ETIOLOGY OF ENTERIC FEVER. 
BY 
J. L. CABELL, M.D., 
OP UNIVERSITY OF VIRGINIA. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1877. ETIOLOGY OF ENTERIC FEVER. 
BY 
J. L. CABELL, M.D., 
OF UNIVERSITY OF VIRGINIA. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PH IL A D E LPH IA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1877. ETIOLOGY OF ENTERIC FEVER.' 
In one of Dr. Parkes’ latest Reports on Hygiene, that for 1873, 
such prominence is given to the rival theories of Buck! and of 
Murchison, as to imply that one or the other, or otherwise the 
twfo conjointly, suffice to cover the entire ground as to the exter- 
nal conditions of the production of enteric fever. With judicial 
fairness Dr. Parkes cited the strongest arguments on either side, 
and contrasted them Avith the weak points of the rival doctrine. 
He concluded “ by expressing the opinion that neither the views 
of Budd nor of Murchison can be considered as wholly proven, 
and that in our present state of knowledge, each must be accepted 
as limiting the conclusions of the other.” The special object of 
this paper is to inquire whether enteric fever, as it occurs in this 
country, may not depend upon other external causes than those 
which are assigned by either of these theories. Such an inquiry 
must proceed on a careful study of the natural history of the 
disease, by which method we may hope to be eventually able to 
eliminate every unessential circumstance, and fix our regard upon 
the efficient agencies in its production. When definite conclusions 
in this direction shall have been reached on trustworthy grounds, 
we may then be in a position to scrutinize, with better hopes of 
success than we can now do, the various speculative doctrines 
which relate to the nature of the infectious material itself. 
In the mean time we may assume the substantial truth of some 
form of the gerin theory, as a legitimate scientific hypothesis to 
be provisionally held, subject, however, to future verification or 
correction. If such a doctrine were not already well nigh de- 
.rnonstiated, its provisional assumption on a few striking analogies 
might serve a very useful purpose in suggesting lines of inquiry 
and guiding our observations. Prof. Huxley has well said that 4 
ETIOLOGY OF ENTERIC FEVER. 
there are periods in the history of every science when a false 
theory is not only better than none att all, but is a necessary 
forerunner and preparation for the true theory. And Dr. Bur- 
don-Sanderson,. after avowing his belief that it is only by the 
investigation of particular cases, by clinical observations and 
pathological experiments, that any progress can be made in the 
inquiry whether there is or is not such a thing as a contayinm 
vivum, deprecates the charge of inconsistency for using most of 
the time at his disposal rather in the discussion of general views 
or speculations, than with the description of new facts, urging 
that “to the man who is occupied in investigation the speculative 
faculty is quite as essential as the critical or sceptical,” and that 
on occasions it may be proper to occupy ourselves with the rela- 
tions of facts about which we may be supposed to be agreed 
rather than with the facts themselves. 
Just two years ago Dr. Klein electrified the medical world by 
the alleged discovery of a peculiar fungus found in the substance 
and on the surface of the mucous membrane over and around 
Peyer’s patches, and subsequently in the veins and lymphatics, 
in cases of enteric fever. As this fungus preceded the intestinal 
lesions it was naturally inferred that it stood in a causal relation 
to the latter. It was seemingly a very significant coincidence 
that this fungus was identified with the crenothrix polyspora which 
Prof. Cohn had found in well-water in a certain district in Bres- 
lau famous for the frequent occurrence of enteric fever among its 
inhabitants. Here then, to all appearance, we had at length a 
positive demonstration of the germ theory as applicable to en- 
teric fever, and a satisfactory identification of the exact species 
of the typhoid fungus. The same eminent pathologist had pre- 
viously described, in minute detail, the structure and life history 
of a microphite occurring in sheep-pox, to which he gave the 
name of oidium variolse. Now the appearances thus interpreted 
by Dr. Klein have been shown by Dr. Creighton to be nothing 
more than products of the coagulation of albumenoid matter 
caused by the preservative liquid (chromic acid and spirits). 
This is candidly conceded by Dr. Klein himself, who, in a note 
published in the Proceedings of the Royal Society for June 15, 
187(1, wholly abandons his first position. This incident natu- 
rally enough casts a shade of suspicion over his interpretation of 
the appearances found in the cases of enteric fever, where the 
same coagulating reagents were employed. ETIOLOGY OF ENTERIC FEVER. 
5 
Nevertheless, the doctrine of a contagium vivum in some form 
must be held to be true, \hough no ocular demonstration of the 
infective agent has been given, nay even though such demonstra- 
tion should be forever impossible by reason of the ultra-micro- 
scopical minuteness of the particles. The analogies which 
suggest the hypothesis are numerous and so significant as almost 
absolutely to exclude a negative conclusion. It is, of course, 
unnecessary to recite in this presence the facts and arguments 
which, as stated by Liebermeister, Burdon Sanderson, Lionel 
Beale, and summarized by our associate, Dr. J. R. Black, are 
familiar to the members of this Section ; but I repeat, that, while 
they do not suffice to indicate the precise characters of the infec- 
tive organisms, they leave little or no room to doubt their real 
existence and active operation in the development of fevers. Dr. 
Beale has stated some apparently plausible grounds of objection 
to the doctrine of the fungus-like nature of the contagium, and 
has elaborated, with extraordinary industry and talent, his own 
theory of bioplasm particles as the germs of disease; while Dr. 
Burdon-Sanderson, in a recent paper to which I have already 
alluded, in comparing contagium to the unformed ferments, and 
denying, hypothetically, or rather with hesitation and reserve, 
that it possesses any morphological characters, seems on the 
point of abandoning the entire doctrine of a living contagium, 
since, according to the commonly accepted definition of life, viz., 
that it is organism in action, it would be a contradiction in terms 
to speak of life where there is no organism. Nevertheless he 
proceeds to argue that such a ferment cannot be a chemical bodv, 
a mere immediate principle, because when it acts on other bodies 
it maintains its own molecular integrity. “ On the whole, it 
resembles an organism much more than it resembles a chemical 
body, for its characteristic behavior is such as, if it had structure, 
would prove it to be living. What is more characteristic of 
living protoplasm than that, while maintaining its own integrity, 
it alters the surrounding medium ?” In applying these views to 
the much disputed question of the generation of bacteria, he 
contends that the objections to the doctrine of heterogenesis are 
as fundamental as ever, and that while the orthodox biologist 
need not now hold that every bacterium must have been born of 
another bacterium, he must yet hold that every bacterium must 
have been born of something which emanated from another bac- 
terium, that something not being assumed to be endowed with 6 
ETIOLOGY OF ENTERIC FEVER. 
structure in the morphological or anatomical sense, but only in 
the molecular or chemical sense. Not only does it fail to exhibit 
characters which can be appreciated by the microscope, but it is 
capable of resisting destructive influences, particularly those of 
high temperature, which are absolutely fatal to the bacteria 
themselves. lie concludes that “ so far as the morphologist is 
concerned, germs have quietly gone out of court and given place 
to things which are ultra-microscopical—to molecular aggregates 
—of which all that we can say is, what we have already said 
about the ferments—that they occupy the border-land between 
living and non-living things.” It will not escape notice that, 
though this statement asserts the non existence of structure in 
the morphological sense, it yet claims for contagium the poten- 
tial characters of life. And after all, the negative proposition 
may have no other basis than the necessary limits of microscopi- 
cal demonstration. Dr. Beale, using objectives of 5'0 of an inch, 
magnifying from 2800 to 5000 diameters, was enabled to demon- 
strate the presence of formed particles not exceeding ttgVot 
an inch in fluids apparently perfectly limpid when viewed under 
lower powers. (Disease Germs ; their Nature and Oritjin. By Lio- 
nel Beale, M.D. Second edition, p. 75.) I hold, accordingly, that 
the theory of a contagium\ vivum has suffered no damage from 
these recent utterances of Dr. Burdon-Snnderson. 
‘ But as already intimated, the special object of this paper is not 
to speculate on the nature of the infectious material, but to in- 
vestigate the conditions, especially thq external conditions, under 
which enteric fever is most readily developed. Such conditions 
are often, nay, perhaps, commonly called causes of the disease, 
and with many persons this has led to no little confusion of 
thought as to the etiology of enteric fever. Conceiving that a 
definite effect cannot own more than a single efficient cause, 
there is a tendency to ascribe the development of the fever to an 
exclusive set of external conditions. Dr. Parkes, criticizing the 
theory of Budd, with reference to its exclusive pretensions, re- 
marked that “ his mind was of that order which refuses to admit 
two different origins for the same specific agent, and the unde- 
niable facts of contagion completely override what seems to him 
the much looser evidence of independent origin.” Nor is the 
ambiguity entirely removed by applying the term “assisting 
causes” to the influences which favor the development of the spe- 
cific agent. The latter alone is the cause in the true sense of the 7 
ETIOLOGY OF ENTERIC FEVER. 
term, inasmuch as it is the one thing whose presence in the 
organism is absolutely essential to- the manifestation of the dis- 
ease. We shall presently inquire whether this infective agent 
ever originates spontaneously, but whether this be possible or 
not, whether it ever lias a purely spontaneous origin by hetero- 
genesis, or is always derived from progenitors of the same species, 
it may still be equally true in either case that some such infec- 
tious material is the cause, and the only cause, of certain fevers. 
But while I freely concede this unity of causation, I maintain 
that the external conditions which are more or less influential in 
determining the development of the infective agent, may be 
numerous and diverse. 
Such a conclusion seems fairly warranted by the evidence 
collected by the late Dr. Derby in his paper on the “ Causes of 
Typhoid Fever as it occurs in Massachusetts,,r published in 
Second Annual Report of the State Board of Health, January, 
1871. Among the medical men of Virginia the conviction of the 
soundness of this conclusion is so strong that they are unable to 
withhold the expression of their surprise at the dogmatic assertion 
of the exclusive views of recent British authorities. I may be 
permitted to cite brief extracts from communications received 
from a few correspondents as representing the general sentiment 
of the profession in Virginia, where enteric fever has prevailed 
very largely, both endemically and epidemically. 
Prof. L. S. Joynes, Secretary of the State Board of Health,, 
says:— 
“ I may say in distinct terms, that I have seen no sufficient reason 
to justify me in accepting the one-sided view of its aetiology which 
seems now to be so generally adopted abroad, or at least in Eng- 
land. I cannot repress a feeling of astonishment on reading in 
a book like Bristowe’s new treatise on Practice, the broad state- 
ment that ‘ it has been proved, apparently beyond all cavil, that 
enteric fever is par excellence the fever of fecal decomposition : 
that it occurs only among those who are exposed to the influence 
of defective drains or foul and overflowing cesspools,’ etc. Such 
an exclusive opinion is, perhaps, natural enough in a great city ; 
but when typhoid fever is studied in rural districts the evidence 
in its support is found to be sadly defective; and I dare say you 
will get few affirmative responses from the physicians of Virginia. 
I have no doubt that you will be furnished with a large amount 
of valuable evidence on this question which will enable you to 8 
ETIOLOGY OF ENTERIC FEVER. 
make a contribution to its literature which will tend greatly to 
repress the prevailing disposition to look at the subject only on 
one side. This tendency to exclusiveness appears to be innate 
and ineradicable. At least it has more or less cramped and en- 
slaved the professional mind from the first dawnings of medical 
science to the present day, and few, even among the leaders, 
appear to be able to rise above it.” 
Dr. Harvey Black, now superintendent of the Eastern Lunatic 
Asylum of Virginia, but for many years a practitioner of medicine 
in Montgomery County, with a large experience in connection 
with enteric fever, says : — 
“That decomposed excrements, especially when taken in water 
that has been contaminated, are potent agents in preparing the 
system to receive the typhoid virus, whatever it may be, I have 
but little doubt; while I am as fully impressed with the belief 
that the disease as frequently results without these excremen- 
titious substances having any agency in its production, an opinion 
based upon the observation of cases where all the circumstances 
and surroundings precluded the idea that the patients had been 
exposed to any such influences.” 
Dr. R. T. Lemmon, of Campbell County, whose communication, 
based on an unusually large experience, will be again referred 
to, says:— 
“ I am disposed to believe that excremental matters contami- 
nating the water or air will originate the disease, but I am also 
satisfied that there are other causes which have as yet eluded 
the investigations of scientists.” 
A striking illustration of this tendency on the part of British 
authorities to trace the origin of enteric fever to a simple factor 
is furnished by a recent paper of Dr. Stewart, of Barnsley, origi- 
nally published in the British Medical Journal of March 10th, and 
copied into Public Health of London for March 16th, and the 
Medical Record of New York of May 5th, under the caption, “A 
New Theory of the Origin of Typhoid Eever.” This gentleman, 
having traced an outbreak of the fever embracing seven or eight 
cases to the decomposition of blood from a slaughter-house, and 
assuming that the blame must be laid upon a single factor equally 
ubiquitous with the disease, sets about to inquire what this one 
factor present in decomposed blood and decomposed excrements 
might be. He arrives at the conclusion that the serum of the 9 
ETIOLOGY OF ENTERIC FEVER. 
blood is this essential factor, typhoid being particularly apt to 
prevail in the fall months after the privies have received the 
serous evacuations of patients with summer diarrhoea. “I do 
not propose,” he says, “to enter into the discussion as to whether 
this disease can have an abiogenetic origin, although the facts 
upon which my theory is founded appear to favor that doctrine. 
Whether the fever arises only from the specific typhoid germs, 
which (according to the advocates of this theory) have a nearly 
omnipresent existence, and have the property of preserving their 
vitality in a dormant condition for many years, ready to spring 
into active and vigorous life when introduced into a proper nidus 
for their development; or whether the poison is manufactured 
from the ordinary germs existing in all the putrefactive processes 
which take place in certain animal fluids, or is elaborated by 
some subtle chemical change in the properties of the substance 
itself, does not signify so much to those who have to deal prac- 
tically with the disease so long as we can put our finger upon 
the factor, element or pabulum, without which these forces would 
be rendered permanently impotent.” 
Now I have to observe that on evidence precisely similar to 
that on which Dr. Stewart traced some of his cases to decomposed 
blood, which happened to have an element in common with the 
discharges of serous diarrhoea, it will be shown that numerous 
cases may be traced to conditions in connection with which no 
such common factor can be assigned except by a gratuitous and 
violent assumption. Moreover, the effect is not coextensive 
with the alleged cause, and the negative evidence is particularly 
strong as against so exclusive a theory. 
In order to ascertain the grounds for the opinions which pre- 
vail in Virginia, I addressed to the members of the State Medical 
Society, a circular letter, soliciting their views on the subject, 
and a report of the observations upon which their views are 
based. It is not necessary to reproduce the whole of that letter, 
which included the following questions:— 
1. Can you recall any cases of typhoid fever originating under 
such circumstances as to exclude the probability of the importation of 
the disease from some other locality t If so, state the facts. 
The replies were : Yes, 58; No, 10; Doubtful, 1. 
Statements of facts to justify affirmative answers will be cited 
further on. 10 
ETIOLOGY OF ENTERIC FEVER. 
2. What conveniences exist in such places for the deposit and final 
disposal of excrements'? 
The answers to this question are so varied as to defy all 
attempts at a definite classification. In a majority of the cases 
the arrangements consist of privies without pits. In many such 
privies the excrements being under cover, and yet exposed to 
the winds, become desiccated and but little offensive. They are 
removed periodically to a compost heap, or scattered upon soil 
in process of cultivation. In other cases there are pits generally 
walled with brick on the sides, but not at the bottom, so that the 
liquefied contents are constantly soaking into the soil. In a few 
cases the water closet system is in effective operation, the soil 
pipes opening into sewers, which have their outlets in some 
small running stream. In a great many cases there are absolutely 
no special conveniences, the male members of a family resorting 
to the woods, the females using chamber vessels, which are 
emptied into a brook if one be close at hand, or into the garden, 
or stable yard. 
3. What is the source of water supply? If wells are used, what 
is their proximity to privies, cesspools, stables, pig-sties, etc.? 
In most of the rural districts of Virginia, the water supply 
is obtained from springs, and generally is of unexceptionable 
quality, but the instances are also quite numerous in which the 
supply is obtained from wells in suspicious proximity to privies, 
stables, pig-sties, etc., and sometimes receiving the surface drain- 
age from kitchen yards. 
4. Have you observed any connection between the prevalence of 
typhoid and the saturation of the soil with organic impurities, though 
the water s pjdy might be adequately secured from the possibility of 
contamination ? 
The replies to this question were: Ves, 17; No, 27 ; some of 
which will require specifications to be given presently. 
5. Have you observed any connection between the prevalence of 
typhoid and a low level of the water in the wells ? 
Seventeen (17) correspondents answer affirmatively. Thirty 
(30) had not noticed the state of the wells, and two (2) reported 
• that the water was unusually high. 
6. Have you observed anything like an antagonism between typhoid 
and malarial fevers, or do you know of any well-observed facts, which ETIOLOGY OF ENTERIC FEVER. 
11 
seem to show that they prevail separately and alternately in given 
localitiesf 
To this question there are sixteen (16) more or less positive 
answers in the affirmative. Thirty-five (35) correspondents answer 
No. Twenty (20) ventilate the controverted relations of typho- 
malarial fevers, some affirming the existence of the typical enteric 
element, and, therefore, denying the alleged antagonism, while 
others earnestly repudiate the doctrine of a hybrid product, and 
regard the fever in question as nothing more than an adynamic 
form of ordinary malarial fever. The correspondents who consti- 
tute this latter class range themselves on different sides of the 
question under consideration, most of them conceding the fact of 
the alleged antagonism, some by express statement to that effect, 
others only by implication resting upon their assertion of the ex- 
treme rarity of typhoid in malarial regions. 
7. Do you know the history of any outbreaks of typhoid fever 
presenting the features of a wide-spreading epidemic ? 
The replies are: Yes, 14; some of which, to be presently cited, 
seem to me to be conclusive. No, 41. 
Each correspondent was requested to state his own views as 
to the causation of enteric fever, which elicited the expression of 
a great variety of opinions touching the secondary causes, the 
writers in most instances avowing their belief in the existence of 
a specific germ as the essential cause of the infection, though, as 
will be presently seen, a very large majority consider that the 
infectious agent may be devoloped de novo. 
Contagion.—As many as eighteen correspondents express a 
conviction of the contagiousness of enteric fever, but in most 
cases no distinction is made between pure contagion or the direct 
transmission of the morbific agent from person to person, and 
that indirect transmission which Liebermeister terms miasmatic- 
contagion, where the morbific agent is developed outside of the 
body, but requires as an antecedent condition that an infected 
person should furnish specific germs. This is an important dis- 
tinction, and should be borne in mind in order toil proper inter- 
pretation of facts, which may otherwise present an ambiguous 
appearance. The oft-cited report of Dr. Austin Flint of the 
outbreak in the village of North Boston, in 1 STS, is so far from 
proving the disease to be contagious in the limited sense just 
defined, that the details given are much more consistent with the 12 
ETIOLOGY OF ENTERIC FEVER. 
idea of some change in the infections agent having taken place 
subsequent to its separation from the patient’s bod}1'. In other 
words, the actual facts would seem to show that the influence 
was that of miasmatic-contagion, rather than simple contagion. 
The first case following the imported one was twenty-three days 
after the arrival of the stranger, and there was reason to believe 
that the poison was received by this and other parties subse- 
quently infected, through the medium of drinking water obtained 
from a well within three or four rods of the privy, in which the 
contents were allowed to accumulate, and in which the dejections 
of the sick stranger who imported the disease had been certainly 
thrown. This is the view now taken by Dr. Flint himself, who, 
in a paper published in the first volume of the Transactions of 
the American Public Health Association, “ On the Relations of 
Water to the Propagation of Fever,” recites the history of the 
outbreak in question, and refers the secondary cases to the con- 
tamination of the water brought about in the manner stated. 
A few, however, of my correspondents, adverting to the dis- 
tinction in question, have avowed their belief in the occasional 
propagation of enteric fever by direct contagion. In most of 
these cases there was no post-mortem verification of the diagnosis, 
but as the primary cases originated in rural districts where, it 
may be safely assumed, there had been no antecedent exposure 
to the contagion of typhus fever, there is every reason to believe 
that the diagnosis of typhoid was correct. 
Dr. Fred. Horner, Jr., of Fauquier County, reports the following 
on the authority of Dr. Chilton, an experienced practitioner of 
Warrenton :— 
‘‘The corpse of a young lady who died after a brief illness 
with symptoms of typhoid fever, in a neighboring county, was 
brought to the residence of her grandfather near Warrenton to 
be buried. The remains were kept in the house over night pre- 
paratory to interment the following day. The coffin was opened 
by request of an aunt. The latter kissed the remains, near which 
she lingered for some time. She became ill in a few days with 
all the symptoms of typhoid, though previously in excellent 
health, and died two weeks after commencement of her illness. 
A brother of the deceased and several other members of the 
familv took the disease, but recovered.” 
In a later communication Dr. Horner, after having obtained 
further details from Dr. Chilton, states that another aunt of the 13 
ETIOLOGY OF ENTERIC FEVER. 
deceased who had nursed the latter during her illness in Essex 
County, and liad accompanied the corpse to the paternal home in 
Fauquier, was seized with the fever a few days after her arrival, 
but recovered. If it could be proved that the other lady derived 
the infectious agent from the living sister rather than from the 
corpse of her niece, the fact would be yet more significant as an 
evidence of direct contagion, since it might be considered that 
after death the body might furnish a nidus not materially different 
from the usual external vehicles of the infection. 
Our associate, Dr. L. D. Waterman, of Indianapolis, Ind., while 
accepting the theory of “acontagium from enteric discharges 
modified in some unknown way after evacuation,” is yet disposed 
to concede that the fever may sometimes be propagated by direct 
contagion. He reports the following case:— 
“Suddenly, without ascertainable cause, the servant girl of a 
noted Methodist minister was attacked in this city July, 1874, 
and then successively his child 5 years old, himself, his son about 
11 years, and his wife. His daughter aged 14 alone escaped, and 
she was sent away during the prevalence of the sickness. A 
privy of the usual out-house kind, a cesspool, twenty feet from 
the well, in filthy condition of decaying fulness, were the only 
discoverable factors There is one fact in connection 
with the local outbreak in this family that is of some significance. 
His residence was the west half of a double brick building. The 
other half was occupied by a family who used water from the 
same well, but had no attack of fever. They also used the same 
privy vault, but by a partitioned off building. They also had a 
cesspool separate. It is hard to believe that either privy or well 
was the source of the disease, after the escape of the latter family. 
I cannot absolutely prove, but believe, that this disease was 
directly contagious, and owing to the periods of successive attack, 
was communicated from one to the other, not from water or 
privy.” 
Dr. M. Gr. Ellzey, in a very interesting and instructive com- 
munication, expresses the belief that the fever, after originating 
in some unknown way, may be communicated from person to 
person. He says :— 
“Two of my sisters were seized about the same time by sharp 
attacks of typhoid (typical enteric cases) in midwinter, living in 
a most healthy and remote country home, snowed up and not 
having visited even a neighbor for six weeks, nor received a 14 
ETIOLOGY OF ENTERIC FEVER. 
visit or held any communication with persons off the place. 
There were no other cases at that time in the family, on the farm, 
or within ten miles of the place, had not been for six weeks 
before, nor was there one within six weeks afterwards. Water 
was used from a spring situated in such a manner that no possible 
drainage from any foul situation could reach it without reversing 
the natural law that water runs down hill. Every circumstance 
was closely and repeatedly scrutinized, and after reflected upon 
by me, without my ever finding out a possible cause for these 
cases. I admit that their nearly simultaneous occurrence was 
strongly suggestive of a common origin, and with this on my mind 
1 searched most minutely into every circumstance connected with 
the surroundings of these ladies, with complete knowledge of the 
entire premises, and all the domestic arrangements of the family. 
These are the only cases that have occurred on that place in the 
past thirty years. Eor a period of fifteen years, with about sixty 
souls, white and black, dwelling there, no physician paid a pro- 
fessional visit. It is not unlikely, I think, that the second case, 
attacked within three days of the first, nevertheless received the 
disease from companionship with her sister, the period of incu- 
bation in this case being very short. I have seen many cases 
where the disease in this typical form has very evidently been 
communicated by companionship with the sick. In view of all 
the facts I have reached, in my own mind, the conclusion that 
the first of these ladies generated within her own system the 
virus producing the fever, and communicated it to her sister by 
their intimate association.” 
The following cases reported by Dr. G. W. Semple of Hampton 
are, some of them at least, strongly suggestive of direct contagion. 
In the first case the patient having been exposed, while suffering 
with the prodromic symptoms, to a cold rain storm about the 
middle of August, 1850, by which he contracted a circumscribed 
pneumonia, the existence of the enteric fever was at first over- 
looked, but subsequently recognized, suspicion being first excited 
by the disastrous effects of depletive treatment. Under a change 
of treatment convalescence eventually set in, but before it had 
made much progress a subsequent accidental exposure to a cold 
draught from the bursting in of the window of his room at night 
during an equinoctial storm caused bis death. The narrative of 
Dr. Semple continues as follows:— ETIOLOGY OF ENTERIC FEVER. 
15 
“The next son, 11 years old, was taken fourteen days after his 
brother first sickened, and after ail attack with like symptoms 
became convalescent in five weeks. At this date having now no 
fever and only slight looseness of the bowels, I deemed it safe to 
remove him. Had him under my own inspection well bathed, 
put on him clean new clothes made for him by his mistress at my 
house, put him on a new bed with new bedding into a spring 
wagon, took him to my house and had him lodged in his aunt’s, 
my cook’s, room. His aunt’s daughter spent much time with-him, 
and in a few weeks was attacked with typhoid which lasted 
several weeks. It was impossible to keep her many cousins 
belonging to my sister-in-law, hired in Hampton, from visiting 
her, and each one who did had typhoid fever. Each was taken 
from the place where hired to my kitchen (in Virginia this 
term is often applied to the entire house of which one of the rooms is 
appropriated to cooking uses, the others being dormitories for servants) 
lor treatment, and no other cases were traced to them. Many of 
these were mulattoes, on all of whom was seen the typhoid erup- 
tion. The mother of the first two patients, about the 1st De- 
cember, went to live at a place where until then there had been 
no case of the fever, and in a few days thereafter her next son 
had the fever. The mother being cook, her sister was put to 
nurse the boy, and her children by frequent visits to her con- 
tracted the fever, and from them it extended first to the children 
of another sister, mother of a large family, and from them to all 
the young negroes above the age to commence the second den- 
tition, thirty-eight in number, and last of all to one of the sons 
of the master of the family, who, contrary to the injunctions of 
bis father and mother, frequently went to his nurse’s house where 
her children were sick. This little boy was kept during bis illness 
in a large well ventilated room in the second story of the mansion, 
the other members of the family occupying only the first, and 
the fever did not attack any other member of the white family, 
but it did not expend itself (among the blacks) until about 1st 
May, 1851. In July it made its appearance on the adjoining 
farm, Mr. Lowry’s, commencing with a negro girl of about 20 
years, and by October had attacked all the young negroes on the 
farm, twenty-seven in number. No white person except the 
youngest daughter of the proprietor had the fever, a young lady 
who had been most indefatigable in administering medicines and 
food to the sick. 16 
ETIOLOGY OF ENTERIC FEVER. 
“I had no idea how the disease had originated at Mr. Boncewell’s, 
where the first mentioned case occurred. His house, as well as 
that in which the patient lived, was scrupulously neat and clean. 
The water was the best in the country, with no source of contami- 
nation near, the pig-sty, the stable, and the barnyard being at 
a considerable distance on a declivity from the house and well, 
and the night soil, soapsuds, and slops were regularly emptied 
upon the bank of stable manure near the stable. The fever how- 
ever had evidently started from that as a focus, and had extended 
by infection to those in my kitchen, from them to others in 
Hampton, and from the same focus to my brother’s-in-law. But 
I could not trace it thence to Mr. Lowry’s, as the negroes all 
denied that there had been any communication. There was no 
local source of origin for the disease, no stable, pig-sties or cess- 
pool near the residence, and the excrements, etc., were all emptied 
into the salt river. The father of the girl who was first to have 
the fever on this farm, had in his house a mattress said to have 
been got from the beach near Old Point in January, 1850, which 
had been thrown overboard from a German emigrant ship wrecked 
there, and the man said that the father of the first mentioned 
patient had got one of the same mattresses before the fever oc- 
curred in his family. This the latter denied, however, and, as the 
mattress had been used in the family for so long a time before 
the fever appeared, I paid little attention to it at the time, but I 
am now inclined to think that the statement of the former was 
true, and that the latter denied it for fear of the ridicule of his 
master. There was no other source from which these two patients 
could have contracted the fever, except from these fomites 
“All the facts of my own observation indicate very strongly 
that typhoid fever is a specific, infectious, exanthematous fever, 
having but one source of origin from the person of the sick. And 
I incline to the opinion that such is its only source, notwith- 
standing all my reading on the subject. I have seen some cases 
of a second attack of smallpox and many of measles, but never 
one of typhoid fever.” 
Dr. W. A. Thom, of Eastville, Northampton Co., reports that 
his region, a very malarious one, is remarkably exempt from 
typhoid fever, and says : “ In a practice of thirty-five years I can 
recall but one epidemic of pure typhoid fever, and that was brought 
here by a young lady who had been at school in Alexandria. 
From her it spread through three families, evidently by conta- ETIOLOGY OF ENTERIC FEVER. 
17 
gion, as it passed successively through those who had been en- 
gaged in nursing her.” 
Specifications given by other correspondents in evidence of 
contagion admit of another interpretation. They make no dis- 
tinction between contagion and infection. Indeed, in most cases 
it is obvious that the writers merely meant to affirm that the 
fever is miasmatic-contagious, the communication requiring an 
intermedium other than the air between the infecting and the 
infected persons, involving too some change in the infectious 
material. 
It must be admitted that evidence, such as has been cited, is 
far from being conclusive. Viewed by itself it suggests the 
idea of contagion as a possible, or even not improbable, solution 
of the problem, but viewed in connection with the overwhelming 
amount of negative evidence, the argument is shorn of much of 
its strength. Physicians and nurses, who attend enteric fever 
patients, are not more frequently attacked than other persons 
who have never seen such cases. “ Up to the year 1865,” says 
Liebermeister, “ I have never seen, in the hospitals which I 
visited (Greifswald, Berlin, Tubingen) a single hospital patient, 
physician, or nurse attacked with typhoid fever, although such 
cases are placed in the general wards. Other observers have had 
the same experience. According to Murchison, during a period 
of fourteen and a half years in the London Fever Hospital, 2506 
patients with typhoid fever were treated, and during that time 
only eight originated in the hospital.” Now contrast this with 
the results of the unequivocal contagiousness of typhus fever. 
In Ireland, according to the same authority, in the year 1847, no 
less than 500 medical men—about one-fifth of the entire number 
—suffered from typhus, and of these 127 died. “ In the Crimean 
War, at the height of the epidemic among the French, out of 
840 attendants in twelve hospitals, 608 were taken sick during a 
period of 57 days; more than 80 surgeons died of the disease in 
the course of the campaign.” 
It was this very epidemic in 1847 to which Stokes, in his 
Lectures on Fever, refers as furnishing proof of the contagious- 
ness of fevers in generals, as he denies the specific distinction 
between typhus and typhoid. 
Thirteen correspondents by express statement, and very many 
more by implication, maintain the non-contagiousness of typhoid, 
on grounds similar to that taken by Murchison and Liebermeis- 18 
ETIOLOGY OF ENTERIC FEVER. 
ter, while most of the number concede its infectious nature and 
admit that the infection may, in some cases, be remotely derived 
from human living beings. 
Dr. Rob. B. Tunstall, of Norfolk, says :— 
“Were I to form an opinion based upon my own experience, 
I should exclude contagion as a mode of propagating typhoid. 
I have had it in my own family five times, and on each occasion 
confined to a single case. Three of these originated out of the 
city and two here.” 
Dr. Wm. Selden, of the same city, speaks yet more emphati- 
cally to the same effect. 
“ In an experience of nearly fifty years, I cannot recall a sin- 
gle case where the disease was imported from any other locality. 
During this long period I have seen a few cases of typhoid fever 
every year, never more than ten or twelve in any one year, and 
all of them were manifestly of local origin. My father’s experi- 
ence, with which I am so familiar as almost to regard it as my 
own, was to the same effect. The disease prevailed here more 
or less every year, even in the last century under the name of 
typhus mitior, or nervous fever, the name typhoid not being then 
in use. I have never met with a single instance where the dis- 
ease appeared to be due to contagion. I have never used any 
precaution against contagion other than such cleanliness and 
ventilation as were required for the sick, and yet I can recall but 
three instances where more than one case occurred in the same 
house in the same season. In one instance two brothers were 
attacked simultaneously ; and in the other two instances both 
cases were exposed to the same cause of disease, namely, a foul 
cellar. My practice has been, for the most part, in the better 
class of society, where strict attention was paid to cleanliness, 
especially to the changing of bed-clothes and the prompt removal 
of all excrementitious matter 
“I am well satisfied that in our city to which my observation 
has been limited, typhoid fever has never exhibited any sign of 
contagion, although the evidence of its being occasionally at 
least propagated from person to person in Europe, seems irre- 
sistible 
“ My opinions are based upon very long, if not very extensive, 
observation, and although chiefly negative may be of some inte- 
rest as opposing the tendency which in the present day is con- 
stantly increasing, to regard almost all diseases as contagious. I ETIOLOGY OF ENTERIC FEVER. 
19 
have alluded to the opinions of my father, and would like to 
mention, as a proof of his accurate clinical observation, that he 
was in the habit of ‘feeding fevers’ before Graves was born. 
One of the first lessons in practice that he ever taught me was, 
that you could not cut short a continued fever by active treat- 
ment, and that the best chance of getting the patient safely 
through it was to sustain him from a very early period by suita- 
ble nourishment and wine. One of my earliest recpllections is 
being fed, during an attack of typhoid fever when I was five 
years old, with Naples biscuit (dry sponge cake) dipped in good 
old Madeira.” 
Dr. Rob. T. Coleman, Professor in the Medical College of Vir- 
ginia, at Richmond, bears a similar but somewhat qualified testi- 
mony. He says:— 
“I can recall no case where the evidence was at all conclusive 
that the disease was imported from some other locality. On the 
contrary, I have known, during the war, in a large number of 
instances, individuals affected with typhoid fever to be removed 
to points more or less remote from the localities where it was 
contracted and scattered broadcast in farm-houses; and although 
no rigid restrictions were imposed as to their intercourse with 
the members of the various households that ministered to them, 
yet I cannot now recall a case originating unmistakably from 
the presence of these patients in the families that entertained 
them. While this is true in my own observation, it is proper to 
state that there is reason to believe that in a few cases within the 
experience of others the disease was contracted by contagion. 
“ I will mention, as typical of a large class, the case of my brother 
Lewis, who, while engaged in nursing a number of students with 
typhoid fever at Concord Academy, where he was aiding my 
uncle Frederick in teaching, contracted the disease and in its in- 
cipiency rode in a carriage about twenty-iive or thirty miles to 
my grandfather’s. Here he was extreme!}7 ill; at one time it was 
thought that his death was inevitable from the excessive hemor- 
rhage from the bowels. Yet no other case occurred although 
there were about seventy-five or eighty people on the plantation, 
a number of whom were variously employed about him as nurses, 
general attendants, etc. etc. My conclusion, then, is, that although 
this disease has many features analogous to the manifestations in 
the exanthemata, the laches rosees and the inflammation of Fever’s 
glands being its local expression, corresponding to the eruption 20 
ETIOLOGY OF ENTERIC FEVER. 
in measles, scarlet fever, etc., and although, like them, one attack 
usually guarantees immunity from subsequent ones, yet that as 
a rule typhoid fever is very mildly contagious, and that we have 
to look for some endemic or epidemic cause to account for its 
extensive prevalence.” 
Doubtless the “ contagion” in such cases is usually mild, as it 
requires a concurrence of conditions and is indirect, the poison 
having to undergo a change after its liberation from the diseased 
symptom, which change may be wholly prevented or its extent 
be greatly diminished by proper sanitary precautions. In the 
exceptional cases, if there be such, in which the disease has ap- 
peared to have been propagated by direct contagion, a plausible 
though purely conjectural solution of the anomaly may be found 
in the assumed fact that, in the advanced stages of the disease, 
when the intestinal glands are in the state of ulceration, and the 
■intestinal excretions are retained by opiate or other astringent 
treatment, the disease germs may find a suitable nidus for their 
further development before their discharge from the bowels, and 
thus supersede the necessity for the intervention of external 
pythogenic influences. 
While, therefore, the evidence of direct contagion in the case of 
typical enteric fever is inconclusive and at best is confined to a 
few exceptional cases, the proof of indirect contagion by means 
of air or water contaminated by the dejections of fever patients 
is such as to leave no room for doubt. It is only the narrow 
exclusiveness of Dr. Budd’s theory—its denial of other modes of 
propagating the poison—which has subjected it to a damaging 
criticism. 
If it were necessary at this date to furnish proof of the fact 
that a case of typhoid imported into a previously healthy locality 
may, under favoring conditions, produce a local outbreak of in- 
definite extent, numerous conclusive observations might be cited 
from the mass of correspondence in my possession. But inas- 
much as this point is seldom contested, and as my space is limited, 
I will cite a single instance which may be taken as a sample of 
many others. Dr. Z. I. Walker, of Brownsburg reports that:— 
“During the summer of 1859, there were thirteen cases of 
typhoid fever at Mr. Bratton’s, in Bath County. His son John 
was a medical student of the University of Virginia. He became 
sick with typhoid fever at the University, went home and died; 
twelve other cases in the family followed rapidly. Persons who ETIOLOGY OF ENTERIC FEVER. 
21 
visited the family contracted the disease. There were no cases 
in that portion of the county. There never was a case in the 
family before.” 
Indeed, as already stated, as many as ten of my correspondents, 
most of whom declare that their experience has been large, have 
had little or no difficulty in tracing every outbreak that has come 
under their observation to a clearly ascertained importation. 
Per contra, fifty-eight( 58) correspondents assert that they have 
observed cases which originated under such circumstances as ab- 
solutely to exclude the probability of importation of the disease. 
These gentlemen accept, therefore, the doctrine of the de nov0 
development of the fever; a doctrine which is not without pro- 
minent advocates even in Great Britain, where the theory of 
Budd is so popular. Thus Dr. Murchison’s theory of a pytho- 
genic origin of the enteric poison has many advocates, and Sir 
Wm. Jen'ner in discussing this question in 1875 said, “My own 
prejudices are greatly in favor of the specific origin of this in 
common with all the contagious diseases. I have long advocated 
their specific differences, and that each has its specific cause, i. e., 
a cause which is unable to produce any other specific disease. 
If each could in every case be referred to emanations from those 
previously sick of the same disease, it would tend greatly to 
strengthen the general views I have long held and advocated. I 
am prejudiced, therefore, in favor of this opinion. I hope it is 
true; but then I must say that at this moment the weight of evi- 
dence and argument is rather on the other side.” He suggested as 
the best mode of settling this question “ to thoroughly scrutinize 
every isolated case that occurs in out-of-the-way country places.” In 
accordance with this suggestion Dr. Cornelius Fox investigated 
twenty-seven isolated cases, only three of which were clearly 
traceable to pre existing cases of this disease. Excluding also 
sixteen others respecting which there was a trace of doubt, there 
remained “eight decidedly untraceable cases, four of which ap- 
parently originated from excremental pollution of water, and the 
remainder from excremental pollution of air.” He cited also the 
particulars of an outbreak of diarrhoea, of only a few days’ dura- 
tion in most of the cases, which occurred in a school at Croydon, 
under charge of Dr. Carpenter, due to the contamination of a well 
by simple sewage, where there had been no antecedent case of 
fever.” And yet, though most of the boys were affected with 22 
ETIOLOGY OF ENTERIC FEVER. 
simple diarrhoea, three had typhoid fever with distinctly marked 
rose-colored spots and of twenty-one days’ duration. 
On this point the testimony of most of the fifty-eight corres- 
pondents who gave an affirmative answer to the first question of 
the circular is very emphatic. A few examples may be given :— 
Dr. C. Duff’ey, Newbern, N. C. “Yes. A number of cases in 
which after most careful inquiry the probability of importation 
was excluded.” 
Dr. C. J. O’Hagan, Greenville, N. C. “Nearly all the cases 
which I can recall since the war, seemed to originate spontane- 
ously. No importations could be traced. Last spring (1876) in 
a family residing in the county, one of the children, a school-boy 
of twelve years’ was attacked while at school near his home with 
typhoid. None of his school-mates had the disease. It attacked 
every member of the family but two. No local cause could be 
discovered.” 
Dr. S. Putnam, Montpelier, Vermont. “According to my ob- 
servation, during a somewhat extensive practice for thirty years 
or more, typhoid fever has more generally occurred as an epi- 
demic from August to November, particularly in dry seasons, 
after a succession of yellow, smoky days, without storm, winds, or 
electrical display, the beds of streams and ponds having become 
dry, or half dry and stenchy, and vegetation parched or shrivelled. 
Under these circumstances, constituting, as I conceive, an epi- 
demic influence, typhoid fever has often soon appeared, more 
frequently in families residing on the banks of streams or ponds, 
also, often in the farm-houses scattered over the hills, here and 
there, without any possibility of tracing the importation of the 
disease, or of its spread from house to house by contagion.” 
Dr. L. B. Edwards, Richmond. “ A farmer who lived eight 
miles from Lynchburg, near the base of the Tobacco Row Moun- 
tains, had not for months before his attack been where there was 
sickness. For several weeks just prior to his attack he had been 
engaged personally in clearing and plowing some 1 new grounds’ 
on the side of the mountain. There was nothing in the history 
of the case that indicated an importation of the disease.” 
Dr. W. H. Bramblett, Newburn, Va. “I can recall a number 
of cases occurring under such circumstances as to exclude the 
probability of importation. In a thinly settled country, as that 
to which my practice is most restricted, there are many isolated 
neighborhoods cut oil* by mountains and streams from other por- ETIOLOGY OF ENTERIC FEVER. 
23 
tions of the county. The families composing these communities 
never have a visitor from a distance; they rarely go out of their 
own neighborhood and never out of the county, in fact occupying 
a position so cut off from communication with the rest of the 
world that the appearance of the disease in their midst would 
appear irreconcilable with the modern theory of its mode of pro- 
pagation. Some of these neighborhoods I have had under ob- 
servation for ten years, and it is here that typhoid fever often 
seems to have its beginning, and can be traced to none of the 
ordinary sources of contagion agreeably to the modern theory. 
The same community is never visited on the year following an 
outbreak, and new outbreaks occur in communities which have 
not been invaded for ten years, or never before at all. I propose 
to report many of these cases in full in a paper which I have in 
hand to be communicated, when finished, to the Virginia Medical 
Monthly.'1'1 
Dr. W. H. Macon, Hanover Co., Va. “Mrs. E., living in the 
county of New Kent, had typhoid fever for thirty or forty days, 
convalesced, relapsed, and died. She had not been anywhere to 
contract the disease ; had not left her farm, certainly not the 
neighborhood. No other case occurred. This case must have 
originated there, if I may use the word, spontaneously, and 
several other cases similar to this might be mentioned.” 
Dr. A. W. Fontaine, New Canton, Va. “I have repeatedly 
seen isolated cases of the fever in different families at the same 
time, and at different times, which gave rise to no suspicion of 
importation.” 
Dr. W. B. Conway, Blacksburg, Va. “ I had here in my prac- 
tice among the citizens of this town (none of them students of 
the college) fifteen cases last year, and two now under treatment 
which could not be traced to importation. They originated here 
from local causes. These were, first, two heavy floods in rapid 
succession that swept through the valleys on each side of the 
town and left the grounds adjacent to the streams covered with 
vegetable and fecal matter; the fecal matter being washed from 
many privies as well as other places of deposit. All this matter 
was exposed to the hot August sun and the exhalations from it 
were carried by the breeze, generally blowing up the valley, 
over those parts of the town where this fever was developed. The 
second cause co-operating with the first, was the filthy condition 
of privies and premises generally, as well as inattention to per- 
sonal cleanliness.” 24 
ETIOLOGY OF ENTERIC FEVER. 
Dr. C. S. Morton, Appornatox Co., Ya. “The majority of the 
cases I have treated seemed generally to originate spontaneously, 
but were generally followed by a number of cases in the same 
family, and in some instances were clearly communicated to 
friends from a distance coming to visit the patient. Privies are 
used chiefly by the female members of the white family. But I 
have known many cases to arise where there were no privies and 
where it was natural to suppose that there was not any accumu- 
lation of the excrements near the dwelling sufficient to contami- 
nate the atmosphere appreciably. 1 am told that typhoid fever 
was a great scourge fifty or sixty years ago when there were no 
privies used in the country as a general thing. The increased 
use of privies at the present day has not been attended by any 
increase of the disease, but rather a marked decline. The water 
supply is obtained almost exclusively from springs.” 
Dr. S. W. Dickinson, Louisa Co., Ya. “I am attending now a 
negro girl with typhoid, who, so far as I can learn, has had no 
chance to contract the disease from any other person ; but her 
brother died with typhoid in the same house about ten months 
before she was taken with the disease. This is the only case I 
can recall where anything was known personally about the 
chances of contracting the disease.” 
Dr. \V. H. Daughtrey, Southampton Co., Ya. “I do not re- 
member having met in my practice with any cases of typhoid 
which I thought were imported, but invariably attributed their 
origin to some local cause. My practice has been in the country 
where privies are generally located sixty or seventy yards from 
the dwelling. The excrements are not generally removed there- 
from. The water supply is derived chiefly from wells. I have 
never, that I remember, attended a case of typhoid where the 
well was less than thirty or forty yards from the privy, stable, or 
pig-sties.” 
Dr. R. L. Sandford, Westmoreland Co., Ya. “ Twenty years 
ago I treated a case of typhoid which could not be traced to 
importation. It was the only case in the family, and no other 
existed in ten miles of the place. Since then I have had many 
cases similar. No special arrangements for the deposit of excre- 
ments. The water supply in this section (tide-water) is ample, 
but mostly from wells, which are generally remote from privies, 
stables, pig-sties.” 
Dr. H. Black, formerly of Blacksburg, Ya. “ In the winter ETIOLOGY OF ENTERIC FEVER. 
25 
and spring of 1875, I treated five cases of typhoid in the family 
of a farmer near Blacksburg. There was no typhoid disease pre- 
vailing in the neighborhood at the time, and there was no circum- 
stances that caused me to believe that it was imported from any 
other locality. These patients were visited by the members of 
two other families living respectively a mile and two miles dis- 
tant and in opposite directions. In each family two cases occurred. 
In two of these, and in all of the five cases, there was an unusual 
degree of irritation of the bronchia of a spasmodic nature. In 
June following, and six miles from the above named residence, 
a broad body of table-land and some ridges intervening, and the 
watercourses running in opposite directions, a young man, the 
son of a farmer, was attacked with typhoid fever, and died at 
the end of five weeks from hemorrhage of the bowels. The 
father was attacked in about three weeks after the son, and died 
after an illness of between four and five weeks. Another son 
who lived a mile off, and who had been nursing his father and 
brother, was taken sick, went home, and barely recovered after 
an illness of many weeks. In all but the last case, undue bron- 
chial irritation existed. At this place, as at the former, the 
excrements were deposited about the out-houses. Moreover, the 
yard at this place, but not at the former, was filthy from being 
run over by hogs, dogs, and fowls. The pig-sty was close by, 
and there was a damp dirty cellar beneath the house. The water 
was from a weak spring, and was slaty to the taste. The spring 
was protected from the surface drainage, which, however, flowed 
around it as it came from the yard on the hill-side above. No 
case of typhoid had been known in the family before. 
“ Had I access to my books I might, no doubt, recall many cases 
where there was not the slightest reason to suppose that the dis- 
ease was imported from other localities, an experience which I 
think will accord with that of most physicians who have treated 
it in the more sparsely settled and especially mountainous sec- 
tions of the State.” 
Dr. Bedford Brown, Alexandria, Ya. “ I have many reasons 
to believe that typhoid fever may be generated within the system 
spontaneously. In my own experience cases have originated on 
high isolated points where the locality was sterile, the drainage 
most perfect, the water pure and limpid, gushing out from rocky 
mountain sides. In one of these instances, the building was new, 
made of wood, airy and comfortable, supported on pillars two or 26 
ETIOLOGY OF ENTERIC FEVER. 
three feet high, underneath which the pure mountain breezes 
had free access, and the situation was on a high mountain point 
without the vestige of a local cause in the form of privy, sty, 
cesspool, inclosure, decaying animal or vegetable matter. Yet 
in this building were two well-marked cases of malignant enteric 
fever following in rapid succession. Neither of these victims 
had left the premises for weeks previously 
“ Thus apart from all contagious and infectious influences, there 
may exist such a combination of circumstances as want, exposure, 
hardship, mental depression, and it may be others, as to generate 
enteric fever. . . . . 
“I furthermore am impressed with the conviction that typhoid 
fever, as it exists and prevails in different localities, is due to a 
difference in its etiological factors 
“I have never been converted yet to the theory of Louis and 
his followers that typhoid fever was strictly a specific disease 
arising from infection or contagion, from the mere fact of the 
existence of a fever which usually runs a definite course towards 
restoration, wfth depressed vital action and ulceration of Peyer’s 
glands and diarrhoea. Pneumonitis might be entitled to the 
claim of specific character on the same principles.” 
Dr. W. S. Stoakley, Northampton Co., Ya. “The cases of 
typhoid fever which have prevailed here exclude all probability 
of importation, and appear to originate from causes entirely 
local, or from some peculiarity of the atmosphere in antagonism 
to that which produces malarial fevers. The abundance of space 
in the country makes it very easy to get rid of excrements, and 
it is very rare that there is impure air from such causes, unless 
it arises from compost heaps with which earth is mixed, or from 
the field where it is spread broadcast. We see this type of 
fever prevailing when every thing like manure is gathered up 
from the premises (even woodpile refuse) and carted out upon 
the fields and mixed with earth.” 
Dr. Alban S. Payne, Fauquier Co., Va. “I remember as far 
back as the winter of 1884, that a gentleman of wealth, living 
four miles west of Warrenton, proposed to emigrate with his 
negroes, during the coming spring, to Mississippi. In the winter 
months a strange malady broke out amongst his negroes, and by 
the following spring he had lost thirty by death. This was 
typhoid fever. There was no sickness anywhere else of a serious 
character in a hundred miles of this plantation. It was a very 27 
ETIOLOGY OF ENTERIC FEVER. 
dry winter, and the springs on the plantation were never of the 
best. In all other respects the topography was good. Privies 
are seldom used by these hardy mountain people, and excremen- 
titious matter is generally dried in the sun or carried off into 
watercourses by the rains.” 
Dr. J. S. Apperson, Smythe County, Ya. “ To none of a 
group of cases of typhoid fever which occurred in my practice 
between the 8th of April and 12th of October have I been able 
to assign any satisfactory cause. They seemed to be sporadic in 
the nature of their origin, and gave rise to no other cases of a 
similar kind. Three lived in an elevated region, a mile or two 
back from the section where the disease was most prevalent, but 
had no communication with those there affected. The remaining 
case seven or eight miles distant, and did not infect others.” 
Dr. Benjamin Lee, Philadelphia, Pa. “The following facts in 
regard to an epidemic of considerable proportions which occurred 
in the town of Wilmington, Delaware, in the spring, summer, and 
autumn of the year 1848, may be of interest. Although I cannot 
say with positiveness that the possibility of importation was 
excluded, yet the general opinion of the physicians of the place 
was that it originated there de novo, in consequence of a large, 
deep, and wide excavation of the principal street, left open for a 
considerable time, undertaken for the purpose of laying new 
water mains. The disease prevailed more extensively, and was 
more fatal in the immediate neighborhood of this excavation 
than elsewhere. Excrements were deposited in cesspools, and 
removed by scavengers. Water supplied by pumping from 
Brandywine Creek into a reservoir may have suffered some con- 
tamination from manufactories higher up the stream, but had 
never produced typhoid before.” 
Dr. W. G. Bogers, Charlottesville, Ya. “The first cases of 
typhoid fever that I saw occurred in Northern Albemarle, at Mr. 
D.’s farm. His dwelling was upon a flat, about two hundred 
yards from Buck Mountain Creek. lie owned about seventy-five 
negroes, whose cabins were upon the same flat, which was a 
little more elevated than the spring, and from fifty to one hun- 
dred yards from it. As there were many negro children, and 
each family raised one or more hogs, the premises were very 
filthy, and so located that the rains, doubtless, washed the filth 
into the spring used by both whites and blacks. There were 
forty-five or fifty cases of typhoid among the negroes, and three 28 
ETIOLOGY OF ENTERIC FEVER. 
or four of the whites also had it. The most of these were siek 
at the same time, and as there were no cases in the neighborhood, and 
it could not be traced to importation or contagion, it was believed that 
the water used for drinking was poisoned by fecal matter washed 
into the spring, whilst the air was rendered impure by emanations 
from the same, and that these probably acted as exciting causes 
of the outbreak of the disease, which was of a very malignant 
form, and proved very fatal. But that this could not have been 
the only cause is proved by the fact that the same filthy state of 
the premises had existed for at least a quarter of a century. The 
cabins had long been old and dilapidated, and yet this was the 
first outbreak there, or in that neighborhood. Though this 
supposed exciting cause had thus existed there for years, the 
fevers that had hitherto prevailed were the bilious remittent, and 
more rarely the intermittent, whilst the diseases generally were 
highly sthenic, requiring active depletion. One or two free 
general bleedings, which would now kill a patient with pneu- 
monia, then cured the disease. Upon the advent of typhoid fever 
all diseases became asthenic, requiring a tonic and stimulating 
treatment. There must, therefore, have been a general atmos- 
pheric cause that did not before exist, which was necessary to 
render the exciting causes of typhoid effective, and gave an as- 
thenic character to other diseases.” 
Ur. Z. J. Walker, Rockbridge Co., Va., whose account of a 
local outbreak of typhoid fever in the contiguous county of Bath, 
arising from an imported case, has been given above, reports 
several cases occurring in his own county, where there was ab- 
solutely no ground to suspect importation. “Brownsburg is a 
small village on the turnpike leading from Staunton to Lexington. 
The situation is a dry one, no marshes in ten miles, the country 
is rolling, drainage good. The village occupies a plateau, bounded 
on the west by a range of hills ; on the east there is a rapid descent 
to a branch which skirts that side of the village. This branch 
is parallel to the main street, and about seventy-five yards from 
it. There are but two rows of houses, one on each side of said 
street. The population is about two hundred. I have resided 
here as a practitioner for eighteen years. During this period I 
have treated in this village about thirty-five or forty cases of 
typhoid fever, all of which, except five cases, occurred on the western 
side of the main street. Not a single house on that side escaped. 
Only two houses on the eastern side were affected. The turnpike ETIOLOGY OF ENTERIC FEVER. 
29 
on the map is the main street. On the east the drainage rapidly 
goes off to the branch. The elevation of the main street above the 
branch is about thirty-five feet. The water supply for the eastern 
side is obtained from springs marked on the map. On the west 
it is obtained from wells. The drainage from the western side is 
effected through a shallow ravine (marked with dotted lines on 
the map), which passes in close proximity to wells, privies, and 
pig-pens. This ravine drains an alley (marked 13), which is used 
by the negroes and boys as a privy. All the privies on the 
western side are situated on the brink of this ravine. The wells 
are also near it. Why the eastern side has enjoyed such an ex- 
emption, I have been unable to determine, unless it be due to the 
difference in the water supply. I have a vivid recollection of 
eight cases of typhoid fever, which occurred in the autumn of 
1865, all of which were on the western side. In September of 
that year, we had a wet spell of weather. There was a consider- 
able overflow. The water in the ravine overflowed its banks, 
sweeping down the excrement from the alley (13), passing under 
my privy (p), and filling an old ice-house (7) on James Withrow’s 
lot. This ice-house is within a rod of the well (8). The water 
in the ice-house soon disappeared, and doubtless percolated into 
the well and contaminated it. Only two families used water 
from this well, my own family and that of James Withrow. In 
a short time there were eight cases of typhoid fever in the two 
families. The water supply was changed after the appearance of 
the first four or five cases. In two weeks after the appearance 
of the first case the eighth and last appeared. No other eases 
occurred in any portion of the village. The cellars of both 
houses were in good condition. The excremental contamination 
of the water was the only assignable cause. I, alone, of my en- 
tire family escaped. I suffered for a week from diarrhoea, and 
general malaise. In the summer of 1866, I treated five cases of 
typhoid on the eastern side of the village; one at Mrs. Kennedy’s 
(1), and four at Win. Withrow’s (2). These two houses are at the 
extreme northern end of the village, one (1) near the branch, the 
other east of the branch. The water supply for both is obtained 
from a spring (12), which is exempt from anything like excre- 
mental contamination. There was no suspicion of importation 
from another quarter. The only assignable cause was the foul 
emanation from the tanyard (4). These were the only cases in 
the village during the j'ear. Indeed, I have had but one case in ETIOLOGY OF ENTERIC FEVER. 
31 
the village since that date. There is not much travel through 
Brownsburg. There is no hotel in the place, and travellers do 
not stop with us. None of the persons attacked had been away 
from home. In March, 1875, I had three cases at a house on 
Walker’s Creek, near the base of the North Mountain. This is 
a thickly settled portion of the county. The three cases occurred 
within a period of a week. There was no reason to suspect im- 
portation. The family, consisting of seven persons, had moved 
into the house about six weeks before the outbreak. The house 
is on a little bluff of about twelve or fifteen feet elevation. The 
spring issues from beneath the bluff. The privy is behind the 
house on flat ground, from which the water during a rainy season 
does not readily run off, but sinks into the soil. I suspected ex- 
cremental contamination, and ordered that the water supply be 
changed. Before the occurrence of these cases there had been a 
heavy rainfall.”1 
Dr. C. O’Hagan, Greenville, N. C. “I have known a single 
severe case to occur in a family where no importation had been 
possible; where the hygienic conditions were good, and where in 
a large family no other member suffered, and where it was im- 
possible to attribute it to fecal contamination of either air or 
water.” 
Dr. John Wilson, U. S. N. “ During my term of service (1872 
to 1875) at the Chelsea Hospital, we had an occasional case of 
fever from the Marine Barracks. The men thus affected had 
been under punishment by confinement in prison ; room situated 
in the basement. The disease could hardly have been imported, 
as the prisoners were less abroad than their companions. It was 
not probably communicated by the water, as the prisoners used 
the same kind of water as the other men. It could not have been 
* EXPLANATION OF MAP OF BROWNSBURG. 
No. 1. Kennedy’s. No. 5. Spring. No. 8. Well, just back of the ice-house. 
“ 2. Win. Withrow's. 1‘ 6. “ “ 9. Pig-pen. 
“ 3. Tanyard. P. Privy. “ 10. “ 
“ 4. Spring. No. 7. Old ice-house. 
“ 11. Well, about 2 poles from pig-pen. The dotted lines ( ) in the western part of the 
town indicate the natural drainage of the high country immediately west of the town (rayine). 
The courses of main and parallel streets are N. 25p W. 
The cross streets run N. 64° W. 
The length of the village is about 90 poles. 
The width of the village is about 43 poles. 
No. 12. Spring (in meadow) used by Mrs. Kennedy and Wm. Withrow. 
No. 13. Alley, used as a privy by the town boys and negroes. 
No. 14. My house. No. 15. James Withrow’s house. 32 
ETIOLOGY OF ENTERIC FEVER. 
by the general atmosphere to which all were about equally ex- 
posed The floor of the prison rooms is considerably 
lower than the surface of the adjoining street, and on the opposite 
side of the street is a hill, occupied by dwellings of the poorer 
sort, so that probably the soil about the rooms is in some degree 
infected with decomposing human excreta and domestic filth.” 
Dr. F. B. Watkins, Richmond; formerly practised in Prince 
Edward Co. “I can recall many cases which originated under 
such circumstances as to exclude the idea of importation. These 
cases originated at home. The majority were negroes living in 
old log cabins. So certain was I that the fever originated in 
certain cabins that I ordered them to be burnt, not simply evacu- 
ated. I doubt not a vast amount of evidence could be arrayed 
to establish the convictions of physicians and of owners of slaves, 
that certain houses were the fons et origo of the fever. And the 
family being removed and the houses burnt the progress of the 
disease stayed.” 
Dr. T. B. Greer, Franklin Co., Ya. “I have witnessed two 
endemics of typhoid fever and have the facts of another, which 
prevailed almost in the same locality, and were confined to a 
space of fifteen miles north and south, and about ten east and 
west, lying just under the Blue Ridge, where the disease origi- 
nated spontaneously. The last of these endemics occurred in the 
fall of 1876. The first occurred in 1842 before I entered the 
profession. Ever since that time there has been more of the 
disease in that locality than in any other part of this or the ad- 
joining counties. This location is on the slope of the Blue Ridge, 
the finest watered and the best drained locality in the State. 
Gradually undulating, without wells, cesspools, or decomposing 
organic matter except forest vegetable matter, this locality is 
also thinly settled and all excrementitious matters are effectually 
and promptly washed off*. The soil, of necessity and in fact, is 
less saturated with organic impurities than other parts of the 
county where the disease prevails only sporadically. It is my 
opinion that here, at least, the disease is attributable to local 
telluric influences which are yet enveloped in obscurity, and to 
which the investigations of the profession will eventually turn to 
find the first cause. There were over one hundred cases last fall 
in this locality. I did not see a single case outside of it, and only 
heard of one. I have noticed for several years that this same 
locality has been remarkable for the prevalence of diphtheria and ETIOLOGY OF ENTERIC FEVER. 
33 
erysipelas. I do not think that there are half a dozen wells in 
that district, and many of the cases occurred in neat, newly set- 
tled places. In other respects it is remarkable for pure water, 
healthy atmosphere, and the comparative absence of all other 
diseases.” 
Other citations will be given in connection with the assignment 
of special conditions. For the present let the foregoing be taken 
as a sample of the affirmative conclusions of fifty-eight corres- 
pondents as to the possibility of the spontaneous development of 
typhoid fever. It will not have escaped notice that in some of 
the cases the possibility of importation does not appear-to have 
been wholly excluded by the facts as reported, but in most of the 
others the evidence viewed by itself seems irresistible. A strict 
logic requires, however, that all the objections to such a conclu- 
sion should be duly considered, and some of these are sufficiently 
cogent. Stokes’s argument founded on the comparatively rare 
occurrence of typhoid in the filthy cabins of the Irish peasantry 
and analogous facts occasionally observed throughout this country 
are not easily reconciled with Murchison’s theory. Here is a 
case in point:— 
Dr. John A. Graham, Lexington, Va., writes: “There is a 
large spring at the lower end of the town of Lexington. The 
ravine, or hollow, running up from the spring is occupied with 
negroes and others in shanties and tenement houses, with hog- 
pens and privies never clean. Now, if it can be proved that the 
filth from the ravine communicates with the channel of the spring, 
what a splendid place for typhoid fever we have here. The 
water is used by all the people in that neighborhood for drinking, 
cooking, etc. Some years ago a dyeing establishment was started 
on the ravine, among the shanties, say seventy-five yards above 
the spring. The dye water thrown out from the back of the 
house, passed through the soil, and came out at the spring coloring 
the water. I think the town authorities had the dyeing estab- 
lishment removed. The privies and the hog-pens remain. I 
have watched that locality for years with an eye to typhoid fever, 
but not a single case has occurred.” 
This is not an isolated case. Many other similar facts are cited 
by other correspondents, and it is well known that Dr. Budd and 
others who advocate his theory of continuous development cite 
numerous and well-authenticated instances in which pythogenic 
influences failed during indefinitely long periods of time to de- 34 
ETIOLOGY OF ENTERIC FEVER. 
velop fever until a case imported ah extra was brought in to 
initiate the zymosis. Now, I say that such facts as these cannot 
be without significance. They are not to be summarily dismissed 
on the ground that positive proof in a few cases outweighs any 
amount of negative evidence. If purely pythogenic influences 
suffice of themselves to generate the disease they should produce 
this result with some degree of uniformity and not exceptionally 
only. What then is the true significance of the facts cited by the 
advocates of a de novo development ? Why simply this, that the 
disease may appear under favorable conditions where importation 
by human intercourse or by fornites has been pretty certainly 
excluded. The unknown factor which, in addition to the pytho- 
genic influence, may be necessary for the development of the 
disease, may be specific germs conveyed otherwise than by human 
intercourse, or exhumed from the soil where they may have been 
deposited at some long anterior period, being preserved mean- 
while in a state of dormant vitality, or possibly multiplying and 
undergoing developmental changes differing from those which 
take place after their introduction into the living body, or finally, 
the disease germs may, as Lionel Beale be formed in 
the system under suitable internal and external conditions. Thus, 
according to any of these suppositions, either of which may be 
legitimately held as a provisional hypothesis, the apparently 
spontaneous development of typhoid fever neither requires the 
abandonment of the doctrine of a contayium vivum, nor drives 
us to the alternative of accepting Bastian’s doctrine of hetero- 
genesis. On the contrary, the supposition of a wide atmospheric 
diffusion of disease germs serves to explain and harmonize the 
otherwise irreconcilable observations of Budd and Murchison. 
The limits of the vitality of disease germs, and of their capa- 
city of diffusion through the atmosphere in clouds of definite 
dimensions, have not been ascertained, but it is in accordance 
with analogy to believe that they may resist destructive influ- 
ences which would be fatal at a more advanced stage of develop- 
ment, and be capable of transportation to great distances in a 
desiccated state without losing their capacity for development. 
It has recently been ascertained that grains of wheat, and even 
of Indian corn (a semi-tropical plant), left several years ago by 
Arctic explorers in a region where the temperature scarcely, if 
ever, rises above 50° below zero, have yet retained their power 
of germination. ETIOLOGY OF ENTERIC FEVER. 
35 
Limiting thus the import of the phrase “ spontaneous''1 or “ de 
novo” development of typhoid fever, we may now inquire what 
external conditions seem to be potential in determining this 
development. The views of several correspondents on this ques- 
tion have been given in connection with the citation of their 
opinions as to the general fact, but we may now proceed to indi- 
cate seriatim the varied conditions which, on evidence more or 
less satisfactory, may be considered to exert an influence in de- 
termining the prevalence of typhoid fever. The limits of my 
space will compel me to withhold a large part of the evidence in 
my possession with reference to the several heads. 
(1) Typhoid fever may be developed by excremental filth, un- 
dergoing moist decomposition with the result of contaminating 
the local atmosphere, and especially the water supply as derived 
from wells, springs, rivers, or rivulets, into which the excremen- 
tal matters have been introduced by surface or subsoil drainage. 
This proposition is so well established on evidence familiar to 
all students of sanitary science, that I consider it unnecessary to 
enlarge this paper with further proof, but will simply say that 
strong confirmation is afforded by observations reported in com- 
munications from Dr. E. M. Hunt, Chairman of this Section, Dr. 
Denison, of Denver, Colorado, Dr. Brandeis, of Louisville, Ky., 
Dr. H. B. Baker, of Lansing, Michigan (Contributions to the 
study of the cause of typhoid fever in 4th Annual Report of the 
Secretary of the State Board of Health of Michigan), Dr. Putnam, 
of Montpelier, Vt., and Drs. Ellzey, Fauntleroy, G. W. Briggs, 
Macon, Basham, Baskerville, Cunningham, Madison, S. P. Chris- 
tian, and others of Virginia. 
(2) Several correspondents refer to reported outbreaks of 
typhoid fever, in England and in this country, which were traced 
beyond the possibility of mistake to drinking milk which had 
become contaminated by the use of foul water in washing the 
milk cans, but none of these cases fell under their own observa- 
tion. 
(3) The influence of vegetable decomposition in determining 
the development of typhoid fever is maintained by a number of 
correspondents, as— 
Dr. R. L. Sandford, Westmoreland Co., Va. “ In conversation 
with a physician of this county some years ago, he related a cir- 
cumstance which strengthened my opinion in favor of vegetable 
decomposition as a cause of typhoid fever. Qne member after 36 
ETIOLOGY OF ENTERIC FEVER. 
another of a family was seized with typhoid, and all the first 
cases proved fatal. Upon examination he found in the basement 
of the house a quantity of turnips and cabbages in a state of .de- 
composition. lie immediately had them all removed, and the 
place cleansed. The cases then on hand recovered rapidly, and 
there were no more afterwards.” 
Dr. R. W. Martin, Pittsylvania Co., Ya. “ Six cases of typhoid 
occurred eight miles north of Chatham on the line of the Virginia 
Midland R.R., when this road was in process of construction. 
The locality had several years before been a favorite spot for the 
development of typhoid. These cases were undoubtedly genuine 
typhoid. The subjects were citizens of different counties, and 
were persons of respectability. None of them had resided in the 
vicinity less than three months. The location was an eminence 
overlooking a large mill-pond to the west. The water from this 
pond supplied two mills, and consequently during the day ran 
down very low, leaving a large surface of mud mixed with de- 
caying vegetable matter exposed to the sun’s rays, and surrounded 
by a large area of saturated soil.” 
Dr. W. B. Gray, Richmond, Ya. “ About two miles north of 
Bowlesville, in Fluvanna, there was a millpond, and for two 
miles north of that I had numerous cases of typhoid fever. ' Not 
far from the head (back) waters of this pond there was a chaly- 
beate spring, which was visited by two young ladies living a mile 
east of the pond. They resorted to the spring a little before 
sunset. Both of them had typhoid fever, while no other member 
of the family had it this year, though about one hundred per- 
sons, white and colored, lived upon the premises. (In 1855, it 
prevailed extensively in this and in the neighboring families.) 
. . . . From the best observation of which I have been 
capable during a practice of twenty-five years, including twenty 
years in the country and ’five in this city, I am satisfied that 
vegetable decomposition is, oftener than animal, responsible for 
typhoid. Whenever I see a prolonged spell of dry weather fol- 
lowed by heavy rains, in midsummer or early autumn, experience 
has taught me to expect typhoid or other form of fever.” 
He states the somewhat remarkable fact, ascertained by in- 
quiries made on the spot by himself and Dr. C. W. Brock, that 
the butchers of Richmond, who for the most part live in a par- 
ticular quarter on the outskirts of the city, seldom if ever have 37 
ETIOLOGY OF ENTERIC FEVER. 
a case of typhoid in their families or on their premises where the 
slaughtering of animals for the market is carried on. 
Dr. C. C. Conway, Rapidan, Ya. “The house in which a 
young man, aet. 19, resided at this place, was inundated during 
the great flood of 1870, and after the water subsided there was 
a heavy deposit of organic matter in the yard and house. This 
was scraped together in large heaps and left to lie exposed to the 
hot'September sun. In about eight days he had slight premoni- 
tory symptoms. Subsequently the fever was fully developed, 
and he died about three weeks thereafter.” 
Dr. Baker’s “Contributions to the Study of the Cause of 
Typhoid Fever,” referred to on a preceding page, contain a 
notice of an outbreak of typhoid fever in the township of Cannon, 
Kent County, Michigan. The cases occurred in the immediate 
vicinity of Malone Lake, which had been drained and lowered six 
feet during the summer, exposing about sixty acres of muck land 
formerly covered by water. Dr. Chamberlin, the health officer, 
gave it as his opinion that the cause of the outbreak was the 
effluvia from decaying vegetable matter. 
(4) Several correspondents make a distinction between vege- 
table decomposition as commonly exhibited and the decay of 
dry timber, ascribing to the latter a far more potent influence in 
the production of typhoid fever. Dr. R. T. Coleman, of Rich- 
mond, if not the originator, is the most earnest and zealous advo- 
cate of this doctrine. He states the grounds of his conviction, as 
follows:— 
“ A large number of slave owners of my acquaintance have 
been struck with a terrible outbreak of typhoid fever in their 
old decaying negro cabins, so malignant at times that new cabins 
were built and the old ones burned before the disease could be 
stamped out. I recollect hearing my former colleague, Prof. 
Beverly Wellford (President of the Amer. Med. Association in 
1853), mention a very striking illustration of the above. While 
the occupants of the old cabins had typhoid fever those in the 
newer cabins escaped. They drank the same water and were fed 
from the same kitchen. Nor was the soil around the old houses 
any more saturated with organic impurities, for, under our old 
Virginia system of farming, all accumulations of filth were regu- 
larly scraped up, and hauled off to enrich the land. There was 
nothing but the decaying cabins to account for the disease. So 38 
ETIOLOGY OF ENTERIC FEVER. 
thought the owners, so thought their doctors, and they acted on 
this hypothesis with success. 
“There was in this city, just before I settled here, a wagon- 
yard which had become excavated by the friction of the wheels 
and the trampling of the horses. The owner was a builder, and 
in a dull season he concluded, in order to give occupation to • 
his hands and increase his revenue, to build on this lot. It being 
inconvenient to haul earth to fill up the excavation he had 
shavings brought from his shop, and these mixed with the soil 
served as the foundation of the house and its surroundings. Of 
some twenty people who lived in that house in the following five 
years, six had typhoid fever caused as they and I believed by 
the decaying shavings. 
“When the war came on I went as a surgeon to Western 
Virginia in the Lee and Loring campaign. When our little 
army reached Valley Mountain, in Randolph County, two regi- 
ments occupied all the 1 cleared land,’ while the rest of the com- 
mand had to camp in an adjoining forest. In this so-called 
cleared land the trees had been ‘ belted,’ and had for years been 
slowly rotting. Many of them in various stages of decay be- 
strewed the ground. We were at Valley Mountain about two 
months, and in this time 30 per cent, of one of the regiments on 
this cleared land, and about 25 per cent, of the other, had typhoid 
fever, while of the regiments camped in the forest not more than 
5 per cent, were attacked. What caused the difference? Decay- 
ing timber, I say—there is no other explanation. In physique, 
morale, equipment, the 21st Virginia regiment was certainly 
equal to any of the others. We had substantially the same 
water, the same rations, and the fever commenced its ravages 
before there was time for soil contamination. 
“ May not this mode of clearing (by belting trees and leaving 
them to rot standing) account for the fact that the mountains of 
Virginia, which in my boyhood were the great fountains of health 
and strength, have become the 'nidus, the most congenial home 
of typhoid fever and its congeners?” 
Similar views founded on similar observations are expressed 
by quite a number of correspondents, but with especial emphasis 
by Dr. Charles Duffey, of Newbern, N. C., and by Dr. A. G. 
Tebault, Dr. C. W.P. Brock, Dr. C. R. Cullen, Dr. R. L. Madison, 
and Dr. F. B. Watkins, of Virginia. The two last-named gentle- 
men refer to the expedient, often resorted to in local outbreaks ETIOLOGY OF ENTERIC FEVER. 
39 
on farms in Virginia, of burning the old cabins before the pro- 
gress of the fever could be checked. There seems to be little or 
no room to doubt the existence of a morbific influence derived 
from the old cabins, but that the factor in question is decaying 
timber is not, I think, equally certain, although the collateral 
evidence given by Dr. Coleman renders his conclusion not im- 
probable. But in a few cases of this kind, which have fallen 
under my own observation, another and very potential factor 
v/as discovered in a mass of sludge, which had been formed under 
a very badly jointed floor by the drippings of slops, and possibly, 
to some extent, of the excreta of children. In these cases there 
was thus soil contamination of the worst sort. 
(5) The influence of a soil saturated with organic impurities 
in determining the development of enteric fever is affirmed by 
seventeen correspondents. Facts stated in this connection by 
several of these correspondents have been already cited in the 
preceding part of this paper. 
Dr. S. W. Dickinson, of Louisa Co., Va., has, like myself, 
noticed the influence of this factor in connection with old negro 
cabins. He says :— 
“ Typhoid fever was very common here prior to the emancipa- 
tion of slaves, when they were often crowded in ill-ventilated 
houses that had stood for years in the same place with the most 
favorable chances for saturation of the soil with organic matters, 
but since the negroes live in the woods in great measure, and in 
new log houses on new sites, that or other causes have dimin- 
ished the frequency of the disease.” 
Dr. R. C. Bowles, of Columbia, Fluvanna Co., Va., also refers 
to a similar exemption of that section of the State which has been 
observed since the war, but, not admitting any improvement in 
the houses of the negroes, he excludes local causes altogether. 
“Since the war, or for a period of ten years, if there has been 
a case of well-marked enteric fever in this township I have not 
seen or heard of it. IIow to account for this exemption I do not 
know. Among the negro population the disease was especially 
fatal. To recover was the exception, though, as slaves, they were 
better fed, better clad, and better housed than now. So far as I 
can say, from personal observation of the disease, it was not due 
to any local contamination of air or water, but was truly epi- 
demic.” 
Dr. A. M. Fauntleroy, of Staunton, Va., refers to an outbreak 40 
ETIOLOGY OF ENTERIC FEVER. 
of typhoid fever during the summer of 1876, which was due, 
he thinks, to the saturation of the soil with organic matters, 
although in this case the wells also were probably more or less 
contaminated. 
“ Goshen stands upon ground which forms a natural basin, 
readily receiving through the porous soil the drainage of the 
surroundings. The soil was saturated with organic impurities 
and other filth. Prima facie one might be led to ascribe the 
outbreak to the soil impurities alone, but from the lack of all 
measures to protect the wells, I am strongly inclined to the 
opinion that it was due to the impregnation of the water supply 
with the specific poison deposited in the latrines. The water 
level in the wells was below that of previous years, because the 
rainfall during the year had been less. The distance from the 
well to the latrine is about fifty feet.” 
(6) Of the seventeen (17) correspondents who have observed a 
connection between the prevalence of typhoid and a low level of 
the ground water, only one or two enter into any particulars, the 
others simply affirming the fact of the coincidence. Where 
particulars were stated they commonly referred to a very foul state 
of the water in the wells, and by implication the contaminated 
water was charged with the production of the fever. Whether 
the surface or subsoil from which the ground water, previously 
high, has receded, is more potential in developing fever than a 
wet soil, cannot be decided from the evidence in my possession. 
(7) That the spread of typhoid fever may be connected with 
some undefined telluric influence not necessarily dependent on 
soil-saturation is asserted by several correspondents, who cite 
some very significant facts in justification of this opinion. I 
refer particularly to the remarkable testimony of Dr. T. B. 
Greer, already cited, respecting the extraordinary prevalence of 
typhoid fever in a part of Franklin County, Virginia, where the 
usually assigned causes would seem to be absolutely excluded. 
I have already given the testimony of Dr. Benjamin Lee, of 
Philadelphia, with reference to an outbreak of fever in Wilming 
ton, Delaware, apparently caused by a deep excavation in some 
of the streets. Similarly Dr. F. D. Cunningham, of Richmond, 
states that in 1873 there was a decided increase of cases of 
typhoid fever in that city concurrently with extensive excava- 
tions in the streets. 
Dr. R. S. Payne, of Lynchburg, Va., in an extremely interesting 41 
ETIOLOGY OF ENTERIC FEVER. 
communication, recalls the changes produced in the medical 
topography of that city and its surroundings by the construction 
of the James Kiver and Kanawha Canal, which was commenced 
in 1831. 
“The low grounds between the hills and the river banks were 
watered by springs from the hills, and as the river bank was 
higher than the foot of the hill the low grounds were necessarily 
swampy in character, and until the grounds were drained by the 
canal we had ague and fever along its line every summer and fall. 
While the canal was in progress of construction, the laborers 
engaged in this work, as well as those upon the farms for twelve 
or fourteen miles below Lynchburg, suffered severely with con- 
gestive chills. If the patient did not die during the third or 
fourth chill, the case generally became complicated with severe 
diarrhoea, the fever assumed a continued type, frequently marked 
with tympanitis and delirium. After the newly lifted earth had 
been exposed to the winter’s frost and a summer’s sun the mias- 
matic features were greatly abated, and the fever now generally 
assumed very distinctly the characteristic features of typhoid. 
Still, on the same farms, and sometimes in the same families, 
you would see during this epidemic a well-marked case of chill 
and fever, but if not arrested within five or six days, and espe- 
cially if the patient took an aperient, however mild, a diarrhoea 
would set in, the intermission would be less and less marked, 
and ultimately the fever take a typhoid character. This pecu- 
liarity was confined to the population residing on the river. 
About two and a half or three miles from the river typhoid fever 
broke out on a plantation with a large family of negroes, and 
many died. There was no malarious complication here. The 
only chill I saw was produced by myself in sponging a patient 
with cold water, with a view of reducing the high temperature. 
A chill came on by the time I had sponged the face, neck, and 
one arm, and the patient died in less than two days.” 
(8) The relations between typhoid and malarial fevers consti- 
tute a very important subject of investigation, in regard to which 
various and diverse opinions are entertained. 
A considerable majority of my correspondents who notice this 
subject at all, adhere to the common opinion that these two 
distinct types of fever have each its distinct specific cause, and 
both may prevail at the same time in the same place. A small 
proportion of this class of correspondents believe further, that the 42 
ETIOLOGY OF ENTERIC FEVER. 
two diseases may coexist in the same individual as a hybrid, 
constituting one of the varieties of the so-called typho-malarial 
fever, the other varieties representing hybrids between malarial 
fever and typhus, or between malarial and relapsing fever. For 
what appears to be very conclusive clinical and pathologico- 
anatomical evidence of the correctness of this view, I must refer 
to Dr. Woodward’s paper on Typho-Malarial Fever, read in the 
Section on Medicine of the International Medical Congress. 
Nevertheless such a position is earnestly controverted by many 
Southern physicians, whose residence in malarious regions gives 
them opportunities for observation on a large scale. Many of 
these observers contend that the so called typho-malarial fevers 
are simply malarial fevers with adynamic tendencies. A similar 
opinion has been recently pronounced by Dr. Loomis, of New 
York, who ascribes the adynamia to pythogenic influences, which 
cannot, he thinks, cause enteric fever in the absence of a specific 
germ. 
Another class of correspondents report observations which lend 
a certain degree of plausibility to the doctrine of an alleged 
antagonism between typhoid and malarial fevers. That this 
antagonism is not absolute is conclusively shown by the occa- 
sional coexistence of the two diseases side by side; and, as I 
believe, as a hybrid in the same subject. Nevertheless, that 
enteric fever is far less common in malarious regions than else- 
where, and that its frequency increases in these very regions 
during periods in which there is a suspension of malarious influ- 
ence, are, in my judgment, well-established facts. 
The late Dr. Elisha Bartlett quotes approvingly the following 
passage from the London Lancet of March, 1847, as the conclu- 
sions to which M. Boudin had then recently arrived. “Those 
localities in which the producing cause of endemic intermittents 
thoroughly modifies the constitution are remarkable for the infre- 
quency of phthisis and typhoid fever. The localities in which 
phthisis and typhoid are particularly prevalent are remarkable 
for the infrequency of intermittent fevers contracted on the spot. 
The drying up of a marsh, or its conversion into a lake, diminishes 
or prevents intermittent fevers, but seems to dispose the organism 
to a new series of diseases, in which phthisis and typhoid fever 
according to the climate are particularly prominent. After a 
residence in a thoroughly marshy locality, an individual enjoys 
an immunity from- typhoid fever, the degree and duration of ETIOLOGY OF ENTERIC FEVER. 
43 
which are in direct proportion to the length and degree of the 
exposure.” 
Even Dr. Woodward, while maintaining that the unknown 
causes of the periodical fevers and of typhoid exist side by side, 
and often coexist in the same person, calls attention to the fact, 
which he justly characterizes as very important, “that intermit- 
tent and remittent fevers often disappear more or less completely 
from neighborhoods in which they have long prevailed and are 
replaced by typhoid fever.” 
At first view this may seem easily intelligible. A newly set- 
tled and badly drained region in a suitable climate has all the 
conditions to generate malaria, and by the time the beneficial 
effects of drainage and tillage are felt, the contagium arising from 
human beings will be sufficiently diffused to give rise to endemics 
of typhoid fever. Dr. Stormont, of Topeka, says, “We have no 
typhoid in Kansas—why I don’t know. Has not this been true 
of all the Western States in the first few years of their settle- 
ment? It was certainly true of Illinois.” 
But Dr. Woodward goes on to sav: “But let me next observe 
that the change thus effected is not always a permanent one. 
Often in individual years the intermittents and remittents reap- 
pear in epidemic-wise in regions such as I have described, and 
then the typhoids vanish for a time, to return once more when 
the temporary prevalence of the periodical fevers comes to an 
end.” My correspondence supplies abundant and emphatic evi- 
dence of the truth of this proposition, as will appear from the 
following extracts of letters:— 
Dr. Charles Duffey, Newbern, N. C. “The fact that we so 
rarely see typhoid in our malarious regions, notwithstanding the 
constant existence of acknowledged predisposed causes would 
prove this (namely, the alleged antagonism). The year 1874 
presented a larger number of typhoid cases than I have seen for 
years, and yet we had unusual immunity from malaria. In 1872 
the conditions were exactly reversed.” 
Dr. S. W. Dickinson, Louisa Co., Ya. “Prior to 1873, typhoid 
was the prevailing fever of this section, and malarial fevers were 
quite unknown. In 1872-3-4, malarial fevers became very com- 
rnon, and we still have some few cases every summer. During 
this time typhoid has been almost extinct, except when originatin'/ 
from imported cases. The sentiment of other physicians questioned 
, on this point is that there is an antagonism between typhoid and 44 
ETIOLOGY OF ENTERIC FEVER. 
malarial fevers, and I think my observations on that point war- 
rant such a belief.” 
Dr. R. T. Lemmon, of Campbell Co., Ya. “I have had fre- 
quent occasion to mark an apparent antagonism between typhoid 
and malarial fevers. In the year 1845 this section of the State 
was fearfully scourged by a typhoid epidemic. The backbone 
or ridges suffered more severely, while the malarial region on 
the banks of the Staunton Eiver and some large and old mill-ponds 
escaped entirely, the usual amount of ague prevailing there. The 
line of demarcation was very apparent. Subsequently I have 
seen cases of typhoid within the malarial region, but no cases of 
intermittent at the same time. I have noticed another fact, that 
the cases of typhoid occurring-in malarial districts were milder.” 
Dr. F. B. Watkins, Bichmond, Ya. “So extremely rare were 
cases of typhoid fever in my field of practice in the valley of the 
James, in Goochland County, where malarial fevers were posi- 
tively epidemic for some years (I saw 52 cases in one season in 
one family of 80 persons), that when I went to the county of 
Prince Edward and encountered my first cases of what every- 
body called “the fever,” I felt great and serious embarrassment, 
and often invoked the aid of professional brethren before maturing 
my diagnosis. This was about 20 years ago, in 1857. I can 
truly say that I had seen no such cases on James River. I saw a 
medical friend to-day from James Eiver, and found that his ex- 
perience coincided with my own. I have conversed with several 
physicians, who, like myself, have settled here (in Richmond) 
since 1865, and they all concur in the correctness of my observa- 
tion that there is a seeming antagonism between typhoid and 
malarial fevers.” 
Dr. J. C. Green, of Danville, Ya. “Since the war there have 
been but few cases of typhoid fever anywhere within the range 
of my practice, and indeed, since 1869, I have not seen a single 
case, nor has a single one occurred within the town limits or im- 
mediate neighborhood. This is the more remarkable, when the 
rapid increase of population has almost transformed a village 
into a populous city, with all its sewerage necessities, while no 
efforts have been made to provide sewers, or in any way to re- 
move the enormous accumulation of excrement and decaying 
organic matter, which are permitted to contaminate air, earth, and 
water. But while enjoying complete exemption from typhoid 
fever, we are scourged with malarial fevers. Within the last ETIOLOGY OF ENTERIC FEVER. 
45 
year there have been quite a number of cases of typho malarial 
fever, which have been confounded with typhoid, but to any one 
familiar with both diseases, the cases have been sufficiently easy 
to distinguish, and warrant me in affirming that we have not had 
a single case of enteric fever since 1869. I am well aware that 
the facts I have stated are directly opposed to the ordinarily 
accepted etiology of typhoid fever, but ‘facts are stubborn chiels, 
and winna be driven,’ and while we have the ideal conditions for 
typhoid outbreaks, we enjoy the most perfect immunity. In this 
same region, typhoid fever had previously existed for a number 
of years, first appearing in 1845, when it supplanted malarial 
fevers, to be itself supplanted by them at a later period. Elder 
practitioners, who witnessed the disappearance of bilious remit- 
tent fevers, graphically describe the appearance in 1845 of the 
new enemy, and the ill success which attended their first efforts 
to treat it.” 
Dr. R. W. Martin, of the same county, gives a strongly con- 
firmatory testimony. Similar opinions, on similar grounds, are 
expressed by Dr. Brandeis, of Louisville, Kentucky, and by Drs. 
Fontaine, R. W. Nelson, Stoakley, Flournoy, S. F. Christian, 
Powell, Z. B. Ilerndon, Adkins, Barham, and others, of Virginia. 
Per contra, a more or less decided negative opinion is expressed 
by a much larger number of correspondents, who consider that 
the existence of the two classes of fever side by side, in the same 
locality, at the same time, refutes the idea of the supposed 
antagonism between them. Unquestionably, this fact does dis- 
prove the theory of an absolute antagonism, but, nevertheless, 
there remains the curious fact that in regions permanently mala- 
rious, cases of enteric fever are very rare, relatively to the 
non-malarious regions of the State, the difference being simply 
enormous, and that in less malarious regions, where periodic 
fevers occasionally prevail, there is often observed an alternation 
between their prevalence and that of typhoid. 
Most of those who controvert the first branch of this statement, 
and affirm the frequent prevalence of typhoid, assume that all 
the typho-malarial cases are pure typhoid slightly modified in 
some of its manifestations by coexisting malaria, whereas, this is 
true only of a part, and perhaps but a small part of the cases, 
the others being, some of them, hybrids between malarial fever 
and other forms of continued fever, and some simply malarial 
fevers with adynamic complications. 46 
ETIOLOGY OF ENTERIC FEVER. 
We have not sufficient data on which to form a conclusion as 
to the explanation of these facts. It might be conjectured that 
the contagium of periodic fevers requires a saturated soil for its 
effective development, while that of typhoid when derived directly 
from the earth, which sometimes would appear to be the case, 
finds more favorable conditions in a comparatively desiccated 
state of the soil, if not for its own germination, at least for its libe- 
ration and passage into the atmosphere. Very many of my corre- 
spondents advert to the fact that typhoid has prevailed more 
extensively in seasons of drought generally succeeding previous 
heavy rainfalls, and a similar observation is made by Dr. Bour- 
don, Medecin de l’Hopital de la Charitd, at Paris, who gives, in 
the April number of the London Lancet of this year, “ a sketch 
of the recent epidemic of typhoid fever” in that city. He states 
that in the months antecedent to the outbreak, the rainfall was 
below the average proper to this period of the year, and that the 
exacerbation of the disease distinctly coincided with the dryness 
and the heat. He concludes that the lowering of the level of the 
water in the sub-soil exposed a whole series of putrid foci, and 
that the high temperature was well adapted to induce fermenta- 
tion, and at the same time to favor the diffusion of the effluvia 
produced, by causing an unusual amount of evaporation. 
(9) The English theories of the causation of typhoid fever 
exclude the idea of an epidemic influence in the old Sydenham 
use of that term as opposed to a purely local influence. In a 
loose way, this term is often of late applied to outbreaks mani- 
festly due to local causes, provided their sphere of operation be 
somewhat extended. It is believed by many, however, that the 
infective principle of enteric fever may occasionally spread by 
atmospheric currents in a definite direction, and invade succes- 
sively various points along the line of its transit, quite irrespec- 
tive of human intercourse. 
Of 56 correspondents who advert to this question, 41 state 
that they have never known enteric fever to prevail otherwise 
than from local causes, while 15 are well satisfied that it does 
occasionally exhibit the characteristics of a true epidemic. Many 
of the former have had so large an experience that their negative 
testimony should have great weight, unless overruled by unde- 
niable and unmistakable positive observations. Such observa- 
tions are, however, not lacking. The late Dr. Elisha Bartlett, 
who was particularly careful not to confound the typical typhoid ETIOLOGY OF ENTERIC FEVER. 
47 
with any other form of adynamic fever, stated that it often pre- 
vails over wide ranges of country, so generally and so exten- 
sively as to assume an epidemic character, and that in this 
epidemic form it becomes migratory in its character, wandering 
about the country, attacking one neighborhood this year, another 
the next, and so on. Similar statements are made by several 
correspondents. I cite a few specifications. 
Dr. R. T. Lemmon, of Campbell Co., Va., who has been already 
mentioned as having had an unusually extensive experience in 
the study of this disease says: “ I have witnessed an outbreak of 
typhoid fever which had all the characteristics of a wide-spread- 
ing epidemic ; no local cause could have had anything to do with 
its existence, and its propagation seemed entirely independent of 
a personal medium. No condition of things exerted any influence 
in securing exemption or mitigating its virulence, except malarial 
surroundings. Very few families living within the bounds of my 
practice escaped, and of the families invaded by it, the propor- 
tion of individuals attacked was 50 to 80 per cent, of the whole, 
and in some instances every one had it. It came from the west, 
and its progress, though rapid, could be distinctly traced east- 
wardly.” 
Dr. Lemmon adds that he has been practising medicine for 
thirty-eight years, lias seen more or less typhoid every year, 
appearing several times in the same families, sometimes after an 
interval of twenty years, but he has never known one to suffer 
a second attack. 
Dr. F. B. Watkins,, df Richmond, states that “in the years 
1860, ’61, and ’62, typhoid fever exhibited the features of a 
wide-speading epidemic in the counties of Prince Edward and 
Charlotte.” 
Dr. W. G. Rogers, of Albemarle Co., says: “In 1847-8-9, 
typhoid fever prevailed extensively throughout the larger por- 
tion of Albemarle and adjoining counties, and, it is believed, in 
the greater portion of the Piedmont region in Virginia. It con- 
tinued to prevail in less degree for several years, and again 
increased about the years 1856-7-8. It has prevailed more or 
less down to the present time, and its epidemic influence still 
renders asthenic nearly all other diseases.” 
Dr. R. W. Nelson, now of Charlottesville, but for many years 
a practitioner of medicine in the counties of Hanover, Goochland, 
and Powhatan, a little above the level of tide-water, adverting 48 
ETIOLOGY OF ENTERIC FEVER. 
to the alternation of typhoid and malarial fevers, so distinctly 
marked as to induce him to believe that there is some sort of 
antagonism, mentions that on the subsidence of periodic fevers, 
after the fall of 1K49 until 1866, typhoid frequently prevailed, 
not usually in circumscribed localities, but epidemically. 
Dr. J. H. Griffin, of Salem, Roanoke Co., states that “typhoid 
or enteric fever first appeared in our region of country at Jones- 
borough, Tenn., in 1841 or 1842, where it was reported to have 
been extremely fatal. It slowly travelled in this direction, stop- 
ping at certain localities, devastating whole families and neigh- 
borhoods, then skipping over a country, sometimes miles in 
extent, it reached this place in the summer of 1844.” 
In a later communication, Dr. Griffin referring to some out- 
breaks in succeeding years, admitted that they might be possibly 
due to local causes, but contended that no such explanation would 
apply to the outbreak of 1844, which he regarded then, and still 
regards, as a true epidemic. In the course of the following year 
(1845) this epidemic, proceeding eastwardly, crossed the Blue 
Ridge and invaded the counties of Campbell, Pittsylvania, etc., 
as already stated in the letters of Dr. R. T. Lemmon and Dr. J. C. 
Green, relating to the antagonism of malarial and typhoid fevers. 
A similar statement is made by Dr. Martin, of Pittsylvania C. II., 
on the authority of his father, Dr. Chesley Martin, who remembers 
that the epidemic was preceded by one of intermittent fever. 
It thus appears, by the concurrent testimony of several com- 
petent observers, that a fever having the clinical characters of 
the typical enteric fever prevailed over large areas of country 
in different parts of Upper and Middle Virginia, at different times 
in the interval between 1844 and 1866, generally succeeding a 
like prevalence of periodic fevers, which, in a very great degree, 
subsided on the appearance of the typhoid affection. I have not 
a shadow of doubt as to the accuracy of these statements, and 
while I would do nothing to discourage any efforts to stamp out 
this formidable disease, I am constrained to say that the condi- 
tions of its development in the rural districts of Virginia are too 
numerous and varied, to permit us to hope to accomplish such an 
end by exclusive attention to the removal of the products of 
either animal or vegetable decomposition. There are yet many 
unsolved mysteries with regard to the conditions of the develop- 
ment and spread of this fever, and it is to be regretted that the 
exclusive ascription of its generation to the influence of putres- 49 
ETIOLOGY OF ENTERIC FEVER. 
cent sewage contaminating the air we breathe or the water we 
drink should be permitted to divert the attention of competent 
observers from other less easily assigned, but possibly equally 
influential agencies. 
In this inquiry into the causes of enteric fever, the specific 
fixedness of type has been assumed. The clinical and anatomical 
grounds for this conclusion, as set forth by Louis, Gerhard, and 
Sir Wm, Jenner, have, indeed commanded very general accept- 
ance, but the doctrine which asserts the possibility of the occa- 
sional blending of types of fever has some earnest advocates. 
Omitting any special reference to papers heretofore published, I 
cite the greater part of a communication from Dr. S. Putnam, of 
Montpelier, Vermont. This gentleman, having a copy of my 
circular, which had been forwarded by Dr. Bowditch, president 
of the Association, furnished a very interesting statement of facts 
derived from a large experience in connection with the typhoid 
fevers of New England. He says:— 
“ In reply to Dr. Cabell, who inquires for the fads which have 
led me to believe in the frequent origin de novo of typhus or 
typhoid fever, I can only state, that, according to my observation, 
during a somewhat extensive country practice for thirty years 
and more, typhoid fever has more generally oocurred as an epi- 
demic from August to November, particularly in dry seasons, 
after a succession of yellow, smoky days, without storm, winds, 
or electrical display, the beds of streams and ponds having be- 
come dry or half dry, and stenchy,. and vegetation parched or 
shrivelled. Under these circumstances, constituting, as I con- 
ceive, an epidemic influence, typhoid fever has often soon ap- 
peared, more frequently in families residing on the banks of 
streams or ponds, but often also in the farm-houses scattered over 
the hills here and there, without any possibility usually of trac- 
ing the importation of the disease or its spread from house to 
house by contagion. 
“Under these circumstances in the fall of 1865, I saw thirty- 
seven cases and made notes of them. In regard to etiology, I 
briefly quote from my report of the epidemic of that year as 
published in the Transactions of the Vermont Medical Society 
for 1866. ‘The fever began to manifest itself in this vicinity 
in August, and cases continued to occur, mostly in September 
and October, but a few in November. The atmosphere in this 
region, according to common observation, was remarkable during 50 
ETIOLOGY OF ENTERIC FEVER. 
the summer of 1865 for heat, dryness, and the absence of elec- 
trical phenomena. Certain localities and families though wide 
apart suffered most, two or three or sometimes four or five being 
sick in the same house. About most of the dwellings in which 
the fever occurred, the sanitary regulations were objectionable, 
many of the houses being old and not as favorably situated and 
constructed for ventilation, cleanliness, and health as those of 
modern date.’ 
“We do not say that these insalubrious conditions were the 
absolute cause of fever, for no such cause exists, we conceive, in- 
dependently of the varied states of predisposition on the part of 
the individual. We simply claim that the conditions may be 
such without and within the human body, that the chemistry of 
nature may and does at times evoke poison or ferment capable, 
under certain conditions of the body, of effecting changes in it 
of a more or less specific character, and that according to our 
experience the conditions without the body tending to predispose 
to or excite the manifestation of fever are often as above de- 
scribed. 
In September, 1859, away in the forest, with only a few acres, 
cleared about the log hut, cow-house, and pig-pen, I attended a 
young man thirteen days with well-marked symptoms of typhus 
fever. As he began to recover, his mother gradually came down 
and continued long sick with equally well-marked symptoms of 
enteric fever. There could be no question of the identity of the 
diseases in either case. They were decidedly characteristic cases, 
and there can be no more doubt that they originated de novo 
then and there.” 
After citing numerous cases of typhus and of typhoid dysentery 
occurring nearly or quite simultaneously with cases of enteric 
fever, Dr. Putnam refers approvingly to Stokes’ doctrine of the 
correlation and convertibility of zymotic diseases, and quotes 
the remark contained in a paper of Dr. Henry Kennedy on the 
“Intermingling of the Types of Fever,” read before the Medical 
Section of the British Medical Association in 1867, that “the 
types of fever are much more mixed and intermingled than is 
commonly supposed or the books teach.” 
In conclusion, it appears that further and careful observations 
are needed to establish on indisputable evidence several of the 
opinions which have been expressed in this paper respecting 
the etiology of enteric fever. In regard to many of the cases ETIOLOGY OF ENTERIC FEVER. 
51 
reported by several correspondents, it does not appear that the 
accuracy of the diagnosis was placed beyond suspicion, and this 
circumstance very materially detracts from the value of the 
conclusions based upon them. It is desirable, therefore, that 
isolated cases, occurring in out-of-the-way country places, from 
which the suspicion of direct importation of the disease can be 
readily excluded, should be thoroughly scrutinized as to the 
grounds of a positive diagnosis, and then as to all the conditions 
both internal and external under which the disease may have 
been developed. Especially does it appear necessary to notice 
the meteorological conditions, which may concur in point of time 
with the development of wide-spread epidemics of fever, and the 
relations of such epidemics with the appearance or with the sus- 
pension of the prevalence of other miasmatic diseases. Dr. 
Henry B. Baker, Secretary of Board of Health of Michigan, has 
already published, in the recent Annual Registration Reports 
for that State, some very interesting and valuable tables exhibit- 
ing the number of deaths from different diseases in connection 
with “ the Meteorological Conditions existing at the same time.” 
Such observations will doubtless eventually lead to important 
discoveries touching some of the conditions of the spread of 
enteric and other fevers epidemic-wise.