Report on the Typhus Epidemic in Upper Silesia

CLASSICS IN SOCIAL MEDICINE Report on the Typhus Epidemic in Upper Silesia

Rudolf Virchow (Archiv. für Patholog. Anatomie u. Physiologie u. für klin. Medicin, 1848, Vol. II, Nos. 1 and 2)

CHAPTER 3. THE DISEASE showed excellent agreement in the different

patients. Nevertheless, it is possible that, even A. SYMPTOMS so, my presentation of the facts might be The following communication relies to a incomplete in some points. This I fear mainly because my observations were made at a large extent on my own findings. These I relatively favorable season and because the obtained in part by observations made at the course of the disease might have been less military hospital in Sohrau, which is under the benign a little before or after. Correction of such direction of Dr. Sobeczko, a man as well versed points also must be left to other observers. as he is experienced, and in part by visits to In the normal course of the disease I believe patients in Rybnik, Sohrau, Pless, Ratibor, it convenient to discern four stages: a prodromal Loslau, Lonkau, Radlin, Geikowitz and Smollna. stage of early symptoms, one of peak The primary basis for this report, as well as for manifestation, one in which the disease abates, later control, was the information furnished by and lastly the stage of convalescence. the local physicians and by those foreign The symptoms, even the existence, of the physicians who had been residing in the area for first stage could only very rarely be recognized some time. Whenever my remarks are based among the rural population, as most of the solely on such information furnished, I shall members of that "class of society" pay too little expressly point it out. The great number of attention to slight symptoms to be able to give patients occurring in a relatively small area any information about them. A few, however, allowed me to form a general view of the stated definitely that they had felt unwell and different stages of the disease in a short time, so weak, had had pain in the joints, chills, that by combining the conditions observed in headaches, nausea, etc., before the disease had different individuals, a picture of the course of broken out. This prodromal stage was more the disease could soon be constructed. I have clearly apparent among foreigners, in particular later attempted to confirm the accuracy of this among the physicians who fell ill under endemic picture by sustained observation of individual influences. Dr. Beifel first felt so unwell on the cases at the military hospital. Results were 27th of February that he took the emetic he was further consolidated by the fact that the commonly prescribing at the beginning of the symptoms as well as the course of the disease disease; he then recovered to the extent that he resumed visiting his patients; on the 5th of Originally published in Archiv. für Patholog. Anatomie March, however, the disease reappeared so u. Physiologie u. für klin. Medicin, 1848. This English pronouncedly that he had to return to Breslau. translation is from Volume 1 of Virchow, Rudolf, Collected Essays in Public Health and Epidemiology, Prof. Kuh, whose definitely ascertained illness edited and with a foreword by L. J. Rather, published seems to date from the 19th of February, had in1985 by Watson Publishing International, Sagamore symptoms before that date which he himself had Beach, MA. Watson Publishing International retains considered to be due to catarrhal rheumatic sole copyright to this translation which it has kindly given us to reprint. All endnotes are from the original fever. In others, the symptoms between the translation inception of the disease and the appearance of

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clearcut manifestations were so indefinite that that information pointing to such later dates are all were deceived with regard to them. Prince doubtful. The majority of patients of all social Biron of Courland had a violent headache after a strata reckoned the start of their illness from the restless night on the 24th of February and felt so moment when it had reached so high a pitch that unwell that his personal physician, Dr. Altmann, they had to take to bed. From the cases urged him to return to Breslau. However, these mentioned it is plain that the disease might have symptoms receded, so that on the next day he already been present for at least 14 days, even continued to Pless. I there saw him on the 27th, though its manifestations were so mild and at a meeting of the local committee, most active vague that no physician was in a position to on behalf of the sick, showing the eagerness and assert its presence with certainty. circumspection which made his presence in the After the prodromal stage, the duration and districts so uncommonly beneficial. Later, at symptoms of which do not seem to be constant, dinner, he ate with a good appetite and has persisted for some time, there begins the conversed in a most lively fashion. The next second stage of the disease, which usually morning he returned to Breslau, where he busied reaches its peak very rapidly. In analogy to older himself in the interests of the Upper Silesians. authors it could be designated as the When I came to Breslau on the 9th of March, I inflammatory stage, because it presents a already found him on his sickbed, which a few number of symptoms of exaltation. However, days later was to become his deathbed. My the mainly depressive character of the affection, friend, Dr. von Frantzius, while returning from which will soon come to the fore, is also Vienna to Berlin, visited me in Pless and simultaneously apparent. The beginning of this accompanied me to Sohrau. There on the 5th of stage is frequently marked by the occurrence of March he complained for the first time of feeling chills and shivers, which the patients describe as indisposed. After a restless night he got up with similar to those of the ague, which they know so a headache and sore limbs; he had a slight fever well. Their duration is not constant; sometimes and a fit of shivering, with a dry, hot skin. these attacks lasted for 1-2 hours and were then Towards noon he had an exceedingly abundant followed by fever without sweating, or they outbreak of perspiration, which greatly relieved lasted for a short time only and were repeated him. During the following days he was quite after a few hours, or after a day or two. A few well; his appetite was even very good; he only patients mentioned only a slight feeling of felt somewhat tired; sometimes he complained chilliness lasting for a while; others denied any of slight pains in the limbs and he was rather feelings of chill whatsoever. quiet and listless. On the 10th, together with me, From then onward the rise of the skin he arrived in Berlin pursuing his business in a temperature was permanent. In general, the skin sober-minded way; he helped in building the was dry and the heat very soon became burning barricades on the 18th. The malady first struck (calor mordax), and that to a higher degree than with greater intensity on the evening of the 21st. I have ever seen in other diseases. When I It is easily understandable that such light placed my fingertips on the forearm of a patient and transient symptoms followed by almost for half a minute to count his pulse, a complete relief from all discomfort are not noted disagreeable prickling sensation sometimes by the great majority of patients and that there is persisted for as long as 10-15 minutes. It lasted a tendency to post-date the invasion of the longest in the lobes of my ears when I once disease to a much later time than the facts of the auscultated a patient by placing my bare ear case would warrant. I am drawing special against his back. Sometimes the skin was attention to this point in particular, as I shall covered with a slight sweat, which was not have to repeatedly come back to it so as to prove always sticky, but in that case the stinging

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sensation of the calor mordax became even belonged among the peculiarities of the disease. more repellent. Skin turgor was then always But it soon appeared that this pain occurred only increased, the face usually reddened, and the in the muscles, and that its apparently greater eyes somewhat injected and shining. intensity in the places mentioned only stemmed The intensity of the fever, inasmuch as it from their being more thoroughly examined. was directly apparent from the circulatory Enlargement of the spleen, sometimes very system, differed according to the nutritional extensive, was frequently diagnosed by condition of the individual. In strong and well- palpitation and percussion; however, all these fed people the fever exhibited a somewhat patients had previously suffered from malaria, inflammatory character during the first days. which they had treated themselves. In those who The contractions of the heart were frequent and had remained free from intermittent fever, there energetic; counts of 96, 100, 104 and more was no tumor of the spleen. rather large and full beats were soon reached; A moderate bronchial catarrh with a the tension of the arterial walls, however, was frequent urge to cough was almost universal rarely strong enough to offer a noticeable during this period; the cough was tormenting, resistance to the pressure of the fingers. In some producing a somewhat viscous, frothy, glossy patients the number of contractions of the heart mucus that was sometimes mixed with a little barely reached the number quoted in the first blood and sometimes a little painful. The days. In all undernourished persons the character respiratory movements were slightly increased, of the pulse differed, the artery was easily the respiratory sounds were accompanied by compressible, the impulse of the blood wave whizzes and whistles. I have practically never was weak, the number of heart beats was seen the common cold in the nose, but I did see frequently 110-120 per minute. catarrh of the conjunctiva of a moderate degree. At the same time the movements of the The prostration of the patients was extreme. intestine were slowed, defecation was rare; if it Not that they would have been unable to move, occurred, the feces were formed and hard. to stand up or even to walk, but they felt so During this period the urine was reduced in fatigued and exhausted that they usually were quantity, acidic, clear, dark yellow and grainy. apathetically lying on their backs. It therefore The tongue was moist, the finer papillae bore a was not an actual, true weakness, but rather a whitish epidermoid coat, while the coarser feeling of weakness, an inhibition of the papillae (papillae fungiformes) frequently were stimulation for movement; not the muscles per yet visible between them as red bodies, so that se or the conductive apparatus of the stream of the surface of the tongue presented a piebald, stimuli (nervous system) must be considered as spotted appearance. The patients felt relatively being affected, but the excitatory centers little thirst; their appetite was moderate, directed (ganglionic nodes). At the same time many to sour dishes. In rare cases the tongue was patients suffered from so-called 'muscular pains.' heavily coated, sticky to the touch, whitish or These were most frequently located in the yellowish, and the appetite gone completely, muscles of the lower extremities, the soles of the with nausea, and a tendency to vomiting or to feet, the legs and also the thigh; not diarrhea. The abdomen was always soft, usually uncommonly pain was felt in the trunk, full, but not swollen; greater accumulation of especially in the abdominal and dorsal muscles; gases and flatulence were not common. I could I saw it rarely in the upper extremities. not find any particular tenderness in any Sometimes it was exceedingly severe, tearing or particular part of the body as a constant pulling in nature, or involving a state of tension symptom. At first I thought that pain in the and increasing upon external pressure and on hypochondrium, especially on the right side, movement. The effect of exhaustion combined

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with the pain in the pharyngeal muscle was indeed it is not the brain alone that is affected peculiar: the patients usually said they could not but also the spinal and sympathetic apparatus. swallow, and when they were prompted to do so Usually after a severe shivering fit we meet with they complained of pain. But at most a moderate the peculiar burning heat of the skin, which even venous hyperaemia was present in the mucous if we cannot trace it with certainty in the nervous membranes of the pharynx and throat. system, never occurs without simultaneous As regards central nervous manifestations, significant changes of such a nature. At the same they were insignificant during that stage. Few time we have a most important excitatory patients complained of headache or dazedness. inhibition (i.e. probably changes in the All were well able to describe their condition, ganglionic nodes), characterized by a great reasonable, and in accordance with their national weariness of the limbs and a reduction in the character even able to do so in a lively manner. peristaltic movement, in secretion, etc.; The majority, however, were restless, increased stimulation is only found in the nerves particularly at night, and talking to themselves of the blood vessels and the muscles. The second all along in a low voice. Almost all of them, and significant group of symptoms is represented by this was one of the most constant symptoms, the catarrhal inflammation of the mucous complained, from the start, of buzzing and membranes, especially those coating the whizzing (huczy) in the ears, which they respiratory tract. compared with the sound of flowing, foaming, On the 3rd and 4th day, sometimes a little water. Later, when the sensation intensified, later, a new change used to appear, namely, which usually was the case, they described it as exanthema of the skin. Since special importance a knocking, like the clatter of a mill wheel. To has been attached to this symptom, we must deal the extent that these subjective manifestations with it in some detail. The exanthema intensified, the power of hearing diminished and preferentially appeared in the two forms that the majority became acutely hard of hearing. It have been known for a long time in the history does not seem likely to me that the cause of of typhous diseases. these manifestations would lie in an affection of The first form is usually designated as the nervous system or in the nerves themselves; measles-like (exanthema morbilliforme; rubeo- the course of development of this deafness, lous eruption). It forms spots averaging 2-3 lines combined with the complete lack of affection of in diameter, but also smaller ones, which are the other sense organs as well as of the head, mostly flat, rarely a little raised, of a pale bluish- rather speak in favor of a catarrh of the mucous red color, fading away at their borders; they membranes, which, analogous to the catarrh of disappear completely on pressure by the finger, the aerial ducts in the respiratory tract, extends and reappear very rapidly when pressure is from the pharynx to the Eustachian tubes and the released; they do not start solely or primarily tympanic cavity. (Compare Pappenheim, in the from the vascular system of the hair follicles, Zeitschr.f. rat. Med. 1844, Vol. I. p. 335). since they are frequently seen to extend over Unfortunately, I have neglected to pay attention several hair follicles at the same time; to this point in the post-mortem examinations so sometimes the hair follicles occupy an eccentric that I must now regard this condition as merely position and sometimes none are involved. Their probable. shape is rarely perfectly round, but usually a In such a manner, sometimes more and little deformed, irregular, even slightly serrated. sometimes less severe, the symptoms usually This exanthema first appears, almost without manifest themselves during the first 3-4 days of exception, on both sides of the lower part of the this stage. It is seen that the most important chest, in the area of the false ribs and in the among them pertain to the nervous system, and epigastrium; from there it rapidly spreads to the

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chest, abdomen and back, appears on the arms contrast, seemed to indicate a much later onset and hands and reaches the extremities; it is very of the outbreak. Thus I found this exanthema in rarely seen in the face, more frequently on the a woman from the Klischtuwka near Sohrau neck. It usually remains but for a short time: in who, according to her statement, had been ill for some cases it begins to fade one day after its 7 days, and in whom Dr. Wachsmann, who had appearance, in others after 3-4 days, or more. taken me to see her, had not observed anything The spots then become pale, so that, when on the previous day. But not all such cases had looking at a larger area of skin, it is merely been under medical observation from the mottled; this slight mottling is easier to beginning; although the patients had been very recognize from a little distance away than when tired, weary and dazed during the first days, they the eyes are too close to the body. I have never had only sought the physician's help when the observed subsequent desquamation. Whenever intensity of the disease had increased. It might true flaking of the epidermis was seen it therefore be possible that in these cases too the occurred also in parts that had shown no above-mentioned timing (3 rd -5th day) applies; exanthema. Even where the spots had already however, I cannot assert this with certainty. disappeared, they reappeared with heat or with Another question, as difficult to decide, is mild irritation of the skin, e.g. after washing the constancy of the exanthema. Whenever I had with vinegar. Summarizing these facts, it will be the opportunity to follow up the development of easily concluded that we here have nothing but a the disease from the first days onward under compound capillary hyperemia of the skin. To somewhat favorable conditions, I always determine the onset of this exanthema exactly is observed the exanthema. This, of course, was not possible, in particular because, as we have not always possible in the cottages of the poor, seen earlier, it was too difficult to determine the as they were so dark and the beds stood in so onset of the disease, or of its second stage in distant a corner of the room, that none but the every individual case. I can best reconstruct the grossest of observations could be made. situation by the example of the physicians who Frequently the skin was so covered with dirt that caught the disease. Mr. von Frantzius had had it was not possible to gain clarity as to the prodromal symptoms of the disease since the 5th presence of exanthema. Some of the local of March; the stage of culmination began on the physicians asserted emphatically that they had 21st, and on the evening of the 23rd the first seen cases that had proceeded without exanthema spots were observed. Mr. Beifel fell exanthema; others did not wish to commit sick on the 27th of February; the second stage of themselves, as they had not been able to make the disease began on the 5th of March and when consistent observations in view of the imperfect I visited him in Breslau on the evening of the 9th manner in which they visited the excessive I found the exanthema developed on the upper number of patients. In fact, it is easy to part of the abdomen, the chest and the forearms; understand that a physician can rarely form a nothing of the kind had been observed a short reliable opinion when he is only able to see a time previously. Mr. Kuh felt seriously ill on the rural patient every 2nd or 3rd day, and that only 19th of February; the first spots of exanthema under the most difficult of conditions, when he were noticed in the morning of the 24th. These has at his disposal only very unreliable cases would seem to indicate that the exanthema information on the case histories. appeared from the 3rd to the 5th day of the Lastly, there arises the question of second (or peak) stage. I could further support differentiating between this exanthema and other this evidence with numerous other cases, the similar eruptions. A conflict had arisen in the validity of which, however, is based entirely on matter among the physicians at Ratibor, which the statement of the patient. Other cases, in has been publicized in the periodical political

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press. Dr. van Decken, judging from the all disappeared upon pressure, whereas later on exanthema, definitely considered the disease to they could not be made to disappear on pressure. be measles, while Dr. Polkow denied this with In respect to this particularly, the war typhus equal emphasis. It now happened that, thus approaches the typhus fever of the English simultaneously with the typhus fever epidemic, (compare Valleix, Arch. Gener., 1839, Sept.- there occurred in the districts an epidemic of Nov.), while the exanthema of the Upper measles that spread rather rapidly, in particular Silesian typhus is exactly similar in its in the orphanages. However, this very co- appearance, as well as in the areas of eruption, to existence most clearly showed that the the well known tâches roses lenticulaires of the exanthema of measles and the measles-like fiévre typhoide and to the roseola of the German exanthema could indeed be distinguished from ileotyphus. The only difference from the one another. Whereas the former regularly abdominal typhus observed in Berlin concerns started on the face or at least affected it the number of the areas of eruption, these preferentially, the latter first appeared on the usually being very limited in Berlin. From the midriff, while the face was not affected in the Paris typhoid fever might differ by the timing of majority of cases; the former formed more its outbreak, which was observed from the 4th to intensely colored, more rounded, slightly raised the 35th day of the disease (Louis, Recherches and densely crowded spots which rather sur la fièvre typhoide, 1841, Vol. II, p. 96). In constantly arose from the hair follicles, the latter relation to the first of these points, I must, exanthema remained paler, was more irregular in however, point out that in Upper Silesia I have shape, flat, and mostly quite dispersed. Taking seen quite a number of cases in which the into consideration the other symptoms of the eruptions were not more numerous than in our disease, confusion is hardly possible. I must, abdominal typhus. however, assert the total identity of this The second form of exanthema is the exanthema with the common typhus roseola. purpura-like or the petechial form. On their first This is also sufficiently documented by the older appearance the petechiae are always small dots, descriptions of war typhus. Ign. Rud. Bischoff at most the size of a pinhead, almost perfectly (Beobachtungen über den Typhus und die round, fiat and of a uniformly bright red color Nervenfieber, Prague, 1814, p. 8) described the which does not change under finger pressure, i.e. exanthema morbilliforme typhosum which broke they are not capillaries filled with blood out between the 3rd and 5th day on the chest and corpuscles, but extravasations of blood. They the forearms and sometimes even on the face, as appeared randomly on different parts of the consisting of rose-red spots the size of a grain of body, sometimes on the trunk, sometimes on the wheat, variously shaped, often oval and one end extremities, without any discernible rules. I have tapering off like a flame; they did not change on never seen them on the face, though I did on the being pressed with a finger, but differed from neck. Of this petechial exanthema I can assert the red petechiae which were of a darker red, with certainty that the onset of eruption is very round, and like flea bites without the central variable. In Lonkau, Dr. Babel showed me 2 dots. The only conflicting item in this persons, a man and his wife, who were lying in a description is the fact that the spot did not bed and had allegedly fallen ill simultaneously 4 change under finger pressure. This, however, days ago; both had petechiae on the most varied seems to find its explanation in a publication by parts of their body. The first petechiae had Wedemeyer (Űber die Erkenntniss und appeared on the body of Mr. von Frantzius Behandlung des Typhus, Halberstadt, 1814, p. towards the end of the first week after the 69), for that author stated that the primary beginning of the acute stage. This time might petechiae, the name given to the roseola, almost generally be considered as the average for the

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appearance of petechiae. This eruption, likewise, spots always appeared between the roseola is not a constant manifestation in all cases. I spots; when the latter had already disappeared, have observed a number of patients up to the the relationship could naturally no longer be indubitable onset of convalescence without ascertained. But the circumstances that the seeing petechiae at any time. When I came to the petechiae usually developed very abundantly in district, most of the physicians had not observed those areas in which the roseola exanthema the petechial exanthema. After I had developed least or not at all, e.g. on the feet and subsequently found several cases in Rybnik, calves, do speak against any such transition. In several physicians told me that they had now the majority of cases I saw the petechiae also seen the petechiae, and that the character of appearing when the roseola had already the epidermis must thus have changed a little. disappeared or begun to fade. However, I have Such a change would not be without analogy. also repeatedly seen both side by side and, in Thus Kennedy observed the purpuralike one case in the Hospital at Sohrau, roseola was exanthema to predominate in the Dublin typhus present on the second day only after admission epidemic during the last months of 1836 to the hospital, while petechiae were already (Medical Report of the Fever Hospital, Cork present on the first day. Finally, O'Reardon Street, Dublin, 1839, p. 17), whereas the (Medical Report of the Fever Hospital, Cork rubeola-like exanthema had been more frequent Street, Dublin, 1840, p. 6) observed the in 1837. I could not find a definite relationship petechiae more frequently among the poorer between the petechiae and the roseola in relation typhus patients than among those of the middle to either localization or time of eruption. A. class and the wealthy. This too was not the case Anderson (Observations on typhus. Glasgow, in Upper Silesia. The above-mentioned married 1840, p. 20) mentioned that the usual eruption couple in Lonkau were well-to-do farmers; they (the roseola) in the Scottish typhus sometimes still possessed potatoes and stated that they had changed to the petechial form, since the red not yet suffered want. Among the roughly 40 color at first disappeared upon pressure, while it other patients whom I saw in that village I found did not later on. I, however, wish to state that the petechiae only twice; the majority of these petechial nature of the exanthema, the presence patients were in the most miserable of condition, of a true extravasate, does not follow from non- since the distribution even of flour had been disappearance under finger pressure. organized only very recently. Wedemeyer (loc. cit., p. 71) objects with justice This much on the exanthemata. I have here to such an identity with the petechiae of a discussed both in detail, as the various questions roseola that cannot be suppressed by pressure, involved could thus be most clearly exposed. Let or, in his terminology, the primary and us now return to the course of the disease. secondary petechiae; the former being merely From the moment when the exanthema first caused by a congestion of the blood in the appeared the course of the disease varied in vessels together with a sort of exudation of the different patients. In general, let us distinguish a blood. I have autopsied a patient in Rybnik who severe and a mild form, as a more detailed in life had appeared to exhibit most numerous discussion of the individual cases would only extravasations of the skin and on autopsy the serve to confuse the general picture. still reddened parts showed only venous During the development of the roseola in the hyperemia with a surrounding imbibition of the mild cases, the various other manifestations hematin (compare Archiv, I, p. 442). I myself tended to intensify. The buzzing in the ears and have never seen a real transition from roseola to hardness of hearing, as well as the congestion in petechiae. Where the petechiae had developed the head, increased; the face was more reddened, while roseola was still present, the petechial the patient felt somewhat dazed and became

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mildly delirious, at least at night. In a few cases hearing increased to actual deafness. Weakness nosebleed was also observed. The skin was was extreme, the lower jaws were so slack that burning hot, mostly dry, and a little reddened all the patients found it very difficult to take up over; the tongue began to get dry, but did not liquids with their lips and to swallow them. The acquire a heavier coating, so that we must circular muscles of the eyelids were not assume the reason for this to lie merely in the completely closed during sleep, the eyes being high temperatures and in breathing with an open mostly rotated upwards and inwards. When mouth. Neither the tongue nor the teeth making an effort to move the eyes there resulted exhibited the well known sooty efflorescence of a fixed and yet somewhat uncertain stare. Some abdominal typhus; the tongue merely turned patients exhibited twitching of varying violence, yellowish, or yellowish brown, and presented a sometimes in the form of a twitching tendon, more flattened and dry aspect. At the same time sometimes in the form of extensive cramp-like respiration became frequently more superficial, fits. In Sohrau, in the clinic of Dr. Wachsmann, I the cough rarer and drier. In some cases there saw a woman in this stage who, according to the occurred at that time a slight diarrhea lasting for very expressive and lively description of her a few days, which usually overtook the patient daughter, had had a generalized convulsive so rapidly that the evacuations soiled the bed. attack. She nevertheless recovered. Her face, in The pulse now speeded up so that the majority general, was very red and hot. Some persons in of patients had above 100, more frequently this condition jumped out of their beds and ran above 110 pulsations per minute; its quality took off for a certain distance; most of these were a turn for the worse: though the flow of the slightly delirious by day and by night. The blood stream remained sufficiently strong, the delirium sometimes definitely bore a character tension of the arterial walls diminished day by of exaltation, even of frenzy, but usually it was day. The muscle pain receded into the of a depressive nature, alternating with a background, while the languor and weakness of soporific state. Thus, a man was constantly the limbs increased markedly. repeating-most revealingly-that he saw calamity In contrast, very early the pulse frequency in sitting in all four corners of the room. In some the severe cases increased to 120 and even 140 cases there occurred a more marked catarrhal per minute; the pulse was strong but easy to diarrhea, without, however, showing compress, the wave of blood was not sharply intensification of the symptoms or reaching delimited but showed some fluctuation; great severity. Thereafter meteorism was very breathing became more frequent and uneasy. rare. After the tongue had become dry, yellowish According to the intensity of these brown and cracked on its surface, it became stiff manifestations their duration as well as that of and could be moved only with difficulty. In the peak stage varied greatly. In the lighter cases some cases (e.g. Mr. von Frantzius, and in a the climax of the disease passed quickly. The municipal functionary in Sohrau, at the exanthema appeared on the 3rd, 4th or 5th day beginning of the second week) a fuliginous coat after the overt outbreak of the disease, the appeared on the teeth, and on the tongue a more symptoms persisted with some in tensity up to brownish, thicker coat. In all patients the skin the end of the week or at most into the following retained the calor mordax, in some despite the week for a few days, the disease then passing rather abundant perspiration of a sticky and into the third stage. Most of the patients whom I stinking sweat. The petechiae gradually saw were of this form, and as I had the increased and the whole surface of the body opportunity of observing them accurately in the assumed a spotted, hyperemic, rash-like hospital at Sohrau, I shall later report on some of appearance. In some patients impairment of these cases in detail. In the more severe cases,

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however, the highest peak of the symptoms used unwilling to give preference to anyone day. to appear on about the 9th-10th day, in a few Usually the so-called critical manifestations cases a little later, for instance on about the 14th marked the transition. In all patients the skin lost day. But in these cases the acute peak stage the burning, stinging sensation of the calor always continued beyond the beginning of the mordax, a light sweat broke out in many, or the first week and almost always included the body surface grew at least soft and moist. In a second week completely. Most of the patients few cases there occurred a vesicular miliary who exhibited this form were strong, well rash, particularly on the trunk. The urine of most nourished people, so that one could not escape was altered; in the majority of cases it was still perceiving a definite relationship between the acidic and produced heavy sediments of intensity of the disease and the bodily strength ammonium urate which, however, were not of the individual, a combination that finds a accompanied by the excessive excretion of certain confirmation in the great predisposition coloring matter, such as in malaria and during of younger and stronger persons to typhus fever. convalescence from inflammations with great In contrast, there was no noticeable relationship exudates, etc. (sedimentum latericium, roseum), between the appearance of the roseola but had a more loamy, dirty gray brown or exanthema and the severity of the disease; it did whitish brown color. In some patients the urine persist somewhat longer than usual in some was decidedly alkaline, with a rapid and patients of the severe form, but in others it faded abundant separation of large crystals of away as it did in mild cases. In cases of the ammoniated magnesium phosphate (triple former nature it did happen, however, that it was phosphate). These changes in the urine lasted for visible up to the 10th or even the 14th day. The several consecutive days; then the urine became extent of the petechiae also did not correspond clear, with an orange or straw-yellow color. to the peril of the particular case. I have seen Then, starting from its borders, the tongue began mild cases with extensive petechiae and severe to grow moist, the dry areas in the middle cases with very few petechiae; other physicians softening or detaching in brown crusts. The saw fatal cases without petechiae. I can, coughing increased again and more easily therefore, only vent my opinion that neither the yielded a foamy sputum, of a whitish slimy, roseola nor the petechiae had any definite purulent aspect. prognostic significance. As the symptoms of skin congestion In those patients who did not succumb to the subsided, the face rapidly paled and the patients, disease by that time (I shall deal with the others often in the course of a single day, presented a in the next section) the severity of the disease collapsed, exhausted aspect, while up to that was now broken and there began the third stage, time they had still presented the picture of a well which we have called the abating stage of the nourished person (this naturally does not apply disease. It corresponds partly to the nervous to those who were already exhausted as a result stage of other authors, inasmuch as in this stage of starvation). Moreover, the advanced muscular the symptoms of weakness, exhaustion, and debility only now first entered the subjective depression are apparent most markedly and feelings of the patients, for now it was not their clearly. In the milder cases, as is evident from earlier false weakness, a sluggishness of the above data, this stage already began in the movement in which movement was hindered by second week of the disease, in the severer cases suppression of stimulation, but they developed its onset could be reckoned to occur from the true weakness, an impairment in their power to third week onward, i.e., in such a manner that move in spite of proper stimulation. At the same the beginning of this stage can be taken to lie time the muscle pains became more prominent between the 7th and 14th day, though I am in many patients, with the difference, however,

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that various muscle areas were designated as Kuh, who fell ill on the 19th of February was being painful in alternation. still in the third stage of the disease on the 9th of The number of heart contractions increased March, when I saw him again in Breslau 9, i.e. in all patients. In the milder cases, though, they after 4 [sic] weeks, although towards its end. dropped rather rapidly, so that in a few days However, he had reached this stage under the their frequency was reduced from 100-96 to 84- worst of conditions. Dr. Neumann fell ill in 76; a large number of the more severe cases, Radlin on the evening of the 23rd of February however, continued with a fast pulse. I have and, after a restless night had himself moved to seen patients where 100-120 contractions were Loslau on the following morning, where I saw counted. In all of them the pulse was him. (He had a moderate fever, his head felt exceedingly poor; the impulse of the blood wave somewhat heavy; calor mordax with moist skin, was very weak, the tension of the arterial walls light coating of the tongue.) He was then soon was insignificant and the pulse could be very taken to Breslau, and when I visited him there easily compressed. I have not seen any central on the 9th of March, i.e., at the beginning of the nervous (i.e., brain) trouble apart from a third week after catching the disease, I was most moderate weakness of memory and a tendency, pleased to find him in full convalescence. in the more severe cases, toward troubled The symptoms during convalescence were dreams. mainly those that expressed the direct During this stage the petechiae disappeared continuation of the conditions already in in most patients by gradually growing fainter at operation. At first there was a general weakness the margins, thus being effaced, sometimes of the transversely striated muscle system. In assuming a light yellowish color, and lastly many patients this was combined with severe being resorbed without residue. In some pains in the muscles of the external parts. When individuals, however, they still increased during these people were asked whether they had any this stage, becoming denser, particularly in the complaint, one could be sure that they would peripheral areas, i.e. at the extremities of the mention pain in one part or another of the body. upper and lower limbs, partly becoming On further questioning, they would show a new confluent and forming larger more irregular place; upon examination, pressure, no matter spots, which, however, as far as I have seen, where applied, would elicit the words boli, boli, never exceeded the size of a lentil. In these it hurts! In the hospital at Sohrau there was a cases, too, regression occurred entirely in the young girl who suffered from such severe pains above-mentioned manner, but then continued in the soles of her feet that she could not sleep until convalescence. for 3 days and nights consecutively and was The duration of this stage was very irregular always weeping. The much lowered energy of and a definite assessment of its limits is not the heart beat was sufficiently evident from the possible at all. The transition to the fourth stage, very feeble pulse, but there was added to it the that of convalescence proper, took place so frequent occurrence of a symptom whose gradually; without any marked or characteristic dependency on such a cause I have shown events, that any fixed timing would be earlier (compare: Beiträge zur exper. Path. und completely arbitrary. In general it might be said Physiol., 1846, No.2, p. 39), i.e. the spontaneous that the milder cases passed into a definite state clotting of the blood in the veins. I had of convalescence at the end of the second week confirmed this by 2 autopsies. I have also seen, and the severer cases at the beginning of the 4th in the hospital at Sohrau, a third most interesting week. Convalescence, however, could be case of obstruction of the jugular vein during regarded as beginning at the moment when the life, on which I shall report in detail. pulse returned to its normal frequency. Prof. The bronchial catarrh in some patients

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developed into real pneumonia. In the third stage quite insignificant, and in this respect there occasionally occurred pains in the chest, recuperation contrasted most markedly from our especially upon coughing, while the respiratory abdominal typhus. But in very severe forms of sound in the lower and posterior parts of the the disease there occurred extreme emaciation. lung became indeterminate; in the 4th stage a Finally, I must mention those irregularities fine bubbly crackling was heard and the sputum of recovery that were due to gross dietetic errors. showed an admixture of blood. However, I never These disorders, whenever I heard about them, met any case in which the degree or the course always were of an alarming character. I saw the of these pneumonias could be considered as first such case in Loslau in the clinic of Dr. serious, had they been treated early. I shall later Türk. A man who was in the 6th week of the report on a case in which the pneumonia had disease and on his way to recovery suddenly was become chronic and had finally caused death. most violently ill after eating liver cooked in I have never seen decubitus in the sacral sour sauce. When I saw him his death seemed region. However, I have been shown several imminent: sunken in, pale face, very emaciated cases with gangrenous decay of the limbs. In body, a pulse of 130, very feeble pulsations, some of them it was not evident from the case respiration frequent, superficial and stertorous, history whether this gangrene might not have diarrhea, vomiting, severe tenderness in the right been caused by freezing, an assumption which is hypochondrium, which, over most of its area not unlikely in persons who go barefoot on snow gave a muted tone. The second case was Mr. and ice. Have I not seen children with bare Preiss, a surgeon in Rybnik, who in the 5th week edematous feet walking on frozen roads and of his disease also was on the way to complete wading in snow water? In many cases, however, recovery. Having on the 23rd of February too it could not be doubted that the typhus was the abundantly partaken of buttermilk, which at that direct cause of the gangrene. Dr. Babel in season, always, is not very wholesome, he Lonkau showed me a boy, 15-16 years old, suddenly felt greatly agitated and experienced whose right foot was mummified, black and violent chills, followed by an intense sensation dried up to the middle of the metatarsal bone; of heat with very high fever and a pulse of 160 the toes of the left foot were in a similar state heats/minute, as well as by abundant bilious and a deep line of demarcation was beginning to vomiting. This condition persisted up to the form in all affected parts. This boy had morning of the 24th, when he again entered a developed typhus and gangrene before the onset new stage of severe chills, developing into a of the severe cold. Mr. Zillmer, the regimental renewed stage of heat, fever and vomiting. On medical officer in Gleiwitz, informed me of the evening of that day, when I saw the patient, another case, in which the leg had become no local affection could be detected; the vomit gangrenous two thirds up the shank and had was strongly bilious. On the morning of the 25th spontaneously separated (the bone having a new attack of shivering fits. Mr. Kunz, the broken when the patient got out of bed). district physician, gave him quinine; the shivers Certain physicians claimed to have seen disappeared, but the vomiting only became more parotitis but such cases were rather sporadic. persistent. Champagne seemed at first to inhibit Self-evidently, atrophies and edema were very it, but it soon resumed, turning into hiccups; the frequent in poorly nourished and neglected patient died on the 5th of March. An anatomical persons, in particular as the various previous examination was not made, as I only arrived in bouts of malaria had a predisposing effect. I Rybnik on the following day. The suspicion that shall later report on one such case. In stronger a liver affection might have developed, as in the individuals, in whom the disease had not first mentioned case, can thus not be further reached a high intensity, the loss of weight was discussed.

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I never saw any extensive scaling. on the next day the buzzing in the ears had I conclude this section by reporting some intensified, the exanthema had further spread on case histories from the hospital at Sohrau that, in the chest. The feet were still exceedingly general, illustrate the prevailing mild form of the painful; he felt very weak. Pulse 92, large, rather disease. I have so selected them that every case strong. Tongue moist, slightly whitish; he still presents some characteristic feature, but shall had some appetite. On the 2nd of March the abstain from any further comment as the above exanthema had faded almost completely; the data convey my opinions in sufficient detail. skin was soft, not very hot, less burning; pulse Case I. Alois Waligura, a robust young man 96, moderately large, easy to compress. The face of about 20 years, was in hospital at the same was pale, somewhat sunken in. Tongue moist, time as his father (compare case VI) and his with a slightly whitish coating. Abdomen soft, sister. The sister had first fallen ill, then the not painful. Strong tingling. Increased hardness father and lastly the son. Without having had of hearing. Cough frequent, moist, easily overt chills he had felt tired, slightly dull and a releasing a formed white sputum; undefined little chilly 4 days earlier and had taken to his breathing with strong wheezing was heard at the bed. When I saw him in the hospital on the 29th back on the right side; on the left side undefined of February, he gave completely reasonable breathing; in front, above, there was marked indications, complained of a slight headache and whistling on both sides; below, indistinct buzzing in his ears, together with some breathing with a buzzing sound. Severe pain in difficulties of hearing; his face was somewhat the soles of the feet and the shanks up to the red. He felt a pervading lassitude. His lower knees. On the 3rd of March the exanthema had extremities, from the feet up to the lower ends of disappeared completely; the patient felt better the thighs, hurt a great deal, the pain intensifying and only complained of dizziness, pain in the with movement or pressure, while no outward feet and legs, and great weakness. The tongue changes could be recognized in these parts. His was moist and clean. The pulse consisted of 80 skin was soft, somewhat odorous, there was somewhat weak beats. The urine was clear, severe calor mordax; roseola was moderately straw yellow, neutral. The respiratory sounds distributed on the lower part of the chest, on the were purer, the thoracic pain had totally upper part of the abdomen and on the back, the disappeared, expectoration was moderate, spots being slightly raised, somewhat darker in slightly mucous and purulent. On the 4th of the middle and disappearing for a moment upon March, the head had somewhat cleared, and the pressure by the finger. The pulse consisted of 96 hardness of hearing had somewhat abated. rather large and full beats; the urine was Respiration had become more free, somewhat saturated and acidic. Even now the expectoration was rather abundant; whistling patient continuously felt chilly, with frequent was present on the lower right side, on impulse to cough, and with some pain in the inspiration. The fever was gradually subsiding. chest on coughing. On auscultation a whistling Same situation on the 5th, 6th and 7th of March; noise was heard when inhaling, in particular in the hardness of hearing was almost entirely the back, in the area of the larger bronchial gone; the head remained completely free. The branches. At the back and below, partially cough eased up. The appetite was good, and the indistinct breathing. The tongue was red, with a pain in the feet had lessened. Only the weakness light white coat only at the center, the abdomen still persisted. soft, some pain in both hypochondria, but no Case II. Halbhauss, clerk from Loslau, 20 changes to be detected on palpation or years old, a vigorous well nourished man from a percussion in the liver or spleen. Stools were non-infected house. According to the report by normal and solid. The night passed quite calmly; Dr. Sobeczko, who had already seen him there,

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he fell ill on the 26th of February (probably the in hearing; the feet painful. The skin moist, a disease had merely intensified at that time, but little sweaty; the urine dark, acidic with an had been present for some time earlier). When I abundant flocculent dirty brownish sediment that saw him at the military hospital on the 29th his consisted mostly of urates and mucus. In the head was heavy, his cheeks had a strong bluish morning a pulse of 100 easily compressible red tint (venous hyperemia); he was hot, his eyes pulsations, its frequency increasing later on. In shiny and with a fixed stare. The hearing much the following night, the patient again slept. On impaired. While the patient was lying in bed, the morning of the 5th, the hardness of hearing and without any external stimulus, he soon had somewhat subsided, but the ears were still began to mumble incomprehensibly in delirium. buzzing; great agitation. The skin soft, but not His skin was soft, somewhat moist; severe calor moist, the urine was flecked, dark brownish, mordax; slight exanthema on the chest. A pulse alkaline, with an abundant sediment and a of 132 moderately large and strong pulsations surface film, both consisting of triple phosphate per minute. His tongue was moist, covered with crystals. The pulse consisted of 116 small and a light whitish coat; the abdomen soft, no pain weak pulsations. A light erosion which was very anywhere; there had occurred several thin, painful had appeared on the sacrum. The tongue involuntary defecations. Rare, rather dry cough. was moist and clean, the abdomen soft, not The following night the patient was restless, painful, no diarrhea. On the 6th of March, after a constantly talking to himself. On the morning of restful night the patient felt better. The soreness the 2nd of March, the patient showed great of his limbs and the cough had completely agitation, he groaned a lot, wanted to get out of subsided, while the buzzing still persisted. The bed. His appearance had markedly changed, he tongue was moist, the appetite was returning. looked much more alert. The skin was warm but The urine continued to contain triple phosphate, not burningly hot and was covered by quite the pulse went up to 112. On the 7th of March profuse sweat; his tongue was moist, covered the subjective condition was well, the pulse with a thick yellowish coat peeling off like quieter, the urine turbid, with a copious, slimy, plaster. In the morning the pulse consisted of flocculent sediment. 100 much stronger pulsations which were not Case III. Johann Klimezar, 34 years old, a completely suppressible. The exanthema still Goralle from Hungary 10 , a very strong, was present. Defecations were pasty and splendidly built man. He had first felt ill 10 days occurred voluntarily; the abdomen soft. ago in Tarnowitz and had already spent 4 days in According to Dr. Sobeczko, a strong bed in Beuthen. At that time he had complained exacerbation of the fever took place in the of great weakness; the physician had evening, the frequency of the pulse increasing, administered an emetic, whereupon he the skin becoming drier and hotter. At night developed diarrhea. On the 29th of February he some restful sleep. In the morning of the 3rd was admitted to the hospital at Sohrau. He great lassitude, severe pains in the feet, much complained of insomnia, headache; particularly agitation, very pronounced deafness. The skin in the frontal region and severe buzzing in the was soft and warm, the exanthema had ears (huczy); his face was much reddened, his disappeared. The tongue moist, with a light forehead hot, his eyes shiny. His skin was whitish coat. The pulse made 104 small, easily strongly turgescent all over, hot, although compressible pulsations. The urine was clear, somewhat sweaty. Exanthema was quite saturated and acidic. Some soft defecations. widespread on chest and abdomen, but in view Little cough. At night again some sleep. On the of the general redness of the skin looked almost morning of the 4th great weakness, face pale and pale. The pulse consisted of 104 large and strong exhausted; much buzzing in the ears, difficulty pulsations per minute. The tongue was red and

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moist. Thirst was moderate; the abdomen soft returning. The petechiae began to disappear. The and not painful. Diarrhea had been present for 2 pulse consisted of 100 smallish pulsations. On days. He had started out with a cough, but had the 5th sediments of ammonium urate were lost it. His feet hurt; they were, however, neither noted in the urine; this continued for a few days, swollen nor changed in any way. The night was after which the urine became clear and straw- somewhat agitated, but there was no delirium. yellow. The condition of the patient remained On the first of March in the morning no further good. The pulse frequency gradually decreased, headache; his thinking was completely clear, he as did the deafness; the patient's weakness, had buzzing in his ears as if a mill were working however, persisted. in his head. His feet too no longer hurt. His skin Case IV. Trautvetter, 27 years old; smith; was moderately hot, the exanthema pale; the born in Tepliwoda near Münsterberg, a very pulse now consisted of 104 moderately strong, strong and well nourished man, had fallen ill on somewhat smaller and softer pulsations. The the 25th of February in a house where no one tongue was dry, brownish and cracked at the else had the disease. Severe chills followed by center. Stools thin. After eating, the tongue very fever, headache and lassitude. These symptoms soon became moist and then showed a whitish very rapidly increased in intensity, so that he had coating. In the afternoon I first noted some to stop working and took to bed on the 27th of petechiae on the abdomen. The night was February. When I saw him in the hospital on the somewhat restless, the patient occasionally 2nd of March, he complained mainly of mumbling to himself. On the morning of the exhaustion and lassitude. His head was free, his 2nd, he was very weak, much buzzing in the hearing almost unimpaired. His skin was moist head, pronounced hardness of hearing. He and warm; the area of the upper abdomen and coughed much, and ejected a sticky, foamy and the hypochondria presented sporadic pale bluish- glossy sputum; when coughing he had a red roseola spots, the urine was dark, turbid, like headache, but no pains in the chest. At the back bad brown beer, acidic, the pulse consisted of 96 of the thorax on both sides of the vertebral weak pulsations. His tongue was moist, with a column bubbly râles were to be heard. The skin slight whitish coating, the abdomen soft, was moist and soft, the pulse consisted of 128 defecation rare, but liquid. A moderate cough. feeble and forceless pulsations. The tongue was Some sleep at night. On the morning of the 3rd, moist, lightly whitish; urine and feces, the latter slight headache and great lassitude. The skin was liquid, were voided in the bed. The roseola was moderately hot, soft; some isolated disappeared while the petechiae increased, exanthema spots on the trunk. The urine was especially on the abdomen. No more pain in the dark, acidic, with an abundant, flocculent, feet. The night was a little quieter. On the 3rd, whitish sediment of urates. The pulse 76, with deafness was most pronounced; vertigo and rather strong and full beats. The tongue was great debility. The skin was soft, no longer moist, plastered with solitary epithelial masses; burning; the congestion in the head had now the abdomen was soft; stools retained. Catarrh of disappeared. His face was pale; the petechiae the conjunctiva. Cough somewhat more frequent rather numerous. The pulse showed 92 small and and moist. The night was interrupted by much weak pulsations; the urine was clear, straw- coughing. On the 4th of March the patient yellow and strongly acidic. The tongue was complained of great muscular weakness and moist, with a light whitish coat; no diarrhea. headache, but not of buzzing in the ears. The Coughing was frequent, the sputum came easily, skin was moderately warm and soft, the forming large, balled, slimy, almost whitish exanthema had disappeared. The pulse made 96 lumps. On the 4th of March the patient was rather small but strong beats. Frequent moist better. Defecation voluntary. Appetite was cough; sputa whitish, balled and slimy. The

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tongue unchanged, covered with whitish ears had increased; moderate deafness. Strong fragments; 3 thin, very copious stools; body soft, pain in the feet. Catarrh of the conjunctiva. Pulse not painful. On the 5th, the skin was warm and 72, moderately large, soft. On the 3rd of March, dry; the urine yellowish brown, a little turbid, after having slept a little during the night, great acidic; pulse 88, small, easily compressible. lassitude. Head free, hearing almost cleared up, Great weakness, much restlessness and but there was a rushing noise in the ears. Skin groaning; moderate deafness. Catarrh of the dry, a little burning; the roseola had disappeared conjunctiva more severe, the eyelids very again; the petechiae were still as red as before. adherent. Tongue moist, with a whitish Urine sparse, brownish, acidic. Pulse 92, small fragmented coat, as if torn; no stools. Cough and weak. Cough moderate, slightly moist. moist, sputum copious, whitish and rather Tongue dry, brownish and cracked; 2 thin stools. purulent; on the 6th less frequent; tongue still Feet very painful. On the 4th of March deafness somewhat streakily coated; urine dark, turbid, increased; cough more frequent and more moist. brownish, acidic. Pulse: 80 rather large and Tongue rough in the middle with a somewhat strong beats. Greater turgor of the skin. On the whitish coat. Pulse 116, easily compressible. 7th condition much the same, the bronchial Great weakness. On the 5th pulse 116 , large and catarrh was decreasing and the catarrh of the empty; enormous weakness. The cough let up a conjunctiva had almost disappeared; there little. Skin dry, but not hot, the petechiae slightly remained great weakness. more bluish-red in tint. The diarrhea did not Case V. Marianna Kubiczkowa, 50 years return. Abundant, sticky, viscous mucus old, a very weak and emaciated person, came excreted in the throat, and at the root of the from a house where a man had contracted typhus tongue. On the 6th of March, pulse 140, small 14 days previously. She had first felt unwell 4 pulsations; the tongue brown, dry, somewhat days earlier, had the shivers, felt dazed, had scabby in the center. Rare cough, moderate aching limbs and was overcome by great deafness, enormous prostration. Petechiae still lassitude. On the 1st of March she was admitted persisting. to the hospital; she still suffered from aching Case VI. Bernhard Waligura, 53 years old, feet, dizziness and buzzing in the ears. Her baker, father of Alois W. (case I). A rather appearance was relatively good. Her skin was emaciated and ill-nourished man. Having warm, a little moist; on the trunk, neck and the suffered from weakness and pain in the legs for extremities numerous red petechiae the size of a 7 weeks, he first had chills 10 days ago, then pin head in the upper layers of the skin; roseola soon developed a severe headache, buzzing, a was not seen. The pulse: 80 moderately large but loss of appetite, great weakness and a not strong beats. Her tongue had a whitish coat, tormenting cough. After admittance to the was dry, smooth and brownish in the center but military hospital, his condition speedily became remained moist for a long time after eating, so alarming that he received the last sacraments drinking etc. Lips and teeth were normal; there on the 26th of February. But on the 29th I found had been no defecation for 2 days; the abdomen him in the following condition: pronounced was soft, tender only in the left hypochondrium. hardness of hearing, pain in the forehead, Percussion showed a dull tone over a large area weakness; but completely lucid. The skin above the false ribs to the left (she had last had a moderately hot; on the abdomen, the chest and bout of malaria 5 years ago). Cough rare and the arms rather small, pale bluish-red roseola moist. On the 2nd of March, roseola appeared on spots with somewhat darker centers, very rapidly the dry but not hot skin of the chest and returning after pressure. The pulse: 88 abdomen, the spots were pale red not raised and moderately large, easily compressible beats. measured 2 lines in diameter. The buzzing in her Respiration a little speeded up. A rare dry

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cough. Tongue moist, with a slightly whitish himself with milk. At the beginning of the coat, abdomen soft, the area of the spleen not present infection, when he already had swollen altered; no defecation. On the 1st of March the feet, he had been lying on the cold floor for 4 condition was essentially unchanged; exanthema days. was still present, some spots were even slightly At the time of examination, on the 29th of raised. The fever was moderate, the cough February, he had a pale, puffy appearance. The somewhat more frequent with a sometimes exanthema was no longer clearly visible; also he somewhat slimy sputum. Catarrh of the was not hard of hearing. The pulse consisted of conjunctiva. On the 2nd of March the patient 100 moderately strong, though small pulsations. was feeling better, but there still prevailed great His skin was dry, but not hot. His tongue moist, deafness. Exanthema was still present on the slightly whitish. He complained of a heavy head, abdomen, but the spots had become very small; and of restlessness. The right half of his face, practically the only part visible was the pale especially the eyelids, showed a marked central point. On the 3rd some dispersed edematous swelling. He complained of severe petechiae appeared at different points; the pain on the right side of the neck which he found exanthema had almost disappeared. The pulse impossible to move. The area from the sternal was quite steady. Skin soft; buzzing in the ears; attachment of the sternocleidomastoid muscle to insomnia; a somewhat heavy head; the urine was the angle of the lower jaw was very painful, clear, acidic, orange yellow. In the following spontaneously as well as on palpation; it was days the patient's condition steadily improved; swollen; in the direction of the internal jugular his appetite returned; the petechiae did not vein under the sternocleidomastoid up to the develop in large numbers and soon disappeared, jugular foramen a hard cord could be felt, the so that on the 6th of March the patient was thickness of the little finger, which could clearly regarded as recuperating. be moved to and fro (occlusion of the vein). This Case VII. Eduard Gettler, 18 years old, pain had started two days ago, the swelling of shoemaker; came from a severely infected the face one day ago. The abdomen was tender house. In that same house there had been 13 everywhere, particularly in the region of the left deaths as follows: 4 members of the Gettler hypochondrium. Above the false ribs, in an area family, 6 of the Kotrimba family, 2 of the of ¾’ in length and ½’ in the breadth, percussion Wyusna and one of the Wilczek family. From revealed a dull tone. On the 1st of March the the Gettler family the father, the mother, a sister pain in the neck was still present, the one-sided and a brother had died. The remaining 4 brothers edema of the face had increased. The hard cord and sisters also all contracted the disease; two of was still clearly palpable. In addition, the patient them still were in another hospital, and the other complained of pain in various other parts of the two (the patient in question and his sister) were body. All muscles (extremities, back, chest) in the military hospital. The father and mother turned out to be sensitive. Otherwise his had died before the new year; the last of the condition was passable. On the 2nd of March, inhabitants of the house, a man by the name of the edema and the pain had somewhat receded Wyusna, had died 8 weeks ago. Soon after his but the cord was still palpable (collateral death the farmer Wilczek moved into Wyusna's circulation having developed). The soreness of lodgings, fell ill and died 14 days later. One of the muscles also had diminished. Some nose- the Gettler sisters, Marianne, nursed him and bleeding. On the 3rd, the edema had yet then also fell ill. regressed, the urine was clear, straw-yellow, Eduard G. claimed to be in the 3rd week of neutral. From then on improvement was the disease. In the winter of 1846-47 he had had continuous. quartan malaria for 4 weeks and had cured Case VIII. Marianne Gettler, 20 years old;

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sister of the previous patient, in the 5th week of treatment. This very pale, thin and weak boy the disease. A solidly built, well-formed girl, not said he had been ill for 3 weeks. His head was too thin. On the 29th of February she unaffected, there was a slight buzzing in his complained of pain on the right side of the chest ears, his eyes were clear and fresh, his lips pale, and of a tormenting cough; these symptoms otherwise normal, his tongue dry, but not were much aggravated on the 1st of March. She scabby. His skin was warm and dry, slightly in particular named the lower right part of the flecked and desquamating on the chest. The chest as the site of affection. Percussion there pulse consisted of 100 small but strong beats. yielded a moderately subdued tone up to 1" Respiration was short and shallow and, because under the armpit, and during inhalation a of the great debility of the boy, laborious; 56 delicately bubbling crepitation could be heard in inspirations were counted per minute. He the whole lower lobe. The cough was very coughed frequently, with little expectoration; the frequent, distressing and persisting; the sputum percussion tone was normal everywhere; was foamy, viscous and whitish; there were 44 auscultation revealed a slightly rattling sound on inspirations per minute. The pulse consisted of the lower left side, and, on the right side, over 120 small relatively strong pulsations. Her face the entire region of the lower lobe, a partly was somewhat bloated, with a livid redness on slight, partly pronounced bubbly râles. The the cheeks (venous congestion). Her tongue was patient moreover complained of pain in the clean and moist; appetite good. Severe pain in abdomen, which was large and full, somewhat the feet. On the 2nd of March the same swollen up by gases, and almost everywhere complaint with regard to the chest; percussion gave a tympanitic tone, which was dull only in unchanged, but the respiratory sounds with a the cecal area. In addition, the spleen was easily large bubbling; in the back they were rather palpable and percussion yielded a dull and undefined with a purring sound during empty tone over an extent of ½’. The condition expiration. Severe pain in the soles of the feet of the patient did not change in the following and from there up to the knees. Skin dry, not hot. days, for which reason I confine my remarks to Pulse 80, hard to feel. On the 3rd, severe muscle the foregoing. pain, spontaneously as well as upon movement, In the above case histories, I have assembled in the extremities as well as in the trunk. Cough partly fresh, partly old, and convalescent cases frequent, with a viscous and whitish sputum; such as constituted the majority of the Upper respiratory sound on the right lower side still Silesian patients. From these case histories it rattling. The face quite pale and sunken in. Pulse will be easier to get a picture on the course of of 80, very faint. Urine clear, straw-yellow, the disease than from long descriptions. The slightly alkaline. On the 4th of March an course of the disease is so simple that there is no especially tearing pain in the hands while the need to discuss it any further. I would have liked pain in the trunk had lessened. Cough frequent, to clear up certain details more exactly. But the still tormenting. Pulse 80, very weak. The impossibility of making an examination without patient continued in this manner. The thoracic an interpreter, with whom it was sometimes also symptoms abated very slowly. The remaining, difficult to communicate, coupled with the manifestations still persist. imperfections of a military hospital which had Case IX. Johann Victor, 11 years old; just been newly established and equipped, and around Christmas of last year he had contracted lastly the very short time at my disposal must all malaria in Baranowitz, where he worked as a serve to excuse me. cowherd. The malaria had at first assumed the tertian, then the quartan form, and had B. DEATH AND THE STATE OF THE CORPSE disappeared after 4 weeks without medical Death occurred either at the peak of the

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disease, in the second stage, or at a much later of the blood in the vessels of the neck as a result time as a result of consequent diseases or of the of incomplete inspiration and insufficient heart above mentioned interruption of convalescence beat. But the true cause of death must be sought due to gross dietitic errors. I shall for the time in the very same cause that had produced fever being limit myself to a detailed account of the and the above mentioned derangement in the former cases, since that of the latter is, in part respiratory and circulatory organs. As already already given and, in part, self-evident. stated, most of the deaths of this sort occurred When death occurred in the acute stage of between the 9th and 14th day of the disease. I the disease it nearly always took place between myself have never seen a case in which death the 9th and 14th day, with a steady increase of occurred earlier, and most physicians in the the symptoms, that I have described in the more districts agreed with me. Laymen quite generally severe cases. The frequency of the pulse named considerably earlier dates, such as the 3rd increased until it could no longer be counted, the day, and usually linked these cases in particular individual pulsations were mostly large, but very with infection. As I shall have to return to this easy to compress and frequently not clearly point, I shall here only say that in every case in separated from each other. At last only indistinct which I was able to check more closely, no undulations could be felt. The head which, as a matter how convincing the original information rule, conspicuously hung backwards, remained had sounded, it was found that the persons constantly hot, the cheeks were intensely red, concerned had already been ill before that time, eyelids and lips always remained open, the but had probably not taken to bed before, or had eyeballs always being rotated upwards and to the only then called a physician. inside. When addressing the patients in a loud Before my arrival in the two districts, only 4 voice to overcome their deafness, they always cadavers had been examined anatomically: one attempted to answer, but tongue and lips failed by Prof. Kuh, in Sohrau, together with his them. Left to themselves they soon became colleagues there; one in Rybnik by Drs. Altmann delirious, in most cases softly mumbling and Biefel; one in Loslau by Drs. Raschkow and incomprehensible words. The skin retained its Turk; one in Pilchowitz by Mr. Willim. All burning character; although sticky sweats were agreed that there were no significant changes, in not rare; in most of them the petechiae particular no ulcerations, in the intestine; at most multiplied, or the skin as a whole was covered they mentioned anemia, the spleen was usually with a sprinkle of red dots, or seemed to be reported to be enlarged and soft; in some covered with a rash, as if it were suffused with patients there was reduction in the consistency blood, and yet this coloration was due only to of the brain, in one other edema of the glottis. I hyperemia of the venous system. Respiration myself was able to perform 4 autopsies, and I was very frequent, shallow and gasping. There am reporting on these here in detail. occurred partial muscular contractions, Case X. Johann Soyka, a vigorous young spasmodic jumping of the tendons and, to a man; died in the evening of the 7th of March in lesser extent also floccillation. the military hospital at Rybnik, towards the 14th In such a manner did the symptoms appear day of the disease, with symptoms as described until their increasing severity caused the death of above. The fever had been unusually severe, the the patient. Comparing the manifestations of the skin burningly hot, intensively reddened last hours of life with the result of the autopsy, throughout, and as spotty in appearance as if it as I shall presently do with respect to a pertinent had been sprinkled all over with petechiae. The case, it could be said with certainty that a venous autopsy took place 12 hours later on the 8th hyperemia of the brain had been present at the around 10 in the morning, in the presence of Dr. end, which had developed from the congestion Heinke and Dr. Samostz from Breslau, and also

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of Dr. von Frantzius. hyperemic, dark red, and covered by a viscous Well built body, moderately nourished, very abundant whitish mucus that almost considerable rigor mortis. The skin a light blocked the bronchia. The right lung had even yellowish tint everywhere; intense bluish-red more numerous connective tissue adhesions; it blotches on the lower abdomen, the upper arms was completely filled with air, highly and hands, the thighs and legs, the individual hyperemic, dark red on the face of the cut; the spots irregular, large, looking like ecchymoses. bronchial mucous membrane was less reddened But on dissection the skin was quite free and and its mucous coating less thick. The only the vessels, in particular those of the diaphragm was covered by a thick venous superficial layer, were congested with blood. plexus. Both feet were bluish-red up to the ankles, with The veins of the omentum were surcharged only a few whitish islands of skin remaining. On with reddish-black blood. Both lobes of the liver incision only venous hyperemia was met up to extended far beyond the edge of the false ribs; the superficial fascia, without extravasation. the spleen was also visible beneath them. The Wherever incised, the muscles were dark red, liver, in particular the left lobe, somewhat resembling smoked meat. enlarged; structure and consistency normal, the The scalp was rich in blood, the bones veins filled with greasy dark blood. The gall normal, the brain sinuses contained much blood bladder quite abundantly filled with dark yellow, with a buffy coat. Strong venous hyperemia of slimy, tacky bile. The spleen much enlarged, the membranes, extensive edema of the pia adhering to the diaphragm with its upper end by mater. The brain substance was of good masses of old connective tissue about 1 foot in consistency, the white matter very rich in blood. length, ½’ across in width, 2" in thickness, very A moderate amount of fluid in the ventricles. firm, but somewhat limp to the touch. The cut Thyroid gland normal. Larynx and trachea surface dark red, very firm, homogeneous, normal, the latter with viscous whitish mucus in looking like goose-meat; the parenchyma, its lower part. In the anterior mediastinum the granular at a broken off surface, did not show veins were strongly congested with blood; lungs the white bodies very clearly, but in one place not retracted. Except for some reddish fluid, the showed a firm hyperemic wedge. pericardium was clear. Heart of normal size, the The stomach much contracted, containing a left ventricle strongly contracted, filled with little fluid stained with bile; mucous membrane rather large clots having a buffy coat that slightly thickened, here and there containing a extended far into the aorta; the fibrous material somewhat altered extravasate in its upper layers. of the buffy coat moderately cohesive, turbid, Duodenum quite normal; rather abundant yellowish white; the endocardium normal. In the secretion of mucus. The small intestine right ventricle, the buffy coat was even more moderately extended by gas and fluids, hard extensive; at the same time it was strongly fecal matter in the rectum. On opening the small granulated by the accumulation of white blood intestine much mucus stained with bile was corpuscles; endocardium normal here also. The found in its upper part while in its lower parts heart muscles were somewhat pale, otherwise there was a greenish yellow fluid mixed with normal. Some old adhesions of the connective numerous flakes of mucus; in the cecum a rather tissues of the left lung; strong venous hyperemia dry and hard fecal coating on the intestinal of the costal pleura; radiating connective tissue surface which increased in the large intestine scar on the lung surface. The lungs contained air and which was finally succeeded by brownish throughout; venous hyperemia pronounced in feculent masses. The mucous membrane of the the lower lobes and moderate in the upper lobes; jejunum was pale and generously covered with the bronchial mucous membrane was highly mucus, with slate-gray points on some parts of

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the villi. From the beginning of the ileum examined and found to be completely normal, onward the solitary glands were swelled up to somewhat anemic, the glands hardly visible. the size of a small pin head; the condition was Spleen greatly enlarged, I' in length, 1/2’ in most marked above the valve, where the follicles width at its center, tapering downwards; bluish- of the patches of Peyer were, also slightly red, limp and shriveled, showing a few hard enlarged. The whole mucous membrane in the nodules of a darker blue; on the cut surface the cecum and the upper part of the colon was of a white bodies were normal; the pulp of medium dark bluish-red hue, the venous plexuses were consistency, grayish red, the harder nodules dark abundantly filled with blood, the glands normal. red and dry. Liver enlarged, pale brownish, Further in the colon the solitary glands were somewhat dirty, flaccid, shriveled, but not again somewhat enlarged, appearing as very friable; bile plentiful, light yellow. Kidneys small whitish points; between them, venous normal, in the calices a turbid, thick, slimy mass. hyperemia in spotty distribution. In the rectum, Urinary bladder empty, normal. the glands slightly enlarged, with a slate-gray The cartilages of the ribs were ossified. point at their apex; in between, pale spots of Numerous adhesions of the pleura, especially on venous hyperemia. The mesenteric glands not the lower lobes. Pericardium normal. The size of enlarged, containing a little more blood than the heart normal, the left ventricle was firmly usual. contracted, the right one flaccid; valves, Kidneys normal; slight catarrh of the renal endocardium and muscles normal. Almost no pelvis; urinary bladder strongly contracted, its blood, in the left heart, some clots with a slight mucous membrane slightly hyperemic; the urine buffy coating, greatly friable. On the right side collected in it flocculent, turbidly whitish. In the much blood, mostly lumpy, dark red, but also inferior vena cava and the crural veins there was clots with a buffy coat, extending into the abundant blood, without a buffy coat, dark, arteries of the lungs. Lungs without tubercles; clotted in lumps, almost tar-like. both lungs edematous, the posterior and lower Case XI. On the 26th of February, at 4.30 parts hyperemic. The bronchial mucous p.m., I sectioned a man in a suburb of Sohrau. membrane intensively reddened, bloody mucus. Dr. Sobeczko had seen him only once; when he Bronchial glands black, not enlarged. already lay unconscious. But his condition Larynx and trachea ossified. Mucous clearly indicated typhus, and a daughter of his membrane intensively red with very bloody lay stricken in the acute stage of the disease. The mucus. man had died in the morning of the same day. Heavy stench, which clung to the fingers for The autopsy was done rather hastily and under a long time and could not be eliminated even most unsuitable conditions on the lid of his after washing with vinegar. An ointment on a coffin. Dr. Wachsmann from Sohrau and Dr. lead white base (Empl. de cerussa) which I had Eichholtz, head physician in Potsdam, were on my finger was not stained black. present. Case XII. On the 25th of February, at 9.30 Moderate rigor mortis. Body emaciated; a.m. I sectioned a man in the miner's hospital in man in the middle years of life. Body still Rybnik, who had been in the care of Dr. slightly warm. Fatty tissues had disappeared, Goldmann. (The latter had just traveled to muscles dark, saturatedly colored. Intestines Breslau with Prof. Kuh and had himself fallen ill strongly distended with gas. Abdominal cavity during the journey). At the time of his admission free. Mesenteric glands normal. The cecum with to the hospital the man was already unconscious. some yellowish feces and Trichocephalus The only thing known was that he had been ill dispar; its mucous membrane of a slightly slate- for several weeks previously, with violent fever, gray tint; of the small intestine about 2' were much coughing and diarrhea. Death had

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occurred on the previous evening. The following its veins swelled with dark blood. The valves were present at the autopsy: Dr. Altmann, normal, the muscles somewhat dark and personal physician to Prince Biron of Courland, hyperemic, the endocardium normal, the from Polish Wartenberg; Wehowsky, army subendocardial vessels of the left ventricle physician for disabled veterans in Rybnik; Dr. abundantly filled with blood. The blood in both Eichholtz, chief physician in Potsdam, and Dr. halves of the heart was thinly fluid, unclotted, Biefel, chief physician in Breslau. dark red, in the right part with some discreet Sturdily built man in the middle years of gelatinous clumps of fibrin, to which were life, moderately thin, military vesicles on the attached numerous whitish easily crushable trunk, on the extremities numerous dark red nodules; in the left heart small white clumps post-mortem spots. Severe rigor mortis. Muscles were swimming in the red fluid. Microscopic all hard, dark red, resembling smoked meat. examination showed the red corpuscles Very little fatty tissue. unchanged; but in every drop of blood examined Top of cranium very small, round, quite there were small islands of white corpuscles. thick, moderately rich in blood, rather adherent The white masses consisted almost entirely of to the dura mater. Dura mater moderately rich in white corpuscles, mostly of quite considerable blood, otherwise unchanged. Pia mater size, granulated, usually showing a round, thickened in some places at the surface, cloverleaf or horseshoe shaped nucleus on especially along the longitudinal sinus; quite addition of acetic acid. pronounced edema especially at the basis. The The pleura entirely normal. The lungs a little sinuses very full with dark, liquid unclotted contracted, without adhesions or scars, with blood. The veins of the pia mater and of the numerous black pigmented spots that were brain substance rather congested. The brain denser on the posterior parts, containing little substance normal, of good consistency air, bluish-red, the cut surface dark red throughout; the gray substance (cortical layer, (hyperemia). The bronchial mucous membrane corp. str. and thalamus, pons) very red. The hyperemic, especially at the bifurcation of the surface of the brain not separable from pia bronchi, mostly on the right side; somewhat mater. The ventricles filled with a little swollen, covered with a thick, viscous, bloody yellowish serum. Hypophysis normal. mucus. On the left side, this condition Tongue with greatly elongated papillae, disappeared lower down; on the right side, especially at the center; these were of a dirty however, the hyperemia intensified below, yellowish-gray color, anemic and dry. The root becoming blackish red; the contents of the of the tongue with congested veins; marked bronchi were rather cream-like, white, non secretion of mucus. The upper part of the transparent, purulent. When cutting through the oesophagus was filled with much mucus, tissues, white masses of pus were seen to be otherwise normal. Thyroid gland very large, surrounded by a dark red halo consisting of the pale, much colloidal substance in the dilated hyperemic bronchial mucous membrane and the foIlicles. Larynx and trachea normal, containing surrounding parenchyma of the lung, which was a narrow dirty gray band of mucus. equally hyperemic (beginning bronchopneu- On its parietal side the pericardium was monia). The bronchial glands rather large, beset with connective tissue (tendonous) nodules intensively black in color, without any the size of a hempseed. In its cavity a little symptoms of recent change. Both pulmonary yellowish fluid. The heart was of normal size; arteries were almost completely obstructed right the right heart, in which the cone of the after the bifurcation: at first there came a very pulmonary artery was a little dilated, had large, relatively dry, blakish-red, sometimes collapsed; the left heart was tightly contracted, grayish-red coagulated mass filling the whole

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lumen and loosely adhering to the arterial wall; villi somewhat thicker than normal in the upper then came dry, yellowish-red sometimes buff part only, otherwise the mucous membrane very colored masses, riding on the sites of bifurcation thin; the solitary glands were slightly enlarged and tightly adhering to the wall, which were almost everywhere; the patches of Peyer were very friable, and usually were continued by a dry heavily flecked in a slate gray hue and presented but red plug that extended rather far into the a wavy aspect. In the large intestine harder efferent branch. The walls of the pulmonary yellow fecal masses adhering firmly to the arteries normal. mucous membrane. The mucous membrane of Abdominal cavity. Position of the viscera the cecum intensely hyperemic; throughout the normal; only the sigmoid bend very far to the lower parts of the tract up to the anus, only the right; the omentum was pushed almost top of the folds were reddened; the solitary completely to the left. The liver smaller than glands were enlarged everywhere, slightly normal, of normal consistency, with a smooth, raised, marked by a slate-gray spot and ring. brownish-red surface occasionally showing The inferior vena cava, the iliac and the slightly yellow blotches. The cut surface had a crural veins were filled with thickly fluid, uniformly light brownish-red color, dark red cherry-red, almost tar-like blood, without any blood oozing from the vessels. The gall bladder clots. The left crural vein from Poupart's relatively large, the bile abundant, thinly fluid ligament to the veins of the shank obstructed by and light yellow. Spleen of normal size, large, dry clots often showing pearl-like blotches consistency greater than normal, the white that filled the whole lumen. They were driest in bodies not changed, the parenchyma (pulp) the somewhat varicose veins of the lower legs. harder than normal, dry, pale buff colored. Dry, yellow-red clots of small size adhering Kidneys somewhat rich in blood, otherwise firmly to the wall of the vessels emerged from normal. In the renal pelvis a strongly mucous some of the muscular branches in the center of whitish fluid. Urinary bladder normal, urine the thigh. The inner layers of the vessels were copious, clear, dark yellow. Pancreas normal. nowhere reddened. The internal surface of the The mesenteric glands somewhat enlarged, aorta had scattered small fatty areas. in the cecal area also intensely hyperemic, but Case XIII . Josepha Malcha, 50years old, not changed in consistency nor in the moisture died on the 5th of March at the Sohrau military content of the parenchyma. The stomach of hospital after having contracted chronic normal size; bilious, thinly liquid content; pneumonia during her convalescence from fundus and cardiac portion normal; the pyloric typhus. In the course of the pneumonia she had part with a heavy coating of whitish mucus; the suddenly coughed up a most evil smeIling mass, mucous membranes thickened, slightly tumid, a an event which was not repeated. In the end she little hyperemic, in many places slate-gray; in suffered from an exhausting diarrhea. The various places there were slate-gray lentil-sized autopsy took place on the 6th of March towards spots. Duodenum well filled with bile, the 3 o'clock in the afternoon in the presence of Mr. openings of the glands of Brunner near the von Frantzius. pylorus beset with slate-gray dots. The whole of Very emaciated body. Rigor mortis. Intense the small intestine contained much very thin icteric staining of the skin. Considerable edema fluid having a fecal smell, yellowish in color, in the left lower extremity. Fat had vanished with numerous yellowish flakes of mucus and an from all parts of the body. acidic reaction; no significant turbidity on Top of skull remarkably round and deep, its boiling; under the microscope nothing to be seen inner surface quite normal. In the longitudinal but intestinal epithelia and flocculent granules of sinus a little buffy coated blood. Dura and pia precipitated bile. The small intestine anemic, the mater anemic on the convex side, pia mater very

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edematous. The brain small, but heavy, tubercles (tubercular granulations) the fact that considerable consistency, almost sticky; cut the compact exudate did not show the friable, surface very moist throughout, the gray matter dry, granulated character of infiltrated tubercle very pale, but of normal cohesion. In the and that a turbid whitish fluid could be pressed ventricles a small quantity of fluid; the right out everywhere speak against such an posterior horn obliterated. Both transverse and assumption. Microscopic examination cavernous sinuses and the veins arising from immediately dispelled any doubt. The masses them and running to the pia mater were always consisted of cells, whether one observed completely obstructed, containing large, usually the evacuated fluid or the cut surface, cells discolored, clots adhering to the walls. which at many points were entirely similar to Thyroid gland somewhat enlarged, pale, those occurring in pus, while at others they had yellowish. The respiratory mucous membrane in largely undergone fatty metamorphosis. the primary respiratory passages anemic. The Therefore, the condition can only be regarded as heart with heavy cushions of fat and large a gray hepatisation resulting from chronic epicardial patches. In the right ventricle strongly pneumonia: an old exudate in the lung vesicles buffy coated clots, but the buffy coat somewhat had very slowly transformed into a perishable wrinkled and friable. In the left heart similarly tissue consisting of cells. The sudden discharge buffy-coated clots with many clumps of white of a large amount of stinking sputum evidently blood corpuscles. Endocardium normal. The denotes the development of the cavity en bloc, upper lobe of the left lung strongly adhering but by massive necrosis: the mortification of the separated below from the costal wall by a turbid exudate and the tissues, together with the exudate mixed with fibrous flakes. The decomposition of the mortified substance, i.e., a parenchyma containing little air, nearly circumscribed gangrene of the lung. That everywhere edematous; the upper lobe firmer, cavities with absolutely smooth walls may result the cut surface airless, compact, gray, lead from such processes is well known. colored, smooth, releasing a whitish fluid upon Liver of normal size, very finely lobate, pressure. No old or young miliary tubercles infiltrated with some cholepyrrhin, with slight anywhere. A large cavern occupied the upper fatty degeneration. The bile very slimy, dark half of the upper lobe of the right lung; it was brown, somewhat flocculent, with various small, filled with a rather thin, stinking, grayish white brown pigment stones. The spleen enlarged, fluid; the inner wall smooth throughout, partly very limp, covered with patches of fresh, fibrous formed by the thickened pleura and partly by exudate, bluish-red, very firm to the touch, consolidated lung parenchyma traversed by grayish-red on the cut surface, dry, offering numerous new vessels. The remaining part of considerable resistance to pressure, no fluids the upper lobes partly edematous, partly oozing out; white corpuscles were not seen. compact. This latter mass was smooth on the cut Kidneys anemic, otherwise not altered. Pancreas surface, its color was whitish in some parts, in normal. Uterus also normal. others slate gray, at a few points it was white The stomach of normal size, with and nontransparent, like tuberculous infiltration. pronouncedly bilious contents, its mucous On pressing a whitish fluid was evacuated. The membrane somewhat thickened and papillary, bronchia of both sides were filled with tough the muscle layer somewhat thick. The intestine slightly purulent mucus. somewhat collapsed. In the small intestine great At first glance these changes might have accumulations of mucus mixed with bile, the been regarded as tuberculous: tuberculous solitary glands in its lower parts slightly infiltration of the parenchyma, a tuberculous swollen, no change whatsoever in Peyer's cavity. But apart from the absence of isolated patches, nor any scars seen, the mucous

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membrane slightly hyperemic in some places. have been characteristic, and, jn case XIII, Dysenteric changes in the large intestine from where the typhus as such had terminated long the valve to the anus; the mucous membrane ago, they were not in a degenerated condition, hyperemic in a pattern corresponding to the i.e. flaccid and slate gray, as they are found after longitudinal and transverse folds in the lower typhous swelling in the stage of convalescence, parts of the intestine, eroded at the top of the but here also they were red. folds, the submucous tissues edematous; no 2. The spleen was enlarged in 3 cases. fresh exudates present. The mesenteric glands However, in one case (XII) it was not only not only slightly enlarged, slightly hyperemic. enlarged, but showed no traces of previous The left crural vein formed a hard cord; it tumescence. The other 3 cases evidently contained a large, blackish, dry, clotted mass, represented residual malarial tumor, as is adhering to the walls; which extended to the sufficiently clear from simple description. Never inferior vena cava; in its upper part it was quite was there the plump, firm, dark red tumor of discolored, softened in the center and filled with (abdominal) typhus which on the cut surface a whitish, pus-like, pasty mass. shows enlarged white bodies (Malpighian If we compare the above autopsy reports vesicles) in a dark cherry red, greatly friable with those of autopsies done before my arrival parenchyma. as well as with the observations by Drs. 3. Peyer's gland groups were entirely Lemonius and Polkow already mentioned, one unchanged. In one case (X) the related follicles may consider it as an established fact that, in this above the valve were somewhat enlarged, in epidemic, the characteristic anatomical another (XII) they showed slate gray spots and modifications of abdominal typhus (fièvre the entire plexus had a wave-like surface as a typhoïde) were not present. As is well known result of the raising of the interfollicular these changes are manifest in the follicular connective tissues above the level of the apparatus of the intestinal mucous membrane, in follicles. The solitary glands were somewhat the mesenteric glands and the spleen, and mainly swollen in 3 cases, and that not only in the small consist in the following: in the first stage (I here intestine, but also (case X and XII) in the large mean the stages of the local process, not those of intestine and the rectum. All these changes the disease) there appears, concomitantly with indicate no more than the presence of a catarrhal hyperemia, a slightly aqueous exudate which affection. In one case (XII) the latter was lends to the organs a swollen appearance; in the certainly chronic, as indicated by the slate-gray second stage the hyperemia subsides, while the coloration of the stomach, of the intestinal villi, aqueous exudate increases, and, by mixing with and of the follicles themselves; in the other two the elements present, and by admixture of the cases the great amount of mucous excretion more solid constituents of the exudate, there present in the intestinal cavity demonstrates the arises the peculiar "medullary" appearance; and catarrhal state with sufficient clarity. As is now finally, in the third stage, the firm constituents of well established, intestinal catarrh is almost the exudate increase, whereby are formed, in always accompanied by changes in the glandular some parts, dry tubercle-like, yellowish-white system, and the above mentioned changes of the necrosed foci. But what did we have in this mesenteric glands can also be related to this epidemic? Let us examine the various organs: condition. However, a simple swelling does not 1. The mesenteric glands in some cases were suffice for construing a typhus, as, for instance, somewhat enlarged and hyperemic. However, in William Davidson tried to do. Swelling of the patients who had died at the acme of the disease, solitary glands, such as described, may be seen they were not flaccid, not greatly enlarged, in the course of the most various acute disease, without the medullary infiltration which should i.e. in pneumonias, scarlet fever, and

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rheumatism; no one will or can deduce from it There probably are few places in the world anything warranting a diagnosis of typhus. where the burial places are as unadorned, the I would now like to examine the constitution various graves as unidentifiable as here. Only as of the blood, in the light of the anatomical long as the ground is freshly thrown up or dug findings. I have had no opportunity of obtaining can a grave be recognized. After a few years all blood during life and perhaps such an is covered by the same smooth lawn. opportunity will be found by a later observer of Consequently, when even the number of the epidemic. In the cadavers, however, even in deceased cannot be obtained from official the acutest of cases, we never found broken registers, the manner of death, the nature of the down, decomposed putrified blood, but on the last disease, will be even more uncertain. At the contrary only well clotted blood with a buffy very best one can obtain a rough idea by coat, which serves to show by a further example comparing present mortality figures with earlier that it is not the lack of fibrin which causes the averages, the picture obtained being, however, typhuses (compare this Archiv, I, p. 572). In distorted, as the foregoing dysentery and various cases, apart from the presence of fibrin, simultaneous starvation contributed in raising the multiplication of the white blood corpuscles mortality. Except for the most recent times, had become so pronounced that the lower incidence figures for disease cannot be obtained surface of the buffy coat had assumed a granular at all, not even approximately, as nobody was appearance (compare Med. Vereinsztg. 1847, ever free to take care of such tables until district No.4). I am drawing attention to this condition physicians were made available. Moreover, the in particular because Allen Thomson observed figures which could then be obtained do not the same in the closely related remittent fever allow any conclusions on earlier times when that prevailed in Edinburgh in 1843. (John Rose starvation in its most horrible form, a winter Cormack, Natural history of the epidemic fever temperature as low as -23°R (= -28.8°C) and the at present prevailing in Edinburgh, p. 113.) disease were all affecting the populations In addition, we found acute and chronic simultaneously. In Sohrau, a city which before affections of the bronchial mucous membrane, the emergency had a population of 4,000, of the mucous membrane of the renal pelvis etc., according to the medical lists, the number of venous hyperemia in different organs, especially patients at the end of the week extending from in the most acute case (X); spontaneous clotting the 20th to the 27th of February was 109; at the of the blood in various veins, in the more end of the following week (27th of February to chronic cases (XII, XIII). I do not discuss this the 5th of March) it was 161, 6 patients having point further as it adds nothing essentially new died. Thus, although the epidemic was spreading to our presentation 11 . in the area and the number of patients had Finally, the mortality rates remain to be increased by half, the intensity of the epidemic discussed. In view of the particular conditions was so low that mortality was only 5.5%. Since I prevailing in Upper Silesia, I can furnish only have already reported that, at the peak of the the scantiest information. When the epidemic epidemic, 600-700 dead had been buried in the was at its peak, not even all deaths were graveyard, it necessarily follows that at that time registered with the clergy in charge of the there must have prevailed a much higher graveyard registers, and frequently several mortality rate; or else the epidemic would have bodies were put into the same grave. spared none of the inhabitants. In the single Traditionally the family bonds of the Upper month of January, 106 corpses were registered. Silesian are rather loose and his feelings of In a report by Canon Heide in Ratibor (compare kinship, except for the closest of relatives, are Die Hungerpest, p. 52) we read: "In the parish of weak; he thus cares very little for his dead. Benkowitz, Ratibor district, which comprises

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2,100 souls living in several villages, the parson period from the 1 st of January to the 11 th of has administered the last holy sacraments to 170 February 1848 (ibid., p. 64). In Lonkau, the persons severely stricken by typhus in the period death register revealed an average of some 60 from the 6th to the 18th of January. Of these deaths yearly for the past 5 years: in 1847 there only 42 persons died during that same period. occurred about 230 deaths, and in the months of Chaplain Bienacki, whom I sent for to help the January and February 1848, 86 deaths; the births overworked and almost collapsing parson, also decreased steadily, for in the previous years visited 60 typhus patients in the period from the there had been about 70 births per year, in 1847 19th of January to the 1st of February, and 55 some 20; in the two months of the year 1848 patients from the 2nd to the 9th of February, and only 4. The number of patients at the end of prepared them for death; of these 33 died." February was some 60; the population of the Although this report naturally only included the village numbered about 1,400. In Geikowitz, more severe cases it does furnish some where 450 inhabitants lived in 38 houses, the indications, i.e., in 5 weeks there were 185 number of deaths, up to the 25 th of February severe cases of typhus among the 2,100 1848, was 26. inhabitants, and 75 deaths, corresponding to an As regards the actual mortality from 8.8% incidence of typhus among the populations starvation, we have fuller information on it with and to a mortality rate of 40.5% among the respect to the Pless district in a small brochure, patients In a meeting of the physicians of the The Upper Silesian Hunger Pest. With official Rybnik district convoked by Mr. Barez on the figures. A question addressed to the Prussian 26th of February, district physician Dr. Kunze Government, Leipzig 1848. The district of Pless estimated the approximate number of patients in covers 19½ square miles and had a population of the district at 5-6,000, and the district president 69,000 inhabitants; it thus possessed a very von Durant at 6-7,000, the number of deaths dense population (3,538 persons per square amounting to 1718 (compare the data provided mile). In 1846 there died 2,399 persons; in 1847, by Dr. Kiinzer, priest of the monks-hospitallers, 6,877. 97 of these, the physicians stated after Die Hungerpest, pp. 57 and 58). According to medico-legal examinations, had died of his figures every third patient almost should starvation. According to a table in the appendix have died. However, the mortality data furnished of the brochure, based on the reports of the by the physicians do not tally with these parsons of the 25 parishes of the district and indications. Dr. Türk in Loslau and Dr. compiled by the rural district council, 907 Wachsmann in Sohrau conceded a mortality rate persons died of starvation, i.e., 1.3% of the of 10%, Dr. Chwisteck of Sohrau a rate of 20%. population. In all, a tenth part of the inhabitants From these diverging opinions the lack of died; from starvation and epidemics, 6.48%. reliable data can easily be gauged. May I now add some further information: In C. THE PATIENTS the parish of Lubom, Ratibor district, with 3,000 The epidemic spared no nationality: Slavs, souls, 276 persons died of starvation, dysentery Germans and Magyars were infected, and the and other diseases in the year 1847, i.e., about alleged immunity of the Jews, which Boudin 9% of the population; in January 1848, 83 traced back to Fracastorius, was here not at all persons died of typhus, i.e., about 2.7% of the confirmed. Of those who escaped the epidemic, population in one month (Die Hungerpest, p. it could not be said that their national origin or 52). In Staude, mortality usually amounted to 28 their previous residence constituted an deaths yearly, but in January 1848 alone it explanation. Some held the opinion that this amounted to 46 (ibid., p. 42). In the parish of typhus fever was practically a Slav typhus and Pless (7,083 inhabitants) 161 persons died in the had to be considered as a peculiarity of the

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Slavonic tribes. However, their own example of the patient. In general, I cannot assert that any has partially disproved them: daily experience special corporeal feature would predispose more was witness against such a view. If the typhus for the disease. It has already been mentioned occurring in Middle and Lower Silesia is of the that persons who were exhausted by previous abdominal form this proves nothing, for it diseases (e.g. malaria) most easily caught should not be forgotten that the conditions of life typhus; this apparently was likewise the case of the inhabitants are different. with those who had suffered severe starvation at Concerning the age of the patients, the the beginning of the epidemic. Later, however, I majority were in the flower of their years, youth also saw confirmed that particularly the young always predisposing for typhus. Nevertheless, and strong were affected rather severely. numerous examples of infection in older persons Previous infection did not absolutely protect are not lacking (compare cases V and VI), and I against relapse. During my short stay I myself am not able to set a limit as to age. As for the could not make direct observations on repeated situation in children, it is different: in general I contraction of the disease, but I have heard of it have seen only very few cases of typhus in from physicians, whose reliability is beyond any children; the lower limit according to Mr. doubt. Thus, Dr. Wachsmann in Sohrau took me Zillmer, regimental medical officer in Gleiwitz, to a mill n the suburb of Klischtuwka, where a was 2½ years. man, his daughter, a servant and a little girl all I could not find any difference based on sex. lay ill. The man had had typhus fever, with very Among the women several were pregnant, extensive exanthema, at Christmas time. He had without the typhus showing any deviation in then completely recovered, had fallen ill again at form. These observations therefore disprove the the beginning of March and now again showed purported "mutual exclusion of the typhous and roseola. He died a few days after our visit. Dr. puerperal conditions." Hamernik (Prager Dmmler, from Berlin presented another very Vierteljahresschr., 1846, Nr. 2) admitted striking example. He had contracted typhus compatibility in the case of "anomalous typhus fever in Prague a few years earlier, had then with imperceptible changes of the blood;" I, dragged himself to Berlin, and there again gone however, cannot concede any validity to his through the course of the disease with very whole argument about the normality and extensive eruptions. Now he had fallen ill in abnormality of typhus and about typhous blood, Chelm (Pless district) and had a very difficult for it totally lacks scientific method. and late convalescence. I have no precise information on the influence exerted by mode of life and occupation D. NATURE AND CAUSE OF THE DISEASE on the infection. In general, however, there All physicians who have personally seems to have existed a certain difference observed the disease (with the sole exception of between the villages in the open country and the the previously mentioned Dr. van Decken) hold, suburbs, which are similarly constructed, on the as far as I know, the opinion that the disease is a one hand, and the inner city districts which can typhous affection. About its closer appellation, boast of better location and construction, on the opinions differed to some extent. Initially, the other hand, the latter being less severely disease was given the name of hunger typhus; affected. The poor, who live in insalubrious Mr. Neumann at first declared it to be dwellings under very crowded conditions, i.e., exanthematous (petechial) typhus (compare Die the rural population and the workers, suffered Hungerpest, p. 70); Mr. Kuh also agreed to the most severely. term typhus exanthematicus (Med. Vereinsztg. Lastly, we have to consider the 1848, No.8); Mr. Barez, however, at the meeting individuality, or perhaps rather the constitution, of physicians in Rybnik, insisted on the identity

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of the disease with the contagious typhus which cannot be answered concisely at the described by Hildenbrand. present stage of our knowledge. If we want to As regards the causes of the disease, those gain some clarity, to arrive at even who considered the disease to be hunger typhus approximately correct results, we must attempt a believed either that it had been caused by short review of the historical development of the starvation, or, as did the majority of the concept "typhus." As is well known the name physicians, they declared it to be the usual already existed in the terminology of Kos, endemic typhus which had only assumed such though only as a general designation for a series dimensions because of the conditions of of diseases, whose connection I, at least, am not privation. All, without exception, physicians and able to perceive. Hippocrates (Opera, ed. K hn. laymen, considered the disease to be contagious Part II, p. 496-506), in the book on internal (compare Kuh); consequently some thought that diseases, described four disease forms the disease had been imported from Galicia and successively, naming each one of them υ . In Austrian Silesia. my opinion the third of these descriptions could I may reply to these opinions with the words be interpreted as acute rheumatoid arthritis. That of Huxham: Parum fortasse interest, num illam of the first form, however, nearly fits the later (febrem) putridam, malignam aut pestilentialem conception of typhus: it is represented as an appellare velis;-quando petechiae erumpunt, acute disease of midsummer, which proceeds quilibet illam exanthematicam aut petechialem with violent fever, high temperature, heaviness, vocat,-et quando a contagio exorta est, lassitude and severe weakness of the limbs, contagiosam.-Ego quidem de verbis contendam stomach trouble, meteorism and the voiding of cum nemine, id tamen necesse est, ut aliquid foul smelling fecal masses, impairments in sight, habeamus, quo nostras ideas cum aliis in consciousness, etc. However, it is clear that, communicare queamus, quae ubi bene sunt since there still are three other diseases classified definitae, insignis quaedam rixae causa under the name of "typhus" which do not fit this relinquitar nemini. ["Perhaps there are small picture, there is a great uncertainty in the differences: you might wish, now, to call this definition from the start. We therefore find in fever putrid, malignant or pestilential. When general that the name was very rarely used by petechiae break out, some one may caIl it subsequent writers up to the present century, and exanthematous fever, and when it has arisen that our disease is listed under quite different from contagion, another will call it contagious names such as febris ardens, maligna, putrida, fever. I shall not argue about words with anyone. synochus, etc., because, to the extent that the Nevertheless, it is necessary that our concepts be doctrine of fever became more complete and well defined when we wish to communicate our more consequent from the ontological standpoint ideas to others, so as to arrive at good results. and from the point of view of its essential Then no one will find cause for dispute."] nature, it became split into the different (Opera physico-medica, Lipsiae, 1773; Vol. II, categories of the nosological systems. How far p. 100). It is hard to reach a scientific conclusion this fragmentation has proceeded can be seen on these different opinions, since the factors most clearly in Boisseau's book which was so determining such a choice are only very long and so widely used in France (Pyrétologie imperfectly understood, and since science itself physiologique ou Trairé des fièvres. Paris, 1831. has not yet arrived at a definitive decision as to Ed. 4me) the character and the origin of this type of Among the most common designations disease. What is typhus? and how does it under which the disease entity now recognized originate and spread? These are questions which under the name of "typhus" was listed in the no one has yet answered satisfactorily, and years before the establishment of pathological

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anatomy and physiology there are in general Here we thus find differentiation between nerve three: febris nervosa (Willis), febris mucosa fever and typhus, between typhus in a narrower (Röderer and Wagler), and typhus (Sauvages, and a broader sense. The only criterion for true Cullen). As the one or the other of these schools typhus mentioned is contagion, for primary predominated in different places, the one or the development from a "peculiar air corruption" other name became established. Have we not cannot possibly serve as a standard for any experienced in most recent times that while physician who has to follow the instructions of long-winded discussions were going on in that regulation. Southern Germany on the subject of Only after anatomical studies had furnished "Schleimfieber" it was no longer remembered in new points of departure for the understanding of Northern Germany what should be understood these affections did more accurate views arise. by such a term? However it was more or less After Röderer and Wagler had directed attention agreed, since Cullen, that contagiousness was to the changes occurring in the intestinal mucous necessarily to be postulated in true typhus. membrane, in particular to those of the glandular Therefore, English physicians up to now were system, Serres and Petit demonstrated, by exact differentiating between typhus fever and studies, the constancy of the affection of the persisting remittent fevers which the German intestinal mucous membrane and of the doctors singled out as typhus from the reign of mesenteric glands in certain fevers, which up to the natural history school onward. When we that time had been described as "essential" read the description of the West African fevers. These observations initiated new remittent fevers, for instance the fever so confusion. On account of the localized affection, accurately examined by M'William which Serres and Petit had named the fever ''fièvre wrecked the well known Niger expedition, these, entéro-mésentérique," still considering the fever according to the German point of view, can only to be the principal factor; Broussais, who be interpreted as typhous affections. opposed such entities on principle, went a step From the above it is easily seen how further; he declared the local affection to variable the meaning of the term typhus actually constitute the main factor, and the fever to be its is, and how greatly the range of the designation consequence and therefore named the disease varies in the different schools. Very "gastro-entérite." Bretonneau, Cruveilhier and characteristic in this connection is the official Bouillaud only more sharply defined these royal Prussian pronouncement on the subject. In views, the first giving the disease the name of supplement B to the regulation of the 28th of dothienentérie, the second introducing the term October 1835, on the methods to be applied in entérite folliculaire and the third that of entéro- sanitary procedures against infectious diseases, mésenterite typhoide. it is stated under §29: "For a long time it has While fever entities were rejected, been customary to call nervous fever every fever inflammation-entities were created. In the long that is prevalently combined with an affection of run such a point of view could not be the brain and of the nervous system, and with maintained. To the extent to which, under the great debility, and to call typhus a higher degree influence of experimentalists, the humoral view of the same condition. But we shall understand again began to find a place in medicine, and to by typhus in the narrower sense only that type of which horizons were enlarged by experiments nervous fever which, having initially originated on putrid infection of the blood, the necessity of from a peculiar corruption of the air, is then also distancing oneself from local affections as a transmitted and spread in its absence by way of primary cause and of seeking a general cause infection, and because of this double condition again moved to the foreground. H. Boerhaave assumes a more or less epidemic character." pointed out the resemblance between the

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feverish nerve diseases and certain poisonings, with respect to typhus doctrine, we must admit for instance that with belladonna, and German that we still do not know anything definite about physicians such as Horn already referred to the the cardinal point of the matter and that our war typhus of 1813 as an "animal poisoning of arguments on this subject are nothing but more the brain and nervous system" (Horn, or less probable hypotheses. But so as not to be [Observations on the treatment of the infectious unjust we must point out that in so difficult a nerve and hospital fever.] Berlin, 1814, p. 14). problem our knowledge has nevertheless From the rather cautiously expressed views of advanced significantly and we have more Andral, Louis and Littré, the opinion that there accurately understood three particularly occurred a change in the blood by the absorption important points which had caused a great of noxious substances gradually gained confusion in the old doctrine. These are the acceptance in France, until, in most recent times, following: Rayer practically derived the local affection 1. The difference between typhous diseases from a general putrid infection and Piorry named and typhous conditions. Before, by anatomical the disease entérite septicémique. studies and by the improvement of techniques, In Germany, where, owing to the influence diagnosis reached the level of exactitude at of Marcus Senior, of Wedemeyer and of others, which it finds itself at present, those febrile the opinion that typhus consisted in an diseases were very frequently identified with inflammation of the brain had been maintained one another whose phenomenology showed the for some time, an opinion which has also found presence of some particular affection of the partial confirmation in the observations of nervous system, mostly of a depressive character Hildenbrand, another view had in the meanwhile (asthenia, adynamia, debility). Every febrile gained increasing acceptance, due to the Natural disease could be assessed as nervous or as History School of thought, i.e., that typhus was typhous, if the affection of the nervous system based on a primary change in the blood and that assumed such a character. It was thus possible, the intestinal affection should be considered as a for example, at first to call a gastric fever secondary local affection. The supporters of nervous and then to let it develop into a typhous Cullen, Brown, and Broussais were increasingly fever (compare with the above cited regulation). relegated to the background, especially, since In such a case the name typhus was conferred on the young Vienna School – a somewhat a disease in which merely the depression of the impatient heir of the Natural Historians.-.began nervous manifestations had reached a certain to exploit its legacy in a distinctly craseological extent. This view collapsed as soon as it was sense, with the result that in the end a large recognized that the fever itself was only an family of different disease entities was created, expression of the general participation of the which were all called "typhus." For a time nervous system in the disease, the expression of chemico-physical examination of the blood the generalization of the disease, and that this seemed to indicate that certain changes in the participation may assume a character of blood (reduction of the fibrous elements, depression under the most varied conditions. If presence of ammonia, etc.) were characteristic we now include all those changes in the nervous for such a family, and a typhous blood mixture system which simultaneously cause fever and was frequently spoken of. Unfortunately, recent nervous symptoms of a depressive character investigations have shown the fallacy of such a under the collective name of typhous state, it is view, and, with respect to the blood, we are now evident that a large number of diseases must be just as far from our goal as we were at any time capable of causing it, as, for instance, acute (compare this Archiv I, pp. 572, 563) 12 . miliary tuberculosis, the major pneumonias, or If we honestly want to clarify our position putrid infection of the blood. In contrast to such

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diseases with typhous conditions are the actual in its particular significance. On the other hand typhous diseases, in which the symptoms of we know that the catarrhal inflammation of the depression of the nervous system necessarily mucous membrane is a priori linked, more than belong to the essential symptoms of the disease any local affection with profound changes in and are not merely accidental, as in a pneumonia nervous activity 13 . These changes other are so that has become typhous or nervous, those strongly apparent, particularly in the catarrhs of diseases in which great perturbations of the the upper part of the digestive canal, in the nervous system, such as shivering fits, usually inflammation of the mucous membrane of the accompany the initial stages of the disease, then stomach, of the duodenum and of the bile ducts, allowing it to run a course that is regular, i.e., in the so-called febres gastricae and although not bound to sharply defined critical gastrico-biliosae, in gastroduodenitis (Stokes), days, while in genuinely putrid infection violent that they constitute the typhous condition, and disorders erupt over and again in an irregular that we see forms corresponding to the old manner, and in acute miliary tuberculosis the concepts of the febres gastrico-nervosae and nervous system is not affected suddenly, but is biliosae putridae. But if we consider the course gradually involved in the disease. We of the disease, a differentiation from typhus is consequently limit the name typhus to a disease quite possible in the majority of cases. process which is always and essentially 3. The exanthematous nature of typhus. I do accompanied with the typhous condition, to a not know exactly how far back recognition of febrile process which runs a regular course this tenet can be traced in the literature, but that coupled with depressive manifestations of the it has already been emphasized with regard to nervous system. From this difference there war typhus can be clearly seen from Bischoff partly follows another, namely: (loc. cit., p. 3). As is well known, the Natural 2. The difference between acute catarrhs that History School has created one of its most appear together with the typhous condition and brilliant paradoxes in that it differentiated typhuses that are accompanied by acute catarrh. between two main forms of typhus: the All typhous affections have the peculiarity of exanthematic and the enanthematic the petechial affecting one or more mucous membrane and the abdominal, i.e. that it granted equal systems in which there develops acute status to the typhous changes in the follicular hyperemia, with changes in their nutrition and system of the intestine and to the exanthema of secretion. As is well known, the respiratory and the skin. Perhaps there is no other maxim which intestinal mucous membranes in particular are more clearly shows the superficiality with which the sites of such catarrhs, and I have already this school expressed its ontological analogies, pointed out (this Archiv, I, p. 249) or that the and the self-complacency with which it diarrheas met in iIeotyphus do not stem from the presented such ideas to the world in affection of the follicles or from the ulcerations, monographic form. Let petechial typhus be but from the simultaneous intestinal catarrh. The studied from the writings of as many authors and Upper Silesian epidemic has furnished the best on as many patients as you please, no difference examples. But these catarrhs are not typhous; will be found between the type of exanthema typhus fever with a catarrh of the bronchial existing in it and in abdominal typhus. Roseola mucous membrane is not a broncho-typhus, the is present here as well as there, and if true catarrh being only a co-effect of the same cause petechiae purpural spots, etc., occur in the latter, that produces the actual typhous symptoms. The real petechiae nevertheless occur sometimes, or fact that it is associated with typhus, that it is a in some epidemics even frequently, in link in the phenomenology of the typhous abdominal typhus, as I myself have seen. The process, does not prevent us from considering it only difference lies in the spread of the

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exanthema, in the number of the spots; it is, sharply typical course. I regard it as probable therefore, only quantitative, and abdominal that the basic cause of the typhus is a change in typhus must therefore be included in the the blood, its poisoning by noxious substances; I exanthematic disease as well as petechial typhus. deny, however, that examinations of the blood But that the modifications in the follicular so far have provided any support for this view. It system of the intestine have been contrasted is a simple consequence of this view, or more from the exanthema of the skin as internal exactly, this view is the simple consequence of exanthema is pure frivolity. The processes which the observation that the changes so far can be observed in the intestine do not have the demonstrated in the quantitative relation of the least resemblance to those taking place in the blood constituents to each other are not primary skin, while they are completely identical with changes, but related only to the development of those which are found in the mesenteric glands. the disease. Whoever assumes a miasmatic or The roseola is a circumscribed capillary contagious origin of the typhous affections and hyperemia, the petechiae are circumscribed does not perhaps enthuse about the theory of extravasations in the skin; the changes in the botanical or zoological parasites (Henle, or intestine and in the mesenteric glands consist of Holland) should never doubt that if the changes a process which, though it begins with in the blood are to be regarded as the cause of hyperemia, ends with abundant and often the disease, they must be qualitative. That up to necrotizing exudates. I therefore in all this time such changes have not been found, earnestness reject any games of analogies, while proves as little against this view, as does the fact I most definitely support the view of the that no specific substances have been found in exanthematic nature of the typhous affections the blood of patients suffering from smallpox recently suggested by Roupell (Treatise on and measles that differ qualitatively from those typhus fever, Lond., 1839), Andrew Anderson found in healthy persons. It would also be quite (Observ. on typhus, Glasg., 1840), Eustace arbitrary to expect such substances to be (Medical report on the fever hospital, Cork demonstrable in the blood during the entire Street, Dublin, 1841), William Davidson ("On course of the disease. Would anyone expect that Typhus in Great Britain and Ireland," translated in metal poisoning, the metal taken in should by Rosenkranz, Kassel, 1843) and Dagincourt remain demonstrable in the blood for as long as (Gaz. Méd. 1848, Febr., No.8). Eustace in the effects caused by it in the nervous system? It particular has correctly pointed out that the is not necessary to invent hypothetical recognition of the disease as having a regular qualitative changes in the fibrin, the protein, and periodic course that constitutes an the blood corpuscle, as is done in the Viennese interconnected process, directly arises from such science of craseology; it is indeed more than a recognition. unscientific to do so, because, as I have already Having underlined these three points, we shown previously, such changes in certain can now proceed with some assurance to answer chemical substances would not fit in with any of the confused question of the nature of typhus. I the known groups of chemical bodies, neither define typhus as an acute disease, which under the isomeric, nor under the isomorphic generally starts with a considerable upheaval of bodies. It is possible that the substance which the nervous system and with severe fever, very qualitatively deviates from the normal blood soon develops a roseola exanthema 14 , very soon constituents and which causes the typhus, i.e., also produces symptoms of depression of the the typhous miasma, may remain in the blood nervous system, is accompanied by an acute for a certain time, but it is just as possible that it catarrhal inflammation of the mucous disappears easily, while the symptoms caused by membrane, and takes a regular, although not it in the nervous and nutritional systems

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continue their course. to the inflammatory process of the skin. It The last difficulty we have to discuss indeed quite frequently occurs that there is no concerns the significance of the local specific ulceration in typhus, as a resorption of the products of typhus, or, in accordance with our exudate might take place during the stage of terminology, the products of the local and medullary infiltration and as ulceration depends specifically disturbed nutritional processes. I solely upon the occurrence of the necrotizing have already mentioned that French medicine (diphtheritic) exudate. If, thus, I cannot conclude differentiates between typhoid fever and typhus that the intestinal affection is the essence itself fever to such an extent that it considers them to of the process, I must nevertheless speak out be definitely different diseases, whereas German with equal certainty against the opinion that this medicine considers the petechial and abdominal peculiar type of nutritional disturbance also typhus as two different manifestations of the pertains to the essence of the process. Typhus, same basic disease. The differentiating character with its changes in the intestinal and mesenteric between the two forms of the disease is the glands and in the spleen, i.e., the entero- specific change in the intestinal follicles, in the mesenteric, abdominal or ileotyphus, includes mesenteric glands and partly in the spleen in the the entire phenomenology of petechial or abdominal, typhoid, form. Davidson (loc. cit., p. exanthematic typhus proceeding without specific 124) who asserts the complete identity of typhus anatomical changes, as was very well shown by and typhoid fever, believes that it would lead to Davidson, and in addition a few other symptoms an endless and very unphilosophical that are absent in the latter. If we consider classification if simple swellings of the intestinal petechial typhus as the simple form, then glands, such as are very frequently seen in something more has been added to it, for Scottish typhus, were to be differentiated from abdominal typhus is a complicated form. What the changes occurring in the typhoid fever of the then is this complication? Anderson (loc. cit., p. continent. This, however, is not the case. The 54) dealt with the matter too lightly. He swellings described by Davison occur in considered abdominal typhus, typhoid fever, as a pneumonia as well as in the typhous affections; purely local disease of the intestinal follicles, they are, in the majority of cases, only the which, as are other local affections, is frequently expression of a catarrhal affection, and accompanied by a feverish condition and pathological anatomy differentiates them in the sometimes combines with typhus to constitute a most precise fashion from the specifically compound disease having the symptoms of both. typhous changes. If we admit the latter and In a very similar manner does Stokes speak of a consider their absence in British typhus, we shall combination of the (Irish) typhus with ileitis. I have to decide, in the main, what rank we want cannot agree with this opinion because no one to assign to these changes. I have already has yet seen such an ileitis without typhus and mentioned above the opinion of the French because the same reasons which can be adduced authors (Broussais, Cruveilhier, Bouillaud), who against the French view on the significance of assume an inflammation of the intestine or of its local affection also apply here. If we observe the glands and consider it as the very essence of the parts affected in abdominal typhus we find that whole process. Some German writers have gone they are more or less closely related to blood even further and have considered the ulceration formation. The intestinal follicles and of the follicles, the intestinal ulcers, as the main mesenteric glands are the main organs for the factor. This is entirely wrong for the reason that absorption and formation of the chyle fluid, the ulcer does not actually pertain to the typhous which, in its turn is the building material of the process, but falls under its results, just as an blood; the spleen has a connection with the abscess or an ulcer of the skin does not pertain cellular building of the blood (compare Med.

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Ztg., 1847, No.4; this Archiv, I, p. 571). Thus, in plague epidemics. Possibly later investigations abdominal typhus there are added to the uncovering the real nature and cause of these symptoms of the simple typhus further diseases may reveal a closer relation of these affections of certain organs connected with the two affections. For the present, however, let us formation of blood. not proceed further than the methods of natural Should these diseases now be considered to science permit. Plague may only serve as an be dependent upon the already altered blood, example of an acute disease in which the nervous system, etc., or should the changes in generalized disease causes a local affection of the blood rather be considered to depend on the glands, as an argument for the dependence of these diseases? Are these diseases, thus, primary the gland affection in typhus on the general or secondary? If one considers well founded ailment, and no more 15 . Accordingly, we what I have described above as constituting the distinguish a simple and an abdominal typhus, essence of typhus, then there will be no question conceding to the latter a secondary affection of that the affections of the intestinal follicles, of organs that are in direct relation to blood the mesenteric glands, as well as of the spleen formation as a characteristic peculiarity. must also be considered as secondary, as Other writers have previously raised the depending upon the primary changes in the question as to what constituted the cause of this blood or in the nervous system, or whatever else complication of typhus. Davidson discussed in a is regarded as the primary site. An example will somewhat imprecise manner place, season, illustrate this point more convincingly. epidemic and other yet unknown influences, and No one can doubt that bubonic plague, the stated in particular that in Glasgow 1/3 of the pest, is a generalized (not local) disease, whether typhus patients exhibited the abdominal form, it be explained according to the humoral or to that the latter was rarer in Dublin, and that it the cellular theory; moreover, no one can deny befell 1/4 of the patients in London, but that that the diseased lymph glands (buboes) are a incidence varied considerably at different secondary manifestation depending on the seasons. Seitz (Bemerkungen ϋber epidemische general cause of the disease. Many writers, such und endemische Krankheitsverhältnisse, 1848, p. as Jos. Frank and the entire Natural History 86) stated that if the place of residence and way School have attempted, by arguments of of life had an influence on the formation and analogy, to represent bubonic plague as manifestation of the fevers, their form, inasmuch practically typhus, equating the affection of as it was the expression of prevalent local peripheral glands in bubonic plague with the lesions, nevertheless seemed to depend upon affection of the internal glands in typhus. Even atmospheric conditions. He based this view in though a resemblance between plague and particular on the observation that, in 1846, there typhus cannot be denied, it does not follow that simultaneously prevailed in Paris, London and both belong to the same "disease family" and Munich a typhus with very little involvement of that a third form should be added to the two the intestine. However, this observation, which, above mentioned forms of typhus, i.e., a plague- moreover, is not based on sufficient data, does typhus. Otherwise I would certainly admit that not meet the case. Although the general my definition of typhus was too narrow; but in character of the weather conditions in Berlin in plague the petechiae appear only in the very late the summer of 1846 showed no deviation from stages and I cannot consider either the petechiae the picture sketched by Seitz, we have or the carbuncles as equivalents of roseola. nevertheless constantly observed the most Pruner (Die Krankheiten des Orients, Erlangen, extensive intestinal modifications in typhus 1845, p. 380) described the Egyptian typhus in patients. And even though it is correct that broad detail and mentioned its presence during abdominal typhus occurs frequently enough in

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England (compare the illustrations in Bright's nature to every typhus. We regard such a Reports of Medical Cases. London, 1827. Plates designation as no less pleonastic than to speak of 13-15), it should not be overlooked that, as a exanthematic measles or of exanthematic rule, it is quite rare as compared to simple glanders. The name petechial typhus might be typhus, and that in Ireland especially the latter is acceptable because of its historical significance, almost endemic. Most probably local conditions but we prefer to propose that it be eliminated of society determine the form of the disease, and altogether from medical nomenclature, because we may suggest as an almost generally valid it no longer corresponds to present views. The result, so far, that the simple form is the more designation petechiae, in the present medical frequent the poorer and more one-sided the food nomenclature, is not used in the same sense as and the worse the living quarters. Albers (Die previously. Fracastorius, who gave the first Darmgeschw ϋre, 1831, p. 101, 302 ff.) argued exact description of this disease (Opera. Lugd. that scrofulosis was a predisposing factor for 1591. Pars I. De morbis contagiosis Lib. II. cap. intestinal affection; although I cannot agree with 6) used the words lenticulae, puncticula, his in part rather strange arguments, it does seem peticulae as synonyms and from then on the correct to me that abdominal typhus occurs more name petechiae was used for a long time as a frequently wherever scrofulosis and tuberculosis general designation for all flat macular most profusely develop, i.e., when, on account exanthemas, whether caused by simple capillary of the mode of living, there is a certain hyperemia or by extravasation of blood. proneness for the affection of certain glandular Wedemeyer, as I already mentioned, still speaks organs. A precise answer to these questions will of primary and secondary petechiae and depend on the further development of medical understands by the former the simple hyperemic statistics, which at the present time is one of our spots on the skin and by the latter the spots of most urgent requirements. extravasate. The relationship between these After having dealt, if only cursorily, with spots and the disease, i.e., whether the petechiae these preliminary questions, it will now be should be regarded as a separate disease, or only possible to give an opinion on several of the as a symptom of a disease, and as the expression views which have been quoted at the beginning of certain changes in the body, has been of this section. In any case, the disease occurring controversial for a long time, as we can read in epidemically in Upper Silesia must be at length in Sarcone (Geschichte der interpreted as being typhus, since, as appears Krankheiten, die 1764 in Neapel sind beobachtet from our previous reports, it is an acute worden, Zrich, 1772, Vol. III, p. 140). Authors exanthematic disease, bound to a regular course, did increasingly agree that the dark red spots that presents from the very beginning severe, passing into a leaden or blackish hue, (i.e., the feverish perturbations of the nervous system, true extravasations) are caused by a very soon develops nervous symptoms of a decomposition, a putrid corruption of the blood. depressive character-especially with respect to The disease called petechial typhus frequently the muscular system- and is accompanied by a exhibits this type of spot, as we have also seen in catarrh of the mucous membrane covering the .the Upper Silesian epidemic; however, they are air passages, and an exanthema which appears as only a secondary phenomenon, since almost all a roseola. We can moreover declare that we had writers agree in contesting any regular simple typhus, not accompanied by any affection relationship with the course of the disease. It is of the organs related to the formation of blood. not permissible to name a disease after a From what has been expounded so far it follows symptom which is only an accidental, even if a that we reject the name "exanthematic typhus," frequent, consequence of certain conditions because we have assigned an exanthematic arising in the course of the disease. But the

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petechiae from which the petechial typhus literature on epidemics could be discussed with originally received its name were not spots of equal justification; I am only dealing with it extravasate, but clearly roseola spots, taches because special emphasis has been placed on roses lenticulaires, lenticulae. It fitted the this point. If, for the time being, we put aside the mentality of the population to call the whole of matter of contagiosity, a point to which we must the disease by the name of the exanthema. return very soon, and restrict ourselves to the Measles, smallpox and scarlet fever are phenomenology of Hildenbrand's epidemic, I expressions for the whole of the disease process believe I must energetically reject any question and also simultaneously for the exanthema, of identity. I must, though, add that I also do not although it was initially valid only for the latter. share the view that Hildenbrand's typhus was a Fracastorius precisely formulated it thus: (febres simple, or, as we say, a petechial typhus. For, illas) vulgus lenticulas aut puncticula appellat, according to Hildenbrand (Ueber den quod maculas proferunt lenticulis aut puncturis ansteckenden Typhus, Vienna, 1810), in the 5th pulicum similes; quidam mutatis literis peticulas stage of the disease which, according to his dicunt [The people call (these fevers) "lenticles" classification, falls in the second week after the or "puncticles," because the spots look like start of the chills, there appeared pains in the lentils or flea bites. Some, corrupting the word, bowels which he considered to be inflammatory, call the spots "peticles."] i.e., the people simply which were always coupled with a tendency for called the whole disease "petechiae" (spotted frequent liquid, very foul smelling feces; fever). Had this name been retained, the later meteorism was an "invariable" symptom during nosology would have been less exposed to that time. These indications definitely denote misinterpretation, and in particular the intestinal affection, and even if one should be exanthematic nature of the disease would have inclined to grant that it might perhaps have been been retained. Now the situation is simply that a simple catarrhal affection, we should not typhus, according to my definition, means the overlook that our epidemic showed intestinal same as the condition which in the 16th century catarrh only exceptionally, while meteorism was was designated as "petechiae." I do not regard as completely absent. However, it would not be feasible the restitution of this old term as this justified, in view of the imperfect state of would cause general confusion. Nevertheless, it pathology in Hildenbrand's time, to entirely seems important to remember that by the rash disallow the possibility that truly typhous erection of nosological systems, each of which affections of the intestinal follicles, the has again engendered dozens of new ones, we mesenteric glands, etc., were present (which have gradually come to understand by the term need not necessarily be ulcerations). Let us keep petechiae, which originally designated that acute in mind that knowledge of the anatomical exanthematic disease which we now call typhus, changes which typhus causes in every organ had the local spots of extravasate on the skin. And only just become available in Germany through while we have previously shown that the term the publication of von Pommer's work (Beiträge "exanthematic typhus" is a pleonasm, we believe zur näheren Kenntniss des sporadischen Typhus, to have now proved that "petechial typhus" Tbingen, 1821). Hildenbrand, moreover stated expresses no more and no less than a tautology. (p. 72), that a "stupor quite similar to inebriation The next question which we are now able to had to a varying degree been the most prominent tackle is the identity of the Upper Silesian and constant symptom during the whole period typhus with the contagious typhus described by of the disease." In Upper Silesia this symptom Hildenbrand. This question has no great general was among the great exceptions. It was in importance as the identity of the former disease particular the lower degree of brain affection, with many other typhous affections quoted in the the complete clarity of thinking that was

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characteristic for the epidemic. Typhomania, a believed the endemic typhus to be infectious, state of apathy toward one's surroundings, of and it could therefore be thought that starvation dreaming in a half-awake state, a thinking might have caused the disease to have become modulated by internal stimulus only, but in such epidemic merely by raising the degree of a way that the reaction to strong external contagiousness, or, on the contrary, that stimulation resembled that of a person just starvation simultaneously increased the number roused from sleep and only partly awake, such of cases. symptoms were almost always absent in Upper Let us begin with contagion. When I came Silesia, even though they sometimes occurred. to the districts and saw one physician after In Hildenbrand's account these manifestations another catching the disease, while all observers, were the most essential and constant. These physicians as well as laymen, regarded quotations will suffice to show the great contagion as a common and everyday difference between the Upper Silesian typhus experience, I at first did not think of looking for and the epidemic described by Hildenbrand. proof. But I then recalled the discussions which From the various views ,on the character of had taken place in recent years on the the Upper Silesian typhus quoted above only contagiousness of yellow fever and bubonic two, now, remain to be discussed, i.e., whether it plague at the Académie de Médecine of Paris, was a contagious typhus, or hunger typhus. Any discussions which shook to their very conclusions on this point will coincide with the foundations views on the contagiousness of etiological questions which have also been infectious diseases thought to be immutably treated at the beginning of this chapter, and we fixed by centuries of observation, and which shall directly turn to their discussion. paved the way for a complete revolution in quarantine legislation, I remembered the dispute * * * on the contagiousness of cholera, and I took the All local physicians, as I have mentioned, liberty of posing the question to the physicians were agreed that in the form of the disease the attending a conference in Rybnik to solicit closer present epidemic did not differ from the endemic proofs. It turned out that two facts were typhus of Upper Silesia. We cannot enter into a advanced as being particularly convincing. Mr. detailed discussion of this view, as all premises Durant, the district president, was later kind for such a debate are lacking. Yet I believe that, enough to provide greater detail, and I shall in so simple a comparison, the general and presently quote this information. But a few unanimous observations have a high degree of remarks must precede it. credibility. Nevertheless, I shall also discuss the If it is true that simple typhus is endemic in other, divergent views, especially as the absence the Upper Silesian districts, then it is logical that of pathological anatomical examinations creates the causes and the requirements of the disease a very great gap. Naturally, if the identity of the must also be local and endemic. Everyone who epidemic and of endemic typhus is granted, the will expose himself to these conditions will opinion which derives the typhus from the thereby place himself in a position to contract famine, as well as that which considers it the disease. All people living under these imported from the outside by infection, will conditions, i.e. a greater or lesser part of the have to be modified; the former in such a way population, is in this situation from the start; that the endemic typhus had gained epidemic everyone who comes from the outside, every development on account of the famine, the latter, stranger, who is subjected to endemic that this had occurred by mutual infection. It conditions, is liable to become infected. Let us must be remembered that one opinion does not give some examples. In Rome, malaria is exclude the other. The local physicians also endemic; the inhabitants suffer from it very

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much; every foreigner who neglects the Potsdam, in Rybnik. necessary precautions, especially at night, can 7. Dr. Glum, pensioned physician from the contract malaria. In New Orleans, yellow fever medico-surgical Friedrich Wilhelm Institute at develops in certain seasons; everyone who Berlin, in Rybnik. moves to northern areas at the right time remains 8. Dr. Scholler, pensioned physician from the free; everyone who comes to the city can fall ill. same Institute, in Loslau. It is thus with cholera in India, with the plague 9. Dr. D mmler from Berlin, in Chelm. in Egypt, with the tropical fevers on the coasts 10. Dr. Stich, government physician for the of Guinea. poor in Berlin, in Pless. Now it is a fact that many physicians, 11. Dr. Tichy from Berlin, in Pless. clergymen, and monks hospitaller contracted the 12. Dr. Mittmann, head military physician at disease while carrying out their professional Ohlau, in Rosenberg. † obligations in Upper Silesia. I here list the 13. Dr. R hle from Berlin, in Rybnik. names of those physicians that were affected in Further, Upper Silesia who are known to me, as I feel 14. Prince Biron of Courland, delegate of the that the medical press has the duty to maintain in Breslau Committee, in Rybnik. † public memory the great sacrifices which the Although this sad list is long, it proves medical profession makes to society in respect to nothing as to the contagiousness of the disease. health and life without any expectation of And if every single local and foreign physician obtaining the laurels of the soldier or the medals had fallen ill nothing whatsoever would follow of the diplomat. from that fact alone. Could not anyone who visited the patients in their lodgings have been A. Local physicians exposed to the same conditions to which the l. Dr. Kries in Rybnik † patients were exposed? What if a society had a 2. Dr. Raschkow in Loslau spirit of sacrifice that would make every 3. Dr. Babel in Pless member put his hands into the fire; would one 4. Dr. Chwisteck in Sohrau then conclude from the circumstance that 5. Dr. Boss in Sohrau everyone had suffered a burn, that the one first 6. Surgeon Preiss in Rybnik † burnt had infected the others? Certainly not! The 7. Surgeon Haber in Rybnik fire would be infectious, but not the people. 8. Dr. Goldmann in Rybnik Thus as long as it is possible to explain the 9. Dr. Krieger in Ratibor † illness of the physicians from the primary 10. Dr. Lemonius in Beuthen endemic cause, these facts cannot be regarded as (11. Dr. T rk in Loslau, in the summer of an argument for the contagiousness of the 1847) disease. The same holds true for the clergymen and B. Foreign physicians the hospitallers. Nothing that I have been told in 1. Dr. Kuh, Prof. of surgery at Breslau in this respect is valid. I am giving some examples Rybnik. as they were told to me: The parson of Deutsch- 2. Dr. Neumann, Assistant at the provincial Weichsel had died of typhus, and his colleague lunatic asylum at Leubus, in RadIin. Franz Grossek from Staude undertook to put his 3. Dr. Biefel, military chief physician at estate in order and to take over his ministrations. Breslau, in Rybnik. The daily and nightly efforts arising from the 4. Dr. Borchardt from Breslau, in Pless. assumption of these duties exhausted him in the 5. Dr. von Frantzius from Danzig, in Sohrau. extreme; he was already feeling very ill and had 6. Dr. Steinberg, military chief physician at to be carried to his sledge while still attempting

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to bring religious comforts to these patients. He monks occurred from exactly that particular took to bed on the following day and died 3 days patient, since they had dealt with so many later (compare Die Hungerpest, p. 75). Two patients? True, one generally hears, not only hospitallers who had nursed him, and the parson from epidemiographers but also from of Czwiklitz, a close friend of his who had again practitioners who had fallen ill during the visited him, contracted typhus soon thereafter. A epidemic that, from a peculiar shock to the man from the parish of Boguschowitz, who nervous system and a sudden horror or disgust worked in the Teschen area near Freistadt, during the examination of a certain patient, they where the disease had become epidemic, fell ill had all of a sudden realized that they had after his return and died very quickly, after "his become infected. Nevertheless, I cannot admit face had become black." The parson of B., who such a feeling to constitute scientific proof. I am had administered the sacraments to him was not aware of having felt any petty fear when stricken immediately afterwards and died within facing infectious patients, but I have never a few days, with petechiae. Surgeon Preiss from scoffed at the possibility of infection. However, Rybnik, who treated him, thereupon fell ill and I remember very well, particularly during the died of the disease. Archpriest Ruska from initial period of studying the Upper Silesian Rybnik, who gave him religious consolation, epidemic, that I was overcome several times by was stricken twice, consecutively, with a gastric such a dread or distaste during the direct and fever. The archpriest of Sohrau who had given close examination and palpation of patients. As the sacraments to many patients fell ill and died in addition I suffered from quite acute gastric 4 days later. Many people attended the funeral. troubles, headaches, etc., for several days, I did One of these, who had carried his coffin, died 3 suspect infection; had I really contracted the days later. Among those who attended the disease I would probably have been inclined to funeral were the smith of Baranowitz and his date contraction from the moment of overt wife. The latter who had been quite well up to distaste. If thus the infection of physicians and then became ill, insisting that she had caught the clergymen can hardly ever be traced back to a malady from the corpse of the dean, and died 3 certain patient, we may assume only the general days later; the smith also fell ill and recovered possibility of infection and the most powerful only with difficulty. argument against this is the endemicity of the I was told this by reliable but uncritical causes. persons. It was no longer possible to check In Sohrau, public opinion indicated exactly the various facts in all cases; but importation of the disease from the comitate of whenever it was possible to do so inexactitudes Wadowicz in Galicia through a Jewish trader by were soon apparent. Thus, for instance, I had the name of Prager. His infection was said to found it very remarkable that in the last case have been kept secret and to have been death had occurred so early, since I had gained propagated to other Jewish families by infection, the conviction that death only occurred between its presence becoming known only when it the 9th and 14th day. Dr. Sobeczko, who had extended to other inhabitants. Mr. Kunze, the treated the archpriest, accidentally remembered district physician, had immediately checked on that he had already felt ill on the Wednesday, these rumors and had found that at the time had first taken to bed on Sunday and died on when the Jew fell ill, the inhabitants of many Tuesday. Assuredly such established houses of Sohrau had already died out. This is inaccuracies significantly diminish the reliability the extent to which one may rely on such tales. of the other points. Moreover, how could it even Let us now consider the two examples remotely be taken for sure that the infection of which are regarded as especially conclusive. I the physicians, clergymen and the hospitaller quote them verbatim from Mr. Durant's report:

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"On the 8th of December 1847, after in Sohrau and he was her nearest heir. His typhus had already been rampant in many inheritance consisted of the bedding on houses of the villages of Brodek and Roy, in which the deceased had died. Pozimorski particular in those of the latter village, a took the bedding to Paulsdorf and hung it up cow was stolen from the village of in the attic. As he feared it might be stolen Paruschowitz, with clues leading to those there he brought it into his room a few days two villages and raising hopes of finding the later and placed it behind the stove. One thieves there. Constable Dolezych followed night his son used the bedding and very soon the clues to Brodek and there arrested Joh. fell ill with typhus. Within 3 days 7 houses Machel, a man under police observation, became infected in the colony, which up to and then, in Roy village, Franz Chylla, a that time had been perfectly healthy." man also under police observation (the These cases, which at first sight appear wives and children of both men were abed conclusive, do not stand up to critical with typhus), and brought the two arrested examination. In the first group we see that five men to the guard room of the municipal persons from villages where typhus was council in Rybnik. In the following night he prevalent were taken away from their families repeated his search in the village of Roy and which were also sick, and brought to Rybnik, arrested Martin Machel, Franz Motzka and partly to the municipal guard room and partly to Joseph Strongek, who had taken flight and the jail of the court of justice. In the former they escaped the previous night, and also came in contact with nightwatchmen, municipal brought them to the same prison. Then three soldiers, and so forth; in the latter with other of these prisoners were transferred to the prisoners. They themselves, as well as these prison of the Royal County and Municipal other persons, fell ill. Afterwards the prison was Court of Justice at Rybnik, and there fell ill cleaned by the wives of the affected night with typhus, infecting all inmates, of whom 6 watchmen, and they in turn contracted the died in short succession. Typhus had also disease. These are the facts. The conclusion broken out at the city prison, and on the drawn from them was that these five persons had 19th of December Constable Dolezych fell already become infected at home or had brought ill, and a few days later privates Paczek and along with them a contagion which they Swientek and municipal sergeant Walter transmitted to all persons who came into contact who had all been present in the guard room. with them, and that the contagion had Moreover, the night watchmen Franz established itself In the jail so well that the Sollonz, Carl Leschnig, Koch, and Jacob women engaged in cleaning it had in turn Rarzellick also fell ill, of whom the last acquired the infection. This conclusion is quite named died. All had been present in the arbitrary. It is not proved that those five persons guard room. I ordered the disinfection and had brought the disease with them, and it is quite cleaning of the guard room, after the possible that they, as well as the remaining prisoners had been taken out. Of the 2 prisoners, only contracted the infection in women who did the cleaning, Antonie Koch prison. Had typhus not been present in Rybnik at fell ill on the second day and Marianne that time it would be easier to disregard this Sollonz on the 4th day, to which I may add possibility. However, according to the inquiries that they were the wives of the night which I made, a chimney-sweep had the disease, watchmen and had already had typhus and in a printer's house all inmates were ill with previously." typhus; in this latter family the wife and the “Smith Pozimorski lives in the colony of daughter had first fallen ill, later the father who Paulsdorf. An aunt of his had died of typhus took care of them had taken to bed and died. It is

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equally hard to see why the wives of the night have occurred in the different families or houses watchmen should have contracted the infection at an interval of 14 days, provided that one did in the prison, as they had the best of not regard the disease to be infectious during its opportunities of contracting it at home from their whole course, in which case no conclusion was sick husbands. Moreover, the speed with which to be expected, and no investigation was the infection and diseases are supposed to have possible at all. In the houses I could not confirm succeeded one another contradicts all other an assumed 14 day interval between infections; observations. That lastly the night watchmen and observations on the infection of foreign the municipal soldiers should have contracted physicians directly contradicted this, as Dr. the disease in prison and from the prisoners is Biefel, for instance, was in the district for 9 days very doubtful, since they could as well have only (19th-27th of February) when he fell ill. contracted it without such contact, as had been Lastly, we must list the facts which directly the case with the other inhabitants in Rybnik. speak against contagiousness. As I have already The second case is even less convincing. The said, the local physicians believed that the Upper smith had not contracted typhus, although he Silesian typhus of the previous years was also had brought the bedding from Sohrau; his family contagious. Mr. Haber, who had treated patients had remained free from the disease, although the in the mining district of Rybnik, in the military bedding was in the space behind the stove. From hospital as well as in their homes for 11 years, the fact that the son fell ill soon after having rejected the possibility of an infection from the slept on the bedding for one night and that then cadaver, of transmission of the disease through seven houses had become infected within 3 clothes, etc., and only accepted transmission of days, it does not follow that the son was infected the disease from man to man in the living from the bedding and that the other inhabitants quarters of the people, as he had never witnessed of the colony contracted the disease from the son direct infection in the military hospital, where in so short an incubation period. None of this typhus patients in all stages of the disease shared can be proved in any way. common rooms with other patients. Up to my Let us now turn to the other criterion of departure from Sohrau the last mentioned fact contagiousness. In nearly all contagions, still applied to the military hospital. A few other especially in the exanthematic diseases, there is patients lay among the typhus patients in an incubation stage of generally constant common wards, for instance one with frozen duration. The question now arose whether such a feet. But the disease befell none of them. 16 period of latency of the disease could be However, it is clear that the assumption of demonstrated in Upper Silesian typhus. My contagion taking place solely inside the home is inquiries of the physicians at first seemed to quite arbitrary. It is but the ontological formula show that this, actually, was the case and that the for the fact that transmission from man to man incubation period lasted from about 14 days up has not been observed, whereas residence in a to 3 weeks. If this was correct we should have house where people had fallen ill was observed had a state of affairs similar to that so to be the cause of the disease. But this fact rather fortunately detected by Panum (this Archiv, I, p. constitutes an argument against contagion and 492) in respect to the measles epidemic on the for the endemicity of the cause. Several of the Faro Islands, even though one could not expect physicians affected traveled to other places at an connections to appear in such purity, as the early stage of the disease, going through its conditions of traffic are much more diverse and course in Breslau, Liegnitz and Berlin. To date I infections would definitely cross. In general one have not heard of any infection starting from might have expected that, with an incubation them in these places. period of 14 days, the disease should always Summarizing all these facts we can only say

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that up to now there are no facts available which which is always cropping up in regard to the prove contagion, and that, on the contrary, contagiousness of abdominal typhus, by stating certain observations are against it, and that that the typhus contagion consisted in a miasma nearly all processes that have been adduced newly developed from the typhus patient, could be explained by the endemicity of the whereby the difference in opinion becomes cause of the disease. Unfortunately, physicians rather one of expression than one pertaining to are as yet not well accustomed to scientific the subject itself. This seems to me the most methods; they are too submissive to instructions fruitful remark contained in his book which has by the authorities, too devoted to dubious been diligently assembled but has become rather considerations of probabilities, to make an exact unpalatable due to its hodge podge of analysis of proofs. In natural science it is the hypotheses, strange ontologies and facts. custom, and the only logical way, not to Experience indeed shows that the incitement of consider anything that has not been proved. In disease in a new individual only takes place at a medicine it is the custom to consider everything certain intensity (concentration of the substance that has not been disproved as being correct and causing the disease) and duration of action, and meriting consideration. Nowhere has this that the degree of the affection stands in a direct principle become more solidly established that relation to the degree of incitement, and that the in the doctrine of contagious diseases, and it efficiency of the contagion is reduced in the takes the most tenacious of fights to move the measure of its dissemination (dilution). As opponents step by step from their traditional regards the last point in particular we have ground. Do not the medical historians go so far available most interesting detailed data in in the defense of old traditional opinions as to Bertog's description of a typhus epidemic which place the arbitrary assumption of writers dating was rampant in Halle in the spring of 1844 back three or more centuries above the (Diss. inaug. de typho Halis vere anni 1844 painstaking observations of new researchers! As observato. Halis, 1844). The observations made if the authority of physicians who believed show most unquestionably that the typhus phthisis, malaria and cancer to be contagious contagion differs essentially from the contagents could adduce the slightest of proofs for the of the true eruptive diseases (smallpox, scarlet contagiousness of petechial typhus, plague and fever, measles), of syphilis, etc., in that in these yellow fever! This genteel manner of criticizing latter there is no blunting in contagiousness by the living experience of daily observation from dissemination, no increase of contagiousness behind the green tops of desks and out of old when increasing the amount of transmitted books must at last stop! substance, transmission taking place by even the If I thus leave open the question of smallest particle of the causative substance. contagiousness of the Upper Silesian typhus Nevertheless, I would not separate the contagion until the day when we shall have direct of typhus from contagia in general, as Riecke evidence, I would like to stress that I do not wish has done, but I would on the contrary, point out to deny it categorically. That typhous affections that the contagious diseases have been treated can become contagious is indubitable. from too one-sided a point of view. These latter According to unquestionable observations, the should be divided into at least three large war typhus, the English typhus, even abdominal groups. The first includes those diseases which typhus (compare Louis, II, p. 368) are always and without exception propagate only by transmitted from man to man under suitable transmission from one individual to the other, conditions. Riecke (Der Kriegs- und such as, in particular, syphilis and the acute Friedenstyphus in der Armeen, Potsdam, 1848, exanthemas, in which the changes in the skin p. 63) has tried to dispose of the controversy, have a critical significance. The second group

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includes those diseases which are caused by the moving atoms, then it would befit such a transmission and propagation of animals and mechanical view that the extent of the internal plants from one individual to the other, i.e. the movement should correspond to the impulse, helminthiases, scabies, perhaps thrush and that the force of the latter would be gradually probably favus. The third group, finally, weakened by the resistance and the inactivity of includes diseases which develop in animal matter and, by chemical attractions, and that the bodies under certain conditions but are then extent of the movement caused should thus stand transmitted to other bodies from the first foci of in an inverse relation to the distance, to the development. Under these I classify the catarrhal extent of the movement. Such a simple theory and the diphtheritic inflammations of the definitely would not apply to syphilis and to mucous membranes, of which the former in its smallpox (compare my essay on puerperal intensive forms consists of blennorrheas diseases in the Verhandl. der Ges.f. (gonorrhea, blennorrhea of the eyes, leukorrhea), Geburtsh ϋlfe, Vol. III, p. 162). Accordingly, if also nosocomial gangrene (typhus traumatique), anyone spontaneously and miasmatically the various typhous affections, puerperal fever, contracts typhus, and others contract the disease glanders, anthrax and rabies. This group of from him by infection, and others again from the affections is generally counted among the latter in such a manner that the intensity of the miasmatic contagions but not rightly so, as disease decreases with every member in the blennorrhea, glanders and rabies can only be chain, one should not conclude, as does Riecke, traced to miasmas by force. The various that typhus does not develop a contagious agent, members of this group show a number of but only that typhus is contagious in another differences from one another, but they are all way than are syphilis, smallpox, etc. alike in that the disease can develop Some have thought that the contagiousness spontaneously. Concerning their contagiousness, of the disease was in direct proportion to the it would be wrong simply to transfer all extension of the skin eruptions, and believed that observations made on infectivity in the first petechial typhus was distinguished from group to this group. I remind the reader of abdominal typhus by these two features. Thus Magendie's successful inoculation of a dog with Hecker (Geschichte der neueren Heilkunde, material from a man infected with rabies, the 1839, p. 161), writing from the historical and dog then biting two other dogs which became ontological standpoint, stated: "The critical similarly rabid (Journ. de Physiol. Vol. I, p. 42). significance of the spotted rash and an almost But the efficiency of the poison then ended. This plague-like (!) infectivity are the essential observation is directly connected with the fact characters of petechial fever, and only when that, in typhus, the infection cannot be continued these characters occur together it is justifiable to endlessly. Rabies and typhus (also glanders?) assign the putrid fever of our recent times to this thereby differ significantly from syphilis and form of typhus." According to these criteria the smallpox, in which transmissibility has no limit. Upper Silesian typhus would hardly be classified In the former the causative substance, the as petechial in the historical sense, for we have contagion, is exhausted quantitatively, in the seen that the skin eruptions coincide with the latter every particle, even the smallest, remains exacerbation of the symptoms of the disease and fully infective. Liebig's well known theory of have usually already disappeared before the contagion thus would completely fit rabies and crisis, and that contagiousness is not established the typhous affections. For, if contagion consists with certainty. Nevertheless it can hardly be in the transmission of the internal movement in doubted that this epidemic entirely corresponds the atoms of the causative bodies to the atoms of with the concept of petechial typhus as another susceptible body by the impulses of the understood in the past decades, i.e., with the

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morbus peticularum of earlier authors. As developing, if not dysentery, as has been regards the relationship between exanthema and recently observed in Ireland and in Scotland. contagiousness, I would like to add that when I Now we have explained earlier that the afflicted raised this question at the meeting of physicians Upper Silesian peoples primarily took their in Rybnik, Mr. Kunze, the district physician, substitute food from the vegetable kingdom, and considered the cases with exanthema to be more we would, therefore, rather have expected to dangerous and more infectious, whereas Dr. find scurvy among them to be more prevalent Raschkow stated that he had seen cases as than typhus. These are the reasons that seem to severe and infectious without exanthema. speak against the view that typhus can be Enough on the question of contagiousness. I directly derived from the famine. have not dwelt on some of the information I was One could, however, suppose that a famine given, such as the dissemination of the disease in which mainly vegetable substitutes are used by beggars, or the contamination of whole might cause typhus under certain climatic households and families, because it was too conditions. Such a possibility should not be vague to prove anything, and, in part, could be rejected off-hand, as typhus epidemics are interpreted in a sense opposite to that given. definitely connected with climatic conditions Thus, only the relation of the epidemic to the and in certain places almost regularly recur at famine now remains to be discussed. certain seasons; and also because at the very If by famine we understand a condition of time when typhus became epidemic in Upper the body social whereby there arises a mere Silesia, it also had reached epidemic reduction in food, though to any assumed degree development elsewhere. I have already of severity, then the development of typhus can mentioned above that this was the case in all in no way be derived therefrom. Simple neighboring Austrian provinces. How similar reduction in food can only cause emaciation, that typhus was to the form flourishing in Upper weakness or finally a typhous condition. But Silesia is evident from the descriptions of the starvation can occur in such a way only in single epidemic seen in Prague. In the general hospital individuals or in a small group of persons. A real there the dysentery prevalent up to August 1847 famine, apart from the reduction in the usual receded, typhus gaining the ascendency in foodstuffs available, always entails the September-October (when 113 new patients consumption of more or less indigestible or were taken in and mortality was 1 : 14.6) and in noxious surrogates. To the extent to which November, by which time dysentery had wholesome food becomes rare, people attempt to disappeared altogether. All cases exhibited replace it by unwholesome foods. Now, can such profuse exanthema, usually a moderate delirium, unsuitable foods cause typhus? This indeed constipation and in general only a slight seems to be the case. In the literature we find a involvement of the abdomen, the disease taking number of examples in which the consumption a rapid and mild course. Sometimes of putrid meat, the drinking of water mixed with convalescence was prolonged. The fatal cases decomposing animal substances (e.g. where the usually came to a close in a few days, the wells and latrines were too close to each other cadavers showing no changes in the intestinal and their contents had been mixing) caused canal. The disease could be recognized only smaller epidemics of "typhus." However, all from the character of the blood (?), acute tumor these examples only indicate the possibility that of the spleen, and in certain cases by lobular animal substances in the process of chemical pneumonia; in some of the cases that occurred in modification are capable of causing the typhous August an added dysentery was the cause of process. Wherever mainly vegetable substances death (Prager Vierteljahresschrift, 1848, V, Vol. have served as substitutes, we rather find scurvy II, analecta, p. 119). The numbers of deaths in

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Prague from the 16th of December 1846 up to constantly on chest and abdomen, great that same date in 1847 was 5,192, which, in a prostration, high fever and severe affection of population of 120,000 inhabitants, corresponds the brain (Gaz. méd. de Paris, 1847, Oct., No. to a ratio of I : 23 (Gaz. des Hôp., 1848. Febr., 42). In Scotland too the epidemic was of huge No. 15). Dr. Götz, head of the municipal extent. In Edinburgh, in the period from June to hospital at Danzig, wrote to me on the 14th of October 1847, 887 cases were admitted to the April of this year: "Since February, when the fever hospital by way of the municipal offices catarrhal diseases (influenza, measles) declined, for the indigent alone; of these 485 died, we too have been kept .busy here by a gastric corresponding to a mortality of 54.6% (Lond. fever of a moderately epidemic character Med. Gaz., 1847, Oct.). Thus everywhere we befalling a population rather similar to the find the same emergency and distress, the same Silesian in its poverty and distress; in its course neglected and, for the most part, bigoted this affection increasingly assumes the purely Catholic population, the same typhus. Further typhous form (always with roseola, rarely with information is not available to me at the present petechiae), and has the peculiarity that beside time. the morbid blood crasis there occur practically In my opinion, the influence of the climatic only local affections of the respiratory organs conditions on health can no longer be interpreted (catarrhs and pneumonic infiltrations of the lung as it was in the past by medical meteorology. If tissues). Only in such cases is our fever fatal. we consider the subject according to the present The intestinal mucous membrane is always state of science, we can theoretically admit three healthy." At the same time the region of possibilities as to how the weather may affect Flanders is being decimated by typhus, and the the human body: deprivations of the population were regarded as 1. Indirectly, by affecting the conditions on the cause of this "terrible" disease (Gaz. Méd., the surface of the earth, the water content of the 1848 , Febr., No.6). Even in Brussels the disease soil, vegetation, the chemical transformation of prevailed to such an extent since the beginning vegetables and animal substances present in and of this year that the mortality was as high as that on the soil, etc. in the cholera epidemic of 1832 (ibid., Jan. 2. Directly, in that the temperature of the air, No.4); nearly 60 physicians have already died in its water content, pressure, and perhaps the Flanders as victims of their zeal and their aerial electricity influence the processes of devotion (Gaz. des Hôp. 1848. Febr. No. 13). animal economy (metabolism). The situation is quite similar in Ireland. 17 In the 3. Also directly, the air currents carrying province of Ulster alone 27 hospital physicians with them foreign substances, foreign in their contracted the disease of whom 14 died (The mixture. Lancet, 1848, Febr. I, 8) Mr. Rodier and Mr. Those authors who have discussed the Guénau de Mussy, who had been sent by the relation of disease to change in the weather have French Government to study the epidemic, both usually considered only the second class of fell ill and the latter died. In the autopsies no effects; the first one has been mentioned only in changes were found in the intestines; only rarely passing, while the third one as far as I know has was the spleen enlarged or softened. The most been neglected altogether. For this reason I frequent condition found was venous hyperemia propose to give it some attention now, so as to of the pia mater, sometimes accompanied by make clear my views. edema. The disease usually ran a course of 9-11 The air currents which pass over the surface days, with frequent relapses; characteristic of the sea take away with them not only water symptoms were especially red or blackish vapor but also carry off salt particles, as is the petechial spots, which were found most case, on a small scale, in the salt works

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(compare Rhenius, Diss. inaug. de atmolutro blowing from the direction of swampy areas, muriatico apud salinas. Berol., 1841). When the and it seems to me that great epidemics of air currents come into contact with large malaria, such as the epidemic of 1847, which surfaces of loose sands, particles are lifted and extended from Holland deep into Poland over carried to great distances, over many degrees of the plains of Northern Germany also denote latitude, as has been demonstrated by the studies analogous conditions. of Ehrenberg on the remains of siliceous shells If we approach our typhus epidemic from of infusoria in the dust deposited. If, finally, such a viewpoint we cannot assign a direct gaseous products are present from the start, it is influence upon the disease to any type of air self-evident that they are mixed in the current. As we have seen, the epidemic already atmosphere and follow its movements. The fine began in the summer of 1847 and soon reached a work of Dove on the law of rotation according to great intensity in various places during a season the points of the compass has shown that the in which western winds were prevailing. In movements of the atmosphere do not only Loslau, however, the disease broke out with consist of waves or vibrations of otherwise eastern winds and reached its peak during the stationary layers of air but also that there always severest cold. In Sohrau the epidemic began to are two sorts of current in more or less regular subside in January and the first half of February, succession, a lower one which carries cold and and it was hoped that it would stop in milder dry air from the poles to the equator and a higher weather. But exactly the opposite occurred. As one which brings warm and humid air from the the air, in the presence of equatorial currents, tropics to the poles. The winds from the north to reached a relatively high temperature the the east are polar, those from the south to the number of patients again increased. The west are equatorial, those lying in between are simultaneous epidemic occurrence among the more or less deflected by the collision of these Czech and Polish populations in the Upper two currents. Accordingly, the polar currents can basins of the Elbe, the Oder and the Vistula, convey to us products from northern countries among the Cassubes on the lower Vistula, and the equatorial currents products of tropical among the poorer population of Flanders, areas. The latter are more important, as the Ireland and Scotland prove nothing since the tropical sky is the actual site of chemical country in between these areas remained free. decompositions. Thus, if for example, one does Although on my return from Upper Silesia I was not wish to regard cholera as a contagious shown a few patients with alleged petechial disease it seems to me that there is no other typhus at the Charité Hospital in Berlin, these alternative than to explain its progressive definitely were cases of abdominal typhus, dissemination from east to west by such partly with petechiae (extravasates), and partly equatorial air currents charged with tropical with very extensive roseola; of two dead patients products. Thus it could easily be explained how which had been so diagnosed, one, on autopsy, the cold of the last winter has hindered the showed an acute miliary tuberculosis and the progress of cholera in Russia and ultimately other extensive pneumonia. caused its extinction, for there exist similar and Both occurrence and intensification of the even more striking phenomena in other places epidemic have been observed in different places, too. Mr. Halleur, missionary in the Gold Coast, and under varied climatic conditions. Thus the told me that in Ashantee the "climate fever" whole question hinges upon the point of the stopped at once with the advent of a peculiar contagiousness of the disease, which wind, the Harmattan. We observe a similar state unfortunately has not been settled. For if one of affairs, on a smaller scale, with malaria that could definitely assert that the disease was not arises on high rocky terrain, when the wind is contagious, one could also directly conclude that

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it had not been caused by climatic conditions of were years of famine, but they did not bring any sort; but if, on the contrary, it was epidemic fevers which, however, raged in the contagious, then its first development might years 1728-31, although 1729 was so rich a year, have depended on atmospheric changes, while that a writer at that time could incriminate the its further dissemination and increase could have intemperate consumption of food products of been independent of them and could have been animal origin as the cause of the disease. In the determined by the general conditions of great epidemic of 1740-41 the fever was already contagiousness only. As I am not in a position to very widely spread before want became decide on this dilemma, I limit myself to attempt pronounced. The severe epidemic of 1817-18 a judgment on the indirect or direct influence of was already most prominent in 1815 when food the atmosphere. was still abundant. In 1815 the fever hospital in Up to now we have no reason to assume that Cork Street, Dublin admitted more patients than modifications in atmospheric conditions (i.e. its in 1817, despite the fact that the preceding year content of water vapor or water droplets, had had a poor crop, the crop of 1817 being temperature, pressure, electrical potential) can better, and that of 1818 excellent; nevertheless, directly create typhus, and even though one the epidemic persisted with increasing violence. hears frequently enough that someone has The epidemic of 1826 subsided in the middle of contracted the disease by exposure to cold or a famine, that of 1836-37 appeared before the getting soaked, it is well enough known what beginning of famine. The diarrheas and such ananmestic information is worth. But we dysenteries which preceded the last epidemic must evaluate quite differently the indirect effect (1847) and first began in the autumn of 1846 of atmospheric changes on the body, and we markedly diminished in frequency during the need only refer to our earlier communications winter, as starvation reached its peak, to return (p. 340, 348) to select for the purposes of the in the spring of 1847 without any perceptible present discussion that meaning which in our cause. The critique applied by the medical opinion it merits. historians themselves not infrequently turned out If, however, one grants such an atmospheric to be too indulgent on account of their desire to influence on the production of the typhus place their information on a broad and general miasma, one thereby admits that starvation, basis. See Hecker on diseases prevalent in 1770. whose relation to the epidemic has particularly After a very bad harvest in that year, epidemic concerned us, will assume a lesser importance. disease broke out in a great part of Europe which That the question of the connection between bore the character of simple typhus (petechial famine and typhus could have assumed the typhus, spotted fever). Because of its prominence it now has assumed has a historical topographical interest for our epidemic, I reason. From the position taken up by the emphasize from among these an epidemic that medical historians such a connection would have broke out in Bohemia and which was described to be answered in the affirmative, since terms by Sagar (Historia morbi epid. in circulo like "hunger fever," "hunger typhus," "typhus Iglaviensi et adjacentibus regni Bohemiae plagis famelicus," "famine fever" are most common observati annis 1771-72). In Bengal, too, after appellations among them. But this is but another repeated bad rice harvests, a famine broke out at of the traditions which has not stood the test of the end of that year (1770), the like of which is contemporary critique. Henry Kennedy (Gaz. not known in recorded history, and which, méd., 1847 , Oct., No. 42), by his compilation of together with a devastating smallpox epidemic, all fever epidemics which have stricken Ireland wiped out 3 million people, i.e. 1/3 of the total for over a century, has provided certain proof of population, within a few months. At that time its untenability. The years 1725, 1726 and 1727 cholera was not present anywhere in Bengal.

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The only epidemic of which we have heard was the year or whether changes take place during that of smallpox, already mentioned. Hecker that same year. (Expressed differently, for the (Geschichte der neueren Heilkunde, p. 120) puts temperate zones this would mean that the it as follows: "It is certain that, in the course of development of plants stands in a certain relation the famine, epidemics of common diseases were to the amount of warmer and more humid air raging among the people; and we may assume carried to them by the equatorial currents, and to with equal certainty that, as a result of drought the precipitation of the water vapor they contain and putrefaction, there prevailed not only by their collision with cold polar currents). If, malignant swamp fevers but also typhus with accordingly, a famine can be ultimately traced to liver affections, as well as dysentery in its most the type of air currents, then the development of virulent form." If this, however, had actually a typhus epidemic, if it really were a coeffect of been the case we would have had information on the same cause, could be reduced to the same it as surely as we have on the smallpox conditions that produce the famine; and if those epidemic; and Hecker's assertion that his conditions are manifest by excessive dryness or assumptions are well founded is the more excessive moisture, we must ask whether the uncritical as it probably arose only from an former or the latter or both are capable of inclination to generalize, which, though causing typhus. From the considerations I have understandable in a historian, is nevertheless discussed in the chapter on endemic diseases, it inexcusable. follows that too much moisture may be regarded Although it can be demonstrated that famine as an indirect source of typhus, and the and typhus do not necessarily stand in a causal relationship of famine and epidemic typhus relation, I would not like to support Kennedy's would then consist in that both can be direct opinion that the simultaneous occurrence of both consequences of the prevalence of certain air was an accidental coincidence. The logical currents but that both coincide only, i.e. are mistake that was made in my opinion merely simultaneous, when the air currents carry with consists in that reflections on these causality them a relatively large amount of moisture. In relationships have been limited to the two this way one could explain that in 1770, in factors mentioned, without taking into Bengal, typhus did not break out, since the consideration that both might be coeffects of the failure of the crop that had caused the famine same basic cause. Hecker in his views on the was due to persisting heat, while in Europe epidemic has, however, implied this possibility typhous diseases broke out everywhere by paying great attention to the conditions of the simultaneously with the famine after steady atmosphere and the soil. But this was not very rains had been pouring down in torrents. fruitful, because his exposé was more artificial Davidson (loc. cit., p. 77) assembled a large than natural, more imbued with the sense of number of facts from which it would appear that natural history than that of science, more the typhous affections used to reach their widest historical than medical, and because with distribution in Great Britain and Ireland when somewhat uncritical erudition, he evidently there was much rain. He did, however, also threw together a number of phenomena which provide statistical evidence, from Glasgow, have nothing to do with one another, finally against the assertion that in the cities typhus arriving at a confused mysticism regarding an developed mainly on the banks of the rivers. But "impulse pervading all life." I cannot regard the question as settled, since, A famine is usually caused by bad harvests, especially for Halle, facts just as definite speak which in turn are caused by too great and in favor of it. Hartung (Diss. inaug. de typho persisting drought or humidity, whether the Halae autumno anni 1841 observato. Hal., weather has such a character during the whole of 1842, p. 9) as well as Bertog (loc. cit., p. 13)

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reported that, in Halle, typhus first appeared on housing, in short, the changed mode of life were the banks of the Saabe in two epidemics, with not the main causes. Davidson has suggested mention of the crucial circumstance that the this for the epidemic of 1837, and I would like to disease broke out in houses with the lowest add that the coincidence of peak infection with location. The manner in which climatic the lay-off of the working men might possibly conditions had shaped up in Upper Silesia in be accidental. For in Dublin, which, as I know, 1847 has already been indicated above, in is not an industrial city proper, conditions were particular how extensive and long-lasting quite similar. In the fever hospital in Cork rainfall had followed on a period of intensive Street, 9,508 patients were registered in 1837, heat and how, accordingly, the food crops had while in 1836 the number had been only 7,658; failed to mature (the potato blight being the largest number of registrations (1,105) especially widespread). Similarly, Fracastorius occurred in May. Mortality reached its peak (14 reported that the epidemic of 1528 was preceded ¾ %) in the same month, when prevailing winds, by so warm and rainy a winter that many according to meteorological tables (G.A. streams flooded their banks; mist exerted so Kennedy, Med. Rep., pp. 3,40,87) blew noxious an action on plants that the buds principally from the west. spoiled, especially those of the olive trees. 18 One might further ask in which way the The question of the causal relationship of typhus miasma that we have assumed is the typhus epidemic to the famine would thereby produced by the humidity of the atmosphere or be settled, were it not for a further objection. of the soil. Some years ago a very similar English authors, in particular Alison and Cowan question was raised in France which, as far as I have stressed the influence exerted by economic know, has never been answered. Assalon, a slumps on the dissemination and severity of physician in Dieuze, reported to the Academy typhus. In 1836, 10,092 persons contracted (Gaz. méd. 1845, No. 29, 32) that in the years typhus in Glasgow; in 1837, after the outbreak from 1829 to 1843 there occurred in the area of the trade crisis, 21,800 persons fell sick; the where he lived alternating epidemics of greatest mortality in that year occurred in May, intermittent fever, typhoid fever and carbuncles, after 8,000 persons had become breadless in in a regular 3 year sequence, and that depending April as a result of the suspension of work in the on the periodical clearing out (exploitation) of a cotton mills (Davidson, loc. cit., p. 87). After the swampy pool which was formed by the lower slump of 1842, 1/6 of the poor in Scotland were Indre river. In the year when it was dry, there affected by the fever, without any involvement prevailed carbuncles; in the second year, in of the middle and higher classes of society. In 2 which the water again collected, malaria; and in months more patients had contracted the disease the third year, when it was again filled with than in the preceding 12 years. In Glasgow, in water, typhous affections. These indications 1843, 32,000 persons were stricken by the fever, were contested by Gabriel (ibid., No. 36) and to i.e.12% of the population, of whom 32% died. my knowledge, the controversy was never (Engels, Die Lage der arbeitenden Klasse in settled. The contradiction between the law of England, 1848, p. 126). These facts are so Boudin and the observations of Mr. Haber as to striking that they cannot be countered, but it the relationship between the amount of water would be mistaken to conclude from them that and the formation of typhus I have already starvation directly causes typhus. It can be mentioned above (p. 369-370), and this related to the increase in mortality, but the important point must therefore be left open for production of typhus and its dissemination could the time being. Theoretically, however, it is only be traced back to starvation if it could be more probable that only a certain moderate shown that the food and food surrogates, the degree of humidity, known to best stimulate

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decomposition, would be suitable for the which are most crowded and where there formation of the typhus miasma, since in the last prevails the greatest poverty (Anderson, loc. cit., resort we must derive it from products of p. 13). Riecke (loc. cit., p. 37) reported many chemical decomposition. instances of typhus epidemics which broke out From the sum total of experience that we in circumscribed localities and can only be have gained with regard to the development of ascribed to the type of lodging. Davidson, on the typhus, it is not probable that the typhus miasma other hand, has assembled many facts meant to builds up everywhere on the surface of the earth show that typhus is caused neither by putrid or even everywhere on cultivated areas in the effluvia, nor by the exhalations of the human way that the malarial miasma develops in body, nor by dirt and impure air in closed rooms, swampy areas. The formation of the typhus but that these are only conditions of its miasma may be observed most surely and dissemination; he does not seem disinclined definitely in closed rooms, in overcrowded always to attribute the original development of military hospitals, in prisons, work-houses, on such local epidemics to the importation of the ships; and, since we have shown above, how contagious agent. However, the only conclusion greatly the habitations of the majority of the that can be drawn from all these facts is that Upper Silesian population resemble such putrid effluvia, exhalations by persons, etc., do localities and how they comprise all factors not suffice to cause typhus under all conditions making for the deterioration of the air, the only and those who have built the entire etiology of item left to be discussed is to what extent the typhus on this basis have been in error. weather or the housing is to be considered Davidson quotes, among others, the authority of responsible for the disease. the famous and most meritorious Howard, who The great influence of housing on the state did not believe that prison typhus should be of health of the inhabitants is shown in the attributed to a lack of fresh air and cleanliness. statistical tables. Holland, who was officially Everyone will gladly concede that these are not entrusted with investigating conditions in the absolute conditions for the formation of the Chortton-on-Medlock, a suburb of Manchester, typhus miasma, since nearly every pathologist found that mortality in streets of the second class has further postulated an unfavorable relation was greater by 18%, and in those of the third between the space available and the number of class greater by 68%, than it was in those of the persons living in it, i.e., a collection of many first class; further, that in the houses of the persons confined in a relatively small room. second class mortality was greater by 31%, and Howard (Nachrichten von den vorz ϋglichsten in those of the 3rd class by 78%, than in those of Kranken-und Pesthäusern, Leipzig, 1791, p. the first class; and that mortality in the inferior 411) sees the true cause of prison fever in the streets which had been improved, was reduced sudden changes in feeding regime and type of by about 25% (Engels, loc. cit., p. 134). The two lodging. But even if one might quote in favor of main diseases causing this mortality were such a view the general experience that in the tuberculosis and typhus. With respect to the hospitals of cities, a significant number of latter, most of the English reports, in particular, typhus patients are those very persons who have show quite definitely that the disease was most only recently changed their place of residence prevalent among that population which is poorly and have moved to the city, one cannot, on the lodged. Nearly half of the patients taken in at the other hand, deny that the change as such fever hospital in Glasgow came from the explains nothing, but that only the peculiar type outskirts of the town, 4/10 from the city proper, of the new conditions, the character of the new 1/11 from its surroundings. The actual foci of food and the new dwellings should be regarded the disease within the city are those localities as significant. For not every sudden change in

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food and lodging is capable of causing typhus must investigate under which conditions they do. and only if the new food is bad and the new Since we have previously discussed in detail the dwellings are unsuitable can those factors be influence of humid weather, since we have incriminated as the cause of the disease. Change pointed out the influence of poor and especially may have a certain significance, but at any rate of overcrowded lodgings, we may now be bold the poor quality of the items exchanged is the enough to conclude that the combination of main thing. Basically, Howard's data express these two factors in conjunction with bad food, nothing else but what I have stated in the chapter unsuitable clothes and lack of cleanliness are on endemic diseases of Upper Silesia. If, with able to create the typhus miasma. Davidson, all epidemically occurring typhous When many persons are crowded into a affections were attributed to importation, to relatively small space the air will gradually be contagion, or, more exactly, to the direct changed by their breath, the effluvia of their transmission of an already existing disease, we skin, etc. Exact studies on this point are as yet would ultimately have to deny the spontaneous lacking. Some observations by Robert Smith development of sporadic typhus. But the annals (Philos. Magaz., 1847, Jan., Dingler's Polytech- of medicine have preserved a sufficient number nisches Journal 1847, July, p. 106) may serve as of examples of the latter. Of these I only wish to a preliminary introduction. In the fluid which point out one from the English literature itself, had condensed on the windows of a hall during a which Davidson will not be able to refute. The concert, Smith found 1% of dry residue; on typhus epidemic which broke out on the ships of evaporation, the liquid emitted a strong odor of the Niger expedition and which was described human sweat and, on heating the residue there by MacWilliam and Prichard surely had a arose an odor like burnt meat, from which one spontaneous origin. This expedition, whose real may conclude that it contained a nitrogenous purpose was completely thwarted by the substance. If, as is mostly the case in Upper outbreak of that disastrous epidemic, has now Silesia, there are added to these substances the acquired a great importance for the very reason exhalations of the animals which void their that it has provided a precise experiment for the excrement into the room and whose feed covers spontaneous development of typhus. As soon as the floor, when to these are added the gases the ships had passed the mouth of the Niger the rising up from the fermenting food stuffs (Zur, epidemic broke out, striking man after man, and sauerkraut), and the vapors of cooking, etc., the ending with the total infection of the crew. What degree to which the air is fouled will be easily further proof do we need? A large number of realized. Nevertheless, we are not justified in persons are placed under the same conditions considering these conditions sufficient to cause simultaneously and all fall prey to the same typhus. Assuredly a second factor is needed. disease, epidemic typhus, the nature of which, Such a factor I am seeking in the warm and on the basis of autopsies, cannot be doubted. moist air which sustains and stimulates the Having convinced ourselves that not only typhus chemical decomposition already begun. as such, but even an epidemic of it, can develop Such warm and humid air can be led to spontaneously without direct transmission of a Northern areas by an equatorial air current and contagion from the outside, it must also be we then shall witness the outbreak of typhus conceded that it would be most arbitrary always under the prevalence of Southern and Western to object by raising possible importation in every winds in a relatively warm season. Such a epidemic, when the absolute isolation of the relationship will best be able to develop at the patients cannot be unquestionably proved. If we height of summer, when the sun is in its further find that putrid effluvia and the like do northernmost position, and when the shores of not produce typhus under all conditions, we the Mediterranean Sea fall within an enlarged

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zone of tradewinds (Dove, in Poggendorf's diseases are affected first and most severely. Annalen, 1846, No.2, p. 259) and when, in our Closer investigations have shown that especially country, their encounter with the northern those worst housed suffered most. According to current produces a rainy season with variable Engels (loc. cit., p. 85), Senior described a street character. In this manner we could explain the in Manchester that followed the course of a ditch typhuses of summer and of the beginning of so as to obtain deeper basements without the autumn, which would find their most conclusive costs of digging (these cellars to be used as analogy in the typhus that breaks out under living quarters for people), and on this street not tropical skies (e.g. the Niger expedition). The a single house escaped cholera. In regard to the case must differ in winter typhus, when it is not plague epidemic of 1841 Pruner (loc. cit., p. the natural warmth and humidity of the air nor 390) reported that, in the Nile Delta, the that reflected by the ground which acts, but the epidemic moved from east to west, bypassing artificial conditions in the lodgings that result some villages or groups of villages and being from excessive heating, cooking in the room, the most severe in areas which were low and lying cohabitation of many persons, the humidity of along the Nile. In Cairo, strikingly, the low lying the floors and walls, etc. This, then, would humid and crowded houses of the Jews and constitute a view resembling that held for certain Christians were those particularly affected, epidemics of plague by earlier authors, for especially if they were exposed to the South instance by Samoilowitz with regard to the wind and shut off from the North wind. In Upper epidemic in Moscow, which has recently been Egypt the plague was observed only in certain taken up again by Pruner. very unsuitably situated places, among poor ilI- It therefore lies within the limits of nourished people. We thus see that under certain permissible speculation to assume that the basis general conditions, which we can only consider for the formation of the typhus miasma is given as depending on the climate, the quality of the when warm and humid air is maintained under housing does indeed constitute a determining such living conditions. By this we do not intend factor for the development of these diseases, to say that the miasma can develop in no other while the dwellings in themselves would not way. On the contrary, from the view that all have produced such diseases. The history of the conditions mentioned should only be considered typhus epidemics themselves provides the most as particularly suitable conditions for supporting useful data in the matter. I shall only refer to the chemical decomposition of a special nature, it recent Torgau epidemic of 1843. In it the disease follows that this same decomposition can occur first erupted in the barracks among the military under the most various conditions, but that the who were housed in inexcusably poor quarters. basic conditions, which will later be understood 50 days later it broke out among the remaining from a further analysis of these situations, must population, 21% of the soldiers falling ill, but always be the same. I also do not wish to assert only 4.3% of the civilian inhabitants of Torgau, that the question has been exhausted by the while from among the farmers and people factors enumerated and that there might not working in the open air no one was affected possibly exist a third or fourth factor in order to (Köppe, Der Abdominaltyphus in Torgau in complete the sequence of conditions. This much, 1843 , p. 23). Riecke (loc. cit., p. 160) has tried however, seems to be certain: the development to explain this state of affairs solely by a miasma of typhus cannot be derived solely from the developed from latrines, but he forgot to explain nature of the dwelling, as might be illustrated by why the epidemic broke out among the soldiers a comparison of the observations made with in Hartenfels Castle at that very time, since the cholera and plague. As is well known, it is in incriminated latrine had always been there. He particular the poorer classes which in both might perhaps have found such an explanation,

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directly or indirectly, in the climatic conditions; cause of the disease, as little as the latter If we transpose Köppe's report (p. 19) into the depended solely and alone on the weather. language of recent meteorology, we see that Since the disease is endemic, its cause must during April, when the epidemic reached its also be endemic, and the cause for its epidemic peak among the soldiers, the Torgau area was appearance cannot be an altogether new one, but the site of a struggle of polar and equatorial air only an aggravation of the old one. We have currents which met one another with violent assumed a particular miasma to be the endemic electrical discharges and precipitation of water cause, which was a product of chemical and which alternatively displaced each other, so decomposition that occurred when the that in the first half of the month there prevailed unwholesome circumstances resulting from the south-western currents and in the second half mode of life of the inhabitants in their dwellings north-eastern currents. It is quite possible that are intensified under certain climatic conditions. even such knowledge of meteorological Accordingly, we have always felt obliged to conditions is not yet exhaustive, that a few seek the cause of an epidemic in such an factors must yet be added to the sources of that intensification of domestic insalubrity and to typhus. Later study must elucidate this point. In attempt a refutation of opposing views. the meanwhile we emphasize only that we have We, moreover, have recognized it as recognized two different factors as important. probable that such a miasma, i.e. a substance Applying these observations to our undergoing a chemical reaction (movement of epidemic, in case later studies should atoms), a chemical agent, reaches the body, demonstrate the contagiosity of the Upper poisoning the blood and causing a series of Silesian typhus as a fact, the course of the secondary changes in the life processes, in the disease could be understood to have run as nutritive processes as well as in the nervous follows: The first cases occurred when, at a system. We, however, protest against the view relatively high temperature, and as a result of the that the infection of the blood must persist for collision of polar and equatorial air currents, the entire duration of the disease, and we have rains fell in great quantity; these at the same pointed out that the only demonstrable changes time caused a famine by impairing the occurred in the blood cells (i.e. multiplication of development of plants used for food; they also the colorless corpuscles), changes that we have promoted various processes of chemical defined as a derangement in tissue formation. decomposition, exposing the inhabitants who In order to illustrate our opinions in a more were crowded in unhealthy dwellings to concrete manner, we shall present yet another conditions that favored the contraction of the analogous example. It is known that gonorrhea disease. Later in winter the epidemic developed patients using copaiba balsam will show various to extreme intensity when, on account of the symptoms. Ricord ( Gaz. des. h ōp. 1846, May, severe cold, the inhabitants stayed in their No. 59; 1847, Oct., No. 128) distinguishes houses, which they overheated stiflingly, even mainly three effects: a revulsive or purgative more, retiring behind their stoves. From then on effect, a general effect depending upon changes the disease might perhaps have spread to the in the blood, and lastly a direct antiblennorrheal wealthier classes by infection. Accordingly, effect, due to the passing of certain constituents starvation and typhus were only an indirect of the drug into the urine. If we analyse this coeffect of the same cause (the weather); more exactly, we find that the balsam first acts starvation might have increased the as an irritant on the surface of the intestinal predisposition for the disease, reduced the mucous membrane, causing increased secretion resistance of the nervous system and increased and movement. According to the suitability of the mortality, but starvation was not the real the conditions for an emulsive dispersion of the

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balsam, resorption by the chyle vessels will take transient presence of etheric oil in the blood is place and the drug will then reach the blood. quite sufficient to explain the symptoms, though Whether it there causes other changes than those not too short a presence, for we see that the more due to its mere presence we do not know, but we completely, and the earlier, the drug is excreted perceive, by the changes in the nervous system by the kidney, the less prominent are the other and in the processes of nutrition and secretion, effects. These hints will suffice to illuminate that its presence becomes evident. Among the clearly the analogy with typhus, which I former processes Ricord particularly mentions intended to demonstrate so as to show in severe congestion of the brain which can particular to what extent the assumption that intensify up to hemiplegia; among the latter we typhus miasma is a (volatile) chemical substance must mention an exanthema of the skin in can explain the manifestations of typhus and will addition to the modification of kidney secretion. allow integration of the positive observations of But the true classical and regular form of the pathological physiology. copaiba exanthema is a roseola that appears preferentially at the joints, always on the side of Endnotes the extensor, next to the ears and at the back of 9. The physicians in Breslau had placed a black the neck, especially in spring and autumn when tablet with the inscription ‘typhus’ in front of his house. the weather is cold and humid, after the first few 10. The Goralles are inhabitants of mountainous doses of the drug. According to Ricord the regions (gora = mountain) travelling in foreign exanthema appears in particular when any direct countries and trading with dried fruits and antiblennorrheal action is absent. In his view, similar items. They are characterized by their the aromatic principle then goes through the skin peculiar costume (narrow trousers, large flat hats, brown raincoats) and by their fine figures. and is absent from the urine. But if it takes the 11. The most recent issue of the Medicinishe latter path there sometimes occur severe lumbar Vereinszeitung (Nr. 16) publishes a letter by Dr. pains starting in the kidney area, i.e., there is a Adloff from Pless in which he states, with regard manifestation of an inflammatory irritation of to the results of the autopsies: “In all cases there these parts. The exanthema commonly was a bloody infiltration in the whole intestine, th though particularly so in the ileocecal area. I disappears on the 8 day after administration of found ulcers only once, but not as large ones as I the drug. have often seen them in other instances.” This We here have a simple so-called drug report which deviates from all previous disease. A balsam that contains a volatile etheric experience is so obscure and so dubious in its brevity that I cannot take it into consideration. oil is introduced into the body and causes “Bloody infiltration” cannot mean anything but symptoms in the intestine, in the brain, on the an infiltration of hematin in the tissues caused by skin, in the kidneys, partly directly and partly decomposition, for no one has ever seen indirectly; we see in particular the appearance of extravasate through the whole intestine andno an exanthema the phenomenology of which one would call capillary hyperemia an infiltration. ‘Ulcers’ per se are not significant, as shows the greatest agreement with the catarrhal ulcers are well known to exist. Reports exanthema of typhus. It surely cannot be of this type only have value if they are disallowed that a part of these effects at least scientifically exact. depends on the absorption of that etheric oil by 12. All authors who have written about “typhoid the blood and on a poisoning of the blood. But it fever” have discussed the changes in the blood at a lesser or greater length; but they are generally would be wrong to conclude therefrom that there agreed that, at the present level of science, we existed a further modification in the consistency are not very advanced in this study (Jaquot, Gaz. of the blood and especially a change that would Méd. 1845, August, No.33). (Transl. from the persist for about those 8 days during which the French). exanthema is present. A relatively short and 13. Zeller, in Winnenthal (Zeitschr. F. Pyschiatrie, 1844, I. 1,p.61) stated: “It seems increasingly

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probable that the conditions of the mucus is disregarded, the expression loses all sense. A membrane of the intestinal canal has a greater storm which rages in the upper layers of air, influence on the general feeling of well-being driving before it the clouds, is like the disease and indisposition, on the tonus of life and on which is supposed to proceed in the blood, like exhaustion, than that of any other tissue, and that the internal movement which forces the blood- other pathological conditons of the brain and constituents apart or together to form new spinal cord are most easily reflected in it.” substances and combinations. But when the 14. Anderson (loc. cit., p. 20) stated: “The eruption storm comes nearer to the surface of the earth, is necessary to constitute the disease; other uprooting trees, damaging houses and smashing symptoms may be absent.” In Glasgow, among ships to pieces-has it then become localized?-not 2,852 cases he found exanthema 1,885 times = at all; it blows over the surface, devastating 80%. Roupell gave the ratio in London as = everything that cannot resist its power, and only 70%. Cowan in Glasgow as = 73.99%. Chomel after a long time and in the far distance is its in Paris as = 77% (compare Davison, loc. cit., p. power broken. 32ff.). If the exanthema is frequently not seen, 16. Dr. Stich, who has just come back from Pless, one should remember that patients very tells me that at the military hospital in the frequently only come under medical observation Hechlowska near Pless a nun of the order of St. at a time when the exanthema has already faded. Elizabeth of Thuringia, who had come in contact 15. I would here like to criticize an expression which with patients only, had contracted typhus. This we have heard from the followers of craseo- would be the first fact supporting contagion with ontology to the point of nausea. It is said of a certainty, if the information as to her contacts series of diseases, arbitrarily derived from a were confirmed. humoral basis, that, when no local symptoms 17. According to a compilation published by Cusak were present, they were proceeding in the blood, and Stokes in the Dublin Medical Quarterly there and when local affections were present, that they died, in 1847, 178 Irish physicians out of a total had become localized. Thus, according to this of 2,700, i.e., 6.74%, and among these were view, if anybody swallowed hydrocyanic acid 64.51% who had died of typhus. From an and died of it, the disease (i.e. poisoning) would average of 10 years, the mortality from typhus in have proceeded in the blood. But what would be Ireland was 1 : 10.59, but among the physicians happening in the blood, if anyone fell on his it was 1:1.55 (The Lancet, 1848, Febr. 1, 7). head and died (due to a concussion of the brain)? 18. This agreement is particularly interesting, as this It should not be forgotten that the entire series of epidemic showed great similarities with the symptoms, for instance those of a typhus, might Upper Silesian one in another point also. As in be initiated by a poisoning of the blood, but that the latter, a very long preliminary stage was all later processes might then be triggered from observed, sometimes without any suspicious the nervous system affected by the substance symptoms; Fracastorius relates that Andreas produced, long after this substance has been Naugerius, a representative of the Republic of excreted from the body and the blood has again Venice, came to France to the court of François become purified. Then, however, the disease Ist at Blois on the River Loire and there was mainly proceeds in the nervous system and not in snatched away by the disease, which was still the blood. Why all this localization? If it is to quite unknown in that country, within a few have any meaning whatsoever, one should only days. take into account critical localizations; since that which becomes localized, is necessarily removed from the blood. If this simple logical conclusion

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