History and Geography

Woodward's concept was born of the frustrations of mid-nineteenth-century medicine, particularly in America.

1800-50

At the beginning of the nineteenth century, diagnosis was based almost entirely upon patient descriptions of their complaints - that is, the perceived func tional derangements that resulted in a consultation with the physician. The physicians placed these complaints in the context of their own experience and knowledge, made a diagnosis, and offered the patient their professional advice. Diseases were collections of symptoms appearing in known orders in particular locations; adjectives were frequently part of a diagnosis, providing further refinement to a relatively limited array of disease nouns. The most common disease was "fever," of which fever was the chief symptom. The symptom fever was essentially the subjective sensation of chill and heat and was related by the medical profession to a quickened pulse. Elevated body temperature was related to fever but was not objectively measured by most physicians until the last third of the nineteenth century. If there was an observed cause of the fever, particularly an inflammation, then the fever was symptomatic. Both pneumonia and erysipelas had symptomatic fevers associated with them. If there was not an observed cause of the fever, then the fever was essential - that is, a disease itself. The essential fevers were categorized by symptom variation, severity, location, pathological associations, and so forth.

The two main categories were periodic and continued fever, but they were also categorized by such terms as malignant, pernicious, epidemic, putrid, spotted, and bilious, based upon the understandings of the physician observing a particular case. Periodic fevers - intermittent and remittent fevers, which had a classic periodicity — were believed to be caused by the atmospheric contamination of vegetable decomposition associated with marshes and other well-recognized areas of periodic-fever endemicity. During the nineteenth century, this poison came to be called "malaria," and the fevers it caused were "malarial" fevers. The continued fevers were more variable: Some were of short duration and only an inconvenience to the patient, whereas others were long and grave of prognosis. Those continued fevers with coma or stupor and of severe aspect were frequently called typhus by the Anglo-American medical world of the late eighteenth century. The adjective "typhoid" was applied to fevers that were typhus-like but not true typhus.

During the first half of the nineteenth century, a group of research-oriented, urban hospital-based physicians began to define disease on the basis of the postmortem findings as correlated with the clinical course. This hospital-based medicine was most strongly associated with the hospitals and pathologists of Paris, particularly René Laennec, Jean Corvisart, and Pierre Louis. In Great Britain, the

Irish clinicians William Stokes and Robert Graves and the London hospital physicians Richard Bright, Thomas Addison, and Thomas Hodgkins were part of the same movement. This approach to medicine spread through the world but did not fully replace the purely clinical approach, particularly among those whose chief interests were in medical practice. In 1829 Louis described a specific fever with lesions of Peyer's patches of the small bowel and named it "typhoid" because he thought it was the disease British authorities of the previous generation had called "typhus." This is, of course, the disease known today as typhoid fever.

All of this nosographic confusion was reflected in the American medical literature. Daniel Drake, the great medical geographer of the interior valley of North America, wrote about the typhoid stage of autumnal fever, by which he probably meant what we might call pernicious malaria. Louis's American students brought his view of typhoid to America, and one of them, James Jackson, Jr., demonstrated that what was commonly called autumnal fever in New England was the same disease Louis called typhoid. Another student of Louis, William Gerhard of Philadelphia, proved that the disease his mentor had termed typhoid was distinct from the disease usually called autumnal fever in Philadelphia.

Based largely on his New England practice and experience, Elisha Bartlett described typhoid fever as the most common disease in the United States. By 1847, however, he realized that malarial fevers were the dominant concern of physicians in the South and Midwest, but not enough people learned of the revised opinion. Support for almost any interpretation could be found in the medical literature of the period.

1850s—1870s

In the 1850s, as the American South became increasingly isolated culturally, there arose a campaign for a distinctively southern medicine. In part, this desire reflected real geographic differences in disease, but in part it was a result of the increasingly strident southern nationalism that led to the Civil War. As a result of this campaign and the preexisting nosological confusion, there was, by 1860, a belief in a southern typhoid fever that was occasionally periodic and frequently cured by quinine therapy.

Etiologic theories of the mid-nineteenth century also contributed to the confusion. Urban diseases, like typhus and typhoid, were believed to be the result of the unsanitary conditions of life in the early industrial city. Crowding, a general lack of cleanli ness, and a combination of animal and human waste, gave rise to a distinct and unpleasant odor in the cities. Where the smell was worst was also frequently the area of greatest morbidity, and it was believed that there were animal miasmas that caused urban fevers, much like the marsh miasmas (malaria) that caused rural fevers. If the two causes were simultaneously present, a combined or composite disease state should be expected. In the camps of the Civil War, that is exactly what was experienced, and typhomalarial fever was the name officially sanctioned for the camp disease that was not obviously a malarial or typhoid fever.

During and immediately after the war, an era when disease theory was changing and the diagnostic precision of the profession was limited, physicians found the concept of typhomalarial fever to be very useful and flexible in diagnosis. There were, however, serious doubts on the part of leading medical theorists concerning the specific nature of typhomalarial fever. In the 1870s, these doubts increased, but so did the utilization of the diagnosis. By the late 1870s, the specificity, in pathological terms, of typhomalarial fever was an idea of the past, but the clinical reality remained, and the name seemed to explain the etiology of the symptom complexities so described.

For the same reasons physicians in other parts of the world began seriously to consider the American diagnosis in the 1870s. In the 1860s, British army surgeons stationed on Malta had identified a new disease originally called gastric remittent fever and later Malta fever. We know it today as brucellosis. In 1875 W. C. Maclean, professor of military medicine at the Army Medical School at Netley, suggested that Malta fever might be typhomalarial fever. James Donaldson, on the other hand, suggested the name "faeco-malarial fever" to reflect more accurately the current understanding of dual causes. By the 1870s, the special role of human fecal matter in the propagation of typhoid fever was becoming accepted in Great Britain, largely as a result of the work of Charles Murchison and William Budd. Similar new diseases reported by the British doctors in the Indian Medical Service and the Chinese Imperial Customs Medical Service were also considered as typhomalarial fever by some authorities.

The primary interest of these physicians was in disease prevention, and the name "typhomalarial" lent force to their campaign for cleanliness. J. Lane Notter explained:

The cause then of this disease is, I maintain, a preventable one. It essentially consists in defective drainage, in having to sleep in houses and breathe air impregnated with faecal organic vapours given off from saturated subsoil or filthy waterclosets, aided by climatic conditions which make enteric fever in Malta assume a malarial type, and which would, under similar conditions in England, simply produce typhoid fever.

1880s

In the 1880s the miasmatic etiologic speculations began to give way to the new germ theory of disease based in medical microbiology. Alphonse Laveran observed the malaria Plasmodium; Georg Gaflky isolated Salmonella typhi. David Bruce discovered an organism that caused Malta fever; he called it Micrococcus melitensis, but the genus was subsequently named Brucella. However, the germ theory and medical microbiology were not immediately accepted by all or even most practitioners. Debate on typho-malaria remained lively, particularly in the American medical literature. Leading physicians saw etiologic research and eventual etiologic definition of disease as the way to resolve the clinical difficulties, but microbiological techniques remained largely in the realm of experimental pathology, not yet overly useful to practitioners. The possibility of specific diseases similar to typhoid and malaria yet etiologically unique remained viable, but the profession was divided on how prevalent such diseases might be. Periodic typhoid and severe malaria were clinically real and needed names. Debate continued, but the terms were changing.

1890s-1900s

In the 1890s, progress in medical microbiology and the development of serum diagnostic tests for typhoid and Malta fevers made etiologic definitions of disease more useful to practitioners, and doubts increased about the utility of typhomalarial fever as a diagnosis.

When America mobilized volunteers for the war with Spain in 1898, the sanitation in the camps was very bad. Disease was widespread and Army Surgeon General George Miller Sternberg appointed a commission of experts composed of Walter Reed, Victor Vaughan, and E. O. Shakespeare to investigate. Using modern techniques - blood smear examinations and Fernand Widal's sérodiagnostic test - the commission proved that most of the cases diagnosed as typhomalarial fever were typhoid. Because the conditions, particularly in camps in the Deep South, approximated those under which Woodward had originally postulated the existence of typhomalarial fever, these results were particularly significant. By the early twentieth century, the diagnosis of typho-malarial fever was widely regarded as an admission of diagnostic failure, and slowly it vanished from the medical literature.

Dale Smith

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