Typhoid fever was among one of the most prevalent diseases in the 19th and early 20th centuries. Measuring its pervasiveness reveals its interspersed relationship with industrial and societal growth in the United States’ incipient era of immigration and industrialization. By the early 20th century, occurrences of typhoid fever decreased as public health measures were implemented in highly populated areas. This type of public regulation coupled with the bacteriological revolution, and the eventual discovery of the microorganism that causes typhoid, lead to a strictly scientific approach of treating the ailment. Comparing the experiences of two patients ailed by typhoid, one diagnosed in 1874 and the other diagnosed in 1918, treatment for the illness has had a discernable change, resulting from public health reform, bacteriological discovery, and shifts in medical thought and practice; these variables did not necessarily lead to a better understanding of treating the disease, but, rather, introduced another viewpoint to which the medical community became drawn.
John Brigram, a 30-year-old laborer originally from Italy, was admitted to the Pennsylvania hospital in 1918 on November 16th. He originally complained of fever and pain in the abdomen, emphasizing that he was never sick before, save for removal of some glands as an adolescent, until the present illnesses onset. Upon inspection, the patient was found to have edema, dyspnea, rosy spots on his skin, and a chronic cough. The patient’s provisional diagnosis was typhoid fever. Weeks before his admittance, the patient admitted to feeling chills, experiencing profuse sweats, and bowel constipation. His eighty-two-day-long stay at the hospital was marked with oscillating fevers, abdominal rigidity, especially above the spleen, increasingly jaundiced complexion, and consistent pain and weakness. Mr. Brigram died single with no progeny jaundiced and weak on February 16, 1919.
Phillip Bryers, a 24-year-old clerk originally from Philadelphia, was admitted to the Pennsylvania hospital in 1874 on May fourth. His history reveals that he was in good health until he had an attack of pneumonia. He recovered from this illness, but, shortly after, he was seized with a chilly sensation and pains in his limbs. After, he had diarrhea set in accompanied by fever, headache, and epistaxis. He was diagnosed with typhoid fever. Upon the patient’s admittance, he appeared very weak and complained of great thirst. His seventeen-day-long stay was dominated by feelings of weakness, cycles of fevers, and bouts of diarrhea, all of which seemed to diminish as his stay progressed. In fact, his last days in the hospital were marked by rapid improvement and upward mobility characteristically similar to that of a healthy man. Mr. Bryers was cured after 17 days.
In the mid to late 19th century, the United States experienced an urban rush, wherein populations from the country moved to the city. This phenomenon coupled with an era of immigration lead to overcrowding in these hosts cities. What followed was a plethora of sanitary problems, exacerbated by the fact that no formal water/sewer sanitation systems existed, leading to disease outbreaks, the likes of which could be easily contained by the implementation of such symptoms. In the case of typhoid, “death rates in America were six times as high, and the American public health community began a crusade against the disease in 1912…. Hopes for greater control of the disease focused on sewers and drinking water supplies [as well as] the supervision of food-related pathways of infection.” Being cognizant of this fact consequently resulted in a change of the ways in which treatment was carried out in most modern hospitals. Take, for example, the cases of Phillip Bryers and John Brigram. The only mention of food or water intake in the former’s case is when detailing his thirst. In fact, no record of his dietary or gestational activity were noted in his patient chart. John Brigram’s chart, on the other hand, had detailed sections on his diet, mainly consisting of complex carbohydrates and digestible proteins, such as rice, pudding, eggs, and a so-called “typhoid diet,” which consists of food that are “agreeable” or compatible with the illness’s gastrointestinal symptoms. Interestingly, the chart also notes the state of his hunger and his peristaltic activity, both of which indicate appetite and, thus, a regression towards normal conditions.
The change in caretaking between the two patients mirrors the public health policy reform that was occurring at the same time in the United States––it’s an inescapable fact that medicine and society shape one another. At the offset of the 20th century, shortly after the discovery of the microbe that leads to typhoid fever, the death rate of the disease in American cities was growing compared to its European counterparts who were enjoying a steep decline in mortality: “In addressing the question of how to tackle typhoid, the emphasis of these American studies was firmly on physician responsibility and public education.” This impressed upon the public a need to prevent and to teach the spread of the disease. At this point and time, there were no rules or regulation stipulating the length of hospital stays for patients with typhoid. It was the hospital and physician’s responsibility to decide when the patient was no longer a carrier, often leading to short, inadequate confinement. The public health reform that ensued this call to action made a noticeable change in patient isolation, as evidenced by the length of stay of the two aforementioned patients. John Brigham’s stay at the hospital was almost five times as long as his counterpart. What’s more, during his stay, it was noted several times, near the beginning of his hospitalization, that his condition was improving. This was not, however, sufficient enough evidence to grant him a discharge. Instead, the staff on hand knew to keep him for longer observation, as his disease made him a carrier. Unfortunately, they were correct to do so, as his condition started to deteriorate; his release would have endangered the lives of those around him, and, as a laborer who worked at a company with a high population of workers, he would have spread his illness to those around him.
While the public health initiative that took place in the early 20th century made physicians and hospital staff more careful when treating patients of typhoid, how did they know, for instance, to keep John Brigham in the hospital as long as they did? The answer reveals its origins in the bacteriological revolution. This era of scientific discovery revealed the microbiological cause of typhoid, introducing an era of laboratory procedures and tests that corroborated the presence of typhoid even when the symptoms weren’t active. Before such discoveries, the main symptoms doctors witnessed in typhoid-ridden patients was a high fever. In fact, the main symptom charted in Phillip Bryer’s medical records was his body temperature. In contrast, John Brigam’s chart featured urine tests, blood tests, temperature charts, albumin indicators, and a series of microscopic examinations capable of measuring urates and phosphates. Interestingly, what accompanied these exams were objective physician observations rather than subjective patient testimony. Indeed, in Phillip Bryer’s chart, although shorter in nature, patient testimony was considered more than in Brigam’s. In a sense, these new diagnostic tools “worked in their capacity to inspire the medical man with self-confidence and his patients with parallel faith in their administration. Ultimately, of course, they were to help provide an increasingly substantive understanding of the biological mechanisms that underlie disease.” The entry of new diagnostic measurements as a result of the understanding of the mechanisms of typhoid unfold a dichotomy in the transition of therapeutic medicine: medicine treating the individual symptoms themselves or medicine eradicating the causal effect (most often some form of a pathogen) of the disease.
Prior to 19th century medicine, physicians viewed the body as a result of its internal systems and workings, one in which equilibrium of said systems reaped the best health. In order to combat disease, they thought, the body would have to be treated in such a way to reach this desired balance. In order to do this, physicians employed medication and treatments that entreated the entire body, basing most of its efficacy from the principle of opposites as set forth by Hippocrates in early Greek medicine. The late 19th and early 20th century saw a gradual change from this form of therapeutics to one in which “physicians began to turn away from a primary concern with systemic balance to instead break down the body into more discrete units and systems each of whose functioning could then be assessed and therapeutically addressed.” Disillusionment with the treatment for typhoid reached a turning around “1850 [when] medicine’s experience with typhoid had demonstrated the ineffectiveness of traditional methods of treatment for the disease.” With developments in physiology in tow, accompanied by animal heat studies, febrile symptoms came under close scrutiny in the second half of the 19th century, as the pathological symptoms that accompanied such temperature rises were profound. For instance, Phillip Bryer’s doctors were seemingly concerned with only his temperature and how to revert it, keeping track only of his temperature on a daily basis and administering IV fluids daily in order to bring him back to his ambient body temperature. Additionally, his physicians used morphia to alleviate the pain accompanied by typhoid. The biological basis of drug treatments was not yet realized, instead “drugs had to be seen as adjusting the body’s internal equilibrium; in addition, drug’s action had, if possible, to alter these visible products of the body’s otherwise inscrutable internal state.” Indeed, it may seem odd that medicines such as these were categorized based on physiological effect, in the aforementioned case pain-mitigation and temperature-reduction, rather than disease-specific treatment, typhoid itself.
Up until the late 19th century, uncovering the cause of disease seemed like an impossible mission; it was enough to just treat the symptoms of the disease and attempt to return a person to their natural state. The bacteriological evolution instilled new hope for disease prevention as “the germ theory underlined and explained the unity of disease patterns already demonstrated by generations and physicians and clinicians.” This knew knowledge lead to increased public confidence and expectations. The emphasis on laboratory medicine and clinical treatments were more than just a way in which confidence was earned, although it was a by-product, it illuminated the causes of diseases that were previously unknown. It gave physicians a new target to strike: “by the 1920s, the typhoid cases that had proved to be so labor-intensive in the 19th century had ceased to be a significant element in hospital administrations. A combination of progress in civil engineering, allied with bacteriological and serological screening along with the establishment of isolation procedures, had worked to decrease typhoid incidence.” This fact is ever present in the case of John Brigam. His chart is filled with serological tests that measure the presence of certain tracers for typhoid, including albumin in urine and leukocyte (white blood cell) levels. The most important, and perhaps astonishing, difference between the two cases is the usage the routine typhoid vaccine along with the usage of calcium lactate (pain) and salicylic acid (temperature-reduction) in John Brigam’s treatment. The typhoid vaccine was developed, although it was not perfect, as a result of studying the microorganism itself, an innovation only made possible by the preceding bacteriological revolution. It is important to note that physicians still used treatments targeted towards specific symptoms in accordance with the vaccines; these innovations sealed the dichotomy of the preceding century, joining the two methods together to form a more effective treatment.
For decades, scientists and physicians identified typhoid as a form of high fever linked to desolate living conditions with no clear-cut solution. To the common physician, the fix was simple: anti-febrile medication and pain suppressants. Unbeknownst to them, the bacteriological revolution that began at the 19th century witnessed the discovery of the typhoid microorganism, as epidemiologists finally unearth a more corporeal causative agent of the disease. What ensued in the 20th century was a national outcry for public health reform. Scientific research was paired with public health campaigns in order to increase awareness in the community as well as in health care systems, with medical administrators implored to pay closer attention to isolation time and carrier potential. This type of reform, both bacteriological and social, lead to reduced incidence of typhoid fever in the United States. While the overall incidence of typhoid diminished in early 20th century as a result of the aforementioned changes, the two patients tracked had two counterintuitive results. While the former patient, Phillip Bryers was cured, John Brigam died. This is not to say that the treatments utilized in the 19th century were superior, but, conversely, it is not to say that the treatments utilized in the 19th century were inferior. In fact, much of the treatments employed in the 19th century lead to successful recoveries, but there were variables, such as population density increases as a result of the industrial revolution, microbiological discovery, and medical reform that increased the chances of survival in the late 19th and early 20th century. The progression of medical practice and treatment does not rely solely on the abandonment of old techniques and knowledge, but, rather, builds upon existing knowledge and applies it to new discoveries.