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 {244} 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.
[Footnote 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 {245} 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 {246} 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.
Hirsch[25] 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.
[Footnote 23: _Transactions of the College of Physicians of
Philadelphia_, 3d S. vol. iii.]
[Footnote 24: Murchison.]
[Footnote 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 {247} 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.
[Footnote 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
construction of sewers with their house connections, seem to favor the
occurrence of typhoid fever. But there is no real antagonism between
the diseases. During the recent Civil War typhoid fever was not
infrequently developed in soldiers suffering from malarial disease.
Indeed, so frequent was it to have the manifestations of the two
diseases in the same individual that many observers at that {248} time
supposed they had a new disease to deal with, to which they gave the
name of typho-malarial fever.
2. EXCITING CAUSES.--Much diversity of opinion has existed in times
past and to a certain extent continues to exist, in regard to the
contagiousness of typhoid fever. In the early part of this century
there was quite a number of good observers, including Nathan Smith in
this country, and Bretonneau and Gendron of Château du Loir in France,
who held the opinion it was an eminently contagious disease. Indeed,
Smith went so far as to say that its contagiousness was as fully
demonstrated as that of measles, small-pox, or any other disease
universally admitted to be contagious. This was also the opinion of
William Budd, who maintained that the contagious nature of typhoid
fever was the master truth in its history. The late Sir Thomas Watson
was also a warm supporter of the same view. At the present time,
however, the large majority of physicians, whose opportunities for
observation give weight to their opinions, do not regard the disease
as contagious in the strict sense of the word. During the past
twenty-four years I have been almost uninterruptedly connected with
large general hospitals, and during that time have had a large number
of cases of typhoid fever under my care, and a still larger number
more or less under my observation. During all this time I have never
known but one case to originate within a hospital, and that occurred
in a servant whose duties did not bring her in immediate contact with
the sick. Murchison's experience with a much larger number of cases
has been very similar. In twenty-three years, in which 5988 cases were
treated in the London Fever Hospital, only 17 residents contracted the
disease, and most of these had no personal contact with the sick.
Liebermeister asserts that he has never known a case to originate in a
hospital from direct contagion. When such cases appeared to have
occurred, they could generally be traced, he says, to some defective
sanitary condition of the hospital.
There are, nevertheless, many facts on record which, unless duly
weighed, appear to lend a good deal of support to the theory of the
contagiousness of typhoid fever. Among the most important of these are
(1) the occurrence in rapid succession of several cases in the same
house, and (2) the limited epidemics which occasionally follow the
arrival of an infected person into a previously healthy locality.
These facts are, however, susceptible of an entirely different
explanation.
1. In those instances in which several cases of the disease have
occurred in the same house, it not infrequently happens that some
defect in its sanitary conditions is detected, or that the
drinking-water is found to be impure. The same cause which produced
the first case may, therefore, also have produced those which
succeeded it. Indeed, the interval between the cases is sometimes so
short that for this reason alone, if there were no other, they could
scarcely be attributed to contagion. It not infrequently happens that
the seizure of one member of a large family is followed on the next
day by that of another, and on the third or fourth by that of still
another. Now, while it is undoubtedly true that the period of
incubation has appeared in some cases to be very short, we know that
under ordinary circumstances it is usually about two weeks.
2. The explanation of the second fact is not more difficult, but in
order that it may be clear to the reader it will be well to give in
detail a few {249} of the instances on record in which the arrival of
an individual sick with typhoid fever in a previously healthy locality
has been followed by an outbreak of the disease. Nathan Smith refers
to two cases of this character. In both of these the disease appeared
to be communicated to several individuals by patients who had
contracted the disease elsewhere. So little is said in the reports of
these cases of the water-supply of the localities in which they
occurred, or of the manner of disposing of the discharges of the
patients, that they would scarcely now be used as arguments in favor
of the contagiousness of the disease. The report of a local epidemic
by Austin Flint, Sr., is more satisfactory in this respect, and is as
follows: A stranger was detained in a small village near Buffalo by an
illness which proved fatal in the course of a few days, and which was
recognized as typhoid fever by his attending physicians. Up to this
time, it is stated, typhoid fever had never been known in the
neighborhood. In the course of a month more than one-half of the
population, numbering forty-three, was attacked by the disease, and
ten had died. The family of the tavern-keeper at whose house the
stranger lodged was the first to suffer, and of the families
immediately surrounding the tavern but one wholly escaped, that of a
man named Stearns. Upon investigation, it was ascertained that this
family alone, of all these families, did not use the well belonging to
the tavern, but had its own water-supply. The occurrence of the
disease naturally produced great excitement, and Stearns, between whom
and the tavern-keeper a quarrel existed, was suspected of having
poisoned the well; but an examination of the water showed this
suspicion to be unfounded. There can, however, be little doubt that
the water of the well, which was in all probability contaminated by
the discharges of the stranger, was the means of propagating the
disease; for although it is said that the family of Stearns was cut
off by the quarrel from all intercourse with that of the
tavern-keeper--a fact upon which some stress is laid by Flint--it does
not appear that a similar isolation existed as regards the other
families affected.[27]
[Footnote 27: _A Treatise on the Principles and Practice of Medicine_,
by Austin Flint, M.D., Philadelphia, 1868.]
The manner in which the arrival of a sick person may cause the
dissemination of the disease in a previously healthy community is even
better shown by the following histories of local outbreaks:[28]
"The water-supply pipes of the town of Over Darwen were leaky, and the
soil through which they passed was soaked at one spot by the sewage of
a particular house. No harm resulted till a young lady suffering from
typhoid fever was brought to this house from a distant place. Within
three weeks of her arrival the disease broke out and 1500 persons were
attacked. At Nunney a number of houses received their water-supply
from a foul brook contaminated by the leakage of a cesspool of one of
the houses, but no fever showed itself till a man ill with typhoid
came from a distance to this house. In about fourteen days an outbreak
of fever took place in all the houses."
[Footnote 28: Wm. Cayley, M.D., _Brit. Med. Jour._, March 15, 1880.]
There are many other observations which seem to render it certain that
the alvine dejections are a most important medium by which typhoid
fever is communicated to others; and yet there is no evidence that
they possess this power in a fresh condition. They have been
repeatedly examined, and even handled, with impunity, and, as has
already been stated, it {250} is rare for the disease to be imparted
to the immediate attendants upon the sick, or in a well-ventilated
hospital to the other patients in the same ward, provided that the
discharges are disinfected and removed immediately after being passed,
and the bed-linen and clothes of the patient changed whenever they are
soiled. The feces must therefore undergo some changes before they
become possessed of virulent properties. This appears to be shown
conclusively by the following facts: (1) laundresses who wash the
soiled clothes of typhoid fever patients not infrequently contract the
disease; (2) the occupants of houses connected by ill-trapped drains
with sewers into which the discharges of such patients have found
their way often suffer severely from the disease; and (3) the use of
water polluted by such discharges is, as has already been shown,
almost certain to induce the disease in persons not protected by a
previous attack.
The following histories of outbreaks of typhoid fever will show
clearly how the dejections of patients may be the means of propagating
the disease to others: