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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

Vol. 6, No. 1.

TYPHOID FEVER: ITS ETIOLOGY AND DIAGNOSIS

*S. R. WILSON, M. D.
DANVILLE, VA.

Never in the history of the world has

there been so much discussion of the
disease, "Typhoid Fever," and is being
done for its eradication by all civilized
nations, as is being done today. Most of
the nations are alive to the fact that in
the past centuries there has been a
needless sacrifice to this preventable disease; and now something must be done.
Heretofore the layman has paid little
attention to it; and the physician seems
to have considered it a minorandlessimportant disease. If there was a case of
smallpox, diphtheria, or scarlet fever
in the community, the people would be
scared out of their wits. The physician would at once notify the health
officer, and the yellow flag would immediately be nailed to the door post as a
signal of danger.
But is this true of typhoid fever?
We say, no. Yet statistics show us that
more people in this country are stricken
and more die annually from typhoid fever than from the above three diseases
combined.
Still we say it is a preventable disease.
Then, what has been our trouble'?
Have we neglected our duties in preserving the health and lives of the people in the community in which we live
and labor, or have we been ignorant of
its real causes and dangers? I am glad
our eyes have been opened, and our intellect sharpened that we may do effectual service in the war against the
great and fatal disease.
It has been well said that "an ounce
of prevention is worth a pound of cure."
That forces me to believe. gentlemen.

we are unable to prevent any disease

without we know its cause, and make
a thorough study of its sources and

methods of transmission.
I believe I would voice the sentiment
of the profession when I say the first
and most important thing for us in any
disease is to ascertain its cause and,
secondly, to know what we have to treat.
Hence the body of my paper for your
consideration, "The Cause and Diagnosis of Typhoid Fever."
The cause of this disease may be discussed under three (3) heads. First,
the exciting cause. Secondly, the predisposing cause, and, thirdly, that cause by.
which the bacillus gains access to the

body.
About one-third of a century ago
(1880), Eberth isolated the specific bacillus and proved it to be the sole cause
of this disease. Therearebacteriologists,
such as Koch, Gaffky, and others, whose
scientific researches coincide with that
of Eberth, that this specific bacillus
was the sole cause of typhoid fever.
Bacillus typhosus bears the name of
the disease which it causes.
It is a short, thick, actively motile
bacillus with rounded ends and flagella.
It grows readily in ordinary suitable
media.
I feel sure that every practicing physician knows too well the exciting cause
to tarry longer in discussing it. Hence
I will hasten to the predisposing causes.
It is a foregone conclusion that anything which lowers the vitality of an individual renders that individual susceptible for the reception of any germ;

*Read before the fifteenth annual session of the National Medical Association

TYPHOID FEVER: -ITS ETIOLOGY AND DIAGNOSIS

that filthy, over-crowded, and bad ventilation, are predisposing causes, cannot
*be justly denied. And also any digestive disturbance by lowering the acidity
of the stomach and allowing the germ to
more readily pass into the intestines,
because these above conditions named
are sure to lower the resistance of the
individual exposed.
Where there is sanitary improvement
in a community the mortality of typhoid fever has been greatly decreased.
One-third of the typhoid fever cases I
have treated in the past eight years
were cases found in homes where sanitary laws had not been observed. This
includes, of course, over-crowded tenements, bad ventilation, and extremely
filthy ones.
I am not trying to convince you that
families who live in homes where sanitary laws are well observed are entirely
exempted from this disease; but I would
like to impress upon you that the mortality of this disease is a great deal less
in those homes where sanitary improvements have been observed. That
stamps upon my mind, gentlemen, an
indelible belief that filth, over-crowding,
and bad ventilation are predisposing
causes to this disease. We now know
why unsanitary conditions predispose
to typhoid fever; because human exereta is the main source of the germ to
the disease. Thirdly, let us consider
some of the more complicated etiological factors.
Those factors by which the bacillus
gives access to the body. I am sure I'd
voice the sentiment of the profession at
large when I say that contaminated
water stands out pre-eminently as king
of all other carriers, in infecting the
.body with this disease.
Whipple stated that in the cities
about 40 per cent of the typhoid fever

25

cases is due to water, 25 per cent to

milk, 30 per cent to contagion, including
fly transmission, and only about 5 per
cent to all other causes.
Dr. Hare stated that every great epidemic has been due to contamination of
the water supply. In the Madstone epidemic in England, one (1) person in every seventeen in that town was infected,
while in the Plymouth epidemic in Pennsylvania, one in every seven was strickened, out of this population of 8,000.
There were 1,200 cases.
An investigation proved that these
cases were contracted from the use of
contaminated water, and the proportion
of the infected would have been much
larger had all the people in Plymouth
used the contaminated water.
Dr. J. C. Hunt, from investigations
of an epidemic of typhoid fever in Troy,
Pennsylvania, proved that contaminated
water was the sole cause of that disease.
Look, for a moment, a few years back
(1899), at the great epidemic in Philadelphia, with a population of 1,300,000
inhabitants, during that year there were
7,985 cases of typhoid fever with nine
hundred and forty-eight deaths. This
was due largely to the fact that the people were drinking of the contaminated
water from the Schuylkill and Delaware
Rivers.
It is uesless for me to emphasize how
water becomes contaminated, for we
know that the source is human exereta.
It suffices to say that all people are
water drinkers, and common sense
teaches us that more people are likely
to contract a disease from a thing which
all people are partakers of. Another
liquid by which the bacillus gains access to the body is milk. It differs from
that of water. I did not state to you in
the preceding pages that water is not
the natural home' of typhoid fever

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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

germs. In fact, they do not live in it

very long. Milk has been proven to be
an excellent medium for bacteria; they
thrive in it and the result is that even
a slight infection of the milk is likely to
produce widespread infection.
It has been said by Mr. Parker, Bacteriologist in the University of Illinois,
that in milk epidemics the persons affected are very largely young people and
children, and are almost entirely patrons
of one dairyman. Therefore, this disease, typhoid, will usually follow his
wagon route. Where the route is very
long, we may expect a wide distribution
of this disease. Personal experience
has demonstrated to me that contaminated milk was responsible for some
cases I had in an epidemic at Keysville,
Va., about seven years ago. Water had
been excluded, because all water was
boiled before being used. Other sanitary
precautions had been given and strictly
observed. The unfortunate persons had
been using milk from a certain locality
and a special dairyman. It was observed
that most all milk drinkers from this
special dairyman contracted typhoid fever, and after investigation it was proven that this milk was contaminated with
the typhoid germ, and was responsible
largely for that epidemic. Ice cream
is a possible cause by which this germ
gains access to the body.
We have learned that this germ is not
killed by freezing. We use contaminated milk in making the cream, after
which we serve in both private and public places. Not knowing, but to our very
sad regret, we have infected the system with typhoid fever.
Oysters, vegetables that are eaten
raw, are likely to be contaminated, especially those vegetables that grow low
to the ground, through these we are
likely to contract typhoid fever.

Vol. 6, No. 1

Flies are consAdered active factors in

carrying this germ by which so many
people are infected. In a certain part
of a town there may be a number of
typhoid cases found, and by close investigation it will be found that there
are several open privies in that section,
and it is likely that some of these privies hold typhoid excrement; and if it
is summer, this excrement will be spread
about by flies. This filthy insect seeks
the vaults to feed, and sometimes to
place her eggs. Then with bedragged
legs and infected intestines, she returns
to the dinner table, where she walks
over the food, and drops her own excrement on many things that are being
used, and as a last resort drowns herself in the milk; and as a consequence,
the system is infected with typhoid fever, and in any season of the year, the
unsanitary privies may be responsible
for typhoid fever.
The possibility of the direct transmission of the typhoid germ through
the air from one person to another must
be admitted. This cause of typhoid
fever is frequently unrecognized, because it is only lately that typhoid fever
has been generally admitted to be contagious; though this doctrine was ably
preached by Dr. William Budd as far
back as 1873.
There are epidemics in which contamination of water or food could be almost
positively excluded. The nurses and attendants who have to do with the stools
and body linen of the patients are alone
liable to direct infection. Still it was
shown by Dr. Oster during a period of
twelve (12) years, (20) physicians,
nurses, and patients contracted the disease. It is firmly believed that the contagion is spread by means of clothing
and wash-linen.
Gentlemen, I hope I have succeeded in

TYPHOID FEVER: ITS ETIOLOGY AND DIAGNOSIS

showing you some of the etiological factors of this disease which we are beginning to so much dread.
I think I'd voice the sentiment of the
diseases to which the human family is
medical profession by saying, of all the
heir, none are so varied in their symptoms, so attendant with complications,
and so difficult to diagnose as typhoid
fever.
For many years this disease was confused with typhus fever and malarial
fever. One century ago (1813) this
separation was made. But it was not
until 1829 when Louis of Paris, from a
number of its cardinal points, made it
possible for the profession to know this
disease from that of typhus fever and
malarial fever.
Yet we cannot forget to praise the
nam.^e of Gerhard, of Philadelphia, when
he in 1837 made this identification complete.
To diagnose a case of typhoid fever is
not an easy thing to do at all times; to
my pleasant and unpleasant surprise.
The first case I had after leaving college
was a typical case of typhoid to contend
with; the symptoms in that case were
so prominent that even a. first year
medical student might have made the diagnosis as typhoid. I came to the conclusion then that typhoid fever was the
easiest diagnoses the doctor would have
to make. I suppose my presumption
was excusable, as I had seen quite a
number of typhoid patients, had read
extensively on the subject, and had listened attentively to the lectures, but
since then I have been puzzled almost to
my wits at times, to know what I really
had to treat. This confusion seems to
be almost as great today among some of
our most prominent physicians, as before the days of Louis, over a century
ago.

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In a typical case of typhoid fever, we

look for the following symptoms:
The characteristic ascent of temperature to which name we often give the
stepladder temperature, the general malaise of the patient, the peculiar-coated
tongue, with red edges, the abdominal
tenderness, tympanites, diarrhoea, or
constipation, the diarrhoea stools so
much resembles pea-soup. They are
commonly called the pea-soup stools, the
characteristic odor, which is often called the typhoid odor, and a history of
the prodromal symptoms, such as a feeling of lassitude, indisposition to work,
headache, loss of appetite, epistaxis,
with these symptoms our diagnosis is
pretty well made as typhoid fever.
But if the color of the patient will
permit it, in seven or nine days we are
more than likely to see the development
of the rose colored rash, seen first on the
abdomen, but may be seen on the thighs
and back, and sometimes on the arm.
In combination with the above symptoms, our diagnosis is about clinched as
typhoid fever.
We also find often the dicrotic pulse
and enlarged spleen.
But, gentlemen, in this disease we do
not have lined out the typical symptoms always as above named. It carries
with it a variation of manifestations.
It is indeed complex in its symptoms, it
is attendant with many complications,
and at times it simulates almost every
variety of disease known to the medical

profession.
Then why is it not sufficient at times
to baffle the best physicians as to its
diagnosis?
I believe there is only one true and
sure method that every physician should
adopt in doubt as to the diagnosis of
typhoid fever, and that is to call into
consultation Mr. Widal.

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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

Let his test be made, and if his test

gives the positive signs we may rest
with surety that we have a case of typhoid fever. This disease must be separated from a number of diseases which
closely resemble it. But owing to time,
we shall consider only the remittent or
intermittent malarial type, whose symptoms similate typhoid fever so closely
at times it seems hard for the physician
to draw a line of demarcation between.
This confusion seems so great by some
of our prominent physicians, until they
have applied the name to the confused
disease as typho-malaria fever. I am
not a disciple of those who preach the
doctrine of typho-malaria fever. I cannot conceive the idea, gentlemen, when
I am making a diagnosis of typhoid fever, that I am making, at the same time,
in the same patient, a diagnosis of malaria fever. I am opposed to this theory by many physicians in my own city,
and quite sure I'll be opposed by some
here.
With the wide experience of Dr. Osler, and through his works many of us
have been licensed to practice, and he
stated emphatically that out of 829
cases of typhoid fever, plasmodia were
found in the blood during the course of
the disease in only one case. He also
stated that there is no such hybrid malady as typho-malaria fever.
But, gentlemen, whom are we to believe? Are we making this broad assertion from the finding through the
bacteriological examination of the
blood, both the bacillus of Eberth
and the plasmodium of Laveran? Or
are we assuming that we have a case of
typho-malaria fever when we have a
patient partaking of the symptoms of
both? Experience has taught me that
errors in diagnosis are inevitable, even
under the most favorable conditions. I
do believe that both germs can exist in

Vol. 6, No. 1.

the body at the same time. But I do

not believe that the two germs exist
at the same time in the same body in
an active stage, if they exist together.
I believe one will be neutral, while the
other will be at work and the neutral
germs will be unable to produce the disease.
Experience has demonstrated to me
that I might have madeaserious mistake
in the diagnosis in the case oftyphoidfever in the past three weeks, had it not
been for the blood examinations. The
particular patient on my first trip gave
to me the following symptoms: Morning temperature 104, severe headache,
preceded by chill, and followed by profused sweats. Constipation, absence of
abdominal tenderness, tongue failed to
reveal the typhoid character, prodromal
symptoms cloudy, attack almost immediately; with these symptoms, I was pretty
sure I had made a diagnosis of malaria
fever. I put the patient on a reliable
purge and quinine bisulpho, and I went
the following evening and found the
patient just about the same, and the following day and found no change in her
condition. I came to the conclusion
then that I might have made an error
in the diagnosis. I took from her then
sufficient blood that I may be sure of a
diagnosis. This blood was examined by
the State bacteriologist and it showed
the presence of the serum reaction for
typhoid fever, but the absence of the
plasmodium of Laveran.
I have had other cases revealed to me,
the symptoms of both malaria and typhoid, but through examination I had a
typical case of either typhoid fever or
malaria fever. I believe that many patients have gone down to their grave
simply because they were roughly treated through errors in the diagnosis.
Let us hold our own among the rank

TYPHOID FEVER: ITS ETIOLOGY AND DIAGNOSIS

29

and file of the men of our profession. cause of the complexity of the sympThere are thousands of death blanks toms in the disease, we cannot afford
that are signed today as typho-malaria to make snap-shot diagnosis; and, fifever, which, if the truth is told, the pa- nally, in all cases of doubt, let us be
tient died from either either typhoid or sure of the diagnosis which will often
malaria.
be revealed only through the blood exGentlemen, as I have said before, be- aminations.
BRASS POISONING
A case of brass-poisoning in a worker in
brass but not a brass founder is reported by
C. A. Pfender, Washington, D. C. (Journal
A. M. A., January 24). The frequent attacks
were first interpreted as malaria, but blood
examination failed to reveal the parasite.
Quite by accident, the patient observed that
his attacks would occur only after he bad been
brazing, never after forgingorweldingwiththe
acetylene-oxygen torch. He would feel apparently well until he reached fresh air, when
as he expressed it, he was suddenly "knocked
out," sometimes hardly able to get home. He
would experience a general lassitude akin to
exhaustion, pain in chest and rawness of lungs,
and a taste as of blood in the mouth and accompanied by a sharp rigor and general contraction of the muscles of the chest, arms
and legs. Dyspnea was pronounced at times.
When the attacks were severe-which was
always the case when he had been exposed to
the fumes for several hours-he would be
literally stricken dumb, unable to move or call
for help. He describes the sensation as being "similar to lockjaw." The worst attacks
he had lasted four hours. His distress was so
great that I resorted to morphin, 1/4 grain, and
atropin, 1-100 grain which afforded relief.
Sweat did not always follow the chills, nor
was fever always present and at no time did
it exceed 101 F. The pulse was rapid and
fairly strong, but he would tremble for hours
after the paroxysm had subsided. As soon as
Pfender found that the brass fumes were the
cause of the trouble he cautioned the patient
accordingly. Installation of better ventilation
in the workshop was recommended and the
patient was advised to intermit his work between jobs with some other employment. He
was given iron and arsenic for a considerable
time and was greatly improved. An annoying nervousness and tremor of the hands and
arms which occasionally troubled him afterward was relieved by from fifteen to thirty
minutes autocondensation treatment with
about 600 to 800 milliamperes of the D'Arson
val current. It struck Pfender that the repeated attacks which the patient suffered
might affect the lungs and a careful physical
examination of the chest showed a number of
minor changes which might predispose to tuberculosis. In conclusion he advises more
care than is usually given in inquiring about
a patient's occupation especially if the disease is refractory to treatment.

BLADDER RESECTION
G. Kolischer, Chicago (Journal A. M. A.,
January 24), reports a case of excision of a
malignant growth il the vertex of the bladder
performed by denud&ng the whole anterior aspect of the viscus of its peritoneal covering and
clamping the top of the bladder far enough
down to insure the resectfion of the vertex and
the tumor in healthy tissue, the clamp being
applied under the control of the cystoscope introduced before the operation, which, however,
in practice was found to be superfluous, as the
incision could have been guided by palpation.
The operation is described in detail and the
healing was complete in three weeks. Three
months later the interior of the bladder was
apparently normal according to cystoscopic
examination, except for a slight distortion upward at the seat of the excision, evidently
due to an adhesion at the top of the bladder.
While it is still too early to predict a permanent cure, the operation is a technical success.
THE FUTURE OF THE MEDICAL MAN
J. G. Adami, Montreal (Journal A. M. A.,
August 23), in his address before the graduating class of Rush Medical College, informs
them that they are only at the beginning of
knowledge. Their teachers have been able to
give them only the basal outlines of the subject. In the second place, true knowledge includes the ability to utilize facts, and the student is only at the beginning of this part of
his education. He protests against a business
ideal in the profession and says we can probably state in spite of such, that ours is the only
profession which, were the making of money
the prime object, endeavors to reduce its opportunities in that direction. Formerly the
function of the physician was only to cure;
but now the time is on us when the physician
must make his livelihood, not so much by the
cure of the patient, but by keeping him in
health and preventing him from falling sick.
Adami does not think we will conquer patho-'
genic germs altogether, and if we should eradicate them we might reduce the resistance to
disease. He thinks that as medicine becomes
more and more preventive it will become more
and more the duty of the community to subsidize the medical man, and he sees the time
when medicine will become a state service like
the army and navy. They are far in advance
of us in Germany and Great Britain in their
progress toward this end, but the future lies
before us and he sees it full of promise.