Typhoid Fever In The Medical Casebook

 

This Week

This week our sample chapter is on typhoid fever. A good number of the book's chapters are on infectious disease. As you would imagine, most of these were grim diseases in the Victorian age – medical disease was just starting to understand how infections were spread, but we are many decades before the advent of antibiotics.

 

Typhoid Fever 

Typhoid Fever + Sherlock

We return yet again to “A Study In Scarlet” for our main references to typhoid fever in the canon. 

Whilst investigating the murder of Enoch J Drebber, Holmes grills the police constable who found the body, John Rance.

“Presently – maybe about two or a little after – I thought I would take a look round and see that all was right down the Brixton Road. It was precious dirty and lonely. Not a soul did I meet all the way down, though a cab or two went past me. I was a-strollin’ down, thinkin’ between ourselves how uncommon handy a four of gin hot would be, when suddenly the glint of a light caught my eye in the window of that same house. Now, I knew that them two houses in Lauriston Gardens was empty on account of  him that owns them who won’t have the drains seen to, though the very last tenant what lived in one of them died o’ typhoid fever. I was knocked all in a heap, therefore, at seeing a light in the window, and I suspected something was wrong. When I got to the door –”

And a little later.

“Ye see when I got to the door, it was still and so lonesome, that I thought I’d be none the worse for someone with me. I ain’t afeared of anything on this side o’ the grave; but I thought that maybe it was him that died o’ the typhoid inspecting the drains which killed him. The thought gave me a kind o’ turn, and I walked back to the gate to see if I could see Murcher’s lantern, but there wasn’t no sign of him nor of anything else.”

Holmes rewards the constable with a half-sovereign for the information, along with some rather brutal careers advice.

“I am afraid, Rance, that you will never rise in the force. That head of yours should be for use as well as ornament. You might have gained your sergeant’s stripes last night. The man whom you held in your hands is the man who holds the clue to the mystery, and whom we are seeking. There is no use of arguing about it now: I tell you that it is so. Come along, Doctor.”

There is an interesting evolution through the books regarding Holmes’ relationship with the police. Initially he is rather scathing of their efforts, as here, but he does develop an appreciation for how they work, and becomes more diplomatic in his dealings with them. 

There is also a brief reference in “The Valley Of Fear”, as part of the back story of John “Jack” Douglas”. His friend and house guest, Cecil Barker, is being interviewed by Holmes and Inspector MacDonald, after the apparent murder of Douglas.

“How long were you with Douglas in California?” asked Inspector MacDonald.

“Five years altogether.”

“He was a bachelor you say?”

“A widower.”

“Have you ever heard where his wife came from?”

“No, I remember his saying that she was of German extraction, and I have seen her portrait. She was a very beautiful woman. She died of typhoid the year before I met him.” 

I’m also going to include a reference to enteric fever in this chapter. Typhoid fever is a form of enteric fever, the other main disease in the group being paratyphoid fever [a very similar disease]. 

Enteric fever has the distinction of being the first disease to be mentioned in the stories, on the very first page of “A Study In Scarlet”. Here we get the immediately captivating backstory of Dr John Watson. Following his injury by a jezail bullet in the Second Afghan War.

Worn with pain, and weak from the prolonged hardships which I had undergone, I was removed, with a great train of wounded sufferers, to the base hospital at Peshawar. Here I rallied, and had already improved so far as to be able to walk about the wards, and even to bask a little upon the veranda, when I was struck down by enteric fever, that curse of our Indian possessions. For months my life was despaired of, and when at last I came to myself and became convalescent. I was so weak and emaciated that a medical board determined that not a day should be lost in sending me back to England. I was despatched, accordingly, in the troopship Orontes, and landed a month later on Portsmouth jetty, with my health irretrievably ruined, but with permission from a paternal government to spend the next nine months in attempting to improve it.

All of our references to typhoid fever demonstrate the seriousness of the disease in Victorian times – a disease that would strike fear into a hardened London policeman, kill a beautiful wife, and cause the medical hero of our stories to be invalided home with ruined health. 

 

Typhoid Fever In Victorian Times 

Enteric, gastric, infantile remittent and pythogenic fevers. The contagion is conveyed by drinking water, milk, and perhaps by the atmosphere or from the soiled linen of patients by direct contact; hence the importance of general and personal hygiene. Sewage, sewer gas and bad drains are other harbourers of typhoid. [5] 

Typhoid fever is another fascinating disease for the book, as the understanding of the disease was changing rapidly through the Victorian period.

Readers may well have heard of John Snow [no, not the Game of Thrones character!], who traced the source of a cholera outbreak in Soho to a single water pump, and stemmed the outbreak by removing the pump handle. But a lesser known figure in the history of epidemiology is William Budd, an Edinburgh University graduate like Conan Doyle. His work on the spread of typhoid fever predates that of Snow. In 1847 he showed that an outbreak of typhoid in Clifton, Bristol, could likely be traced back to water drawn from a single communal well. He is credited with lowering the annual deaths in Bristol caused by typhoid fever from 2000 in 1849 to 29 in 1866.

In 1874, a Polish scientist, Tadeusz Browicz, was able to see a bacterial bacillus microscopically in the faeces of typhoid sufferers. His work was continued by Karl Joseph Eberth, a German pathologist, who wrote a ground-breaking research paper in 1880. He not only managed to isolate the bacterium in 18 of 40 typhoid cases, but also used “control” cases to demonstrate that victims of other diseases did not have the bacterium present.

I love that Conan Doyle managed to fit some typhoid fever epidemiology into his first story. The concept of the ghost of the typhoid victim haunting the drains that killed him is brilliant.

Conan Doyle was known to be highly interested in preventing the spread of infectious diseases, such as typhoid fever. He volunteered as a medic in the Boer War, and subsequently wrote an article on enteric fevers for the British Medical Journal [26], strongly advocating better prevention of water-borne diseases, and also typhoid immunisation.

The invasion is insidious, marked by headache, malaise, listlessness. Then there is fever as much as 105°, cough with bronchitis, diarrhoea with pea-soupy stools, large spleen, gurgling in the right iliac fossa, tympanites, rose coloured spots chiefly on the abdomen. The temperature rises slowly in staircase fashion, there being an evening rise of two degrees, with a morning fall of one, until the end of the first week. [5]

Haemorrhage from the bowel may occur during the first week, but it is then usually slight and due to mere congestion and irritation by food; its dangerous period is during the third week, when the sloughs are separating from the ulcers. Perforation is another great danger during the fourth week. A fall in temperature usually attends severe haemorrhage and perforation. [5]

Death may occur from asthenia, neurasthenia, perforative peritonitis, or pyaemia.

Sequelae are very common especially constipation, “after fever” and slow recovery of speech and brain functions. Phlegmasia dolens, nodes on the long bones, abscesses, parotitis, phthisis, anaemia, and wasting are not infrequent. [5] 

There are a lot of terms in this section to explain, some of which I had to look up myself. Tympanites is a term for flatulent distenson of the belly [“like a drum”]. Asthenia is just a term for physical exhaustion, whereas neurasthenia is nervous exhaustion. Pyaemia is an old term for what became septicaemia, and has now become the catchier sepsis. Phlegmasia dolens is what we now call a deep vein thrombosis [DVT].

In no other disease have so many drugs been brought forward as specifics, and, nevertheless, none can be accepted as such. The same general rules must be, therefore, observed as in the management of other infectious disorders. Free ventilation, cleanliness, careful dieting, and good nursing, are more to be trusted than drugs. There is no doubt, however, as to the value of reducing the heat of the body by means of cold sponging and baths, but they must be frequently repeated in order to be of any real use. The bath is much more efficacious than sponging, but at the same time it requires a staff of well-trained and intelligent nurses, which it is impossible to provide in small hospitals, or in the houses of the poor. [6]

Purgatives and solid food must be prohibited. The nursing is the most important part of the treatment, because judicious feeding is more than half the battle, and the other half consists in avoiding accidents due to the unreasoning acts of the patient; sudden movement, getting out of bed, or straining have to be prevented, the bed pan must therefore be systematically used, or what is better, where expense is no object, a sheet of compressed sphagnum moss, which soaks up all the fluid passed by the patient, may be placed in a suitable position and removed and burnt when necessary. [5]

Plain milk should not be given, but it should be guarded with barley water and should be boiled. Condensed milk properly diluted, vegetable soup carefully strained, mutton broth or veal tea skimmed, whey and weak beeftea or Brand’s essence, raw meat juice, are suitable articles of diet, and these may be thickened with Mellin’s food, gelatine or other malted foods in strict moderation. [5]

In hospital practice see that friends do not surreptitiously introduce food, for mistaken kindness often induces them to yield to the solicitations of the patient. [6]

Where much headache is complained of you may keep the head covered with cloths wrung out of cold water. If the pain is very violent at the early stage of the fever you may apply a few leeches to the temples. [5]

Haemorrhage should be treated by perfect rest and avoidance of effort, the stools being passed into napkins; opium should be given by mouth. Gallic acid, turpentine, acetate of lead, and ergotin are other remedies. An ice-bag over the right iliac fossa and iced water rectal injections are also employed. [5] 

Again there is lots in this treatment section meriting comment.

I really like the emphasis on the importance of nurses in managing the disease, as the profession doesn’t get a lot of mentions in the Victorian medical texts.

Using sheets of compressed sphagnum moss as incontinence pads seems incredible, but sphagnum moss was commonly used for stemming menstrual blood at the time. The Sphagnum Moss Company of Portland, Oregon, used a nurse called the Sphagnum Moss Girl to advertise their premier product, the catchily titled Sfag-na-kins.

Finally we have the usual terrifying list of medicines used when the patient becomes really sick. Opium, turps, lead, LSD [ergotin is a precursor] and iced water rectal infections are a horrifying selection of treatment options.

 

Next Week

We will have a look at rheumatic fever, continuing our current theme of diseases that are largely now historical. Rheumatic fever was a very important bacterial infectious disease in the past, as it potentially led to a range of serious complications. Though we still see plenty of disease caused by the same bacteria, the complications are now very rare, and we don’t entirely know why.

 

Buying The Book 

The Medical Casebook of Sherlock Holmes and Dr John Watson is available from all good bookstores including Amazon USA, Barnes and Noble, Amazon UK and additional formats like Kindle.