IS THERE A "TYPHO-MALARIAL FEVER?”

SAMUEL H. CHARLTON, M. D., SEYMOUR.

Twenty-five years ago Dr. J. J. Woodward, assistant surgeon in the regular army, met with what he considered at that time a new form of fever amongst the federal soldiers on the Chickahominy river, to which he gave the name of "Typho-Malrial," after a careful study of the disease. The name typho-malarial fever implies a mixed form of fever that is caused by the action of malaria and the special cause of typhoid fever, and, notwithstanding there has been considerable controversy over this term, it has met with sufficient favor to give it a place in the classification of fevers. This type of fever has become quite prevalent in the western and southwestern States during the fall and early winter months, and it certainly has many of the elements we find in typhoid fever combined with those of remittent fever. By some of our physicians it is called typhoid and by others typho-malarial; and the sooner we can agree as to whether it is a mixed form of fever or not, the better for us, as well as our patients. This discrepancy of opinion amongst medical men demands a more thorough study of this particular form of fever, as to its cause, symptoms and pathology. Frequent post-mortems should be made in fatal cases, without which it will be impossible to determine the correctness of our diagnosis, or understand the pathological changes that led to a fatal termination. Having admitted the name typho-malarial fever into our nosology and thereby recognized the theory that it is a hybrid fever, resulting from the causes of malarial fever and typhoid fever combined, and as stated by the Section of Medicine of the International Medical Congress, in 1876, at Philadelphia, it devolves

upon us, as medical men, to establish the theory that these two factors cause this disease, if it be possible to do so. While thus engaged we may find good reasons for accepting the views of Dr. Loomis in his lectures on fevers, in which he claims that this fever is produced by the combined action of a septic and malarial poison.

Under the head of etiology he says: 66 It is difficult to determine the true etiology of typho-malarial fever. That malarial poison is necessary for its development there can be no question. It is equally certain that some other poison besides malaria is in operation whenever this fever prevails. That this poison is not the specific poison of typhoid fever is apparent from the fact that its development and spread, as far as can be determined, is in no way connected with the excrements of one suffering from this fever.”

Believing as I do that what we call typho-malarial fever is not a new disease, and that it always results from the same exciting causes, malaria and septic poison, in all countries, and that it was called by other names, as bilious-typhoid, miasmatic typhoid, remitto-typhoid, swamp fever, etc., and that to our own lamented countryman, Dr. J. J. Woodward, we are indebted for the light he has given us in regard to the etiology and pathology of this disease, so that his name and typho-malarial will be treasured in medical history and endure so long as medical men may inhabit the earth, all febrile disease, of whatever name it may be called, may be said to depend upon some morbific agent or agents, resulting from the decomposition of animal or vegetable matter, or from the excretions of diseased persons. These poisons may be found in the air we breathe, the liquids we drink, or in the food we eat, and when taken into our systems in sufficient quantity become the cause of fevers of various kinds. These morbific agents are capable of producing changes in the blood itself directly, and through its circulation may affect the whole organism. Each of these different fevers is characterized by symptoms peculiar to its own type, and yet each exemplifies the different varieties of infection which cause it. "Large cities furnish a much larger amount of decaying organic matter fitted for the developement of the zymotic and septic varieties of disease, while in the country districts, decaying material is principally vegetable and is the cause of malarial disease, but never

the cause of specific infectious disease; but when the spores of septic disease are introduced into the system already under the influence of malaria, they as certainly produce the phenomena of typho-malarial fever, as the pathogenic spores of the various infectious diseases will produce their special disorders, or the specific poison of typhoid fever will produce that disease."

This statement, however, can only be true in degree proportioned to the power of resistance of each individual in neutralizing its effect on his system. Accepting this view in relation to septic poisons we can readily understand why impure water containing septic matter may develope typho-malarial fever, as was the case in the city of Evansville five years ago this summer. In a letter from Dr. A. M. Owen, of Evansville, detailing some of the principal conditions present during the prevalence of the epidemic The says that Evansville contained a population of about 40,000 at that time, that the water supply was obtained by a system of water works from the Ohio river at a point above its sewerage and from private cisterns and wells. In consequence of a severe drought which necessitated repairs, the works were stopped and a temporary supply was obtained by a pump placed in the river some distance below the works, and also below the outlet of two of the principal sewers of the city. This occurred during a period of prolonged drought in which the supply of cistern water became exhausted and they were refilled with river water thus obtained. Soon afterwards, about the first of July, an outbreak of typho-malarial fever commenced and continued until September, when it began to subside, that not less-than five hundred cases occurred within the city limits. This epidemic was attributable to impure water supplied from the river, and to the filthy condition of the sewers. This epidemic clearly illustrates that typho-malarial fever may originate from contaminated water, as will also typhoid fever, when water is contaminated with its own specific poison. Five years ago, Minneapolis, having a population of 75,000, had an epidemic of typhoid fever, during which they reported six hundred cases at one time, all resulting from contaminated drinking water on account of imperfect sewerage. Epidemics of this kind have occurred in various other places resulting from similar causes within the last few years.

In southern Indiana, typho-malarial fever generally prevails from July until the end of the year. In the city of Seymour, with a population of 5,000, in 1881, we had over one hundred cases, and a larger per cent. of deaths than at any other time, many of the cases being of the septic type of the disease. In 1884 we had about the same number of cases with comparatively few deaths, as the larger per cent. of the cases were of the malarial type. The history of this fever can never be written until medical men agree whether it is a new type of fever or not, and, if not a new type of fever, that it has prevailed at all times and in all places where the causes have existed, but that it has been called by some other

name.

Dr. Flint says in typho-malarial fever the symptoms distinctive of typhoid fever are intermingled with those of periodical fever. The symptoms referred to are those connected with the abdominal lesions of typhoid fever, namely, diarrhoea, tympanitis. and iliac tenderness. The symptoms become more or less marked during the second week of the career of the disease. The characteristic eruption of typhoid fever may be observed. The ataxic symptoms, belonging to the typhoid state, namely, low delirium, deafness, subsultus tendinum, etc., occur more frequently earlier and are more marked than in connection with simple remittent. Enlargement and suppuration of one or both parotids are sometimes observed in cases of typho-malarial fever.

This form of fever is preceded by a forming stage longer than in simple remittent. The duration of the febrile career is longer and the gravity of the disease is greater. Perforation of the intestine is liable to occur. Bronchitis is a common complication and pneumonitis is developed oftener than in simple remittent fever. Convalescence is apt to be protracted in cases of typhomalarial fever. In different cases of the latter the phenomona of typhoid fever and of periodical fever are intermingled in varying proportions. In some cases the periodical fever and in other cases the typhoid phenomena preponderate. Cases will approximate on the one hand to simple remittent; on the other, to typhoid fever. Cases of typho-malarial occur in most, if not all, malarial regions. This fact shows that the special cause of typhoid fever is not held in abeyance by the prevalence of malaria and produced only after

the latter disappears.

In speaking of the etiology of typhomalarial fever he says: "That it is caused by the combined. action of malaria and the special cause of typhoid fever; and' when practitioners say that remittent fever is converted into typhoid fever, that the mode of expression is not accurate, as there is not a metamorphosis of the one disease into the other, but a combination of both diseases, the phenomena of the one or the other disease predominating in different cases." I make this quotation from Dr. Flint, than whom there is no higher authority in this country, to remind you that learned men in the medical pro-fession will sometimes differ in regard to the causes of disease, although I believe many physicians accept his views on this subject.

Dr. Loomis includes typho-malarial fever in the list of malarial fevers but claims it is produced by the combined action of malaria and septic poison, thus showing a discrepancy between these authors. Before determining which of the distinguished authors is correct in regard to the cause of this disease more evidence must be required. The medical history of ancient and modern wars goes to show that camp fevers were quite prevalent, especially in malarious districts, in over crowded camps with imperfect sewerage and other conditions favorable to the development of septic poison. In all large cities where malarial diseases are comraon septic poison may be found in sewer gases or in contaminated water, and there is no question but contaminated water is an important factor in the production of this fever in many of our smaller cities and towns.

In the town of Seymour, during the prevalence of this fever, we ascertained that impure water was one of the factors in producing this fever, and in all such cases the septic type of the disease predominated and most of the cases were of this type in the fall of 1881. In looking over the records I kept at that time I 'find we had almost every variety of the disease, ranging from the mildest malarial type to the severest form of the septic type, and in cases of the septic type we had excessive diarrhoea or dysentery in quite a number of the cases. Hemorrhage from the bowels, high temperature, ranging from 104° F. to 105° F. Delirium, subsultus tendinum, tympanites, abdominal tenderness, nervous pros