TYPHOID FEVER. 
RELAPSING FEVER-PLAGUE. 
BY 
c 
GEORGE B. SHATTUCK, M.D., 
OF BOSTON, 
PHYSICIAN TO THE CARNEY HOSPITAL ; PHYSICIAN TO OUT-PATIENTS, BOSTON CITY HOSPITAL ; PHYSI- 
CIAN TO BOSTON DISPENSARY. TYPHOID FEVER. 
3 
TYPHOID FEVER. 
BIBLIOGRAPHY. 
Hagenbach, E.: Epidemiologisches aus Basel. Jahrbuch fur Kinderheilkunde, 
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la nappe d'eau souterraine de Paris.. Gaz. hebd., 2 Ser. XIII., p. 785, 1876.-Doe, 
O. W.: Efficacy of Cold Water Treatment in Typhoid Fever. Boston Med. and 
Surg. Journ., XCIV., p. 244, 1876.-Propagation of Enteric Fever by Infected 
Milk: the Eagley Outbreak. Lond. Practit., XVII., p. 225, 1876.-Low, R. Bruce: 
Is Enteric Fever ever Spontaneously Generated? Brit. Med. Journ., I., p. 659, 
1876. - Fereol, S.: Sur le traitement de la fievre typhoide par les bains froids. 
Union Medicale, XXII., December, 1876.-Discussion a la Societe Medicale des 
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suchungen fiber die Uebertragbarkeit des Typhus Abdominalis auf Thiere. 
Archiv der Heilkunde, XVII., p. 156, 1876.-Woodward, J. J.: Typho-malarial 
Fever: Is it a Special Type of Fever? Trans. Internal. Med. Con., p. 305, Phila- 
delphia, 1876.-Goltdammer: Kaltwasserbehandlung des Ileotyphus, Bericht 
uber die Resultate der Kaltwasserbehandlung des Ileotyphus im Krankenhaus 
Bethanien in Berlin. Deutsch. Archiv f. klin. Med., XX., p. 52, 1877.-Prof. 
Peter: Les bains froids coup sur coup dans la fievre typhoide. Union Medicale, 
XXIII., 3 s., 1877.-Raynaud, M.: Du traitement de la fievre typhoide par les 
bains froids. Bull, gener. de therap., p. 433, 1877.-Albu: Typhus und Grund- 
wassergang in Berlin. Berlin, klin. Wochenschr., XIV., S. 422, 1877.-Liber- 
mann: De I'influence des bains froids sur les complications laryngiennes de la 
fievre typhoide. L'Union Medicale, XXIII., 3 s., p. 298, 1877.-Edes, R. T.: The 
Cold-Water Treatment of Typhoid Fever. Boston City Hosp. Rep., p. 205, 1877. 
-Murphy, Shirley F.: Antipyretic Treatment of Enteric Fever. London Lancet,. 
L, p. 791, 1877.-Dudgeon, John: On the Sanitary Condition of China. Sewage,. 
Drainage, and Typhoid Fever. Glasgow Med. Journ., IX., p. 179, 1877.-Cabell, 
J. L.: Etiology of Enteric Fever. Trans. Am. Med. Assoc., p. 411, 1877.- 
Senator: Ueber die therapeutischen Wirkungen des Salicins. Berlin, klin. 
Wochenschr., XIV., S. 182, 1877.-Stone: Etiology of Typhoid Fever. Tr. Maine- 
Med. Assoc., p. 383, 1878.-Letzerich: Experimentelle Untersuchungen fiber 
Typhus Abdominalis. Arch. f. exper. Path, und Pharm., IX., S. 312,1878.-Hope, 
W. T.: Typho-Malarial Fever. Trans. Tennessee Med. Soc., p. 63, 1878.-Treatment 
of Typhoid Fever in Bellevue Hospital. New York Med. Record, XIV., p. 366, 
1878.-Clark, Alonzo: Lectures on Fevers. N. Y. Med. Record, XIII., pp. 261, 
281,301,1878.-Pepper, W.: Lecture on Typhoid Fever. Phil. Med. Times, VIII., 
p. 193, 1878.-Thomson, William: Typhoid Fever, its Cause and Extent in Mel- 
bourne. Melbourne, 1878.-Ballard: Enteric Fever at Ascot. Sanitary Record, 
IX., p. 277, 1878, X., p. 35, 1879.-Collie A.: Value of Cold Baths in Enteric Fever. 
Lond. Practit., XXI., p. 347, 1878.-Marks: The Prevention of Typhoid Fever. 
Report of Board of Health of Wisconsin, HI., p. 22,1878.-Gairdner, W. T.: Cau- 
tions in respect of the so-called "Antipyretic Treatment " in Specific Fevers. Glas- 
gow Med. Journ., X., pp. 416, 499, 1878.-Liebermeister : On the Antipyretic 4 
TYPHOID FEVER. 
Treatment of Specific Fevers. Glasgow Med. Journ., X., p. 449, 1878.-Smith, F. 
G.: Treatment of Hyperpyrexia. Lond. Prac., XX., p. 20, 1878.-Geissler: Be- 
richt liber den Typhus. Schmidt's Jahrbucher, CLXXVII., S. 57, 1878.-Immer- 
mann: Ueber Prophylaxe von Typhus-Recidivien. Corr. Bl. f. Schweiz. Aerzte, 
Nos. 23 and 24. S. 697, 737, 1878.-Homolle : La Fievre Typhoi'de, Revue Gene- 
rale. Rev. des Sciences Med., XI., p. 769, 1878.-Walder : Ueber die Typhus- 
epidemie von Kloten. Berlin, klin. Wchnschr., 1878.-Klein, E.: Experimental 
Contribution to the Etiology of Infectious Diseases. Quar. Journ. Microscop. 
Sciences, XVIII., N. S., p. 170,1878.-Ewart, J. Cossar: Life History of Bacillus 
Anthracis. Quar. Journ. Mic. Sci., XVIIL, N. S., p. 161, 1878.-King: Etiology of 
Typhoid Fever. Med. Times and Gaz., I., p. 118, 1879.-Jacobi, A.: Typhoid Fever 
in Infancy and Childhood. New York Med. Record, XVI., pp. 385, 411, 1879.- 
SOyka : Boden. Real-Enclyclopadie der gesammten Heilkunde. Wien, 1879.- 
Jenner, Sir Wm. : Treatment of Typhoid Fever. London Lancet, II., p. 715, 
1879.-Smythe, G. C. : Antipyretic Treatment of Typhoid Fever. American 
Practit., XIX., p. 7, 1879.-Billings, J. S.: Buck's Hygiene and Public Health, 
Introduction, I., New York, 1879.-Thomson, W.: Typhoid Fever; Contagious, 
Infectious, and Communicable. Brit. Med. Journ., I., p. 343, 1879.-Murphy, 
Shirley F.: Etiology of Enteric Fever. Brit. Med. Journ., I., p. 581, 1879.- 
Collie, A.: Etiology of Enteric Fever, with an Account of Nineteen Cases which 
occurred in the Homerton Fever Hospital. Brit. Med. Journ., I., pp. 341, 
385, 424, 1879.-Stedman, C. E.: 150 Cases of Typhoid Fever in Boston City Hos- 
pital. Boston Med. and Surg. Journ., CI., p. 499, 1879.-Skrezcka, C.: Typhus 
Morbilitat in Berlin. Vrtljschr. f. Gerichtl. Med., Berk, N. F., XXX., S. 143, 
1879.-The Recent Epidemic of Enteric Fever in the Caterham Valley. Brit. 
Med. Journ., I., p. 669, 1879. Ibid. Med. Times and Gaz., I., p. 505, 1879.-Wal- 
der : Typhoid Epidemic Originating in Diseased Meat. Med. Tinies and Gaz., I., 
p. 149, 1879.-Mason, A. L.: Reports on Progress in the Theory and Practice of 
Medicine. Bost. Med. and Surg. Journ., C., pp. 426, 459, 1879.-Cabell, J. L.: 
Salicylic Acid in the Treatment of Enteric Fever. Virginia Med. Monthly, V., 
p. 424, 1879.-Fauntleroy: Typhoid Fever; its Etiology and Treatment. Vir- 
gin. Med. Mon., V., p. 415, 1879.-Frankland, Prof. : Sewage. Journ. Soc. of 
Arts, XXVII., 1879.-Collie, A.: Etiology of Enteric Fever. Brit. Med. Journ., 
I., p. 84, 1880.-Alison : Etiologie de la fievre typhoide dans les Campagnes. 
Archiv. Gen. Med., Jan., Fev., Mars, Paris, 1880.-Folsom, C. F. : Suggestions 
as to the Causes of Typhoid Fever. Bost. Med. and Surg. Journ., CH., p. 
227, 1880.-Ewart, Joseph: Enteric Fever in India; with some Observations on 
its Probable Etiology in that Country. Med. Tinies and Gaz., I., p. 231, 1880. 
-Caswell, E. T.: The Alcohol Question from a Medical Point of View. Trans. 
Rhode Island Med. Soc., Providence, 1880.-Hoff, J. V. R. : Typho-Malarial 
Fever; the so-called "Mountain" Fever of the Rocky Mountain Region. Am. 
Jour. Med. Sciences, Jan., 1880.-Zuelzer: Abdominal Typhus. Real-Encyclo- 
padie der gesammten Heilkunde, S. 11, Wien, 1880.-Greenfield, W. S.: Lec- 
tures on some Recent Investigations into the Pathology of Infectious and Conta- 
gious Diseases. Lond. Lancet, I., pp. 83, etc., 1880.-Campbell, A.: Spread of 
Typhoid Fever to Animals. Brit. Med. Journ., I., p. 555, 1880.-Carpenter, A.: 
A Consideration of some of the Fallacies which are based upon a Narrow View of 
the Germ Theory. London Lancet, I., p. 79, 1880.-Ballard, E.: Observations 
on some of the Ways in which Drinking Water may become Polluted with the 
Contagion of Enteric Fever. London Lancet, I., p. 82,1880.-Cayley: Pathology 
and Treatment of Typhoid Fever. Brit. Med. Journ., I., pp. 391, etc., 1880.- 
Carmichael, Neil: An Experimental Investigation into the Trap and Water- 
Closet System, and the Relation of the same to Sewage Products, Gaseous and 
other. Glasgow Sanitary Journal, N. S., IV., No. 49, 1880. 
The last four or five years have been by no means inferior to their TYPHOID FEVER. 
5 
predecessors in the amount of attention and interest which this subject 
has demanded at the hands of professional and scientific men. In fact, 
investigations, observations, and theories have increased rather than 
diminished. As might have been anticipated, however, there is little or 
nothing to add to the pathology of the disease, and the work which we 
have to record, whether in the form of experiment, observation, or theory, 
falls almost entirely under the divisions of etiology and treatment. 
Of work, there has been much, of advanced posts in the unexplored 
or debatable regions which have been taken possession of in tjie name of 
accurate knowledge and securely held against all assault, until a fair title 
has been established for science, we can point to very few. 
There is still much discussion as to whether typhoid fever is a conta- 
gious disease, and as to whether it has at times a de novo origin. The 
question of contagion continues to be obscured by the varied uses of the 
word contagious. If all writers would agree as to the subject, there would 
be less conflicting differences of opinion. The poison of typhoid fever, 
it is generally agreed, is probably particulate, neither liquid nor gaseous. 
The classification of the disease as miasmatic-contagious is perhaps 
still the best possible, in so far as it expresses the more usual manner of 
its propagation. In formulating the statement that the disease is not 
contagious, it should be remembered that strict personal contact is meant, 
and if what we are able to affirm is to be limited to so small and unim- 
portant a point, it might be as well to express the relation of typhoid 
fever to some other zymotic diseases from the stand-point of a contagium 
as a matter of degree rather than of kind. If we say that typhoid fever 
is never directly transmitted from person to person, the statement must 
be qualified by the admission that at times, even if rarely, the stage of 
development of the poison outside the human body, if such be necessary 
for a further reproduction of the disease, occupies a very short period, 
perhaps some hours only. Otherwise we must await further knowledge 
to explain a by no means small class of carefully observed cases. In the 
United States at least, there no longer exists any confusion between typhus 
and typhoid fevers to complicate a problem which is sufficiently difficult 
without it. A few points, among many, which affect the question of 
contagion may with propriety be touched upon. 
Jacobi, contrary to the usually received opinion, maintains that 
typhoid fever is not rare eithei* in infancy or childhood. Dr. Wiltshire, 
of St. Mary's Hospital, London, after reporting a case of enteric fever in 
an infant six months old, expresses a suspicion that this disease is not 
unfrequently overlooked in young children; " gastric fever," "infantile 
remittent fever," " low fever," " slow fever," being assigned as the cause 
of illness. Others also suggest that one reason why adults are at times 
exposed with impunity is, that having had the disease in infancy they 
are protected. These suggestions again remind us of that border-land of 
typhoid, where we find "cess-pool" fever (Clark), "typho-malarial" 
fever ( Woodward), "slow" fever, all of which by complicating observa- 
tions confuse our views, not only as to etiology, but also as to contagion. 6 
TYPHOID FEVER. 
Constant observations, moreover, only serve to confirm the tenacity of 
life of the typhoid poison under favorable circumstances for long periods, 
its activity even when extremely diluted (Caterham epidemic), and its 
transportability in bedding, clothes, etc. These facts must be kept in 
mind in forming opinions as to contagion. 
Dr. CbZZze, of the Homerton Fever Hospital, a strong contagionist in 
the strict sense of the word, has published a number of cases occurring 
at Homerton among the nurses and attendants which he is convinced 
arose from from fresh enteric stools. He thinks their age-so large a 
proportion being over thirty-has some bearing upon the small percent- 
age of physicians and attendants in hospitals who contract this disease. 
The greatly diminished liability of persons over thirty years of age 
scarcely needs further illustration. Out of 4,928 total admissions of 
enteric fever to London, Stockwell, and Homerton Fever Hospitals, 
3,915 were under 25 years of age, 4,352 under 30; out of 1,436 admissions 
to Homerton between 1871-1878, inclusive, 1,158 were under 25, 1,279 
under 30 years, v. Rothmund reports nine cases of typhoid fever among 
the attendants in an army hospital within nine months, although the 
sanitary arrangements were especially good in his estimation. 
Mr. Murphy, in discussing Dr. Collie''s conclusion that the twenty cases 
of enteric fever, reported by him as occurring among the attendants at the 
Homerton Fever Hospital, had their origin in the fresh stools of typhoid 
patients, shows that between the years 1855-1878 inclusive, five thousand 
five hundred and sixty-nine enteric patients were located in the London 
Fever Hospital, and during that time nineteen persons engaged in the 
Hospital were attacked, ten of these were in no way connected with 
enteric fever patients or wards, and one was a laundry-maid. Estimating 
that about the same number of nurses are engaged in the two hospitals, 
he calculates that if the Homerton Hospital were to maintain the same 
number of attacks among attendants it has done for the past six and a 
half years, it would in twenty-four years have nearly sixty of its nurses 
attacked. He concludes that such a difference must be due, not to causes 
common to both hospitals, but to some difference in the structure of the 
hospitals themselves; and the only difference suggesting itself is the 
drainage. Dr. Collie, in his reply, reasserts his former view, and excul- 
pates the drainage which had been thoroughly investigated. He explains 
the different results given by the statistics of the two institutions, by a 
dffierence in the age of the nurses; those attacked at Homerton being all 
under thirty, except one of that age. Unfortunately we do not know the 
proportion of nurses at the London Hospital under thirty years of age. 
Sir Thomas Watson says: I hold that, like small-pox, etc., the disorder 
may be taken by breathing emanations from the sick person's body or 
bed, and that scrupulous care should be taken in all cases not to inhale 
the poison in that way. 
The practical point which the present state of knowledge in regard 
to the contagion of typhoid fever should cause to be emphasized is the 
immediate disinfection of the alvine discharges of typhoid patients, or TYPHOID FEVER. 
7 
even of those suspected of this disease. Without denying the elimination 
and absorption of the poison by other surfaces than that of the bowel, 
the evidence in regard to the propagation of the disease does not, to 
our mind, demand that isolation be practised with it as with small-pox, 
at least where there is no overcrowding and good ventilation can be 
secured. Greater precautions doubtless are necessary when dealing with 
this malady in small, ill-ventilated rooms with foul air, than in the 
wards of a well-ordered hospital, and it is very difficult to resist the evi- 
dence of contagion afforded in some cases under the former circumstances. 
If contagious, the poison is at least much less volatile than those of 
the more strictly contagious diseases. 
ETIOLOGY. 
The last five years have brought us apparently but little nearer a 
definite solution of the origin of typhoid fever, or of the process of ela- 
boration of the poison producing the disease; but the manner of its trans- 
mission to man has been further elucidated by the continued careful 
investigation, especially in England, of drinking water and milk supplies, 
and illustrated by an extensive epidemic among the frequenters of a 
musical festival at Kloten (Zurich), seventy per cent of whom were 
attacked with a disorder which numerous autopsies showed to be typhoid 
fever, in so far as an autopsy performed by skilful hands is still accepted 
as proof of this disease. Some of the meat consumed at this festival is 
reported to have been putrid, and the symptoms manifested by many 
cases would indicate the disturbing element of septic poisoning. The 
chief source of the poison in this outbreak, however, was traced by so 
competent an observer as Huguenin to veal coming from a sick calf. 
Persons living away from Kloten, who were not present at the festival, 
but who purchased and eat the brain and lungs of this animal, were 
similarly taken ill. Confirmation of Huguenin's unavoidable conclusion 
was believed to have been found by another observer, Walder, in the 
apparent communication to their own calves by some of those infected 
at Kloten of a disease producing intestinal and glandular lesions, resem- 
bling those of typhoid fever in man. 
Curiously enough, an outbreak of sickness occurred at Andelfingen, in this 
same province of Zurich, in 1839, among five hundred persons who partook of 
putrid meat. This was long cited and generally accepted as proof of an autoch- 
thonous origin of typhoid fever. The meat was simply putrid, it was both veal 
and pork; the animals from which it came were not known to have been ill, and 
it has been since shown {Liebermeister) that the disease was not typhoid. 
The Kloten outbreak stands on a different basis, and the number and charac- 
ter of the physicians who attended those attacked, assisted at autopsies, or report 
the circumstances, lend additional value to the occurrence. 
Every year our knowledge of the intimate nexus which binds together 
our domestic animals and man seems to become closer, and we are 
slowly becoming aware that the presence of such diseases in animals is 
fraught with evil consequences to ourselves. Of late we have begun to 8 
TYPHOID FEVER. 
suspect that typhoid fever and diphtheria may be in some cases commu- 
nicated to the human subject, not merely by milk, but through the cow 
by some modified disease which we do not know {Greenfield}. 
In the contamination of milk supplies, whether by a legitimate use 
of infected water for washing dairy utensils, by its illegitimate use for 
dilution, by cattle themselves diseased, or bringing on their bodies poi- 
sonous particles from fields manured with the excrement of human 
beings suffering from typhoid fever; and again in diseased meat we have 
two modes of transmission which were hardly thought of until quite 
recently, and in contaminated water-supplies a third mode, which, 
though generally accepted, was not admitted by so distinguished a sani- 
tarian as v. Pettenkofer four or five years ago. Other now unsuspected 
modes of transmission will undoubtedly be traced in the near future. 
In the mean time, the source of many outbreaks is clear which would 
before have remained a mystery, and the temptation is diminished to 
resort to so unsatisfactory a theory as the pythogenic for a source, or to 
so unphilosophical a belief as that in spontaneous or equivocal gene- 
ration to explain what we cannot understand in the transmission of this 
disease. Epidemic outbreaks and sporadic cases, inexplicable under our 
present knowledge and methods of observation, are and will be reported. 
• 
Typical of such epidemics, though longer than most in duration, was that 
occurring at Ascot, which prevailed intermittently during a period of four and 
a half years. It was worked up by Dr. Ballard, a competent and skilful inves- 
tigator. There were two apparently distinct outbreaks, the first apparently end- 
ing in September, 1875, the other apparently commencing in July, 1876. Before 
the first outbreak, no similar epidemic of enteric fever had been known at Ascot 
for over forty years. The inquiry left no doubt as to the relations of the milk of 
a particular dairy-farm with the epidemic ; it was found that of 68 cases of fever 
in 39 families, no less than 58 cases in 31 families occurred amongst persons using 
this milk. Dr. Ballard found abundant opportunities at the farm for the con- 
tamination of the milk with filth, and especially with excremental filth, but was 
unsuccessful in establishing its contamination with a specific contagium. Not 
being content with the explanation of a de novo origin, and having to find an 
intermittent cause to account for the intermittent outbreaks, Dr. B. suggests sev- 
eral ways possible or probable for introduction of the specific poison. A theory 
based upon the geological formation of the country, and the conveyance of the 
specific poison in the subsoil water as a vehicle, down about half a mile of hillside, 
is the one preferred by him. Bearing in mind the epidemic at Lauten (Liebermeis- 
ter), such a hypothesis is worthy of consideration, but it is precisely in connection 
with a milk epidemic like this that we may hope for more light in the future. 
In this instance, there is no report of the condition of the cows. 
As an example of the sporadic class of cases, the following reported 
by a medical officer of health for an English rural sanitary district will 
serve: 
Three members of a family of four were attacked successively in as many 
weeks with typhoid fever. They occupied a house consisting of four fair-sized 
rooms. It was built on a hillside, facing the junction of four wide valleys, " a 
more exposed situation could hardly be imagined." Above the house were miles 
of moorland ; both house and privy were at a distance from any highroad, and TYPHOID FEVER. 
9 
quite out of the way of tramps. "There was an entire" absence of enteric fever 
from this district, a very thinly populated one ; neither the father, the first vic- 
tim, nor any of the others had been out of the district for a very long time, they 
had no visitors, the water supply was examined and found pure, the house was 
clean; the privy was full of filth and running over, and the fourth member of 
the family, a boy, who was not ill, is said not to have used this privy. 
Given these data, and they are almost more than typical of those pre- 
sented by the mountain farm house in Virginia, cited by the President 
of the American Public Health Association, of cases in New England 
reported by Nathan Smith sixty years ago, by Dr. Stone, of Maine, re- 
cently, and by many country practitioners who are shrewd observers, and 
we have, if we choose, a de novo generation of typhoid fever with its 
origin in filth. Such was the conclusion of the health officer, who was 
probably trained under the supervision of John Simon. The imagina- 
tion, however, is no more exercised by the dried particle carried on the 
wind, and real knowledge is much furthered by a continuance of care- 
ful observations unbiased by preconceived theories until another such a 
step forward is taken as was made in tracing the milk epidemics, the first 
stage to which was the now universally accepted infection of water sup- 
plies; the Kloten epidemic again may present us with another link in 
this chain. • 
The advance in knowledge of the causes of disease by statistics is of 
a mathematical necessity extremely slow, as well stated by Dr. Billings 
in the introduction to Hygiene and Public Health of this series, and 
advance by the other most valued method, experiment and investiga- 
tions in comparative pathology, is limited, as was there pointed out, by 
the fact that specific diseases seem usually specific to certain animals, and 
that many of the diseases of man cannot be communicated to the lower 
animals. The difficulties in this direction are increased in investigating 
typhoid fever by our continued ignorance of the specific germ or particle, 
the unknown factor of the problem. The last five years, however, offer 
encouraging advances in neighboring fields of inquiry. Dr. CotsOtr 
Eivart, following in the steps of Cohn and Koch, has shown by his in- 
vestigations the close resemblance existing between the harmless bacillus 
subtihs and the dangerous bacillus anthracis of splenic fever; the exist- 
ence of the spirochcete obermeten in the blood of those suffering from 
relapsing fever has been pretty well established, the infectiveness of the 
blood has been proved by the inoculation of monkeys with the disease by 
Carter and Koch, and of men by Motschutkoffsky, the microphyte has 
been cultivated outside the human body by Carter and Koch, and the 
history of the organism worked out by several observers; the cause of an 
infectious disease of hogs, the hog plague or typhoid fever of the pig, a 
disease named by him " infectious pneumo-enteritis," has been announced 
by Dr. Klein to be a microbion very similar to the bacillus subtilis, 
which he has succeeded in cultivating, thus observing the various stages 
of its development, and in transmitting the same disease to mice and 
rabbits by inoculation; Klebs and Crudeli believe they have found the TYPHOID FEVER. 
10 
vegetable organism giving rise to malaria in man, and have produced, as 
they report, intermittent in animals by inoculation. M. Pasteur, pur- 
suing the observations of Messrs. Moritz, Perroncito, and Toussaint, 
veterinary surgeons, considers it proved that a diarrhoeal disease of 
chickens, "cholera des ponies," is caused by a microscopic organism. 
This microbion is extraordinarily virulent, and M. Pasteur has not only 
cultivated.it outside the living body, and reproduced the malady by in- 
oculation, but shown that the disease is self-protective, and moreover 
that a modified microbion developed in the body of the guinea-pig oc- 
cupies the same relation to this disease as the vaccine virus to small-pox. 
Following in this general direction, L. Letzench believes he has 
transmitted typhoid fever from man to rabbits by introducing by the 
mouth as well as by injecting subcutaneously inferior organisms (which he 
classifies as schistomycetes), suspended in distilled water, and obtained by 
repeated washings from the stools of persons affected with typhoid fever. 
Tn view of the preceding uncertain results of Birch-Hirschfeld's, and 
negative results of Bahrdt's experiments in this direction, these results 
of Letzerich stand greatly in need of further confirmation. According 
to this experimenter, the four rabbits receiving the injections died after a 
varying period of pyrexia, and a post-mortem examination disclosed in- 
filtration of Peyer's patches, enlargement of the spleen, and invasion of 
the various organs and tissues, especially of the spleen and mucous coat 
of the intestines, by these schistomycetes. 
Septic poisoning may possibly, in the opinion of some, account for 
all the changes observed; we will only venture to say that the experi- 
ments as well as the conclusions require much corroboration before we 
can regard typhoid fever as a " schistomycosis." They are mentioned 
merely as indicating a line of inquiry which has proved fruitful in con- 
nection with other diseases, and may yet disclose the unknown term in 
the typhoid fever problem. 
* In the mean time, we are doomed to constant disappointment in seek- 
ing in any one agent an exclusive or even controlling influence upon the 
propagation of this disease. It is always much more difficult to explain 
the existence and absorption of immense quantities of filth without 
typhoid fever, than the comparatively few cases of typhoid with filth 
surroundings, where the source of infection cannot be traced. 
" Typhoid fever is by no means a disease of the filthiest towns, or of 
the filthiest parts of towns. Since I commenced investigating this ques- 
tion, I have been amazed at the immense amounts of urine and excrement- 
oxidized, incompletely oxidized, and as they come from the bladder and 
intestines-that are consumed in drinking water, and inhaled at the rate 
of 9,000 litres of contaminated air a day, and this for years, by young, 
old, and middle-aged persons, without any disease resulting that may be 
attributed to filth. I do not mean to deny the danger of filth. Espe- 
cially filth decomposing without the free access of air constitutes, in my 
mind, one of the most important secondary factors of disease; one, too, 
which may become so essential a factor in some diseases as to absolutely TYPHOID FEVER. 
11 
be the one without which, in an aggravated form, the disease cannot 
exist, as, for example, in cholera, plague, and yellow fever" (Tfyfeom). 
Dr. J. Ewart, after giving in detail a description of the utterly inde- 
scribable filthiness of the back-slums of many parts of the European 
and most parts of the native quarter of Calcutta, observes: "That the 
difficulty does not consist in not finding plenty of animal filth to account 
for any amount of enteric fever, but in understanding how it is not still 
more prevalent than it is in such an unsavory city. The ' reason why 
this form of fever is not more frequently met with amid such an abun- 
dance of faecal matter in a state of putrescent fermentation, is probably 
to be discovered in the fact that fortunately most of it is not pent up in 
ill-ventilated sewers, but exposed daily to the powerful antiseptic influ- 
ences of the atmosphere and sunlight in open drains, open privies and 
latrines, and in comparatively open cesspools. The impression which has 
been gaining ground of late years that, as the sewering of the town has 
been advanced, so has enteric fever been more frequently observed, lends 
countenance in support of this view. This augmented prevalence, how- 
ever, may, in some measure, be owing simply to greater recognition of 
the fever, although it must not be forgotten that attention has been 
directed to the endemic existence of the disease during the past fifteen 
or twenty years. " 
Foreign physicians who have written upon the sewage, drainage, and 
sanitary condition of many different towns in China, including Pekin 
the capital, comment without exception upon the wretched condition of 
drains where there are any, the offensive methods for discharging the 
functions of drains where there are none, and the general neglect of 
sanitary laws in public streets and private houses. In this connection 
these same authorities call attention to the remarkable infrequency of 
enteric fever. In Canton only two cases of typhoid were observed by one 
practitioner during a period of more than ten years. Two physicians 
report an entire absence of typhoid and typhus from Amoy, though full 
of typical fever-dens. In Foochow only seven or eight cases of typhoid 
were seen by.a Scotch physician during eleven years' practice, until 1872- 
'73, when four cases occurred. There seems to be the same immunity 
also from the other exanthemata, except small-pox : intermittent and 
remittent fevers are common. To the objection that much typhoid 
probably exists in such localities which is overlooked, it is fair to reply 
that it evidently does not occur with the frequency or severity which 
might be anticipated. 
It is unnecessary to pursue this point further : filth does not create 
typhoid, though frequently affecting its development. Something is 
necessary besides the decomposition of healthy or even of albuminous 
{King) excrements. 
Neither is the key to the whole subject to be found in low ground- 
water. The labors of v. Pettenkofer, Buhl, Wagus, Buchanan show that 
for some places, Munich, Berlin, etc., a periodic connection, at least, 
exists between falling ground-water and increasing typhoid, but the con- 12 
TYPHOID FEVER. 
nection is not invariable for every year and for all places. Wet seasons, 
as well as dry, are followed by and coincide with abundant typhoid. The 
inhabitants of the ground floor and lower stories of houses, in Berlin at 
least, do not yield the largest ratio of typhoid cas'es. Of 1,087 cases of 
typhoid fever recently investigated in Berlin, the results of which were 
published by Dr. Skrezcka, the ratio of the sick per 1,000 inhabitants 
increased from 0.83 in the basement to 0.84 on the ground floor, 0.96 
and 0.95 in the first and second stories, 1.1 in the third story, and 1.4 
in the fourth and fifth stories. Similar statistics are given for the 939 
deaths from typhoid fever reported in the year 1875, excluding those 
where the story of the house was not stated in the death returns; the 
figures are as follows : 0.89, 0.91, 0.95, 0.90, 1.03, 1.74. The calcula- 
tions in both cases were based on the census of 1871 ; they may not be 
absolutely exact, but are pretty nearly so, and relatively are quite so. 
The highest rooms being the cheapest, are occupied by the poorest, the 
least cleanly, the most crowded population. Other influences besides tel- 
luric thus make their weight felt. v. Rothmund states that in Augs- 
burg considerable increase in typhoid occurs with scarcely noticeable 
changes in the level of the subsoil water. Thomson declares in regard to 
Melbourne, Australia, and the neighboring country that, from clinical 
histories, combined with all available telluric and meteorologic data, v. 
Pettenkofer's subsoil theory of typhoid fever malaria is found inapplica- 
ble. Drs. Lewis and Cunningham, in a report to government on soil 
changes as affecting disease in Calcutta, say : the greatest prevalence of 
fevers during the period of observation occurred coincidently with the 
period of highest water level. 
Moreover, of late years the Munich observers themselves seem to have 
desisted, for the present at least, from explaining the connection between 
fluctuations in the subsoil water and the frequency of typhoid, and to 
confine themselves simply to the continued repetition of the fact {Lie- 
bermeister, 1876). 
Touching the influence of the season of the year upon the frequency 
of typhoid, it may be remarked that, as far as observations go, the north- 
ern part of the United States, and certainly New England, offer no excep- 
tion to the general rule that the frequency of typhoid increases as the 
summer advances ; that is, typhoid increases in frequency from July to 
October or November, and then declines. Curves of fluctuation for 
Basle, London, or Berlin would probably represent roughly most of our 
towns. It is different where peculiar local conditions operate, as in 
Munich. 
A statement of the deaths from typhoid occurring in Basle during 
fifty years gives the following for the different months : 
Jan. Feb. March. April. May. June. 
192 143 137 121 160 169 
July. Aug. Sept. Oct. Nov. Dec. 
186 202 237 237 236 193 
(Hagenbacli). TYPHOID FEVER. 
13 
Relatively this might stand for Boston, New York, or Chicago. 
Influence of Age.-The same authority gives a table of the deaths 
from typhoid during 50 years in Basle according to the age so far as that 
was noted in individual cases, to which we have added the percentages. 
Total number of cases 2,059. 
AGE IN 
YEARS. 
NO. OF 
CASES. 
PER CENT 
OF TOTAL. 
DISPOSI- 
TION IN 
COMPARI- 
SON WITH 
AVERAGE 
= 1. 
AGE IN 
YEARS. 
NO. OF 
CASES. 
PER CENT 
OF TOTAL. 
DISPOSI- 
TION IN 
COMPARI- 
SON WITH 
AVERAGE 
= 1. 
0- 5 
108 
5.24 
.95 
46-50 
107 
5.14 
.94 
6-10 
85 
4.12 
.74 
51-55 
100 
4.85 
.87 
11-15 
106 
5.14 
.93 
56-60 
60 
2.91 
.53 
16-20 
239 
11.12 
2.03 
61-65 
53 
2.57 
.47 
21-25 
404 
19.62 
3.54 
66-70 
45 
2.13 
.39 
26-30 
290 
14.08 
2.54 
71-75 
26 
1.26 
.23 
31-35 
186 
9.03 
1.63 
76-80 
8 
0.39 
.07 
36-40 
143 
6.94 
1.25 
81-85 
2 
0-09 
41-45 
129 
6.26 
1.13 
86-90 
2 
0.09 
Sewers, Drains, Water Traps and Closets.-Prof. Frankland's 
experiments with lithium in the sewers of London show that where the 
current is continuous and the liquid quiet, the lithium cannot be detected 
by spectroscopic examination in the sewer gas, but when the liquid is 
splashed and agitated it readily can be; for lithium substitute specific 
particles. It is well when possible- to have sewers so arranged that they 
can be occasionally flushed with pure water. The importance of placing 
house drains in sight, of thoroughly ventilating them, of connecting with 
the sewer by iron pipe and hanging it to the house, are now better appre- 
ciated. 
Dr. Carmichael, of Glasgow, has lately published some valuable experi- 
ments in regard to water traps and closets. He concludes that: Water 
traps are for the purpose for which they are employed, that is, for the 
exclusion from houses of injurious substances contained in the soil pipe, 
perfectly trustworthy. They exclude the soil pipe atmosphere to such 
an extent that what escapes through the water is so little m amount, 
and so purified by filtration, as to be perfectly harmless; and they ex- 
clude entirely all germs and particles, including, without doubt, the spe- 
cific germs or contagia of disease, which, we have already seen, are, so 
far as known, distinctly particulate. Other sources of contamination 
must be looked for, except where there is some faulty construction of the 
trap itself, and these faults of construction are sufficiently numerous. 
Among other sources of foul air than faulty traps he considers none more 
common and pestilential than the ordinary pan water closets, with its 
perpetually nasty trunk. His views in regard to the pan water closet 
are those of Ford, of Philadelphia, expressed in Buck's Hygiene, of Bird, 
of Latham, and it is to be hoped of all intelligent people who unfortu- 
nately know anything about it. 
Cases which run an Irregular Course.-Recent years have 14 
TYPHOID FEVER. 
scarcely put us in a more favorable position for discussing inis part of 
our subject with profit. Materials and observations have accumulated, 
especially in the United States, but the difficulty of differentiating a 
diagnosis between mild typhoid and " cess-pool " fever without an autopsy 
still exists, and the pathological distinctions between the lesions caused 
by typhoid fever and septic poisoning are not sufficiently defined to 
make an autopsy in all cases a positive indication. These fundamental 
difficulties are reflected in the views of good authorities and of practi- 
tioners of extensive experience. The utmost caution is still required in 
judging of such cases. 
The influence of malaria in excluding or modifying typhoid is also an 
important factor. 
Prof. Clark, of New York, thinks the question is a little unsettled 
whether the excretions from healthy persons can produce typhoid fever; 
his impression, however, is that, when these cases are closely examined 
in the new light, they will be found to be what is described as "cess-pool 
fever." Dr. Loomis ascribes the adynamia in the so-called typho-mala- 
rial fevers topythogenic influences, which cannot, he thinks, cause enteric 
fever in the absence of a specific germ. Dr. Cabell reports that this is 
the view taken by many Southern physicians, with whom he has corre- 
sponded on this subject, and whose residence in malarious regions gives 
them opportunities for extensive observation. The majority of his cor- 
respondents express the common opinion that typhoid and malarial fevers 
have each its distinct specific cause, and both may prevail at the same 
time in the same place; a small proportion of these believe that the two 
diseases may co-exist in the same individual as a hybrid typho-malarial 
fever. This is the view advocated by Dr. Woodward, supported by Dr. 
Hoff, and accepted by Dr. Cabell himself. This last gentleman, however, 
acknowledges, as we believe very properly, a certain degree of antagonism 
between typhoid and malarial poisons, that enteric fever is far less 
common in malarious regions than elsewhere, and that its frequency in- 
creases in these very regions during periods when there is a suspension 
of malarious influence. 
Dr. Hoff, surgeon in the U. S. Army, gives the clinical histories of 
five cases of a disease which he identifies with Woodivard's typho-mala- 
rial fever, which occurred among troops under his charge in Wyoming 
Territory, not far from the Rocky Mountains. He considers himself 
forced to attribute the source of the poison to the water in a stream 
having its origin in the melting snow of the mountains. The cases wore 
all of the same type; there was one death in which an autopsy revealed 
the characteristic lesions of typhoid fever. Dr. Hoff sums up his obser- 
vations and conclusions in brief as follows: 1st. The fever of the Rocky 
Mountain region is a hybrid disease, the prominent features of which 
are typhoid, the modifying, intermittent. 2d. It appears during or 
after exposure to field service, generally, though not necessarily, in 
late summer and early autumn, and seems to bear no relation to typhoid 
infection as now usually accepted by the profession. 3d. At its incep- TYPHOID FEVER. 
15 
tion, this disease manifests itself as an intermittent of quotidian, 
tertian, or other form; this stage is followed, in about two weeks, 
by the typhoid stage, lasting about four weeks, in which typical 
typhoid symptoms may be observed, modified in a greater or lesser de- 
gree by intermittent indications. 4th. The pathological anatomy of the 
disease is that of typhoid fever. 5th. The treatment should be anti- 
periodic and antipyretic. 
TREATMENT. 
Next in importance to the etiology, as measured by the amount of 
attention it has received of late years, comes the treatment of typhoid 
fever. 
In reference to the general treatment of the disease and to especial 
manifestations, Sir Wm. Jenner's address delivered in Birmingham, be- 
fore the Midland Medical Society, forms, on account of that distinguished 
gentleman's long experience and generally recognized authority upon 
this subject, a very valuable contribution. He believes that, in the pres- 
ent state of pathological knowledge, it is impossible to fix the treatment 
of typhoid fever on a more sure basis than individual opinions founded 
on experience. Owing to the complexity of the disease and the great 
individual differences in the sick, he regards it as scarcely possible to 
find two cases in all respects identical, and quite impossible to collect 
records of a sufficient number of cases practically identical to determine 
by numerical analysis the best mode of treatment. This leads him to 
advocate careful attention to the symptoms in each case as they arise, and 
so-called specifics either as antidotes or forms of treatment do not find 
favor in his eyes. The fever he would meet by rest, quiet, fresh air, 
mixed liquid food, and bland diluents, and the exclusion of fresh doses 
of poison; the intestinal lesion by the careful exclusion from the diet of 
all hard and irritating substances, and the removal from the bowel of 
any local irritant. Of pure water internally, Jenner, with Liebermeister, 
advises in this disease an unlimited supply, and this advice is worth 
taking to heart. 
Diet.-In common with others, Jenner admits the value of milk as an 
article of diet in fever, but cautions against its indiscriminate employ- 
ment in almost unlimited quantities, reminding us that a pint of milk 
contains as much solid matter as a full-sized mutton-chop. Undigested 
and irritating curds, and very abundant fecal accumulations are the fre- 
quent accompaniments of a simple milk diet as carried to an extreme of 
late years not unusual. When catarrhal inflammation of the intestines 
is present, milk is the best diet; if the curd appears in the stools, the 
milk should be diluted with water or lime-water; when the bowels are 
torpid, beef or mutton broth may be given alternately with the milk, 
though neither of these is anything like as nutritious as milk (Pepper}. 
Opium, Jenner is convinced, is on the whole a most dangerous remedy. 
In the early stages of fever, it disturbs digestion and checks secretion; in 
the later stages of the disease, .its influence on brain, heart, and secret- TYPHOID FEVER. 
16 
ing organs is sometimes fatal. With hemorrhage its use in enemas 
may be, and with perforation its use in some way would be unavoidable. 
Calomel.-Dr. Alonzo Clark says we have been very familial' with the 
use of calomel in the treatment of typhoid fever in the United States, 
but that it has been pretty generally abandoned. Nor would a more 
general reliance be placed, as far as we can learn, upon any specific action 
to be expected from iodine either in altering the character or shortening 
the duration of the disease, whether administered as Lugol's solution or 
as iodide of potassium. 
Alcohol.-When, forty years ago, Dr. Todd introduced to the profes- 
sion the alcoholic treatment of fevers, he was as much alone as are those 
who now propose to do away with it entirely. Since that day the spec- 
tacle has been presented of the constant and indiscriminate use of alcohol 
in all forms of disease. To such an extent has this been carried that a 
large body of distinguished practitioners in England have felt called 
upon to issue a circular denouncing this indiscriminate use, and demand- 
ing a much greater restriction in its application (Caswell). The 
tendency at the present time in the United States and in Great Britain 
is undoubtedly a reaction against the excessive use, and toward a more 
rational use of alcohol in fever, and especially m typhoid. Stimulants 
are only demanded for the relief of certain symptoms (Pepper). Alcohol, 
by its influence on the nervous system, is of the greatest value in the 
treatment of typhoid fever, but it should only be given for the purpose 
of attaining a definite object; its effects should be watched that the 
desired result may be obtained from as small a dose as possible. It calls 
forth strength, but does not create it, and is therefore more frequently 
indicated and in larger doses in the later stages. 
Tremor out of all proportion to other sign§ of nervous prostration is 
evidence of deep destruction of the intestine. A small, deep slough will 
be accompanied by great tremor; a large extent of superficial ulceration 
may be unattended by symptoms. Now it is deep ulcers following sepa- 
ration of deep sloughs which are especially liable to give rise to severe 
hemorrhage and perforation. In these cases of tremor, alcohol should 
always be given to increase nerve energy and to limit sloughing and 
ulceration. Delirium is, as' a rule, one of the symptoms which are in- 
fluenced for good by alcohol, but in which its effects should be most closely 
watched. When the urine contains a considerable quantity of albumen, 
alcohol should not be prescribed, unless for the relief of some symptom 
immediately threatening life, and then with the greatest caution. It is 
in exceptional cases only that more than twelve ounces of brandy in the 
twenty-four hours can be taken without inducing some of the worst 
symptoms of prostration. Nearly all the good effects of brandy, when 
its use is indicated, are obtained by four, six, or eight ounces in twenty- 
four hours. When in doubt of the wisdom of giving alcohol in a case of 
typhoid fever I do not give it, and when there is a question of a larger or 
smaller dose I prescribe, as a rule, the smaller (Jenner). The use of 
stimulants is regulated by the state of the pulse; if the beats are growing TYPHOID FEVER. 
17 
in rapidity and losing in strength, if they pass 110,115, 120, a half-ounce 
of spirits or a glass of champagne is given; if there be from any cause 
doubt of the need of alcohol in a rising pulse the dose is given with the 
finger on the wrist; if the pulse steadies or slows, the wine is repeated 
on its rising. Twelve ounces of spirits daily is said to be all that the 
worst case needs, but this limit is constantly and necessarily exceeded 
with favorable results {Stedman). 
Antipyretic Treatment.-The combat with pyrexia has gone on 
briskly, and quinine, salicylic acid, salicylate of soda, digitalis, alcohol, 
and cold baths continue to be experimented with as antipyretics, whether 
separately in larger or smaller doses, or in varied combinations. There 
is nowhere great unanimity of opinion as to the positive value of these 
agents, or the best methods of administration, but the evil effects of 
excessive or prolonged elevation of temperature are generally conceded, 
as well as the fact that, in some uncomplicated cases, an otherwise 
inevitably fatal result may be averted by the timely employment of one 
or more of these antipyretics. 
In general, it may be said that, in Germany, where professional atten- 
tion was recalled to the importance of controlling febrile action in 
typhoid, the antipyretics still retain the confidence originally expressed 
in them, though in a modified degree; in France, they have gained a 
place, though their use there has certainly never excited much enthu- 
siasm; perhaps the German indorsement proved unfavorable to them; 
whilst in the United States and Great Britain, where the experiments 
writh cold baths at least have been much less extensive than in Germany, 
there seems little disposition to adopt cold baths as a constant form of 
treatment, though their value is recognized in certain cases and at certain 
periods of this disease. Many good authorities in those countries doubt 
the wisdom of the employment of large doses of quinine and salicylic 
acid, whilst others seem more than satisfied with the results obtained 
from these drugs. The truth is, that some patients bear best one form of 
antipyretic and others another, and, in a certain proportion of cases, all 
fail, either partially or wholly, to effect the object aimed at. If, in any 
given case of typhoid fever, the pyrexia gives cause for anxiety, and fif- 
teen or thirty-grain doses of quinine are well borne, without giving rise 
to symptoms of nervous or gastric irritation, the administration of these 
full doses, especially at evening, will often control the fever. Salicylic 
acid is now less used than salicylate of soda; salicin is thought to produce a 
more prolonged, though slower effect upon the temperature than quinine; 
and in combination with this last the others are considered to increase its 
efficiency and to diminish the liability to relapses, which most authori- 
ties are now agreed is greater under antipyretic treatment. When any or 
all of these drugs are ill borne or insufficient, resort must be had to the 
application of cold-whether in the form of cold bath, gradually reduced 
bath, sponging, or sprinkling on a sheet-and that either alone or in con- 
junction with the above drugs. There is no doubt that, when quinine is 
well borne, its combined use diminishes the number of baths required. 18 
TYPHOID FEVER. 
Each case must be its own rule for the dose of the drug, for the form of 
application of cold, and if baths are given, for the temperature and dura- 
tion of the bath. Mild cases do not require baths, and, in advanced 
cases (the third week) they are not safe. Great care should undoubtedly 
be exercised in administering them to young children and old persons. 
Liebermeister, in Germany, and Dumontpallier, in France, now employ 
an apparatus for applying cold. There is a refrigerating envelope through 
which the water runs, and by means of stop-cocks and thermometers 
the temperature of the body can be lowered continuously or intermit- 
tently, and the change effected readily noted. 
In a late reply to a vigorous attack by Prof. Gairdner, of Glasgow, 
upon the German antipyretic treatment, Liebermeister says: The antipy- 
retic treatment is not, as you believe, a matter of routine. On the con- 
trary, with it the cases are more individualized than with any other 
method of treatment. Each agent is used only when necessary, and when 
none is necessary none is used. But, in order to know what is necessary, 
one must, of course, observe each individual patient much more thor- 
oughly than has hitherto been customary. It is just the routine hitherto 
pursued for which we propose to substitute a method of close observa- 
tion, very exacting on the medical attendant, which offers the greatest 
obstacle to the introduction of the antipyretic treatment. 
Dr. Austin Flint says that his observations as regards the antipyretic 
treatment are sufficient to lead him to believe the statement by Lieber- 
meister that, under this treatment, "the old picture of a typhoid fever 
patient is no longer to be seen," to have a solid foundation in clinical 
experience, although somewhat extravagant, and to concur with this writer 
in saying that thereby " typhoid fever has lost a great part of its terrors." 
Drs. Edes and Stedman report the use of graduated baths, combined 
with internal antipyretic treatment, in a considerable number of cases, at 
the Boston City Hospital, with favorable results. 
Out of 32 cases entering, during the first week of fever, in Dr. Edes' 
service, in the course of three years, 1872-1874, there was only one death. 
A series of 46 cases entering this hospital at an earlier period, likewise 
during the first week, but not treated antipyretically, showed a mortality 
of a little over 10 per cent. 
The statistics of the results of treatment and percentage of mortality at 
the Bellevue Hospital, New York, since the introduction of antipyretics, 
up to the year 1879, are not of a character to be of much practical value, 
but, as far as they go, are not especially favorable. Graduated baths have 
been tried there a number of times, and the opinion is expressed that 
they are uniformly annoying and depressing to the patients. At the 
Massachusetts General Hospital, antipyretics, and certainly cold baths, 
have not been systematically tested, but the usual rate of mortality at 
that institution, about thirteen per cent, is not an unfavorable one. Dr. 
Smythe, of Indiana, from an experience of eighteen cases, considers cold 
baths and quinine as indispensable in typhoid, but the latter as the more 
valuable of the two. TYPHOID FEVER. 
19 
Dr. Nathan Smith published a short essay on Typhoid Fever in 1824, 
in which there would be little to change, even at this date; in it he gives 
the results of his experience of this disease in New England, and shows 
that he was in the habit, since the latter part of the last century, of using 
cold water, when indicated, externally as well as internally, with freedom 
and courage, and that he recognized its value in certain cases. Sir Wm. 
Jenner says that neither his own limited experience nor the evidence 
adduced by others in its favor has carried conviction to his mind of the 
advantage of the treatment by cold baths. At the same time, he recog- 
nizes the fact that the direct cooling of the body is, in some cases, essen- 
tial to the preservation of the life of the patient, and mentions with favor 
the graduated bath, tepid sponging, the wet pack, and cold to the head 
by the india-rubber tubing cap. He expresses himself as having been 
disappointed in the effects of quinia and salicylate of soda as reducers 
of temperature, wdiile he has occasionally seen both do much harm by 
disturbing the stomach and interfering with digestion. Dr. Pepper 
expresses himself even more strongly, and says that he never administers 
the enormous doses of quinia given by German physicians; that there 
is so much unnecessary irritation of the mucous membrane produced 
that heroic treatment, such as this, should only be adopted as a last 
resource; that he is in the habit of giving about twelve grains in the 
twenty-four hours. 
The graduated bath was adopted at St. Thomas' Hospital, London, 
and Dr. Ord says, in regard to its use there, which was quite general, 
that the practice, though not uniformly successful, has not, in any 
instance, done any known harm, and has, in all probability, averted death 
in several cases. 
In regard to the graduated bath, Dr. Greig Smith, of the Bristol 
Royal Infirmary, is confident (though he thinks the contrary is very gen- 
erally believed) that the endeavor to prepare the system for a tempera- 
ture of 60° by lowering it from one of 90° in half an hour or so causes 
more depression than to plunge the patient at once into the requisite 
cold. It certainly causes more discomfort. In this opinion Dr. Collie, 
of the Homerton Fever Hospital, where baths have been successfully 
used, coincides. Moreover, he says they have never given more than 
three baths in twenty-four hours, and should not, in any case, give more 
than four; that the duration of the bath should not, as a rule, exceed ten 
minutes, and, in children of ten, not more than seven minutes; that, in 
most cases, the bath should be discontinued toward the end of the second 
week, and, if an antipyretic is needed, quinine should then be given. 
To young children and elderly persons quinine should be given instead of 
the cold bath. 
Mr. Murphy, Resident Medical Officer of the London Fever Hospital, 
writing in 1877, stated that up to that time the cases of typhoid treated 
antipyretically in that institution had been too few to urge as statistical 
proof of the efficacy of that treatment, but the results on individual cases 
had been sufficiently satisfactory to lead to its general adoption in this. 20 
TYPHOID FEVER. 
hospital. He further says :>It is not contended that it will insure the 
recovery of every patient suffering from enteric fever; that it will save 
life in those patients who die in the second week of their illness from the 
direct influence of the poison; iror that, when commenced late in the third 
week, it will undo the injury that has already occurred. It is not believed 
that it will shorten the period of illness, for it has even appeared to prolong 
it; although this may be due to the fact that the more severe cases have 
been bathed-cases which would under any circumstances have run along 
course. But there is a large class of cases which, under the expectant treat- 
ment, die at the end of three or four weeks, worn out by the continued 
pyrexia, and these can without doubt be saved by an early and systematic 
antipyretic treatment. Without the bath, quinine will only control the 
temperature in the milder cases. Quinine will never altogether replace 
the bath, for it is not followed by the favorable effects of the latter on 
delirium and in producing sleep, but in conjunction with the bath it is a 
most useful aid; sponging or wrapping in sheets saturated with cold water 
are useful in mild cases, but cannot be relied on in severe ones. The 
difficulties of the treatment are inconsiderable, it is not attended with 
any danger, the patients rarely object to it, and by some it is liked. The 
reduction of delirium, the quiet sleep, the general feeling of comfort it 
gives the patient, are sufficient to convince the most sceptical that the 
cold bath is one of the most useful therapeutic agents we have in the 
treatment of enteric fever. 
The following from the Revue des Sciences Medicales, 1878, reflects 
very fairly the French estimate of baths up to that period. To our knowl- 
edge, there is not a single hospital service in France where baths are used 
as a general method of treatment. M. Fereol, one of the physicians who 
recently has resorted the most to baths as a method of treatment, cited 
a series of forty-three cases, of whom only two were bathed. M. Bern- 
heim, at Nancy, says that often out of ten or twelve cases of typhoid only 
one will require baths. M. Raynaud regards baths as an energetic form 
of treatment, with which one should not be extravagant, but reserve it 
for cases where the situation of the patient is sufficiently grave to author- 
ize the physician to combat it. 
One must, moreover, distinguish the conditions in which baths should 
be ordered regularly and continuously, the only true refrigerant method, 
and those cases where occasionally in the course of the disease recourse is 
had in a temporary manner to some one of the processes for applying 
cold. 
Physicians at Paris who have had recourse to the new method of 
baths agree that for grave cases the advantage is on the side of cold 
baths (Fereoly, some are inclined to think that a number of recoveries 
would not have been procured by any other method, and think they 
cannot with certainty attribute any death to the treatment. It does not 
seem probable, however, that cold baths will be accepted in France in 
the immediate future as a general method of treatment in typhoid fever, 
but the indications for their use are constantly better defined, and the TYPHOID FEVER. 
21 
different processes of hydrotherapy are gradually more and more em- 
ployed, whether as a regular and constant application in certain severe 
cases, or in a casual way, and as an exceptional measure to combat tem- 
porary complications. They are not a specific, but a very energetic 
agent destined to bestow great benefits in proportion as we understand 
better the conditions in which they are to be resorted to (Homolle). 
M. Peter, in an article which is robbed of much of its value by a too 
evident anti-German feeling, attempts to show that the treatment by 
baths is less a process of cooling than one of revulsion ; that its good 
effects do not arise from the lowering of the temperature, but from a 
profound perturbation of the nervous system; in short, that the lower 
temperature is but a very indirect result of the treatment. He complains 
that in the struggle of the " hypo" with the " hyper" of "cold" with 
" warmth," the patient has disappeared altogether. That there are no 
longer therapeutics or treatment of symptoms, but a mere arithmetical 
problem, a subtraction. He thinks, apparently with Jenner, that the 
best therapeutic system, especially in the treatment of typhoid fever, is, 
and always will be, to have none. 
Raynaud's experience with the treatment by cold baths in the Lari- 
boisiere Hospital was rather favorable than otherwise. In the years 
1874-1876, after excluding the mild cases, there were 117 typhoid 
patients with 17 deaths, 2 of which occurred immediately after entrance; 
this gives a mortality of 14 per cent. During the year 1873, out of 30 
cases under expectant treatment, there were 8 deaths, 26.7 per cent. He 
attaches more importance to prolonged pyrexia than to mere elevation; 
after the twelfth day of the disease he expects but little benefit from 
baths, and never applies them after the eighteenth day. Given a tem- 
perature of 104°, lasting five to six days with only slight remissions, he 
would regard the cold bath as a necessity. A bronchitis would not 
offer an impediment to baths, pneumonia and cardiac weakness with 
small pulse are decided counter-indications. 
M. Foltz found physiologically that cold clysters have a local action 
on the intestine, and a general action shown by a decided slowing of the 
pulse and fall of temperature after a lavement of half a litre of water 
at 50° Fahr. This coincides with Dr. Rutenberg's experiments. In fe- 
brile conditions analogous effects are produced; moreover, nervous mani- 
festations are soothed, thirst is appeased, the appetite is stimulated, the 
secretions augmented. These effects are the more manifest and persist- 
ent the lower the temperature of the water, the greater the quantity 
injected, and the more frequent the injections. M. Foltz orders, as a 
rule, lavements of about a pint at 50° to 55° Fahr., repeated every two, 
three, or four hours, or at longer intervals during sleep or when the tem- 
perature falls. In his cases, the number of lavements varies from thirty 
to three hundred for each case. 
Twenty-seven typhoid patients were treated, with one death, fifteen 
of these had a severe form of typhoid. This mode of treatment has objec- TYPHOID PE VER. 
22 
tions which readily present themselves, and is not likely to become gen- 
eral, but may be occasionally of service. 
Prof. Immermann has published some interesting remarks on the pre- 
vention of relapses. Between 1872 and 1877, Immermann treated about 
1,200 cases of typhoid fever in the hospital at Basle; 15.6 per cent of 
these suffered relapses. The proportion of relapses varied in different 
years from 12 per cent to 19 per cent. Having in vain guarded his 
patients from all error in diet, and kept them in bed until the end of 
the second week of continued absence of fever, he was unable to doubt 
that the relapses were independent of external influences, and in the 
great majority of cases arose from the liberation of unconsumed por- 
tions of the original poison. He attributes the increase in the propor- 
tion of relapses, from 8 per cent to 10 per cent ten or fifteen years since, 
to the present percentage, indirectly and directly to the new antipyretic 
treatment. Indirectly, on account of the diminished mortality; directly, 
on account of the use of hydrotherapy and antipyretic medication which 
interfere with the natural,destruction of the poison in the course of the 
disease. To combat this result, he had recourse to a secondary disinfec- 
tant treatment. To twenty-two convalescents he administered, from 
the first day with absence of fever, daily doses of from sixty to ninety 
grains of salicylate of soda, and continued it during ten or twelve days. 
Of these twenty-two, only one had a relapse, and in this case there was 
a grave imprudence in diet. Among 93 patients not submitted to this 
supplementary course there were 27 relapses. A second series of experi- 
ments gave 1 relapse out of 29 convalescents of both sexes treated with 
salicylate of soda, and in this case the exhibition of the medicine was 
begun by mistake only on the fourth apyretic day; 67 other cases of 
typhoid offered 15 relapses. To sum up, Immermann experimented dur- 
ing two successive years, 1877, 1878, with salicylate of soda upon 51 
convalescents from typhoid, among whom the relapses did not exceed 4 
per cent, whilst amongst 160 others not so treated, the proportion of 
relapses amounted to 23.6 per cent. 
The statistics of Dr. Goltdammer in regard to the treatment oy cold 
baths, in the Bethanien Hospital in Berlin, are the most extensive which 
have appeared of late years. They cover a period of nine years, from 
1868 to 1876 inclusive, during which 2,068 cases in all were treated, with 
a mortality of 13.2 per cent. They deal with a homogeneous material, 
subjected to similar general influences, are full, carefully compiled, not 
made to support a pet theory, and their value is enhanced from their 
being comparable, to a certain extent, with a series of 2,228 cases dur- 
ing the years 1848 to 1867 inclusive, drawn from the same population, 
subjected to similar general surroundings, and treated in the same hos- 
pital on the expectant plan. In making up the report, the former dif- 
ferent use of the terms " typhus" and " febris gastrica" has been taken 
into acccount, and the rate of mortality in the early series thus rendered 
more, rather than less favorable. Moreover, no proof exists that the 
type of typhoid fever has changed in Berlin of late years. From the TYPHOID FEVER. 
23 
early scries of 2,228 cases during the years 1848 to 1867, there were 
105 deaths: 18.1 per cent. From the second series, 2,086 cases during 
the years 1868 to 1876, there were 267 deaths: 13.2 per cent. A diminu- 
tion in mortality of 5 per cent in favor of the period of cold baths is 
shown, that is to say, 100 deaths were avoided during the period of cold- 
water treatment. 
The average length of time in the hospital was : 
1858-1867 inch (for 1,086 cases) 46.1 days. 
1868-1876 inch (for 1,519 cases) 39.8 days. 
Difference, 6.3 days. 
There was thus a difference of 5 per cent in.mortality, and of 6.3 
days of treatment in favor of the period of cold baths. In the preceding 
series, all cases, the light, the severe, and the hopeless are included. In 
order to arrive as nearly as possible at an approximative mortality during 
the period of hydrotherapy, Dr. Goltdammer deducts from the second 
series sixty-four deaths, occurring when the patient was brought in too 
late to use baths, or in a condition already hopeless from existing com- 
plications, and thus obtains a mortality of 10.5 per cent for the cases 
subjected to cold baths. The method he designates as a tolerably severe, 
but not excessive one. The baths were given at a temperature ranging 
from 68° to 82° Fahr., generally about 75°, with a duration of from ten 
to fifteen minutes. Sensitive patients, or those with cardiac weakness, 
were given baths of 88° Fahr., lowered in the course of fifteen or twenty 
minutes to 78°. 
Temperatures were taken in the axilla every three, and in severe 
cases every two hours, and whenever 104° was reached a bath was given. 
Of the patients bathed regularly, the majority had three or four baths 
daily, the more severe cases five or six, and a very few seven. Baths 
were omitted in the night. All cases were subjected to treatment in 
which no counter-indications existed, or in which the course of the dis- 
ease was too light to justify treatment. As counter-indications arc men- 
tioned especially cardiac weakness, also stenosis of the larynx, lobular 
pneumonia, pleurisy, intestinal hemorrhage, peritonitis. Salicylic acid 
and quinine were occasionally given in the evening in cases of persistent 
high temperature. It was not found that the baths were agreeable to 
the patients, but neither wa§ there much resistance, and they were cer- 
tainly quieter, slept better, and were less troubled with bed-sores. One 
case of syncope in the bath occurred, with subsequent fatal result. The 
records of the last three years, '74, '75, '76, being more full, present 
some interesting tables which a?-e appended. An increase in the propor- 
tion of hemorrhages from the bowel was not observed. 
The statistics of Dr. Goltdammer give no positive information as to 
the relative frequency of relapse under the expectant and the cold-water 
treatment, as there were no exact data on this point in the early series of 
cases; his opinion, however, coincides with that of other observers, being 
that the proportion of relapses is increased by the baths. By excluding 24 
TYPHOID FEVER. 
indiscretions in diet, and fresh infection from without, he concludes that 
in the great majority of cases the relapse had its origin, whatever might 
have been the exciting cause, in the same infection which caused the first 
attack. This view is also somewhat strengthened by the fact that most 
frequently the mild, short, abortive forms of typhoid, less often the mod- 
erately severe, and rarely the severe cases were those followed by relapse. 
One case passed through a pretty severe typhoid in this hospital, returned ten 
weeks later with another severe attack, which was followed by a relapse. This 
individual, therefore, experienced three clearly marked attacks of typhoid within 
six months. 
The apyretic interval preceding the relapses varied from 3 to 21 days, 
and averaged 8 to 9 days. Among complications and causes of death for 
these 783 cases were perforation 13 times; 51 times hemorrhage from the 
bowels = 6.5$ with 21 deaths; 9 times diphtheria with 8 deaths and 7 
unsuccessful operations; and 13 times pleurisy with 8 deaths. 
MORTALITY ACCORDING TO AGE. 
AGE. 
NUMBER. 
DEATHS. 
PER CENT. 
51 
7 
13.7 
15-20 " " 
224 
27 
12. 
21-25 " 
274 
42 
15.3 
26 30 " 
121 
21 
17.3 
31-40 " 
73 
18 
24.6 
41 vsars and over 
32 
15 
47. 
775 
130 
16.7 
MORTALITY ACCORDING TO PERIOD OF ADMISSION. 
PERIOD OF ADMISSION. 
NUMBER. 
DEATHS. 
PER CENT. 
Unknown 
33 
1 week (1-4 days) 
113 
9 
7.9 
1 week (5-7 days) 
215 
23 
10.7 
2 weeks 
335 
67 
20. 
3 weeks and later 
87 
31 
35.6 
783 
130 
16.6 
The duration of fever in those who recovered before and after entrance into 
the hospital was: 
For men 21.9 days. 
For women 24 days. 
22.9 days. RELAPSING FEVER. 
25 
RELAPSING FEVER. 
BIBLIOGRAPHY. 
Obermeier: Weitere Mittheilungen uber Febris recurrens. Berlin, klin. 
Wochenschr., Nr. 35, 1873.-Budberg: Ueber Febris recurrens. Diss. Berlin, 
1873.-Semon: Zur Recurrens Epidemie in Berlin, 1871-72. Diss. Berlin, 1873.- 
J. Simon: Relapsing Fever in the Metropolis. Lancet, I., p. 72, 1873.-F. Bae- 
nisch: Die Complicationen und Nachkrankheiten der in der Greifswalder Klinik 
behandelten Faile von Typhus recurrens. Arch. f. klin. Med., XV., S. 53.- 
Litten: Die Recurrens-Epidemie in Breslau im Jahre 1872-73. Arch. f. klin. Med., 
XIII,, S. 128, 1874.-Ponfick: Ueber das Vorkommen abnonner Zellen im Blute 
Recurrens-Kranker. Centr. Bl. f. med. Wiss., Nr. 25, 1874.-The same: Anato- 
mische Studien uber Typhus recurrens. Virchow's Arch., Bd. 60, S. 153.-Birch- 
Hirschfeld: Ueber die Spirillen im Blute Recurrenskranker. Arch. f. klin. 
Med., XIII., S. 346, 1874.-Munch: Protokolle der Sitzungen der Gesellschaft 
odessaer Aerzte, VII., 1874.-Unterberger: Febris recurrens im Kindesalter. 
Jahrbuch fiir Kinderheilkunde, N. F., X., S. 184, 1876.-Heidenreich: Ueber den 
Parasiten des Riickfallstyphus. Berlin, 1877.-II. V. Carter: Notes on the 
Spirillum Fever of Bombay. Med. Chir. Trans., LXI., p. 273, 1878.-Motschut- 
koffsky: Materialien zur Pathologic und Therapie des Riickfallstyphus. Arch, 
f. klin. Med., XXIV., S. 80, 192, 1879.-Holsti: Om rekurrensepidemin i Helsing- 
fors under aren 1876-77, afvensom Sannua Sjukdoms upptradande i Finland. 
Nordiskt med. Arkiv, XI., 1, 1879, Stockholm.-F. Cohn: Zur weiteren Kenntniss 
des Febr. recurrens und der Spirochaeten. Deutsch, med. Wochenschr., V., S. 
189, 1879.-Koch: Die Uebertragung der Recurrens-Spirochaeten auf Affen. 
Deutsch, med. Wochenschr., V., S. 327, 1879.-L. Riess: Weitere Beobachtungen 
fiber Febris recurrens. Deutsch, med. Wochenschr., V., S. 651 u. 663, 1879.-H. 
V. Carter: Contributions to the Experimental Pathology of Spirillum Fever, No. 
1. Med. Times and Gaz., I., p. 304, 1880.-Enke: Ueber den Riickfallstyphus. 
Magdeburg, 1879.-Lewis: The Presence of Micro-organisms in Normal and 
Diseased Blood. 1879.-W. Friedreich: Das Auftreten der Febris recurrens in 
Siiddeutschland. Deutsch. Archiv f. klin. Med., XXV., S. 518, 1880. 
This disease is not indigenous in the United States. Cases were 
reported by Clymer in 1844, and by Flint in 1850-51. The malady was 
confined to recent Irish immigrants and did not spread from them. It 
was reimported again in 1869, and prevailed to some extent in that and 
the following years in New York and Philadelphia, where its diffusion 
was, according to Flint, undoubtedly due to a contagium. Since its 
disappearance in 1870 nothing more has been seen of it in this country. 
We have been unable to learn of any epidemics of infectious disease 
answering to the description of bilious typhoid or relapsing fever as 
having prevailed among the negroes of Philadelphia and North Carolina, 
and, therefore, cannot share the opinion expressed by Prof. Hirsch, that 
this disease was the cause of a peculiar mortality among those people. 26 
RELAPSING FEVER. 
The old term, famine fever, which is now discarded, indicates, not that 
the symptoms included under the name are caused by want, but that 
want, overcrowding, and their concomitants favor the development of 
the disease. The name, however, serves to remind us that the present 
distress in Ireland, the home of relapsing fever, is very liable to be fol- 
lowed by a general outbreak of this disease at various points, and increas- 
ing emigration would in all probability bring it again to our shores. 
In 1873 Obermeier described a spirobacterium found by him in the 
blood of those attacked with relapsing fever. This was identified as the 
spirillum, or more properly the spirochaete of Ehrenberg. These two 
microbions form respectively the fifth and sixth group in Cohn's classifi- 
cation of schizomycetes or schizophytes, and compose Tribe IV., that of 
spirobacteria. As both names have been applied to .the microphyte of 
relapsing fever, they will be used interchangeably in the present article, 
though spirochaete is the more correct designation. Since this discovery 
by Obermeier, much attention has been given to the etiology and pathology 
of relapsing fever, materials have been accumulated, and the relations 
of the microbion to the disease carefully investigated. It cannot be 
affirmed that positive results have as yet been reached, and many of the 
observations of those who have had opportunities to make such are very 
conflicting. This, however, is to be expected in the present transitional 
state of knowledge upon this and kindred subjects, where the best 
authorities are working in fields still new, and all are not equally experi- 
enced in methods of research. 
Some investigators, as Heidenreich, Vandyke Carter, Motschutkoffsky, 
Holsti, Enke, believe they have found this parasite invariably, or almost 
so, at some stage in every case when the blood was examined microscopi- 
cally; others, as Riess and Lewis, report a number of cases in which 
spirilla were not found during any stage of the disease, and again 
instances in which they were not discoverable during one or more periods 
of pyrexia. Such conflicting observations naturally make it desirable 
to suspend judgment as to the precise relation of the microphyte spiro- 
chaete to the disease relapsing fever. Whether it is simply attendant 
upon, or how far it is causative of the disease, we are not quite yet in a 
position to decide. It is a little premature to shout, "No relapsing 
fever without spirochaetes, and no spirochaetes without relapsing fever " 
(Unterberger). Our present knowledge would not justify us in declaring 
any given case as not one of relapsing fever because spirochaetes are not 
found during the pyretic stage. When spirochaetes are found in the 
blood, however, it is pretty safe to suppose that one has to do with this 
disease until it is shown, and that has not yet been done, that this parasite 
exists in the blood under other conditions. It is also necessary to remem- 
ber that, as other hitherto unobserved agents may perhaps influence the 
febrile paroxysms, so other conditions of the blood besides temperature, 
such as amount of water, oxygen, etc., may affect the regular development 
of the microzyme spirochaete. The spiral bacteria found in various secre- 
tions and in water {Billroth, Cohn, Ehrenberg) are similar to our RELAPSING FEVER. 
27 
spirochaete, but careful inspection shows some differences, the spirochaete 
plicatilis found by Ehrenberg in water being somewhat larger, and, what 
is more reliable, inoculation does not produce specific results. 
Both men and monkeys have been successfully inoculated with the 
spirillar blood of relapsing fever (Motschiitkoffsky, Carter, Koch'), and 
this inoculation carried to the second and third stages. Blood in which 
spirilla could not be found was successful in the hands of one experimenter, 
but it was taken in the earliest stage of a pyretic onset which soon 
developed the organism. Other non-spirillar blood did not produce 
specific results. There is no absolute proof that in these cases it was the 
spirochaetes and not some other accompaniment of the injected blood 
which transmitted the disease. Koch announces that he has found this 
microphyte in the tissues of an inoculated monkey killed at the height 
of a relapse, something not previously observed and which we have not 
seen confirmed, and also that he has successfully cultivated it outside the 
living body, following the same methods which he pursued with bacillus 
anthracis of charbon; this had not been done previously except by Carter. 
The further step, adopted in charbon and which forms the missing 
link, of reproducing the specific disease from the spores of the microphyte 
and from the organisms obtained from these, as far as we can learn, has 
not yet been taken. If Cohn's view is correct, that only bacilli form 
spores, the terms, though not the method, of the step would be altered. 
Even the successful attainment of this step would not be proof that no 
other agent caused relapsing fever. There are, however, limits to a 
rational and healthy skepticism. One thing appears from recent observa- 
tions, that the spirochaete does not precede the pyretic attacks with suffi- 
cient constancy to be relied upon as a warning. To this short summary 
of the relations of this organism to the disease under consideration we 
add a brief synopsis of the more important recent investigations bearing 
on the subject. 
All recent writers agree that one attack of relapsing fever does not 
protect the individual from a second entirely new one. Litten states 
that five fresh reinfections took place among the hospital patients at Bres- 
lau during the epidemic of 1872-73, whilst seventeen other patients who 
had already passed through the disease in 1868 were again attacked in 
1872-73. 
Dr. J. Motschutkoffsky, of Odessa, had a very favorable opportunity 
to etudy relapsing fever upon a rich material in the hospitals of that city 
between the years 1873-76 ; and he*had the unusual advantage of being 
permitted to inoculate a number of human beings with the disease. 
During two years he made over two thousand preparations of the blood. 
In regard to the spirochaete, his observations led him to the following 
opinions and results: We do not yet know the origin nor the process of 
destruction of the spirochaete. It was never found in any of the secre- 
tions oi' excretions, and is not eliminated unchanged from the body. He 
reports having twice witnessed the process of its dissolution in blood 
into a finely granular detritus. Litten gives twenty-four hours, Munch 28 
RELAPSING FEVER. 
over twenty-four hours as the length of time it retains its power of 
motion outside the body, Heidenreich saw it move one hundred and 
thirty days aftei' being taken out of the body and sealed up in a glass 
tube, and thinks this organism preserves its activity best in a tempera- 
ture of 58 to 70° Fahr. Our author saw it move thirty-seven days after 
being subjected to similar conditions. He was unsuccessful in cultivat- 
ing it, as were also Weigert, Lebert, and Heidenreich, but Koch and Carter 
have since succeeded. The addition of equal parts of water to the blood 
is fatal to the spirochaete, but it also loses its activity more and more the 
thicker the blood becomes. Its activity is not affected by any internal 
exhibition of quinine, salicylate of soda, or other agents, and externally 
only affected by about 1$ of quinine. It withstands a low temperature 
well, but begins to cease moving at anything below 32° Fahr.; it revives, 
however, in blood which is warmed after having been cooled to as low a 
point as 15° Fahr. 
In regard to the relations of the microbion to the disease, this inves- 
tigator thinks it impossible to deny the dependence in some way of the 
process of relapse upon the spirochaete ; for he affirms that the appear- 
ance of a paroxysm and of spirochaete are nearly synchronous, that the 
termination of the paroxysm and the disappearance of the parasite are 
nearly synchronous, that inoculation with apyretic blood is unsuccess- 
ful, that occasionally the spirochete may not be found in the first days 
of pyrexia, but that they must be present, as this blood is equally effec- 
tive. During an attack spirochetes are a constant element in blood ; 
during apyrexia, are found exceptionally. 
He does not recall a single attack during his investigations, extend- 
ing over three years, in which spirochetes were not to be found in the 
blood of the living. This agrees with Heidenreich. This latter alone 
on one occasion discovered this parasite in the blood of a person dying 
from relapsing fever, and then they were without motion. Cohn, Ehren- 
berg, and others have found organisms very similar to spirochaete in the 
secretions of the mouth, in water, in cysts, etc.; and Cohn is disposed to 
regard these different microphytes as representing merely so many differ- 
ent stages of the same. This is far from, being proved. Jf. did not see 
spirocluetes a single time, either during incubation or apyrexia, and 
noticed no difference in their size at different periods ; in number they 
increase from a few hours after the beginning of the pyrexia up to about 
a day before the crisis. 
He cannot accept Heidenreich's theory that the destruction of the 
microphyte is dependent on the pyrexia, as it does not agree with the 
facts, but thinks it more probably depends upon the degree of consist- 
ency of the blood. Though we cannot stop the disease by any remedies, 
we may, perhaps, be able to shorten the attacks by withdrawing liquid 
from the blood. 
"Bilious Typhoid" of Griesinger, of which Lebert makes a separate 
division, and is rather disposed to regard as a distinct though similar 
disease in v. Ziemssen's 2d edition, 1876, Motschutkoffslcy regards as RELAPSING FEVER. 
29 
unquestionably nothing more than relapsing fever with an hepatic com- 
plication, probably a catarrhal affection of the fine bile ducts. He bases 
this view upon the following observations : In sixteen cases of undoubted 
so-called bilious typhoid occurring in Odessa, he found the spirochtete in 
the blood in all, andjflie organism taken from the blood of the last eleven 
cases was subjected to the same tests as those taken from the blood of 
relapsing fever patients, with the same results. Secondly, an individual 
inoculated with the blood of a "bilious typhoid" patient developed, 
after the usual interval, the ordinary relapsing fever uncomplicated by 
icterus. Thirdly, a patient who was exposed to relapsing fever during 
convalescence from typhus, developed " bilious typhoid" with spirochsetes 
in the blood; at this time there was no case of "bilious typhoid" in that 
wing of the hospital, nor had there been, as far as could be learnt by 
careful investigation, for more than two months ; moreover, infection 
from without was rendered improbable by the length of time the patient 
had been in the hospital. Holst? s report of the epidemic at Helsingfors in 
1876-77, in which the mortality was large, in which many cases exhib- 
ited marked icterus with other symptoms of bilious typhoid, though still 
running the usual course of relapsing fever, and showing spirochaetes in 
the blood, is confirmatory of the Odessa observations, and of the identity 
of the two diseases. Miinch's experience with autopsies upon those dying 
from "bilious typhoid" led him to call attention to the coincidence that 
the liver in many of these cases shows signs of previous pathological 
processes (cirrhosis, syphilis, etc.). 
In the late Berlin epidemic (1879) Riess observed one case of " bilious 
typhoid " with plentiful spirochaetes in the blood. 
Motschutkoffsky sums up his experiments with the inoculation of spi- 
rillar blood briefly as follows: He did not succeed in inoculating animals, 
although monkeys were tried among others. Only blood was available. 
Milk, sweat, urine, saliva, and excrement were without effect. Blood 
was only effective during pyrexia; apyretic blood gave negative results. 
Blood taken during pyrexia, e. g., the first hour of a commencing attack, 
was good, whether spirilla could be seen under the microscope or not. 
Artificial recurrens differs in no respect from the natural. 
He did not find that reinoculation increased the virulence of the 
disease. Blood from recurrens biliosus produced simply recurrens. 
The period of incubation was from five to eight days. The period of 
apyrexia about equalled that of incubation. 
In 1877, Dr. II. Vandyke Carter had an opportunity of observing a large 
number of cases of fevers in camp and in hospitals in Bombay. Between 
April and December, about three hundred and fifty cases presented them- 
selves offering all the characteristics of the relapsing fever of Europe; in 
all these cases, spirilla were found in the blood, and Carter has applied 
the name "spirillum fever" to the disease. The questions raised by 
Carter of the influence of a malarial taint upon this disease are of inter- 
est, and will doubtless receive more attention. He regards want, crowd- 
ing, and contagion as the immediate causes of spirillum fever. He 30 
RELAPSING FEVER. 
examined the spirilla carefully, and his results correspond with those 
obtained in Odessa, lie was unable to find spirilla except in the blood; 
he doubts the identity of similar filaments found in the saliva of fever 
patients, for they were present during the apyretic interval, and the same 
were found in his own saliva during health. He observed that the para- 
site has a natural tendency to seek a liquid medium, and he concludes 
that the relationship obtaining between the abundance of the parasite 
and the intensity of the fever is a contingent one, though commonly at 
particular times the connection between pyrexia and the parasite is close. 
He did not succeed in cultivating the spirillum outside the human body. 
Within the last year, 1879, and since the above investigations, Dr. Carter 
has succeeded in communicating " spirillum fever" to monkeys by inoc- 
ulation with spirillar blood. Forty-four trials were made upon fifty-one of 
the common small Indian monkeys (Lemnopithacus Entellus and Macacus 
radiatus); defibnnated blood was injected subcutaneously. Of thirty-one 
inoculations made with spirillar blood, twenty-two were successful, and 
nine failed; all nine inoculations of non-spirillar blood and seven of desic- 
cated blood (mostly infective when fresh) gave negative results; four 
injections made with saliva of fever patients and a healthy man pro- 
duced serious, but not specific results. Carter found that intensity of 
infection increases by repetition, and, as in man, the blood at invasion- 
attacks is not so active as that of relapses, so the monkey's blood, at sec- 
ond remove from man, was found to produce a fatal result in the two 
cases in which it was used. Motsch/utkoffsky's experiments upon men 
led him to a somewhat different conclusion. Carter's investigations will 
be published more fully, but the main conclusions arrived at are stated as 
as follows: (1), that the spirillum or relapsing fever of man is directly 
transmissible to a quadrumanous animal; (2), that there occurs a non- 
febrile infection of the blood prior to " fever;" (3), that, though the 
blood spirillum was never seen in the monkey without fever ensuing 
sooner or later, yet the pyrexia is secondary in time, and is susceptible 
of highly varied manifestations. Carter has now succeeded in cultivating 
the spirochsete outside the body. 
Dr. Koch, of Wollstein, at whose instigation we believe Carter made 
his experiments, has likewise succeeded in cultivating spirocheetes, pur- 
suing the same methods adopted by him with the bacillus anthracis of 
malignant pustule, and has also succeeded in inoculating monkeys 
with relapsing fever. One of these was killed during the active period of 
the disease, and the spirochsetes were found in the various organs and in 
the skin. This result has never been reached with the human body, and 
should be reaffirmed. 
Dr. Lewis, of Calcutta, who studied "spirillum fever" in India 
simultaneously with Dr. Carter, in his lately-published results, does not 
agree with the latter either in his observations or his conclusions. He 
regards the spirillum merely as a coincidence, and as no more essential to 
relapsing feverdhan is famine. 
Prof. F. Cohn, of Breslau, however, finds serious defects in Lewis* RELAPSING FEVER. 
31 
methods of microscopical research, which he thinks quite invalidate the 
conclusions arrived at, and he is unwilling to regard Lewis as an author- 
ity. The observations which are published which indicate a positive 
connection between the parasite and the disease are certainly far more 
convincing than any negative results we have seen. 
Holsti says relapsing fever was first recognized in Finland, in 1865, 
and was probably introduced from Russia. In 1866 it was accompanied 
by typhus. In 1867 it began to diminish in Russia, but this was a disas- 
trous year for Finland, on account of a total failure of crops. With fam- 
ine associated itself an outbreak of relapsing and typhus fevers, of such 
extent and severity that in 1868 about a third of the population was at- 
tacked by one or other of these maladies. In 1869-70 relapsing fever 
still existed in Helsingfors, but was milder and more rare, after the latter 
year disappearing altogether. At the beginning of August, 1876, it ap- 
peared in Helsingfors afresh at two quite distinct points simultaneously. 
It was impossible to trace its introduction from without. The epidemic 
developed rapidly, reached its culminating point in November and Decem- 
ber, and diminished slowly, so that the latter half of 1877 presented only 
a few sporadic cases. There were about 600 cases during this epidemic, 
and of these Holsti saw 437. The disease confined itself almost exclu- 
sively to the poorest classes, occupying dirty crowded dwellings. One 
collection of habitations occupied by the most wretched of the urban 
population furnished 146 cases of the disease out of 560 inhabitants. The 
general rate of mortality was large, 7.8$. In 20$ of the total there was 
but one febrile crisis, about the same proportion had two or three crises, 
occasionally there were four, five, and even six separate attacks; the first 
attack lasted as an average 6 days; the second, 3 to 6, and the third 
only 3 days. The average duration of the first intermission was 7.2 days, 
that of the second 8.4. 
The blood was examined for spirilla in forty cases, and the organism was 
always found. They appeared generally one or two days after the com- 
mencement of the fever, and disappeared shortly before its termination. 
They could not be found during the intermission. This writer states 
that they were most abundant during the first access of fever. He could 
not establish any correlation between the intensity of the attack and the 
abundance of the spirilla in the blood; nor could they be traced in other 
secretions of the body, as the saliva, sweat, or urine. He reports as little 
success in cutting short the attacks with salicylate of soda as do other 
experimenters. 
Dr. Enke's report of 136 cases which presented themselves in the 
Hospital at Magdeburg offers testimony of a positive character. He 
says spirilla were found in every case without exception, in some cases, 
indeed, only after persistent and repeated examinations. In a few in- 
stances where relapsing fever was suspected, it was only after as many as 
eight preparations of the blood were made that spirilla were found. 
Enke's conclusion is, that spirilla are to be regarded, not simply as an 
accompaniment, but as a cause of this disease. 32 
THE PLAGUE 
Dr. Riess took advantage of a mild epidemic of relapsing fever, which 
developed itself in Berlin early in 1879 and dragged on through the year, 
to investigate with all possible care the connection between spirochaete 
and the changes in temperature. His results are based upon 77 cases of 
undoubted relapsing fever, and emphasize somewhat the difficult nature 
of this inquiry, and the caution necessary in drawing conclusions. Riess 
regards his cases as typical relapsing fever, but acknowledges that in a 
considerable number there was a certain irregularity and indistinctness 
about the relapses. This may explain his results where they vary from 
those of others. He observed a striking want of congruity between the 
appearance of spirilla and elevations of temperature. 
The spirilla were seldom constant during the height of the relapse, 
one day spirilla were found and another day none. The length of time 
elapsing from the beginning of a relapse to the appearance of spirilla 
varied much; they appeared on an average from a half to one day later 
than the first rise in temperature; their behavior toward the close of the 
relapse was equally varied, occasionally not disappearing until some hours 
after' the crisis. Not unfrequently no spirilla at all could be found dur- 
ing an entire pyretic period; out of 96 pyretic periods they were absent 
36 times. Again in a few cases no spirilla could be found during any 
stage of the entire course of the disease. 
THE PLAGUE. 
BIBLIOGRAPHY. 
J. Netten Radcliffe: On the Prospect of a Reappearance of Plague in this 
■Country and on the Continent of Europe. Med. Times and Gazette, I., p. 83, 1876. 
-A. Hirsch: Was hat Europain der nachsten Zeit von der orientalischen Pest zu 
fiirchten? Deutsche Vierteljahrschrift f. offentl. Gesundh., VIII., S. 377, 1876. 
-The Same: What has Europe to Fear in the Future from Oriental Plague? 
London Practitioner, XIX.' p. 223, 1877.-Colvill: Plague in the Province of 
Bagdad, 1876-77. Rep. Med. Off. Local Gov. Bd., 1877, pp. 143-146, Lond., 1878. 
J. N. Radcliffe: Memorandum on the Progress of Levantine Plague in 1877 
and part of 1878, together with an Account of an Outbreak of the Bubonic 
Plague of India (Mahamari) in 1876-77. Rep. Med. Off. Local Gov. Bd., 1877, pp. 
139-157, London, 1878.-Castaldi: Plague in Resht, 1877. Rep. Med. Off. Local 
Gov. Bd., 1877, pp. 147-180, Lond., 1878.-Adler: Die Pest in Bagdad in den 
Jahren 1874-76. Allg. Wien. med. Ztg., XXIV., S. 32, 43, 55, etc., 1879.-Dopp- 
ner: The Plague in Russia. (Transl. of the first official medical report of the disease 
in Astrakhan). Lond. Lancet, I., pp. 173-175, 1879.-The Pest in Russland. 
Wien. med. Wochenschr., XXIX., S. 65, 1879.-A. Hirsch: Ueber die Beulenpest. 
Berliner klin. Wochenschr., XVI., S. 85,1879.-De Lesseps: Surles mesuresprises 
par 1'Intendance Sanitaire de Marseille, dans la Crainte de I'lnvasion par la Peste. 
Compt. rend. Acad. d. Sc., Paris, LXXXVIIL, 324-327, 1879.-J. N. Radcliffe: 
A Short Account of the Progress of the Plague from its Reappearance in 1853. 
Med. Times and Gaz., Lond., I., p. 251. 1879.-Virchow: Ueber die Pest. Berl. THE PLAGUE. 
33 
klin. Wochenschr., XVI., S. 117, 230, 1879.-Plague: Papers relating to the mod- 
ern History and recent Progress of Levantine Plague. Prepared from time to time 
by direction of the President of the Local Government Board, with other papers, 
etc. (Presented to both Houses of Parliament by command of her Majesty, 1879). 
London, 1879.-Hirsch: Mittheilungen uber die Pest-Epidemie im J. 1878-9 im 
Gouvernement Astrachan. Berl. klin. Wchnschr., XVI., 445, 465,1879.-Abstract 
of Lectures on the Plague Epidemic in the Year 1878-79 in Astrachan. Delivered 
before the Berlin Med. Soc. by Prof. Hirsch, Member of late Germ. Plag. Com. 
Lond. Med. Timesand Gaz., II., pp. 359, 416. 1819.-M. Sommerbrodt: Zur Symp- 
tomatologie der " Pest von Wetljanka." Berlin, klin. Wchnschr., XVL, S. 477. 
498, 1879.-Tholozan: Plague in the Caucasus; a Study in Sanitary Science, 
Lond. Practitioner, XXIII., 224, 1879.-Tholozan: Les trois Dernieres Epidemies 
de Peste du Caucase, chronologic, geographie, prophylaxie, Par., 1879. - The 
British Commissioners' Report on the Plague. Brit. Med. Jour., II., 515, 1879.- 
Ed. Dickson: Resume du Rapport sur la Peste de 1876-77 en Mesopotamie. Gaz. 
Med. d'Orient. Constantinople, XXII., p. 49, 1879.-J. C. Wise: Plague. Hyg. 
and M. Rep. U. S. Navy, IV., 777, Wash., 1879.-Petresco: Memoire sur 1'Epide- 
mie de Peste du Gouvernement d'Astrakhan. Bucharest, 1879.-Second Annual 
Report of the State Board of Health of the State of Connecticut. Hartford, 1880. 
-The Plague on the Volga: Reports of the German Medical Commission. Lon- 
don Lancet. I., p. 613, 1880.-Mittheilungen fiber die Pest-Epidemie im Winter 
1878-79 im russischen Gouvernement Astrachan. Berlin, 1880.-The Plague in 
Russia. Brit. Med. Jour., I., p. 91, 1880. 
The continued outbreak of epidemics of plague of greater or less 
magnitude at various points, some of them widely separated, since the 
one of 1871 in Persian Kurdistan, the last-mentioned in the American 
translation of v. Ziemssen's Cyclopaedia, have impressed still more strongly 
upon the medical world the fact that the plague is still an active disease, 
especially in the Ottoman and Persian dominions ; and the actual appear- 
ance of the disease in an epidemic form in south-eastern Russia has shown 
that the warning given by certain distinguished epidemiologists of a 
possible danger therefrom, under certain circumstances, to Europe itself 
was not uncalled for. In 1875, and again in 1876, Mr. Netten Radcliffe, 
in papers read before the "Society of Medical Officers of Health" in 
England, discussed the prospect of reappearance of plague in that coun- 
try and in Europe. In 1876, Prof. yl. Hirsch brought the same subject 
to the notice of the profession in Germany. 
We give a brief summary of the outbreaks of plague succeeding that 
in Persian Kurdistan in 1871, for which we are indebted largely to these 
two writers. The plague appeared in Kurdistan in the winter of 1870- 
71, in a mountainous part of a district which is said to have been free 
from the disease for forty years ; it continued throughout the greater 
part of 1871, and out of 7,000 people it was found to have affected at 
least 1,120, of whom 891 or 79.5$ died. The next outbreak of plague 
occurred two years later in the winter of 1873-74, when the disease 
reappeared in Mesopotamia, on the lower Euphrates in the same district 
attacked in 1867, but on the opposite side of the river. This outbreak 
was more severe than the preceding one ; the disease prevailed actively 
during the first six months of 1874, and it is estimated to have caused 
4,000 deaths among a population of 80,000, appearing afresh in the 34 
THE PLAGUE. 
winter of 1874-75, and lasting until the summer of that year. In all 
these countries, owing to the tendency to concealment to avoid isolation 
and quarantine, the number of cases and of deaths is more apt to be 
under- than overestimated. In March of 1874, plague broke out among 
the highlands of the Assyr district of Arabia, extending to within a short 
distance of Mecca. In April of this year it again declared itself among 
the nomadic tribes of the hilly district of Bengali in Tripoli. In 1876 
we find plague again devastating the Euphrates valley, during which 
year it is estimated that not less than 20,000 persons were killed by it 
in this district. It ravaged Bagdad during this and the following year, 
carrying oft more than 5,000 victims. Already in 1876 it had reached 
south-west Persia, later in this year appearing in north-western India, 
and about the same time in northern Persia, in the Province of Azcrbi- 
jan and in Astrabad, from which it extended in 1871 to the Province of 
Ghilan on the Caspian Sea, attacking especially the principal town 
Resht, which has an active commerce with Astrachan, at the mouth of 
the Volga; it had been utterly desolated by plague in 1830, having then 
a population of about 40,000. Before the close of the year 1877 the 
plague is estimated to have killed about 4,000 people in this town. Cases 
of the disease are said to have occurred during this year at several places 
on the Caspian littoral of Caucasia, and it is also said that a number of 
cases were reported to the medical department of the Russian govern- 
ment as occurring in south-western and north-eastern Russia; but in 
regard to this the information is not very definite. Quarantine against 
importation of plague from Persia was not established on the Russian 
coast until April, 1877. From July to September, 1877, about 150 cases 
were observed in the town of Astrachan and the surrounding places of a 
disease which showed a resemblance to a mild form of plague, or was 
actually considered as such. According to Hirsch, the disease manifested 
itself chiefly by swelling of the lymphatic glands, the tumors being seated 
for the most part in the submaxillary, and also in the axillary and ingui- 
nal glands. A febrile state of variable duration, lasting even fourteen 
days, preceded the swellings in some cases. These swellings varied much 
in size; often they resolved, sometimes they suppurated; but with the 
exception of only one case, where the tumor became septic, and death 
followed by pyaemia, all these cases terminated favorably. Only a few 
patients were confined to bed. In no instance whatever were persons 
coming in contact with these patients infected, a fact which was verified 
especially in the hospitals; the garrison of the town also escaped entirely. 
These cases were seen by Dr. Dbppner, the principal medical officer of 
the Cossack forces in the Province of Astrachan, and the description 
quoted corresponds with that given by him of the early cases in the subse- 
quent epidemic at Wetljanka, with that given by Dr. Cabiadis of the 
cases of glandular swellings free from fever which preceded the severe 
outbreaks of plague at Bagdad and Hillah in 1876-77, and also with the 
symptoms and course of a few sporadic cases observed in several parts of 
Russia in 1879, but especially by Prof. Botkin in St. Petersburg. These THE PLAGUE. 
35 
cases in St. Petersburg gave rise to much discussion and difference of 
opinion, but Prof. Botkin stoutly maintained that they were the result 
of a mild form of the plague poison, and in this view was supported by 
others. 
This mild type of plague-if such it was-which showed itself in the 
town of Astrachan in the summer of 1877, was followed in October of 1878 
by the appearance of a similar malady at Wetljanka, a small stanitza or 
Cossack village, situated on the right bank of the river Volga, about one 
hundred and fifty miles from Astrachan, the inhabitants of which are for 
the most part devoted to fishing. This mild form rapidly developed into 
a disease of a malignant and fatal character, exhibiting all the recognized 
features of the oriental bubonic plague. From its comparative proximity 
to the termination of an important line of railway, this outbreak attracted 
the attention and excited the interest, not only of Europe and England, 
but even of this country, and we shall, therefore, give a somewhat more 
detailed account of it. 
Whether the poison causing this outbreak had an autochthonous 
origin or was imported, and if imported, how, must remain undecided. 
The data on which to form an opinion are derived from the reports of 
Dr. Doppner, the surgeon-general of the district, and from those of the 
commissioners of the different European Governments appointed to serve 
as an International Commission for the investigation of the plague in 
Russia. It is not easy to reconcile the sometimes conflicting statements 
of these authorities; Prof. Hirsch and Dr. Doppner, for example, differ- 
ing as to the distance of Wetljanka from Astrachan by fifty-six versts or 
about thirty-seven miles. Dr. Doppner labored under the disadvantage 
of occupying an official position and having to justify a previous course 
of inaction; the commissioners, under that of arriving on the scene inde- 
pendently and after the termination of the epidemic. The commissioners, 
moreover, had to carry on their inquiries by means of interpreters. Dr. 
Colvill, of the British Commission, was disposed to adopt the theory of 
an " independent origin " of the epidemic-and his previous experience 
of the disease in the Euphrates Valley lends weight to his opinion- 
autochthonous in the sense of indigenous, not in that of de novo, as 
explained by his fellow-commissioner Dr. Payne. 
The most probable origin under the circumstances would seem to have 
been in importation, either from Astrachan or from some of the fortified 
towns, as Erzeroum, Kars, Bayazid, in eastern Asiatic Turkey which 
were besieged and sacked by the Cossack troops. The belief of the great 
majority of the Commissioners, including Prof. Hirsch, the head of the 
German Commission-a belief shared by the parish priest at Wetljanka, 
by the local authorities, and by Count Melikoff, sent as Governor-General 
of the Province-was that the poison was imported in packages of goods 
which reached Erzeroum or Kars from places in Persia or Mesopotamia, 
already infected, remained unpacked in the bazaars, and falling into the 
hands of Cossacks were sent by them as booty to Wetljanka. 
Prof. Hirsch mentions a very clear case of infection with plague by THE PLAGUE. 
36 
means of clothing brought in a box from a house where people had died 
of the disease to another house at a distance, which fell under his own 
observation. 
As far as its situation and sanitary conditions are concerned, Wetljanka 
seems in no respect to favor the prevalence of zymotic diseases any more 
than any of the other eighteen stanitzas of this district. The last time 
plague visited this village was in the year 1807-08; it -was then supposed 
to have been brought by pilgrims from Mecca; it spread along the Volga 
as far as Sarotov; there were but few cases, and the mortality was small, 
not above one hundred for the whole district. The following account of 
the epidemic of 1878-79 is in the main that of Prof. Hirsch. It began 
in October, spread from Wetljanka as a centre, to six or eight villages on 
both sides of the Volga, and was practically at an end by the first of 
February. 
The progress of its development in Wetljanka may be observed from 
the table, of mortality which is accurate up to the middle of December, 
at which time the parish priest, who kept the records, succumbed to the 
disease: 
Deaths. 
From Oct. 1 to Oct. 7 1 
" " 8 " 14 0 
" " 15 " 21 2 
" " 22 " 28 3 
" " 29 to Nov. 4 0 
" Nov. 5 " 11 1 
" " 12 " 18 7 
" " 19 " 25 8 
Deaths. 
From Nov. 26 to Dec. 2 7 
" Dec. 3 " 9 56 
" " 9 " 16 169 
" " 17 " 23 54 
" " 23 " 30 33 
" " 31 to Jan. 6 19 
" Jan. 7 " 14 12 
On the whole there were 373 deaths at Wetljanka during the whole 
period. By subtracting the average number of deaths that occur (accord- 
ing to an average of several years) from October till January in that place, 
viz., fourteen, there remained 359 deaths from plague; in other words, 
in a population of about 1,750 individuals, 20 per cent of the whole 
perished with the disease. It is very difficult to arrive at the number of 
cases that recovered. According to very barely trustworthy statements, 
this was said to have been 81. If those are added to the 359 deaths, we 
have a morbidity of 440-that is, 25.3 per cent cases of illness amongst 
the inhabitants, with 82 per cent deaths of the total number attacked. 
After Wetljanka, Prischib was first attacked with the disease. Here 
the number of deaths was 16, which occurred in five houses. Afterwards 
there was a small outbreak of the disease in Staritzkcje, where 7 individ- 
uals succumbed in one house. On the left bank two places had only a 
few cases, namely, Michailowka, where in one house 4 cases occurred 
with 3 deaths, and Udatschucie, where in one house 2 individuals died 
of plague. Selitroucie suffered the most severely; here in four houses 32 
individuals succumbed to the disease. It was said that in the steppe two 
plague-cadavers had been found, and that opposite to Wetljanka, in an 
island in the Volga, several mortal cases of plague had occurred amongst 
the inhabitants of Wetljanka who had fled there. It is impossible to THE PLAGUE. 
37 
make out whether those statements were well founded or not, but it 
might be not far from the truth if the total number of deaths from plague 
in the district were estimated at 450. 
About Dec. 18th a cordon was drawn around Wetljanka and toward 
the beginning of January a general cordon of five thousand soldiers 
around the whole infected district, with quarantine stations at the north- 
western and south-eastern extremities on both sides of the river. The 
quarantine arrangements are reported to have been very imperfect, and 
the speedy termination of the epidemic is not attributed especially to 
these dispositions. 
SYMPTOMATOLOGY. 
The various descriptions of plague which have been given by those 
having personal experience of it during its greater frequency within the 
last five years agree in most particulars with the account given by Lieber- 
meister in the first edition of v. Ziemsseris Cyclopaedia. It is greatly to 
be regretted that the Russian Government did not promptly avail itself 
of the favorable opportunities afforded by the epidemic at Resht and in 
the provinces of Astrachan to have the symptomatology and pathology of 
the disease carefully investigated by competent persons, whose services it 
could easily have commanded. No post-mortems were made during the 
Wetljanka epidemic. The following analytical statement of 1826 cases of 
plague noted by Dr. Giovanni Gabiadis, at Hillah, during the epidemic 
of 1876, is taken from an account of the characters of epidemic plague 
in Mesopotamia in 1876-77, prepared by Dr. Dickson, Physician to the 
British Embassy at Constantinople, from Dr. Gabiadis' notes. Dr. 
Gabiadis occupied an official position under the Persian Government 
and had every opportunity for observation. 
As a rule, an attack of plague lasts from a few hours to four weeks, and Dr. 
Cabiadis considers that one-third of the attacks end fatally. From the accom- 
panying table, however, 1,826 cases of plague seen and registered by him at Hil- 
lah, in 1876, the proportion of deaths to that of the attacks is 52.6 per cent. But 
a great many cases of plague, he observes, are never made known, and would 
thus diminish very considerably this percentage of its 'mortality; whilst the 
deaths, on the other hand, must all be reported in order to obtain the permit of 
interment. 
Analytical Statement of 1,826 Cases of Plague noted by Dr. Cabiadis, at 
Hillah, during the Epidemic of 1876. 
From 2 months to 9 years, ..... 277 
" 10 years " 19 " . . . . . 617 
" 20 " " 29 " . . . . . . 432 
" 30 " 39 " . . . . . 292 
" 40 " " 49 " . . . . . . 123 
" 50 " " 59 " 52 
" 60 " " 69 " 18 
" 70 " " 79 " . . ... . .11 
" 80 " " 89 " 3 
An old man of 113 ....... 1 
Total,.1,826 38 
THE PLAGUE. 
Sex: Male, 889: Female, 937; total, 1,826. 
Result: Recovered, 865; died, 961; total, 1,826, 
Manifestations:- 
Glandular swellings-in the groin, ..... 710 
" " axilla, . • • • • 466 
" " neck, ..... 98 
" " several places, .... 122 
1,396 
Carbuncles, ........ 36 
Dependent on the nervous centres 
Coma, ... 28 
Convulsive shake, . . 9 
Petechiae, . . . 120 
Epistaxis, . . .2 
Haemoptysis, . . 6 
Haematemesis, . . 27 
Sanguineous diarrhoea, . 14 
Menorrhagia, . . . 2 
" " circulating system 
" " assimilative organs 
Bilious vomiting, . . 32 
Bilious diarrhoea, . 16 
Jaundice, . . .2 
Dr. Cabiadis does not attempt to deny the contagious properties of 
plague, but the experience acquired by him during the outbreaks at Hil- 
lah (the ancient Babylon) and Bagdad has convinced him that no great 
risk is incurred in touching a person affected with the plague, provided 
exposure for any lengthened period to the atmosphere of the apartment 
occupied by him is avoided. He says that those persons who lived in the 
same house with a plague-smitten patient, but who avoided touching him 
or his clothes, through feast- of catching the infection, generally did get 
the plague; whilst those who lived in houses exempt from the malady, 
but who visited plague-patients and handled them freely, without remain- 
ing long in the same room with them, hardly ever caught the disease. 
ColvilTs description of the symptoms of plague, as observed by him on 
the lower Euphrates in 1875, agrees with that of Dr. Cabiadis in the 
main. Both of these observers mention the vomiting and spitting of 
blood, and hemorrhages from various surfaces as not unusual. This was 
doubtless the same disease which invaded Wetljanka, and in this respect 
these accounts agree with those of Dbppner, an eye-witness, and of 
Colvill of the epidemic at that town in 1878-79. Sommerbrodt, HirscJi's 
colleague on the German commission, says: It cannot be strictly denied 
that at a certain period of the epidemic pulmonary symptoms were 
prominent. Prof. Hirsclt's account of the symptoms in the Wetljanka 
epidemic differs somewhat from those mentioned, and we quote what he 
says: 
I do not intend to discuss at present the question whether, as some maintain, 
the epidemic plague known by the name of the " black death " and'the so-called 
"Indian plague" are identical with the Levantine bubonic plague; or whether 
they differ from each other, as I have assumed and still assume, by definite symp- 
toms which reveal an affection of the lungs. Perhaps at another time I may re- THE PLAGUE. 
39 
turn to that question; to-day I have only to say that the lung affection named 
had not the character of pneumonia, but of pneumorrhagia; and that in the course 
of the disease in the Astrachan epidemic no such complication either with pneu- 
monia or with bleeding from the lungs could be observed. In a few cases only 
slight bronchitis seems to have been observed as a complication. Moreover, I 
will not deny that cases of pneumonia occurred at the time of the epidemic; only 
I do not believe that they had anything in common with the plague. As in all 
former plague epidemics, there are three forms to be distinguished, according to 
the degree of development of the disease. The first form is slight, partly with- 
out fever, a sort of ambulatory plague; where without any other grave symptoms, 
a bubo was formed in the axillary, inguinal, or submaxillary glands, which soon 
suppurated or resolved, and where the whole process was terminated in that 
way. Cases of this form seem to have been more frequent, especially in the be- 
ginning and towards the end of the epidemic. Of those we saw ourselves a few, 
as I have just said. But, secondly, there was a series of cases of a graver charac- 
ter, where buboes were formed after an illness of several days, and where the 
whole organism was deeply affected. Most of the buboes in those cases became 
purulent, and recovery was only exceptional. A third series of cases was observed 
in the form of the so-called pestis siderans, where no localization of the morbid 
process in the lymphatic system was formed at all, or the buboes were so small 
that they escaped the attention of the surgeons and the friends of the patients. 
Those cases proved fatal without exception, in two or three days. 
Under the protection of Prof. Virchow, it may not be rash to express 
a regret that Hirsch should have introduced an apparently unnecessary 
element of confusion into the study of the disease. Plague is probably 
plague just as typhoid fever is typhoid fever all the world over. It is 
very evident from the accounts of the various epidemic outbreaks that 
soil and circumstances modify the plague poison and its manifestations 
as they do those of typhoid fever, so that some symptoms, and notably 
buboes and hemorrhages, vary in frequency and severity in different epi- 
demics and at different periods of the same. 
A frequent affection of the lungs hardly requires a different name, as 
" Indian plague," any more than we should now speak of " black death," 
because the hemorrhages in the skin were unusually large or confluent. 
The erection of the Pali plague, and the endemic disorder observed in a 
small district in the Himalayas near Nepaul, into a distinct disease under 
the name of Indian plague savors somewhat of the " Schreibtisch." 
According to Radcliffe, who follows Planck, Mahamari (the " great 
plague," a term also applied to cholera) and locally designated gola or 
phutkia (bubo)-the several terms being generally used in the sense of 
pestilence-seems to have been first noted in Cutch, in 1815, and during 
the six years 1815-1820 the disease prevailed in parts of Cutch, Katty- 
war, and Sindh. In 1823 the malady is reported to have appeared among 
the Himalayas, in the district of Garhwal, a district lying to the north of 
and contiguous to Kumaun. In 1834-5 it was prevalent in parts of 
Garhwal. In 1836 the disease broke out at Pali, in Marwar, Rajputana 
(whence the name Pali plague), and it subsequently prevailed in several 
parts of the Meywar and Marwar districts. From 1847 to 1853 Mahamari 
seems to have been present in a more or less active form in, or at least 
rarely absent from Kumaun, and in the last-named year the malady was 40 
THE PLAGUE. 
also observed in Rhilcund, the district lying immediately to the south 
of Kumaun. In 1859-60 the disease was again active in both Kumaun 
and Garhwal; also in 1870. From 1870 to the outbreak of 1876-7, in 
Kumaun, there does not appear to have been any record of an appear- 
ance of the disease. In 1876-77 forty-one of the hill villages in the 
mountainous district of Kumaun, on the southern slopes of the Hima- 
layas, suffered from this malady; in forty of these villages two hundred 
and ninety-one persons were attacked, of whom two hundred and sev- 
enty-seven died. Mr. C. Planck, the Sanitary Commissioner for the 
North-Western provinces and Oudh, inspected the infected district at 
the time of the prevalence of this outbreak, and has given a detailed 
account of the results of his inspection. He regards this disease as the 
same as the Pali plague at Rajputana and contiguous provinces to the 
westwards-so likewise does Hirsch-and, moreover, identifies it with 
oriental or Levantine bubonic plague. Planck says: The symptoms 
and character of this disease coincide very exactly with the description 
of plague, with the exception that the appearance of petechiae (purple 
spots) on the skin has not been noticed in the Kumaun form of the 
disease. No appearance of that nature could be seen on the skin of 
the sick persons examined, and no evidence of such appearance in any 
case could be obtained. He attributes this absence of visible petechiae 
to the fact that the people examined were all dark-skinned. For a more 
detailed description the reader is referred to p. 48 of " Papers Relating 
to the Modern History and Recent Progress of Levantine Plague, 
London, 1879." 
The most palpable and evident of all the causes which predispose an 
individual to an attack of plague during an epidemic Dr. Cabiadis con- 
siders to be poverty with its accompaniments. In his experience he found 
that the poor were seldom spared; the wealthy hardly ever attacked; in 
this respect presenting a contrast to cholera. 
TREATMENT. 
Recent epidemics have added nothing whatever to our knowledge 
upon this point; the treatment is purely expectant. 
Prophylaxis.-According to Cabiadis, the most effectual means for 
the protection of a community against the propagation of plague are the 
isolation of the sick, the destruction by fire of their clothes, and the 
whitewashing with lime and free ventilating of the domiciles in which 
cases of plague occur. The plague reappeared in only one out of three 
hundred and fifty houses which had been whitewashed after an outbreak 
of plague in them, whilst its reappearance in houses which merely had 
been abandoned for a time, after an attack of that disease, but which 
had not been whitewashed, was of frequent occurrence. The other disin- 
fectants tried, such as sulphur fumigations, lighting fires, and throwing 
a solution of sulphate of iron into the drains, gave no decided results, 
except when associated with the whitewashing and airing of the infected 
houses. THE PLAGUE. 
41 
v. Peltenkofer recommended sulphuric acid as a disinfectant, as he 
found it the most reliable means of destroying the bacteria of charbon. 
Virchow thinks dry heat would prove more reliable in disinfecting effects. 
All recent writers agree with Aubert (De la Peste on Typhus d'Orient, 
Paris, 1840) that civilization alone has destroyed plague in Europe, and 
it alone will annihilate the disease in the East. 
Quarantine and Cordons Sanitaires.-The late epidemic in the 
province of Astrachan is but little instructive in regard to the value of 
these measures, for the epidemic was already at an end when these steps 
were taken. Hirsch concludes his remarks upon the Astrachan outbreak 
as follows: 
The principal task of a public sanitary administration must lie, according to 
my conviction, in a strict supervision of the places which are menaced by the 
plague, and in a well arranged isolation of the first centres of the disease. If we 
should have learnt nothing more from that small plague-epidemic than to esti- 
mate sufficiently the value of such isolation of infected localities for avoiding 
further propagation, the victims have not fallen in vain. 
The value of quarantine must vary with the conditions under which 
it is applied. For countries like England and the United States, quaran- 
tine against plague would be unnecessary if not impracticable. There 
are other countries where quarantine might be desirable if a strict one 
were possible, which the exigencies and temptations of modern commerce 
render very doubtful. 
The rag-trade would be the most probable means by which plague 
might be introduced into the United States when prevalent in the Levant. 
New Haven is said to be the only port in this country that receives whole 
cargoes of rags, and these come for the most part from Egypt. After the 
outbreak at Wetljanka, measures were taken by the National Board of 
Health for the disinfection of cargoes from infected ports. The Connec- 
ticut State Board of Health, in its second annual report, states that re- 
ports from the paper manufactories in the State, where the bales of rags 
are unpacked, fail to show the communication of any other disease than 
small-pox by rags, and that by domestic rags in a few instances. 
A proper distinction is to be made between medical inspection, disin- 
fection, and cleansing as practised to-day and in this country, and the exer- 
cise of measures hitherto implied by the term quarantine, in regard to which 
we may quote the language of Mr. John Simon in his eighth annual re- 
port: A quarantine, which is ineffective, is a mere irrational derangement 
of commerce, and a quarantine, of a kind which insures success, is more 
easily imagined than realized. Only in proportion as a community lives 
apart from the great highways and emporia of commerce, or is ready and 
able to treat its commerce as a subordinate political interest, only in such 
proportion can quarantine be made effectual for protecting it. In pro- 
portion as these circumstances are reversed, it becomes impossible to 
reduce to practice the paper-plausibilities of quarantine. The conditions 
which have to be fulfilled are conditions of national seclusion, and the 
fulfilment of such conditions by England (or the United States) would 
involve fundamental changes in the most established habits of the country.