20] 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.
[Footnote 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.
[Footnote 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.