V I E W S 
ON THE 
PREVENTION ANE TREATMENT 
OF 
TYPHOID FEVER. 
v/ 
STEPHEN SMITH BURT, M. D., 
PROFESSOR OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS, NEW YORK 
POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL. 
FROM “THE NEW YORK MEDICAL JOURNAL,’’ MARCH 2, 1«89. 
NEW YORK: 
Printed by Pusey & Co.. 1398 Broadway. VIEWS ON THE PREVENTION AND TREAT- 
MENT OF TYPHOID FEVER.* 
By STEPHEN SMITH BURT, M. D., 
PROFESSOR OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS IN THE NEW 
YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL. 
During the last three months of the year just 
passed there were 413 cases of enteric fever reported 
in the city of New York, including 122 deaths; and in 
Providence, R. I., there were 329 cases and 70 deaths 
recorded within the same period. 
In recounting these statistics I do not so much seek 
to point a moral in regard to the percentage of deaths 
as to draw your attention to the many instances of this 
fever that have been noted in the short space of three 
months in two of our large Eastern cities, where the 
intelligence of the inhabitants is certainly not below 
the average of such places. 
From our knowledge of human nature we are justi- 
fied in concluding that all the cases that occurred during 
this period were not reported, while, at the same time, 
it is reasonable to suppose that most of the fatal results 
were ultimately put on record. And, if these inferences 
* Read before the Medical Society of the State of New York, February 
5, 1889. 2 
be true, we can easily see how there would be consider- 
able room for error in calculating the ratio of deaths 
from such reports. But, on the other hand, it is fair 
to presume, after due allowance for mistakes in diag- 
nosis, that the actual number of cases was in excess of 
what appears in the statistics. 
Now, this evident persistence of typhoid fever in 
enlightened communities where it should not prevail, to 
say nothing of the apparently high rate of mortality, 
which is possibly somewhat fallacious, has led me to 
consider the facts in regard to the spread, prevention, 
and treatment of this affection. 
Although the topic that I have selected is certainly 
of great general interest, yet my treatment of it may 
seem rather trite to many of you because of a contin- 
gent lack of novelty. Still, I hold that a thing is but 
half known which is not generally acted upon, and if 
we would learn what men believe we must observe 
what they do. 
Typhoid or enteric fever is a preventable disease 
and quite a needless affliction to the human race. 
Nevertheless, each year we are called upon to grapple 
with this malady, and the idea of its extinction is 
regarded by many as fanciful instead of reasonably* 
feasible. The fault must lie partly with ourselves and 
not wholly with the rest of the community. Moreover, 
it is not so much ignorance that we have to plead as a 
lack of sufficient will to live up to what we know. 
If the germ theory of disease is a correct one, and 
it would seem to be, we ought to follow the example of 
the surgeons and endeavor to keep out the bacteria. 
Our task, to be sure, is a much more difficult one than 
theirs, for these little enemies of the human race come 
clothed in the garb of peace, and steal into our citadels 
by the natural paths. The brain of man, however, 3 
nurtured by experience, each day finds itself better able 
to solve this problem. 
Enteric fever is not contagious in the strict sense of 
the word, but rather infectious, if such a distinction is 
allowable. That is to say, it is indirectly conveyed by 
means of excrementitious matter, but not communicated 
directly from person to person. A rod-shaped vega- 
table parasite, discoverable only by the microscope, of 
the genus bacterium and species bacillus, is the disease 
germ of this malady. From the evacuations of a 
patient, after a few hours, these germs multiply, spread, 
and, what is more, retain their virulent activity for a 
great length of time and under the most varying cir- 
cumstances. Yet because of a considerable interval 
between the passing of a stool and its final putrefaction, 
at which time the poisonous ptomaine is evolved, im- 
mediate contact with the patient is rarely if ever a 
means of infection. 
In such a number of instances of careful search by 
painstaking and trusty observers has an eruption of 
typhoid fever been traced to a source that plainly owed 
its infection to a previous outbreak of the same disease, 
that this deduction regarding its origin has been veri- 
fied and the sequence of cause and effect established. 
Unpolluted by man, the earth is free from the germs 
of enteric fever; but, criminally careless or ignorantly 
neglectful, he scatters the seeds that generate misery 
and entail suffering upon his fellows. 
So far as contagious and infectious diseases are 
concerned, the public weal might be fitly compared to 
the strength of a chain, which is no greater than that 
offcits weakest link. Hence the importance of boards 
of health, of inspection, and of quarantine, to enforce 
the law upon the few for the safety of the many. But 
short of flagrant disobedience to sanitary rules, there 4 
are many minor infringements that work no little injury? 
for, after all known precautions have been observed, 
one may be subjected to the mercy of a thoughtless or 
selfish neighbor. Consequently, until it is not only 
granted, but, furthermore, acted upon, that the welfare 
of our fellow-men is also our own, unnecessary disease 
and premature death will be the lot of mankind. 
The poison of enteric fever is undoubtedly due to 
living germs that are voided by the patient, which 
multiply with great facility under favorable circum- 
stances, and which are preserved, it is believed, for 
years in a congenial atmosphere. Thus, wherever these 
germs are scattered they form colonies of great potency 
for evil. Little fine particles, too small to be seen by 
the naked eye, they are borne by the wind, diffused by 
gases, or conveyed by means of fluids in various direc- 
tions. And the victim of their noxious power, predis- 
posed in some way not well understood, takes them into 
his system through the air he breathes, the fluid he 
drinks, or the food he eats. 
In certain portions of the world the struggle for 
existence between man and vegetable and animal para- 
sites is so great as to render these regions almost 
uninhabitable. Indeed, at all times and in all places the 
price of life is continual watchfulness. And the person 
who relaxes his vigilance is daily in danger of being 
carried off by the enemy that lurks among us in mi- 
croscopic tenuity. 
It is pretty well established that the gaseous eman- 
ations from sewers, or the water that may be polluted 
by human excrement, however pernicious, will not pro- 
duce enteric fever when taken into the system unless 
they contain the germs or toxic principle peculiar to 
this malady. 
Perhaps of all means of propagating enteric fever 5 
our drinking-water is the most common, because the 
most likely to reach large numbers of persons. Bright, 
sparkling, and clear, it may still be the vehicle of end- 
less infection. Ice, too, harbors the bacilli character- 
istic of this affection. These same germs of disease 
when cast into a public sewer find suitable pabulum 
for growth and multiplication, whence they spread to 
the houses by means of the constant diffusion of gases. 
By the overflow of vaults or the leakage of pipes they 
saturate the earth and ebb and flow in the tide-water 
of the subsoil, from which they find their way into 
adjacent wells and poison the water, or into neighbor- 
ing cellars and vitiate the atmosphere. Even the milk 
we drink is liable to pollution from its strong affinity 
for water in the laboratory of unscrupulous purveyors. 
Therefore, while the surgeon, armed with antiseptic 
weapons of defense, stands guard over his wound, we 
have literally to scour the country in search of the 
foe. 
As a means of stamping out this infectious disease, 
first of all comes the absolute need of destroying in 
every instance the excreta, or the germs therein, as 
they are expelled from the patient, This is not only 
a moral obligation, but it should be made a legal neces- 
sity. Then, when as much attention is given to the 
plumbing, draining, and ventilation of a home as, in 
many instances, is bestowed upon decoration, the 
dreadful scourge ought gradually to disappear. 
In the selection of a house in town or country, the 
water-supply and the drainage should be made the 
objects of the most careful investigation, for these are 
the two sources most liable to become vehicles of 
infection. Stationary basins should be excluded from 
all sleeping-rooms, and the waste-pipes in every case 
should be exposed to view and not buried in the walls 6 
or floors. It would be better if the bath-rooms and 
closets were in a detached portion of the house. Fil- 
tered rain-water is the safest for drinking purposes, and 
the ice employed to cool it should not come into im- 
mediate contact with the fluid. Wherever there is the 
slightest danger of pollution the only safe means for 
the prevention of infection is to boil the water. Sim- 
ple filtration will not destroy disease germs, but, if 
raised to the boiling point, water is freed from all 
bacteria, however tenacious of life. In like manner 
meats and food in general should not be kept in direct 
contact with ice, nor even in the same compartment. 
And the outlet of a refrigerator must not communicate 
with a sewer. All this we know, you say, but do we 
act upon our knowledge ? Do we take pains to see 
that our patients are as well informed, and that they 
make proper use of their information ? The periodical 
outbreaks of enteric fever would seem to answer this 
pertinent question. 
Unless these simple precautions are taken in every 
instance, we have to thank ourselves for the weeks of 
illness, and perhaps years of sorrow and regret that 
we bring upon ourselves by our own negligence. 
Finally, after all has been done that our present 
knowledge enables us to perform in the way of preven- 
tion, there may come a lapse of caution, a blind, foolish 
trust that things will take care of themselves, or some 
stupid member of the community, far removed from 
our supervision, may subject us unknown to the poison 
of enteric fever, and we fall victims to the malady. 
Hence, in the present state of imperfection in which 
we exist, we are obliged to consider the treatment of 
this disease, which, as I have already ventured to 
claim, ought not to prevail and would not be the 
scourge it is but for our own improvidence. 7 
It would be hazardous to predict in view of the 
apparent revolution in medicine that the germ theory 
seems destined to bring about, that some material may 
not be discovered which, introduced into the system, 
will counteract the poisonous effects of these germs. 
But at present the indications point to the much more 
natural, not to say rational, method of exclusion ; and, 
although this involves an amount of care and watch- 
fulness that is often irksome, nevertheless it would 
appear to be the course that is generally required in 
life, for without labor nothing is given to man. 
I am wholly in accord with those who believe that 
the pyrexia of typhoid fever is, in a degree, a con- 
servative process. 
Fever may be defined as an exaggeration of the 
normal physiological heat production and heat dissi- 
pation, but with the heat-regulating mechanism thrown 
out of gear. The neurotic hypothesis of pyrexia seems 
to have been verified by the demonstration that heat 
production is controlled by the nervous system. Chemi- 
cal changes that take place in the glands and muscles, 
which give rise to heat, are directiy dependent upon 
innervation. An injury to certain limited portions of 
the brain, known as heat centers, will produce fever; 
and in like manner the injection of pyrogenic sub- 
stances into the circulation is supposed to have a 
similar influence upon the central nervous system. Thus 
the typhoid poison taken into the blood provokes an 
elevation of temperature by its effect upon the heat 
areas, unless the central nervous system should be so 
overwhelmed by the toxic products of the bacilli as to 
become paralyzed. 
When fever is produced it slowly causes oxidation 
of the foreign substance, but, like many another energy, 
it is potent for evil as well as good, and must be kept 8 
within bounds. On the other hand, without fever the 
malady may still be a malignant case of typhoid poison- 
ing. Hence pyrexia is not all of enteric fever. It is 
rather the combination of pyrexia with the poisonous 
element than the elevation of temperature alone that is 
harmful; for it has been demonstrated that a gradual 
rise of bodily heat not septic in origin can progress to 
a very considerable height without much permanent 
damage to the tissues. Consequently the question 
occurs whether too much attention is not being given 
to the dangers of what is supposed to be hyperpyrexia, 
and not enough to the other factors of the malady. 
This fever is undoubtedly one of the manifestations 
of Nature’s struggle to rid the system of the unwelcome 
poison, and in the milder cases of infection the human 
economy proves itself equal to the occasion, yet in many 
instances the toxaemia is so profound that the patient 
sinks under its baneful influence. But between these 
extremes there lie many stricken with this affection 
whose fate hangs upon threads that may be rudely torn 
by blundering hands or gently gathered up by the spirit 
of enlightenment. 
We have no specific with which to combat this dis- 
ease, and the indications for treatment are to supplement 
Nature in her endeavor to accomplish this end. I do 
not wish to appear as an advocate of expectancy to the 
exclusion of all else ; nevertheless, it is very desirable 
to have the moral courage not to produce an unwarrant- 
able disturbance in the system, with the vain hope of 
hastening a process about which Nature requires her 
own time. Therefore, I would earnestly testify in favor 
of the simpler therapeutic measures, and simplicity, after 
all, is an evidence of the highest evolution of our art. 
The peculiar intestinal lesions of this malady demand 
absolute recumbency, even though the general prostra- 9 
tion is not sufficient to enforce it. Fresh air in abun- 
dance, without draughts, is a prime factor in its manage- 
ment. It is my conviction, however, that, except for 
the most urgent and dangerous complications, any 
medicine that disturbs the stomach had better never be 
administered. Pure milk is the best food. Solid 
material should not find entrance into the body until the 
fever has subsided, and, what is more, until the intesti- 
nal ulcers have healed, which is further on. This 
should be impressed upon the attendants and the 
reasons given, and, futhermore, the warning should be 
repeated in those dangerous days of convalescence. 
Predigested milk is the most suitable form in which to 
feed the patient, but it is important to remember that 
milk is food and not adequate to quench thirst. 
Alcohol is one of .our powerful allies in the treat- 
ment of almost all diseases upon occasion, yet it may in 
many instances be withheld with benefit. It is the con- 
dition of each individual and not the disease that must 
determine its employment. The rapidity of the pulse 
in enteric fever is supposed to be directly due to the 
pyrexia; still, with low tension, and possibly dicrotism, 
we are feeling the effects of the typhoid poison. Aus- 
cultation of the heart, to learn the quality of the first 
sound, shoujd be daily practiced, as herein lies our best 
euide for the use of stimulation. Weakness of the first 
o 
sound calls for aid. 
As an instance of deference to the indications of 
nature I would cite the employment of opium in cases 
of intestinal haemorrhage, which insures absolute 
quietude of the intestines while coagula have time to 
form in the bleeding vessels. 
The importance of guarding against bed-sores by 
the early use of a water-mattress is great, for it is easier 
to prevent these ulcers than to heal them. Moreover, a 10 
frequent change of decubitus to avoid hypostatic con- 
gestion of the lungs should not be overlooked. 
In the choice of means to reduce the temperature of 
the body a very difficult and delicate problem is pre- 
sented to the thoughtful observer. I would strongly 
recommend the medical attendant to weigh well the 
question wether it is not better to allow the fever con- 
siderable latitude than to reduce it at the risk of destroy- 
ing the patient’s inherent power of resisting the chemical 
poison, which is at the bottom of the whole matter. 
If quinine has an antipyretic effect in typhoid fever, 
it seems to me the amount required to accomplish this 
end is often harmful. 
Antipyrine, while it may reduce the temperature, is 
productive of so much cardiac weakness that it is a 
serious problem whether it had better ever be admin- 
isered in enteric fever. 
The application of cold water in the form of a tub- 
bath, even when carried out with the utmost caution 
t 
by the gradual lowering of the temperature of the water 
is very liable to induce prostration if not collapse ; and 
the final return, in some instances, of the same or a 
higher bodily heat would seem to show that, although 
the surface is cooled, and even more than the surface, 
heat-dissipation is checked for some time afterward, ' 
while heat-production continues undisturbed in the 
deeper structures. At all events, whether this supposi- 
tion be true or not, my experience with tubbing in 
typhoid fever leads me to exercise a great deal of 
caution in the selection of cases for its employment. 
But, on the other hand, the milder expedient of spong- 
ing with tepid water appears to be almost always fol- 
lowed by an improvement in the general condition of 
the patient, and never by any of the ill effects that are 
so prone to succeed a tub-bath. 11 
Before closing I would like to mention the 307 cases 
of enteric fever of Dr. Cotting, of Boston, spoken of in 
Flint’s “Practice of Medicine,” that were treated with- 
out drugs of anykind, wherein there was a mortality of 
but 10 per cent ; and likewise the celebrated exploit of 
Alonzo Clark, in the treatment of 250 cases of typhus 
fever, at Bellevue Hospital, with a moderate amount 
of stimulation, and naught else but food and drink and 
fresh air in great abundance. They all ended in re- 
covery. 
Such facts as these ought always to be remembered 
when, in the enthusiasm of the moment, we are quick to 
ascribe some special virtue to our latest therapeutical 
venture. 
Finally, the main points that I would emphasize in 
this necessarily brief survey of my subject are that, as a 
race, we are responsible for the existence of enteric 
fever, that its extinction lies in our own hands, and that 
in the treatment of the disease we should be ever mind- 
ful of our limitations. 
37 West Thirty-second Street.