Clinical Observations on Endemic Typhus (Brill's Disease) in Southern United States

History, Rats, Fleas, and Opossums: The Ascendency of Flea-Borne Typhus in the United States, 1910–1944

“…Maxcy reported that African Americans rarely contracted the infection; for example, in Savannah, GA in 1920, only 2.2% of the cases of FBT were observed in African-Americans, even though they comprised 47% of the population [96]. A similar racial disparity was also noted in series from AL in 1935 and 1943 [31,98].…”

“…On the other hand, when he analyzed the cases with respect to the place of employment, he saw a higher attack rate in persons working in groceries, feed stores, and restaurants. From these observations of seasonality, absence of household transmission, and transmission within food establishments, Maxcy proposed a rodent reservoir and transmission by fleas, mites, or possibly ticks, but not by lice [96]. The conclusions of Maxcy are considered to be classic examples of epidemiologic inference [97].…”

“…Maxcy correctly surmised that the available laboratory evidence (i.e., WFt positivity) "testifies to the identity or very close relationship of the etiological virus [of FBT] with that of Old World typhus." [96].…”

An Outbreak of Endemic Typhus Fever in Nashville, Tennessee—Its Epidemiology and Control

“…During the first two months of 1940 and prior to the time control measures had been completed in Area 2, 3 cases occurred among employees of a freight depot in that area. During the summer and autumn of 1940, 4 cases were reported from the immediate section around Area 1, and 7 cases from the immediate territory around 4. One or the other of three foci in the city was determined as the probable source of infection for 70 cases.…”

“…The erythematous lesions did not become definitely petechial or hemorrhagic except in 2 patients. It has been stated 4 from observations elsewhere that the rash becomes petechial in the severest cases. In Tennessee it appears that a petechial eruption is an exception rather than a rule.…”