Wednesday, February 27, 2008

Medical Depart #12 - Typhus Wasn't There

As promised, I am following up my post last week about Dr. Margaret Humphrey's latest book, Intensely Human: The Health of the Black Soldier in the American Civil War (John Hopkins University Press, 2008) with the interview I did with her in late 2006 regarding her interesting research on typhus in the Civil War. Enjoy!

by Jim Schmidt
from the September 2006 issue of
The Civil War News

“The records do not furnish a single instance of undoubted typhus as having occurred among our troops in the field…typhus was fortunately a stranger to our camps.” - Medical and Surgical History of the War of the Rebellion

Consider a disease spread by body lice among people weakened by malnutrition, huddled together for warmth, and deprived of clean clothes or frequent bathing opportunities. One would suppose that the Civil War’s overcrowded prison camps, North and South, would have provided an optimal environment for the disease to spread. But it didn’t!

The disease in question was typhus, and in her recent article, “A Stranger to Our Camps: Typhus in American history” (Bulletin of the History of Medicine, Summer 2006, Vol. 80, No. 2, pp. 269-90), Margaret Humphreys, M.D, Ph.D., provides an excellent review of the disease in American history with a special emphasis on the curious absence of typhus in the Civil War’s camps and prisons.

Dr. Humphreys teaches medical history at Duke University. She has focused her research and publications primarily on tropical diseases, particularly yellow fever, dengue, typhoid and malaria, and has a particularly interest in infectious disease in the Old South. She is the author of numerous articles and two books, including Yellow Fever and the South (Rutgers, 1992).

In addition to her own work, she is currently Editor in Chief of the Journal of the History of Medicine and Allied Sciences. Her current research, the history of medicine during the American Civil War with a special focus on the health of the black soldier, will be published in a forthcoming book from John Hopkins University Press.

Dr. Humphreys admitted to her great fortune in having a job that combines her two loves: history and medicine, and traces that interest to her youth. “I grew up in West Tennessee and went to Fort Donelson with my Brownie troop,” she told me, adding: “so the Civil War interest has always been there, but it’s only in the past few years that I have turned to it professionally.”

Dr. Humphreys also told me that much of scholarly American medical history ignores the Civil War, or doesn’t know what to do with it. For example, in her book on yellow fever, she stopped at 1860 and started again at 1875. She thinks one reason for this gap is that researching medicine in the war requires careful study of entirely different set of primary documents and a different approach than most medical historians are used to.

Dr. Humphreys’s article begins with an introduction to the biology of typhus. Typhus fever is caused by the bacteria Rickettsia prowazekii and is spread by the human body louse. The louse sucks the host’s blood, taking in the rickettsia with the blood meal; the bacteria then multiply in the louse gut and are expelled in the feces. When the louse moves to a new human host, microbes in the feces can penetrate the new victim through skin broken by itching. It spreads rapidly in conditions of crowding, cold, and poverty.

Typhus manifests itself with the sudden appearance of fever, headache, and intense pain in the bones and joints, and as the disease progresses it can also lead to delirium and coma. After about a week, a rash of small red spots appears, which can then develop into painful bedsores. If the patient survives, the illness is usually over within two weeks. What distinguishes typhus is its dramatic mortality: epidemic typhus kills 10 to 60 percent (or even more) of its victims, while related diseases, like Rocky Mountain spotted fever (caused by R. rickettsii), kill at most 5 percent.

The bulk of Dr. Humphreys’s article discusses the appearance and history of typhus in North America, beginning with its appearance in Mexico after the Spanish conquest and a possible outbreak during the American Revolution among British sailors anchored off the American coast. Historical reports of the disease can be difficult to interpret because of confusion about the differences between typhoid and typhus which resulted in crossed or misdiagnoses. In the 1830’s, American William Gerhard found that he could distinguish between the two fevers based on changes in the gastrointestinal tract observed during autopsies.

Despite the advances in photomicrography and pathology made by Joseph Woodward during the Civil War, autopsies were still relatively rare, and in fact there were more than 2,500 reported cases of typhus among Union troops, with more 900 deaths. Experts at the time, however, questioned the statistics and noted that diagnoses of typhus became rarer as the war went on.

How could period physicians and surgeons be so sure that typhus wasn’t present in the camps and prisons in the absence of laboratory evidence and in the face of conditions that seemed ripe for the disease? One clue would have been a tragic mortality rate, especially among caregivers. Dr. Humphreys notes Dr. Charles Smith’s entry in the Medical and Surgical History that had typhus gained access to the camps, no search of individual records would have been necessary. As Smith put it, “The death-roll of our medical officers and hospital nurses would have been sufficient.”

In 1867, Confederate surgeon Joseph Jones wrote even more adamantly about the lack of typhus, noting that he made a comprehensive examination of prisons, hospitals, and camps during the war and concluded that “No case of true typhus fever came under my observation…” He spoke especially of what he called the “great experiment” at the Andersonville prison camp, supposing that “if typhus existed anywhere in the Confederate States it would be found at Andersonville and especially amongst the foreign elements of the Federal armies, which had been but recently imported from the bogs of Ireland…”

Dr. Humphreys finishes the article by considering explanations for the peculiar absence of typhus in the Americas above the Rio Grande, and concludes that there is no obvious answer: it might have been simple luck, differences in clothing manufacture (cottons instead of wools) between America and Europe, and inherited immunity from European ancestors, or even an inefficient American louse. Whatever the reason, we can be thankful that typhus wasn’t added to an already-too-long list of diseases that ravaged soldiers, North and South.

Those wanting to learn more about the role of infectious diseases in American military history might start with a special supplement to the April 2005 issue of Military Medicine, the official journal of the Association of Military Surgeons of the United States (AMSUS). The issue was devoted to the “History of U.S. Military Contributions to the Understanding, Prevention, and Treatment of Infectious Diseases,” and includes no less than eleven articles on vaccines, malaria, sexually transmitted disease, and other diseases that have plagued the American soldier, sailor, and Marine throughout history.

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