THE ET IOLOGY

TY PH O I D FEVER

AND ITS PREVENT ION

0

00 0

‘ING 10 0 . oMI ‘L'

E'

OI'

MLECTURES

DELIVERED AT THE ROYAL COLLEGE OF PHYSICIANSIN

W. H CORFIELD ,M.A F.R.C.P

HON.

OONSULTING SANITARY ADVISEB TO OFFICE OF WORKS. AND

monsoon or aroma : Annpunno Em u : u m am : mu ms.

Lemma ; PBI SlDlN'l’ or m nmm onoowu . 80mm or mxo o x ;

pu t-91m m? or m 8001111 or m xcu om ens orm u n; won-Pm mm 0: m su m“? xxs

‘n'mu50m m m m“. m ow or Pm aox: com et. om w

"m m: n’noxsm ”a m m or m ROYAL soon" or mw c m m or ” Low :

nosou u m m 0: 1m: tsoe or new“ or ru se: u m or nu :Humm u s: soon-n or m mo nu ns ; u oxonu r oou u rom o

m m 07 111: turn. AW 07 m m : or snows .

or 133 m m com o: m um“oroo xsu m onx, m or m I OYLL mea nor Emm a or “AL?

ta ww or m m ien. ao c mr or sww w .

LONDON

H . K LEWIS. x36 GGWER STREET. W.c

TABLE OF CONTENTS.

LECTURE I.

Typhoid v . Enteric

Histo rical , Murchison

Chi-istOpherMayr’s Work onTyphode FeversMayr’s W W W (Table I.)Mayr’s Five Species o f Typhus (Table II.)Phthisis clam d by Mayramong fevers

DescriptionofMayr’s five species of typhusMayr’s view of contagionHildenbrand on typhus feverHildenbrand on overcrowding

Louis ’ Work on Typhoid FeverTyphus and typhoid fevers distinct from one anotherGendron on typhoid epidemics insmall placesContagiousness o f typhoid fever

Ohomel's work on typhoid feverVarious names o f typhoid fever

Impossibility of tracing contagionin large citiesGaultier de Claubry

’s memoir onthe d iflerences

.betw en14. 15

Typhoid rash simulating typhus rash 14Montault's memoir on the d iiferenoes between typhBonillaud ’

s definition of typhoid feverLombard’s investigations

Gerhard and Penno ok’s ditto

Barlow’s paper on The Distinc tio n

Stewart on same subject

15. 16

16

17

17

17. 18

between Typhoid

18. 19

19.2930‘ 21

vi

pass

William (afterwards SirWilliam) Jenner on the IdentityorNon-identity of Typhoid and Typhus Fevers 22-25

William Jenner on the d ifierentcauses o f these diseases 25

Typhoid fevercontagious 25

Murchisonon the etiology of continued fevers 26-28

Murchison on the cause of typhoid fever . 28

Murchison onthe incubation period o f typhoid fever 29

William Budd ontyphoid fever 29

SirThomasWatson’s views . 29

Budd on the contagiousness o f typhoid fever 30

Tyndall’s view on the contagiousness o f typhoid fever 30The Author’s paper Onthe Alleged Spontaneous Pro

duction o f the Poison o f Enteric FeverThe poison is particulate

Contagious ornon-contagious ?Dimculty of tracing typhoid feverNotself-generating

LECTURE II .

Predisposing causes 34

Outbreaks connected withym ralW oond fiim 35-38

Whitehaven , Grantham, and Debenham, by Dr.

Bristowe 35.36

Bridport, hy Dr. Bu chanan 36

the reduction o f typhoid by public improvements 36, 87Winterton, Lincolnshire. by Dr. Theme 37

during 1870-73Selborne, Hants, by Dr. Blatall

Outbreaks at Runcorn, byMr. Spear ; Hatfield, Broad0ak, by Dr. Richmond ; and Widnea by Dr. BruceLow

P olluted Water as a cause o f typhoid

Festiniog, by Dr. Buchanan ; Harpenden , by

Dr. Hunter . 38

Guildford, by DrBuchananSir John Simon’s observations onditto 40,

Dr. Buchanan’s observations onthe period of incubation

SirJohn Simon on polluted water .

Ou tbreak at Wieken Bonant, by Dr. Buchanan .

Market-Weighton, Yorke, by the Author Stone,Staffs ; by Dr. Ballard

Nor-wood, byMr. PowerHitchin , byMr. Power “

Dr. Buchanan's remarks ond ittoBeverley, Yorke (deep well), by Dr. Page

V111

PM!Outbreaks caused by water from deop mm

Oaterham and Bed hill, by Dr. (afterwards Sir

Richard) Thorns Thorns, Dr. Buchanan's

(Brad ley, by Dr. Gresewell

Houghtcn-le-epring, by Dr. Page

Worthing and NeWMIsle of Wight. by Dr

Bo und a, by Dr. Bruce LowWatersiphoned froma pond into a well ; observationby

the Author

Diagram of d itto

Reporte eentby Dr. Pistor o f Berlinvia , Oosel (8ileeia), hy Dr. Hewins

Beutben(Silesia). by Dr. Bloch

Belgi 58. 59

Outbreaks atMarcherand Bastogne, 58

Causes of typhoid fever in Belgium 59

Pollution of water supplies atorneartheirW 59 65Brickswortb. by Dr. Thoma Thorns 59

Olermout-Ferraud , France, by Drs. Bro uard el and

In the barracks of the Marines at Lorient, France.62.83

Rotherham, by Dr. Theodore Thomson 64

Penrbynaid e, Horsforth and Camborne, by Dr.

64.85

Outbreaks due to pollutionof stream andMevagiseey.Cornwall, by the AuthorBangor, by Dr. BarryMytholmroyd, by Dr. Page

Valley of the RiverTees, by Dr. Airy

Outta-hall Paper Mills , near Godalming, by

King's Lynn, and mm.“

hyDr. BruceRunnington. and Nose-ind iged ale. by ditto

ix

W W W by Dr.MaeleanWilsonKing’s Lynn and Gaywood. by Dr. St. George

llkeston, hy Dr.WheatenReport ontyphoid fever, byMr. HiramF.Mills flh eea»

ehusetts. U .S . 69-71

Paterson, New Jarsey, U .S.A hy Dr. JohnLealNewark, hy Dr. Herold

Reporte forward ed by Dr. Pieto r om 'iin 73

viz" 73

73

Table d Cases of Typhoid Feverin St. George's, HanomSquare, by the Author

Author, ontyphoid fever in Lond on"

Mr. Shirley Murphy on typhoid fever inLond onThe Arsenal (Woolwich) , by Dr. Davies

Millbank Prison, by Dr. de Remy

Pollution of waterwhile inthe m in:Oroyd on, by Dr. A. Carpenter

Lewes, Wolverton, Tideswell, and Dewsbury. byDr. Thorns Thorns

Mr. Spear

Falmou th. hy Dr. G. S. Buchanan 85

Waterpo llutedm ithm bm d ebiem d iato tko lwm

Spread of typhoid fever byWmted milk

to the Supply of Meat and MilkSir John Simon’s remarks on

Outbreaks at Islington. Balsall, and Moseley Heath ,by Dr. Edward BallardMarylebenc,byMr. Rad clifie and Mr. Power

PLO]

St. Albans, by . Dr. Saunders and Mr. Shirley

Murphy 93, 94

Lower Sheningham, by Dr. Airy 94

Swanage, byMr. Harvey 94

Leiehhard t, N.8 .W., by Dr. Ashburton Thompson 94

Nottingham, by Dr.WhiteleggeSpennymoor, by Dr. Page 95

Shildon, East Thickley, and Helmsley, byDr. BruceLow 95

Ernest Hart onoutbreaks due tomilk 95

Olifton, by Dr. Davies 95

Ooleford and West Dean , by Dr. Fletcher 96

Marlborough (Mass .,U .S .A h .yDr Sedgwick 96, 97

Reports forwarded by Dr. Pieter of Berlin 97. 98

viz., at various places in the Rhine Pro vince and the

Eiffel by Dr. Ricken 97, 98

Aix-la-Ohapelle, etc. by Dr. Schlegtend al " 98

Outbreak m anInfantry Regiment, by Dr. Kraemer 98

LECTURE III.

Typho id conveyed by oysters and other shell

Sewage in Oysters, by SirCharles Cameron

Typhoid fever from eating oysters at Brighton, byDr. Newsholme

Outbreak of typhoid from eating oysters, Wesleyan

University, Connecticut, U.S.A., by Professor

SirWilliam Broadbent on Typhoid from OystersDr. Bulstrode on Oyster Culture in Relation to

Disease 101. 102

Dr. Newsholme on Enteric Fever in Brighton fromsewage contaminated shell-fish 102

Dr. Bruce Low onoutbreak at Southend 102Dr. Chantemesse onOysters and Typhoid Fever 103Dr. Chantemesse’e experiments 102, 103Dr. G. S . Buchanan on outbreak at Brightlingsea 103Mr. Shirley Murphy oncases in London in 1897to

1899 attributed to shell-fish 103. 104

Outbreak in Cornwall 104

Dr. Klein's experiments on cookies 105Dr. Theodore Thomson and 001 Marsh on typhoid

fever in Chichester

Typhoid fever in Belfast

Poisoning by uncooked mussels

Mr. Shirley Murphy on oases in London in 1900Hamer on an outbreak caused by eating fried

106, 107Shirley Murphy onditto 107Turner on an outbreak spread by ice-creams 107, 108Parsons on an outbreak spread by gim -beer 108

PM!Mr. F . E. Atkinson on an outbreak spread byMad

Case o f H .R.H . the Prince of Wales in 1871. probably

Outbreaks of typhoid fever traced to sewer-air 110-118Dr. (afterwards Sir George) Buchann on typhoid

from sewer-airat Croydon and other places 110-113

Dr. Buchanan on disconnecting-traps for hou se

113-115

Dr. Buchanan’s diagrams of disconnecting-traps 114

Outbreak at Trnre, by Dr. Blaxall

WestRiding House o f Correction, by Dr. Ballard 115

Padstow andMeltonMowbray, hy Dr. Blatall 115, 116

York, by Dr. Airy 116, 117

H .M.S .Monarch at Gibraltar, by Fleet-Semen

H.M .S.Minotaur at Gibraltar, by Fleet-Surgeon117. 118

New South Walm, by Dr. J. Ashburton 118

Foundling Hospital , by Dr. J. F . J. Sykes 118

Case traced to themarking of clothes 118

Outbreak amongnurses atUniversity Co llegeHeepiml 118. 119Dr. Priestley oncases spread by mangles . . . 119

Dr. Renon on typhoid fever in a ward nextto a creche :. 119

Typhoid fever and ground or subsoilwater

Professor Pettenko fer onLyons and typhoid fever

Outbreak at Teriing, by Dr. Theme Thorns 121,

Professor Buhl on typhoid fever and ground

Report on typhoid fever at Liege. sent by Professor

Felix Putzeys

SirCharles Cameron on typhoid feverinDublin 122.Ditto, re cases ongravel and clayOutbreak at Lawrence , Otsego CountyMadison.Connecticu t, by Dr. Lind slayMold , Flints , by Dr. Wheaten“Wycombe Marsh , by Dr. G. S.BuchananChiebester, by Dr. Bulstrode

Stockport, by Dr. Charles Porter

Aldborough, East Riding. by Dr. BeeoeSwinto n and Pendlebury , by Dr. Theodore Thomson126SirRichard Thorne’s remarks on

PAGE

Marsh

Outbreak atInueen,nearBasleYork, hy Dr. Edmund Smith

Poisoneaid te be earried by animalsOutbrmke due to earth-closet:Outbreaks due to d irectcontagionNorth Tawton, by Dr. W . Budd 129, 130At various places in Massachusetts, by Dr.

130Bed lingtenand Newfield Moira, by Dr.H. F. Parsons 131

Temple Cloud, by Dr. Sweating . 131

Outbreaks in New South Wales , by Dr. J.Ashburten131

Amlwch (Anglesea) , by Dr. SweatingQuarry Bank. by Dr. WheatenPotterepury, by Dr. Bulstrode "West Bromwich, by Dr. G . S . Buchanan

Lambeth. by Dr. J. Priestley “

Shirebrook, by Dr. CopernanMr. Shirley Murphy on Cases in Londonin 1900Dre. Foord Caiger. Bulstrode, Alfred Hill, Niven ,

Manby, Franklin Parsons, and Goodall on the

contagiouenese of typhoid fever 134, 185

The Poison of Typhoid Fever 135-147Mr. (afterward s SirJohn) Simon’s views

Dr. Klein’sm earehes

Eberth’e bacillus

Dr. Ga’

fiky’

s investigations 138-139

MM . Rodetand G. Beer (of Lyons) on the typhoid

Dr. Horton-Smith“

onthe persistence of the typho idbacillus in the body 139, 140

Dr. Houston on d ifierence between bacillus coli and140

Dr. Klein’s experiments on the bacillus typhosus 140

xiv

PAGE

Dr. Sanarelli on the absence of the bac illus coli from

Dr.WatheletondittoProfessorWright and Surgeon-Major Sample onthetyphoid bacillus inurine

Dr. Edmund Oautley on the typhoid bacillus inmilk 142Dr. K1einond itto inmilk, cream, and cheese 143

MM. Grancherand Du champs ontyphoid bacillusin the soil

Dr. SidneyMartinsnd Dr. Houstonond ittoDr. Justyn Karlinski ondittoDr. Klein on the fate o f pathogenic microbes in the

German Commissio n ondittoMM. Remlinger and Schneider on the ubiquity of

the typhoid bac illusDr. John Robertson's experiments with soil out ofdoors

Liebermeister ontyphoid curvesTyphoid Fever in Armies

147. 148

Dr. G. Pratt Yule ontyphoid fever in camps spreadby dust

Typhoid feverat Quetta spread by dustDr. Leigh Canney’s suggestionof a Royal Water

00798 "

Sir Wm. Broadbent and Major Firth ’s opinions on

dittoDr.Washbo urnon conveyance of the disease by fliesand dust

Dr. Howard Tooth ontyphoid fever in South Africaspread by d ustand flies.as wellas by water 149, 150

Lt.C ol. Quill onair-borne typho id fever in 150Dre. Elliot and Washbo urn on inoculation for

Dr. George'l‘

urner ontypboid feverinSouth Africaspm d by water

Profm or J . Lane Notter on the causes o f typhoidfever in Sou th Africa

SirJohn Simon’s dictum re public water supplies

Disinfection of typhoid excreta by 152, 153

!V

PAGI

Dr. Salteton enteric fever in the NetherlandsDr. Schierbeck on ditto in CopenhagenDr. James Davison on ditto inBuenos-AyresDiminution of general death rate in London and in

England and Wales with tables 3and 4Dr. Bulstrod e

’s typhoid fever chart and maps

Diminution of death rates from continued fevers and

diarrhoea in England and Wales, table 5Diminution of death-rates from typhoid fever in England

and Wales and in London, table 6Chart showing mortality from typhoid fever in England

and Wales and inLondon 157-159

Diminution of typhoid fever at Munich 159

Diminution of typhoid fever in Paris 159

https://www.forgottenbooks.com/join

2

the factthat I well remembersuflerwhatwas cafled “brain fever." The

the Po ison of Enteric I'ever.” It was

which

thatit

ph u

zto near the mid d le of the last century.

oid”

alao a better name'

o " forthan agenu al dheasa for we d o not call other fevers by namesmerely d enoting the orgam inwhich their most specific

lesions o ccnr. As DnCharlesMurchisonsays : “ Itwould notbo d esirahle to have any name d erived frcmthe abd ominal

as this wo uld d o to revive inthe mind s o f

o f Bro usaais"—vis. , thatthe

caused by the intestinal inflammation. I mayname of the organismnow id entified with

the t “bacillus typho sus” and not bacillus entericus

The historical partof the subjecthss beenso fully treatedDr.Mumhisomwho has given us a summary o f the

history of tyrhoid fever from the time oi ppocrates

onward s, that t is quite unnecessary forme to gninto theearlyp

artof itinany d etail. I think it d esirable however,that should go at some lmgth into theknowled of thiszd isease at the beginnin o f

and o f e d evelopmentof such knowl geanaccount insome d etail, and as far aswords of the authors themselves, of the moston the subjectsince the early part of the lastcentury—workswhich have real] ad vanced o ur knowledge, written by greatmu tera the mecfical giants o f their d a .

Inthe flrst place l wish to introduce to yo ur notice s

hitherto unknown author, a copy of whose work I have foundin the library of the BoyalMed ical and Chirurgical Society.

I referto him as anunknownauthorbecause his work is notreferred to Mumhisom altho h he cites a great

number of both on us an typhoid fever,nor,so far as I canilnd , is it erred to by any other writer.

There isno of this work inthe library o f our Collegeo r inthat o theMed ioal of Lond on. or even

the British Museum. 0 copy that I foundinthe library of the BoyalMed ical and Chirurgical So cietyhu beenthem formsny yeara buthas beenread byno one,as its leaves had notbeeneeparated whenl found it. Itis writteninLatinand is entitled, “Specimen Practicumd o Bemed iis Efiicaoissimis inMorbis Contagiosds ac Psw m

dario . ac Quond am Maj. StatusMilitaris Medico Supremo, et Magni oso comii MilitarisVind obonensis Medico Primario. Co llegii Medici Vind obo o

nensis Bodali,” and was published in Vienna in the year1806. In this treatise fevers are d ivid ed into eight classesorgenera (see Table L ).

TABLE I.

I

Synochus lmputris sou Febris Continuenonpatria1. inflammatoria.2. FebrisMilan.

3. Fabric pituito sa.

I I .

8 us putris utplurimumMalignus, senFem-ls continua pu ts-Id aut urimummall

fi ns. Quinque species Typhorum.

I I I .

Febris intermittent.Iv.

Febnes contia remittentes seu oompooitnct

Febris ard ens sensew er.

V.

Febres epid emicmintercurrentes.Val-loin.Martini.

VI I I .

Febris lenta, hectica.Phthysis pulmonalis.

The five species of typhus under Genus II. are shown inTable II. as follows

‘

TABLE II.

Outages SpeciesMAM-um.

Mime ecru: gangmenoms. conic (stand er.voeatur etiam Pu tts occid ental“.seu patam . coa

epid emics flo ra amcricana .

4

view takenof them at the be

how much was known about them and .hcw

farth

gwcre d istinguished one from another. Each of thesevisions is consid ered byMayrto be a geuus and each

of the sub-divisions a species— that is to say, a distinctdisease and not a mere variety. This is clearly shown by thesub-divisions of Genus V.

— viz., small pox, measles, andscarlet fever—which are o bviou sly distinct diseases. I mayat once draw amention to the remarkable fact that heincludes pulmonary phthisis among fevers as the only speciesof Genus VI IL. entitled “Febris lenta, hectica.

" He doesnot, however, tell us whethm' he considerswas a contagimu fever ornot, but he probably did, as t ughout thesouthern parts o f Euro it

phas alway8 been considered a

contagious disease.WHY: first genus is continued fever, of

which he considers that there are two species. His secondis typhus of which he describes five species, which he stylesd iversae species,

” as follows :Prime.Mime cam penile” contagioms senPam

oriental“. By this he no doubt meant true con oustyphus fever, with which the oriental lague was tedand confused up to that time and l

lliter still, for he says

further on in his treatise that to the genus called typhusbelong “the fever of hospitals, one, camlis, ships, andman others, as also espec ially s true Pestts orientalis.He erefore recognised that his first species of typhus wasthe feverof prisone and othercrowded places.“Secundo. Turks: m es magnum , contagiem .

ictm d esu pestilenr vo catur etiam Peetie oooid entalu , senb riepertile

’

nr, contagion, epid emics flo w mm .

”Or

true contagiou s yellow fever.

“Tertio. mm em u non-watt: pumas-bilia ry

senbi m, senFabric m gu inea STOLLH ,

sen ” bun-alts Simian gnalem sordes putrid ae

e systemate co in sanguinem attractae generare

sanguineo primario natnm ; a collnvie bilis pntrid ae insen secund is viis abund antis nata, vel exsanguine

primis viis in secundas delatamitio r, lentins decurrens, non con

contagion.

" A ectl

definition of one of themed ia of typhoid fever, of whichhe further says, so that there cannot be the slightest doubtabout the matter Haec Species hi potissimum cuminfiammatoria febre anttopicis eflectio complicata ease

solet, cum ant sine exauthematibus ; inde Peri neumoniaemaligano , Hepatitid es, Dysenteriae etMesenteri des grayis

Quarto. MM“ new nam es: we platinum noncontagiom , sen febris nervosa, sen febris lenta nervosa

5

putrida pituitosa Stollii, a pituitaortns, tarde d ecnrrens.

” Anothertyphoid fever of which he remarks

Haec Species mu cum infiemmatoria etbiliosa f ebreac topicis afiectionibns, cum ant sine ennthematibns permixta et complicate su e solet.” And further adds thefollowing shrewd observation which anyone who has hadanythin to d o with the treatin o f m es o f typhoid feverwillagree 15th In nullo merits-um genera tanta estpatientia, exspectatione cunotationeque ad bene et elicitermed end um : est enim d ifi cilis bujne morbi ed s et

Therapia.” Typhoid fever is described as “nervous ever"by

Gilchrist, Huron, and Manningham ; as “nerven fieber”

Germanwriters ; "fievre nerveuse ” the French ;“low fever" or “brainfever"by many glish writers.“Quinto. fl‘gphus rpm-ins sen fictitius .

"Apparengequivalent to them ime-as gastrique of French authors .

says that it is often confused, as mightbe expected, with thehas m us of the third or fourth species—Le , with typhoid

ever.These five species .o f “typhus Mayr considered to bedis tinct diseases, but his third, fourth, and probably fifth,were evidently o ur typhoid fever, in which he thusrecognised eithertwo or three diseases ; and who shall sayevennow that he was wrcn ‘

l Itwo uld not be inthe leastdegree sur

grisiu

fif itwere efinitel proved that under the

term cid ever"we now incl e at an rate two quited istmct Mayr, therefore, cleary dist bed

betwew typhus and cid fevem. He putthem own asseparate diseases bel g to the same genus, typhus beinga contagious fever, and typhoid. including the third, fourth,and fifth spec ies of the genus, being non-contagious. Itbecomes now exceedingly interesting to ascertain what furtherdifferences he points o ut between the two diseases . Hsays und erthe heading,

"Diagnosis P J-imae ettertiae speeieiTyphi

”:“The symptoms of the first and third species of

typhus (that is to say. of typhus fever and typhoid fever)are in commonand very similar except that inthe first

es o f t ns more bad symptoms a pear inthe eick

in the es of typhus, an that in the first

Wes of bus bones, anthraces, vibices, are moren o thaninthe third species o f typhns, and thn

the first and second species o f bus bus ands most heal y men bynot happen in the thirdwhich) the prodromata

precede a long time before the disease breaks out ; andthat in the first and second species o f typhus onac countoftheir contagious nature the mortality is far greater than inthe third and fourth non-contagious species of typhus."

Under the heading, Cam haremfebrim ,

” Mayr saysBesides contagion, which aflects d ifierentpeople in various

waynthere is also a pestilential contsgious poim which is

6

transferred and commnnicated to others in

also in the m

these were the causes of the third, fourth, and fifth species

of his genus ofEhns—that is to say, of typhoid ever.

in book he refers again to contagione length in a chapter entitled De Chatagiis, towards

e and o f which chapter he says “It is, moreover,to be noted that certainly not all the typho d e conta

gons are of so volatile a nature that the are always

an absolutelyderef

al

zrxzd

t‘

il

i

la vola in theatmosphere, an ore er equal) canact only in true epidemic fashion, b

i

til

tga

thm y of them,

and some of the most virulent and malignant, as atleastas a strong d egree o f heatd oesnotactn them, owa sufficiently fixed character and remain fora longer orshorter time u various other bodies which catch themviz. , upon erent goods, especially those of wool andcotton, of silk, of leather, feathers , fiax, or the skinsof animals, clothing, paper, wood, beds, walls, and b dings

,

and often after many months they break out from these

and propagate disease and death farand wide.I must now direct your attention to another remarkabletreatise, the work of J . Val de Hildenbrand, Professor ofPractical Medicine at the Universi of Vienna, which wasublished there in 1810, and a trans tion o f which was pubhed in Paris in 1811. In this treatise the authormaintains

that the word ty'pcl

l

ins " has been improperly employed tood esignate a

gemu iseasa and thatit oughtto be used as

the name 0 a particular sp ecies. He says that the truetyphus has often been mistaken for another fever, ju st ascertain otherfevers have been mistaken fortyphus. But

,

"

Itis a fever o f a speeial

pred isposed to it. By reasoncf aneruptionwhich is peculiarto it it belongs to the family of the exanthematic fevers,among which the contagious fevers ord iimil find theirplace. Ithas a co urse determined in periods andalso d ifierentcharacters in its d iflerentperiods, bntwith a

cmstantsymptom throughout the whole course of the disease,which is stupor with delirium or

‘typhomania. And hegoes on to distinguish it from the fevers known by the namesof malignant, nervous, asthenic, putrid, and bilions—ia fact,from the feverwhich we now know under the denominationof typho id. He then describes the varieties of contagioustyphus under the names of pestilential or oriental(the plague), perhaps also occidental typhus (the ye w

fever ofMei-lea) and ord inarya

t

yphus. Of the latter he

says that it is peculiar to Europe we must include underit, bastard s/ ar se m agma

-Miss, the typhus o f h tals andlazarettes, of prisons, o f camm o f vessels, and o besiegedcities, showing clearly that by it he means what we understand as typhus fever and that he was quite aware of thecircumstances under which it flourishes. In Section VI. ofhis work he discusses the causes and modes of developmento f the disease. He says that it is always produced bycontagion and that one attack of it almost alwaysdestroys for a certain time, but rarely for the whole oflife, the bility to the d isease. He says that

the contagion spread by means of clothes, woollenstud s, furs, linen, dirty bedclothes, and even by bedsof straw or of hay on which typhus patients have lain.

He dis ntes the view that the air of marshes has anythingto do the disease, pointing o utthat it produces fevers ofthe intermittent type.

poFor him overcrowd

rfiis the cause

o f typhus fever, altho h he gives all tto previonsobservers in the foil sentence Army doctors bym ot researches have been the firstto show us under whatcircumstances and how the air canbecome the canse o f

typhus. It Minder“, D. Monro, J. Pringle, and others havespecially pointed ontthe d angers which air ucea whenit is overc with human exhalations. is intruththe rein-one the m taglmu m tter and of tlie eontagiea ojtyphus. It is equally and too much confirmedby terrible examples that exhalations of healthy mencrowd ed and pressed together into o small a space have also

the most harmful infiuence upon health. Ind pfisons, houses

o f cormotion, smallrooms of vessels, and in the establish

ments where many men otherwise healthy live together intoo greata number the air ofiers the same danger.” Healso insiste thatthe d isease may be avoid ed by preventing

Civil and military authfi ties onghtnever to lose sight oi

thk immrtanttruth. Itis the d uty of all thou who are

object.“ It is thus quite evid ent thatthis author inthem ig years of the nineteenth century had a perfectly clear

id ea o f whattyphus fever waa o f its causes. and o f the wayto t it. He says inthe most positive mannerthatitisa ctd iaease fmm the other continued fevers whioh we

School. Inthis firsted itionM. Lo uis d escribes, with the

hand of a master.typhoid feverintheminutestmanner. Hemaintains that the ulceration of the W e patcbw is imcharacteristic lesionand he says : “W tks altm tioa oftbs elliptic all the lesions of the muco us membraneoi the er intestine observed incases of the typhoid

https://www.forgottenbooks.com/join

10

have invaineearched forthe spota inquesfionona number

observer. Further on he cornplains that “the state of theviscera of ind ivid uals who have perished from the d ifierentepidemics o f typhus has oftenbeenneglected ; and in thiscase the mostcertainand easy means o f sasarin oneself ofthe identity or d ifierence between typhus and e typhoid

affection escapes us." He then quotes M . Gaultier deOlauhry and authors of other writings and says that“after a fashion these descriptions, although assuredlyvery incomplete

i118seem nevertheless to show, as far as

go , the cor

‘nfamtive study of the sympto msin tea the identity has and the typhoid affec

tion. It will be

tynoticed how very guard ed this

sentence is, but M. Louis was not content with that verystatement, for he goes on instantly to make the

o llowing astute remark : “One cannot be to o muchastonished, however, in admitting this identity that a

of the small intestine,

epidm ics of us. And only three pages further onhesays :

“From e presenttime itmustbe acknowled ged thatevery acute ailectionwhich is not aecom

Eamed inits course

with the special alterationof Peyer’

s patc isnota typhoidafiection, although one does not find in the auto thesigns o f any other affection, and thus the typhus ever of

lish is necessarily a very d ifierent disease from thatwith w ch we are engaged." And then speaking of theobservations of Dr. Shattuck of Boston he adds : “That

whilst the local symptoms, the d iarrhma, the meteorism, aremore o rless completely abmnt in the otherwhich is aecompanied by au eru tionvery d ifierent from the first andalso much more a undant, and attacks persons ofage. He

mrld d

i

z

;Imutish

idto his£3111

,

tmuses

ints out at t 0 ever " t enightinplacesllzio

tuated low d ownyP

and inhabited hy

gto o

cannotbe one o f the causn as only the eighteen part ofthe cases fulfil this condition. He

yactually gives one case,

"Observationfid bis," where the use of a d water in

which a certain amount of chopped-up hay hem mixed

11

was followed a wello d eveloped and tatal case of typhoidfever in whi the ulcerations of the Peyer's patches werefo und after d eath. With regard to the uestiono f conwhich he didnot touch in the first tion of his hecomes positively to the conclusion that it is a contagiousd isease, and that the Paris ysicians had d enied this

because ina t oity it is ultto trace the course o f

contagion. e quotes largely from the work of M . Gendronof Chateau-d u -Lo ir on epidemics of small pu ss to provethatthe dm is transmiMd d irectly and ind irectly fromperson to person. He also quo tes from the same authorsome remarkable instances proving the immunity conferredby an attack o f the disease, and at the same time provinim contagious character. These are so interwting thatthink them worth quoting, as follows

1. Three jonrnalists contracted the d isease at a certainho use ; twocommunicated lt to their families gthe third d id notd o so . he waslooked sfterby hls wife who had had the d lseese eeveralyesrs before.2. A d omestic servant of 00nteresu transmitted t oid fever to

his sista '

, the niece o f hls master and mistress, and visite d her

3. AtPetitGénee a yo ung maninfecte d all who looked after him

m um and mother; these had both previously had

: the husband &,m and the wife two years before the

epid emic which this very son4. lnlBfi the u me d isesse wu imported into a freeh famlly atPetito

Genu and d id not lkmlpito of the visits o f the lnhabltantso f the hamlet, whlgmo

nndlm d y beenoncenttacbed .

c At eightyears apsrttwo epld emlcs attacked Ooemont and the

second -pend anthose whomthe finthsd notspu ed .

He concludes, then, first that the disease observed in thesecountry places byM. Bretonneau , Leuret, and Gendronwhether inthe sporadic orepidemic state was unquestionablytyphoid fever, because the characteristic anatomical lesionwas commonly found among those who died from itand " it must be recognised therefore that the typhoidafiectionis contagious, at any rate in the departments.But he adds that others have since made similarobservationsin Paris. Thus, M. Putegnat “has reported that after avisit made to a person who returned from a village where

t

yphoid fever prevailed a woman was attacked by thisiaease and a few days afterward s her husband and theirsixchildren were also attached . A Is person escaped—shewas BZ

gzs

gs of age. M. Putegnata so reports other similar

facts w leave no doubt as to the contagious character o fthe disease. And he finally concludes : “ It seems to mehenceforth impossible

,afterall that goes before, to deny the

confi

ne characterof the typhoid affection, even in Paris.”

I next draw attention to the work of ProfessorA. E. Chomel tied “Leeons de Clinique Medicale(Tome L , Fievre published in 1834, but deliveredbefore then. Dr. mel considered typhoid fevera separateand distinct disease from typhus feverand gave it the name

12

intestinal exanthema of M . Andral, m m orWM Ol retonne a o l ally,follicularenteritis o f many patho logists). We shall preferably call itby thename of m or fim becanseof thc analogy which it o inim symptoms with the

typhus o f camps.’

He go es onto ad d that the vario us

fevers mentioned above have common characters which

d am e. The typhoid afiectionwill therefcre occupy inmol aoa

positionof great importance because italmostes place by itself o f a whole class o f d isem " He

then describes most minutely the symptoms and course of

eruption which is special oid fever and consists insmall woken-od or,, d isapm preu ure o f from half aline to two lines in round in shape, without

thighs, the arms, and the forearms. Further on he intsout that “the taoha mcéa m «lltéf a are easily

guished from the petechise and from the bites o f fieas,because inthese latter there is extravasation o f blood at thesurface of the d ermis, and that their co lour, instead oflessening under the influence of pressure, wo omes more prono unced by the discolouration of the skin which surroundsthem. Inthe typhoid spots, onthe con , the rednessdisappears altogether, as ere there isevidently congestion, and where

“when the pressure ceases,

one aw e the redness rea

pxpear immediately.” Further on,

again, he points outthat a oertainnumber o f cases thm'

e

is intestinalpomhmmorrhage and sometimes perforation, o f which

he says : “Perforation of the intestinal walls is the most

in55 persons who had died from boid fever, a proportionof one in seven. In discussing the esions produced duringthe course of the disease he says : “The anatomical lesionswhich constantly or almost constantly accompany thetyphoid afiectionare situated in the follicles of the intestinesand the mesenteric glands. These are the only lesions

18

which onemeets with inalmo stevery cc se . He includ es inthe follicles of the intestines the isolated ones W e

2hnd e) and the agglomerated ones (Peyer

’

s

he d escribes minutely the ulceration theioniclesf

mLike all the other authors of the time hs find s

that “the causes of d fever are involved in thegreatest obso urity.

”to the question of con

nhe points outthat “ is a great d iflem ce of

op amonofmed ical men—the majority inFrance d eny

every kind contagioninthis d isease A few. however

opinion. He points out that the first reason why contagionhas beend enied to this malad y “is that of all the g

ersonswho can surround a patient attacked with typhoi feverthere are few who are susceptible of contracting the diseaseOne und erstand s in efiect that the father, the mother.the

o

d o otor the nurses, many of the sick in h

are immune to the contagion either because most o themhave alread y passed the age atwhioh the typhoid d isease ismo“commonly developed, or because they have alreadybeenattacked by it, or, lastly, because are among thenumber cf tho se who are immune by co tution. Anotherreason is that inhospitals on account of the ventilationsuch diseases even as small-pox are not y transmittedfrom one patient to another." He also points out that thenegative proofs on which the anti contagionists rely are

entirely from observations made in Paris. But it is not incities as large as Paris that one canstudy contagious diseasesfrom the

upointof view of their transmissibility, because of

the dime ty. or even of the impossibility, in most o f theoases to trace there the course of the contagion. It isnot, therefore, by negative pro ofs collected in a city likeParis that one cansupport an opinion unfavourable to contagion. lyphoid fever, according to him, only eflects thesame person once. “This circumstance is an importantfact, for there are only a few d heases which attack butonce the same person, and among these diseases there 18 notone which is not obviou sly contagious typhoid fever wouldthen be the only exception to this law if it were not con

mans like the other d iseu es with which it sharesimportant character. Lastly, another point which

is in favo ur of co on is the analogy which exists

between the typhoid ection and the typhus o f camps,of which no one disputes the contagious character."

He then discusses the resemblances and d iflerencesbetween them two diseases and formulates his conclusionsas follows : “1. The opinion ad opu d by most Frenchmedical menthat the hoid afiectionis not contagiouscannot be admitted as emonstrated . 2. 1f this disease is

14

contagious it is only ao to a feeble and with the oonoum oe ot ciroumstanoes as W ilma 3. If furtherobeu vatiom ahow in typhus fem anatomieal lesions

beyondso lved." Thua after his minute and aocurate aeoount ot

feverand his evid ento onviotionthat itis a separate

that it

I amrelieved from theof variou s otber authors

Paris and were published inthe

These memoirs were answer-ate

quiexistententre le typhuset Infi v e typhoid e d ans l

’

etat

actual de la science. The flmt was hy M. Gaultier deOlaubry. Inthis paperhg like everyone else u

pto thattime,

consid ers the oriental e to be a typhus fever

He states that MM. etit and Serres gave to a typhoid out

break atthe Hbtel Dieu in1812 the name of “fibvre entéromésentérique ” and that they like MM. Louis and Chomel,consid er ita separate d isease. Eveninthe pege of introduction to his memoirM. Gaultier de Claubry shows the bentof his mind. for. after describing typhoid fever as “ that

gm continued fem , ao -called by

which has as oonstant

themesen .

"he goes onto say

forth a com parallel between the two affections (typhus

32m fevers) inord er to bring out the analogies andoes, if tlm-am auy.

" And so we find thatquiteearly inhismemoirstthe end o fthe second chapterheconcludes with (und er the head o f ptomato lTypho id and

(Alm not analogygmlance,

”an thie a

v

lzgrently

t

merel becauseWm tdifferent forms o f

intensity Later he tells us that inthe tvm fevers the

lentioularerutftionis the same butthatintyphus itis more

abund antan petechiaLbutthatsometimes itie the same in

15

There was no

Of the intestinal lesiona as of the

tions have sometimes been found in the mucous membraneof the intestines “there is not only a greater or lesseranalogy but anmoetatable id cntity cf organic changes inthe two fevers,

” and he makes this statement in 8 its of thefact that a little furtheronhe praisesthework of Lombardof Genevawho says that boutthe six years during whichhe has studied the subject wi the greatest attention he hasnever seen a single case of typhoid fever in which theintestinal canal did notpresent after death the lesion of theelliptiml patches of the smallerintestine, butthat he saw withthe greatest s that the cases (of typhus fever) atGlasgow and Du lin had no such lesion oraffection of themesenteric glands, and that this was the general

‘

enceof the med ical menthere. As to causes, M. Ga tier d e

Claubry shows that all authors agree that overcrowding is thecause of typhus fever, but he points out that Louis showedthat this could not be the cause of boid fever, as only oneeighteenth o f the subjects of t were found to be underthat omand thatmost o f the cases were among thenewcomers to Paris. It is a pity that M. Gaultierde Olaubrydid notmy more attention to this point. If bs hed hewo uldhardly vs concluded his memoir with the sentence“Typhus fever and t

yphoid fever are one and the same

disease to which it wc d be convenient to give the name o f

memoir was byMMontault. It, like the

utany psrti-pm. as he gives no hintcf anynotions ; indeed, he says in his introduction

that he has wally shown himself jealous o f giving pro ofof a mind free m preconceived ideas and occupied by anardent love of truth and guided by observation and reasoning after the well-known precepts of Hippocrates, Baglivi,and Bacon. ” In the firsttwo parts o f his memoir he giveswhathe calls the history of the two d iseases , und erwhich heincludes causes, symptoms, lesio ns, and treatment. In thethird part he discusses the analogies and d ifiereu ces betweenthem. Perso us o f all ages are exposed to attacks o f hus,while it is certainl not so for the typhoid fevers he waysspeaks of typho

'

fevers, not Typ d feveroften occurs without overcrowding. Contagion, general]admitwd for bus, is not for typhoid fever, whiis also more 0 sporad ic epidemic. He here quotesHildenbrand as distinguishing completely typhus from the

https://www.forgottenbooks.com/join

Dothienenttrie is at its maximm in autumn and at

its minimum in winter In us nc such conneaionh observed to u istand that is cftenatits

two diseases with the greatest minuteness and accuracy.

“Atabcutthe th ornlnth day the typhoid eruptien,consisting of ion ular rose-coloured mm min,

a onthe abdomen, back, and ; it is not an

19

the fo urth or fimftgi d ay, sor&etimes before, and is

commo nly profuse, amount em on hearingcertainratio to the intensity and d uratwg

fio f the d iseu e.

The d urationo f d othienentérie may be stated onanaverageo f from ZO to SO d aya The average d umtionof typhusin43 fatal cases msntioned by Dr. Beid was 18i d aysso that pears to runits co urse muchmore rapid lythan rie.

”He sums u the differences between

the two fevers as follows : “A cranes in the manner o forigin, a d ifierence in the seasons of occurrence, and adiflerence inthe mod es o f attack ; a d iflerence inthe seriesof symptcma a d ifierence inthe external appearanca and a

difference in the duration of the diseases a difference inthe ages at which they cccur, a d ifference inthe sexes inwhich they princ ipally prevail, and a d ifierenoe in themortality which they respectively occasion. While the greatand cro wning d iiference o f all is the existence of a particularanatomical lesion in one, and the absence of any obviousanatomical lesicninthe other. Surely two d ism es whichd itfer in all these particulars cannot be identical. ” Nowonder that Dr. Murchison says : “This paper has receivedbas attentio u from subsequent writers than it deserves.” I

will go farther than that and will say that although previous

d iseases, and altho ugh some of those writers whom I havementioned had so far as to a clare that the two

d im wm erent from one another, Dr. Barlow wasthe firstmanto give a d etailed and complete ac co unt of

the d iflerences betweenthe two d iseases and to establish

once and for ever that they are entirely distinct from oneanother. The only important fac t in connexiw with thetwo d iseases thathe d o es notpo int o utis the d iflerence in

inthe same year— viz. , onApril t h and 23rd , 1840—Dr.

oid fever all is vague and uncertain, butwhat

concerns us to know is whether the conditions we

assigned oauses with the facts ascertained by himself in

these remarlrable word s

article : ‘The causes oi

at all.neither does he venture to say that typhoid and typhusfevers are distinct diseases, for he sums up the matter as

follows : "Ona review, then, of all thathas beenad vanoed ,

that itwould

ma; no rd o I

a faith o ffo r is careful extenuive, and minute inquiry without preposm sionorlove of stem. and a satisfacto ry solution mustsoonbo arrived at. o that he does not really lead us asfar as Dr. Barlow had alread y d one.inthe year

?1841 a wo rkyentitled "Traité de l'Enterite

Vo llionleuso Fitvre Typhph .oid e by 0. P. Porget, Profm or

o f Clinical odicine at the niversity of Strasburg, waspublished inParis. consisting, infact, o f lectures previously

givenby that physicianto his students, to whom it issd .ioato d (The preface is dated November, Inthese lectures he s

peaks oi the “Mal d istinctions between

has and t ti levera u yisayi gn that th have only beenined in recent times.

8He gives d enbrand the

credit o f bsi the authorwho had done more than any otherto point out t 0specific nature of typhus fever, but he d oesnot that the other fevers from which Hildenbrand distingu has it are neoessarily non con He thendiscusses the views oi M. Gaultier de bry and otherauthors who maintainthat us and typhoid fevers werethe same diseases. M. Forag

bu cuses himself for qu

sopfl

rnany authorities by saying that he has nothad thee

go! observing epid emic hue. He is evidently

mnohfi with8the views of . Gaultier de Claubry

and adm that it is possible that many o f the grave febrileal‘eotions nlerred to may be id entioal, but he d efines hisownobject as which I pro fess to show isthat ourspm d io hus m m ,W e“fever—ins. word,the grave contin fevers o f o ur country—are, and cer

21

tainly always have wen, associated with follicular enteritis.Let this be well und ersto od . We dothat which we have not seen of

to occupy us exclusively. He is perfectly clearaboutthe that the d isease has this special lesionand he

(givesthe following definition Follicular enteritis is

efined by itwlf—that is to say, that the lesion which namesit is its fundamental character. Follicu lar enteritis is theinflammatio n of the intestinal follicles, as pneumonia is theinflammation of the lung.

” And again Follicular enteritisis a material fact, as pneumonia, hepid itis, cancer. variola,arc . Why, then, should we refuse to make a disease of it ?

Whatwe have to do here is to establish the reality offollicular enteritis as an evident morbid fact ; it is to re

cognise its right to a place in the catalogue of d iseases.’ Forhim, among several alterations in the intestinal canal thoseo f r

’s patches are the most characte ristic, and he

descri them in great detail, referring to the observationsof Bretonneau , Louis, Chomol. andMontault on perforationo f the inte stine inthis disease. Although he mentionsthe rashes mesa he evidently d oes not consider themas especial! characteristic of the disease any more thanthe so da o r the petechia which he also mentions .As to the cause of the d iam while he considersthat itmay be produced by foul air and decomposing foods,he says that the causes sont tree variables etn’oifrentriende spéciiique.

" It is evident, howevery that be attachedsome immrtance to foods as a possible means of conveyingthe disease, fo r he says : Is it not, indeed, singular thatsome would deny that food, fo r instance, has the power ofdirectly produc ing follicular enteritis, when they attribute toit without d imculty gastritis, colitis, and villou s enteritisitself ?” Afterquoting a number of other authors, some ofwhom maintainthat the disease is conta

gious and others

thatitienot, he gives his own opinion as o llows : “As forme, a pupil o f the Paris School. I have denied the con onuntil after my removal to the country . as indisputableshowed me that typhoid fever canafleotpm ons who staynear sick persons. Whether it is by the inoculation of aspecific virus (contagion) or by inspiration of airvitiated inany other manner (infection) I do not know ; but this ispositive, that the disease is com m in certain circumstances somewhat rare and still undetermined. ” Thissentence, I think, expresses the view that is held most

generally now. However, he in fine concludes “that there

is nothing invariable and essential in the causes of follicular

Such was the position whenDr. William Jenner (after

s fle thus ves the d lsease the name oi what he regard s as lteimriortam. characteristic lesion, calling it fo llicular enteritis"

evcu s worsename io ritthan“enteric fever."

22

wards SirWilliam Jenner. Bart one of the ablest

ooncomitants of a dMif ithas continned for a ginnfima which timemustbe determined by aw te w 'ies of

observations for every d istinct afhection. anatomicalcharacter is not be rtremarked — and this is of immeneeimportance—necessarily the cause of the disease. for itmaybe merely a ptom ; butthen, if the d isease be not out

shortby d it is an invariable symptom.

” Ju ne: saw

thatthe crucial question was the d etermination of the factswith to the intestinal lesions. He remarks : “Londonalone anthe cifies o f Eumpa fmmthe faotof fever, withand without intestinal disease, being almost co nstantlypresent within its bounds, aflord ed a field for observationcapable o f settingthe vexed questionatrest. InEd inbnrgh,writes Dr. Christison. the intestinal lesion is seen oftenenough only tO prevent physioians being of itscharacters. InDublinitappears to be eq y unfr

zguent,

while on the continent fever without led on the

The Lond onFever H l, by oo llecting withinimm lscases of continued fever-

0mall parts o f the great metropolis,

23

ofiered peculiar faoilities ior its stu d y. During two years

he mad enotes ofnearly lOOO oases o f acute d isem of which66 were fatal oases of oontinued fever which were examinedby himafter d eath. This waenm ry, as itwas eeeentialthatthe presenoe or abeence oi the intestinal leeionsho uldbe d emonstrated . Of the GB cases he found thatinZtithed isease of Peyer

's tohes existed . Theee were oases o f

typhoid tever. In remaining 43 the agminated glands,as the unassisted eye co uld d eteunine were inaso far

in the symptoms of the two d iseases and oonclnd es by comhating two assertions thathad beenputforward

“to acco untforthe d inerences in symptoms which existed in continuedfeverwith and without entero-mesenterio disease." 1. Thattyphoid fever is merely fever complicated with lesionsof a particularorganan t is there fore to be expected thatcertainsymptoms referable to. and dependent on, that lesionwill be presentand so farmod ifythe symptoms o f the dmHe maintaina onthe contrary, thattheW ot

the two d iseases inthe oases hs exanfined widely,“such differences having no apparent connexion with the

—o f the rash of the two d iseases, and the tend ency to looalinflammations, to erysipelas, and to ulceration, observed inthe cases of typhoid fever here analysed cannotwith anyshow o f reasonbe consid ered to have beend epend entonthedisease of W e tches—Le , inthe same way as theabd ominal signs un bted ly were . The faotaleo thatthe

d urationof typhoid fever, end eveno f fatal oasee of it, is

considerably thanis thato f typhus fever also struok

me rery fo The shortcomparative d urationo f the casestyphns teverhere consid ered is another remarkable point

of d ifierence, totally inexplicable by the hypothesis that

m averis t

‘ylphus fem withintestinal ulceration. Hadrecovered it might have been said that

the intestinal led onpro longed the d isease inthe oases o f

typho id fever, butthat all the fatal oases of fever, with a

beenpreeentinthe oases o f id fever, should have hadamuch longeroourse thanall ose other fatal oases o f tever

after death appears to me inexplicable onon the suppositionthatthe fom er is simply the latter d iem with thisMeas lesionw perad d ed . Letme repeat by this hypomm ,

we are asked to imagine that d eath is retaeded infever byannive uloerationo f the smell intestines and enlargement,

hring forward tcogen pro ots o f the id entity of the specificm es of the two ad ections ere they ask us to edmitits Go th.

”

d ifierences obcerved depend onvariations inthe epidm ic

asses-tion, for

The cases

are also rarely absent from the ward s o f the same insfitution. Itis thcre ocmmonto see the patients occu bedsside by side and presenting respectively the omariredcharacters o f either d iseese. IL I repeat, the two afiec

tions were md ly the same fi sease thw the same epcid emicconstitution o ught to have impm ed onboth the same

feature s, in ”d in both the same localto the m e tend ency to ced averic

fluence which the

lesions inthe one and the abeenoe fmm the other gro‘zgmighthave oocasioned . The analysis otevery symptomevery leeionshows thatthe two afiections were not thusassimilated by the

iprevalence of any particular e id emic

m stitution. ButMuf the imaginafim cou d be supposed to change trcmweek to weeh to cause the case attacbed to -d ay to have

us fever, the individual who takes the disease to -mm'

row

to ve typhoid fevermtill itcould notao co unttorthe fact,as well estahlished as any fact inmcd icine, thattyphoidfever rarely, if ever, afiects m ons more tban50yeare ef

agg while age exerts little influence ind etermining the

o ccurrenc e o f typhus fever. Thea thm the assertionthatd fever is mere typhus fever mo d ifled by theepidemic tutionis as irreconcilable with

as thatthe formerd iseese is simply the latterwith abd ominal

mm .

" He then repeats the distinctions betweenopox and scarlet fever and concludes : “ If, themthe

https://www.forgottenbooks.com/join

26

read a paper before the Boyal hied icaland Chirungical Socie on April Z7th. 1853. cnfitled .“Contributions to the

‘

ology of Continued Fever, or anInvestigation of Various Causes which Influence the Pre~

valence and Mortality of its Different Forms.” In thisadmirable paper, describing the results of his observationsat the London Fever Hospital, he establishes the followingimportant points (besides many others) which I will give inhis own words

2. 8ex has no iniiuence o ver the prevalence of continued feverno ro verthatof any o f its ifiorms.

3. Typhoid fever is pro-eminently a d isease o f child hood andad o lescence, atwhich period s o f life we know thatthere is a marked

bariu m

sha

m|r

rm

Typho

h mmganmflare above 0 us

no pred ilectionforyo uth- o f hns one-half, and o f relapsingMar

one~third , o f the cases are shove4. bus and re lapsing fever appertainexclusive! to poverty andMimon, and seld om ornever occu r are the y exceptfrom

d irect con on. hoid fever attacks po or and rich witho utd istinctiom

w TY?

5. Inlarge cities hue and fever ars ier the mostlimited to those ties remarkab the overcrowd ing o f

inhabitants zand in d istricts the are seid om or never metwith exceptas the resulto f irectimportaton. onthe ctherhand .occurs alike inthe ccntre aud suburbs o f ci z inthe crowd edhouses o f the po orand inthe spacio u smansions o f the snd alsoinisolated houses and hamlets inthe country ,withen any traceable

6. Whenfever breaks o ut ina house or locality itseid om ornevu '

thatsome oi the cases are typhus and othm typhoid , buthappenstyphus and relapsing feveroccurnotunfrequently to gether.

7. Over-crowd ing with d eficientventilationand d estitutionappeartobe the essential causes o f typhus and rela

gsing feverand to be capable

o f genera them d e now , fl“while t ere isno evid cnce thattheyhave anv s influence overt pro d uctionof typhoid fever.

8. Typhu s is eminently conzgio us. Typhoid feveris also cmMhutina ru ore limlted deme pcssibly thro ugh a d iflerent urn.

Again, c s has inno tsnce beenpreved to comrnunicstenortypb incommunicate typhus. Anattack of either animmunity froma future attack o f itself, butnoto f the other.

10. inall o f the ievers there is notmuch d ifl'erence inthe mcrtaiitycf the two seaes.

11. The rnhrtaii frcm t us is greatc the very pccrthanthaw ingtterM.Mappe r-a to mm mortal inall cissses .

i 'rhe braw ted interrcp tionmart afta the wonls d c mso inthh pu agraph h mina as is thatalso inpangr-apt o llowing flre

wcrd“gencrating.

typhoid, andalso thathe “asccrtained thatinseveral instances patientsentered as

‘labo urers’had been inth eir-aim ,

inevery such case the feverwas typho Of the tsadmitted to the fever hospital “most of those mayhave beensupposed to have occu the best cond itionshave beenadmitted with typhoid ever. . Thus the proportion of family servants admitted with typhoid has beenthree times that

yof typhus, of policemen six times, and of

shopmen more than d o ub

ée

rela

On th

f

e other“hand

among ‘pau typhus an psrng ever ta en toge er

have beenpf’err

g

fi

ht times as frequent as typhoid, and o f

64 vagrants ’ admitted with fever in not a singleinsmuce was this typhoid. Again : Typhus feveramong the rich, except as the result o f contagion, isexcessively rare, while cases of typhoid originating witho ut

trm ble contagion are far from uncommon. Ithen, it may be concluded that typhus and relapsing

fever are for the most part confined to the po or, butthat

typhoid fever makes no d istinc tions between one class andanother. He shows that typhus feverprevails ino vercrowd edlocalities, whereas "a careful study of a great number ofrecord ed outhreaks of fever in co untry towns and villages

tEngland has convinced me that these outbreaksinvariably typhoid. It is also a fact worthy of

notice that several instances have come under my ownobservation of t id fever making its appearance in anisolated house the co untry. in a family living ineasycircumstances without any traceable source of conmgion, ofits attacking several individuals, and then disappearing without spreading beyond that house . Dr. Bartlett also makessimilar observations as the results of his experience inAmerica. On the other hand, I am acquainted with noinstance of typhus or relapsing fever originsus in thisway .

” He agrees with Dr. Jenner that ever andtyphoid feveroriginate from d ifl

'

ereatfoci 0Motion.

“Inno ls instance d uring the lOyears have I rnetwith a case

of typ us and typhoid admitted from the same family, o r

evm from the same house except (and the exceptionshave been only one

mor

wtwo after the lapse of many

months or gives a number“triof

cases inwhich typhoid fever wast,t’associated with

ennnations from decomposing organic matter inmchurchyards, inc” and organic impurities in

-water. These cases (actually da from 1747onwards) included the celebrated outbreak the Westminster School and Abbey Cloisters in1848. known as the

fining ?“ 3: 15:11 : s i m mnvm m - irm

is either anend emic d isease or its‘m ~

It is mo st prevalent in autumn a? “mi

ss

weatha'. S

alt

.

is ind epend ent o f o vercrowd ing and attacks rich andpo or ind isa

-rminately . 4. It may be te d

previo us case by fermentation o fw ane]:Mgr“? °f 3

organic matter. 5. Itmay be communicated by the sick to per na inhealth,

buteventhenthe iconis not. like that o f m a

fi agivenecum

With regard to No . 1, I will note that typhoid feverep idemics are often very widely spread. Nos. 2 and 3 are

universally admitted and I Will say no more abou t them.

29

Nos. 5, and 6 im y the view so strongly held b Dr.

Murchiso n that the is caused by a poison needby d ecompo d ng fa ces, which poison is not co ntained in thefresh excrement, and therefore amount to a denial of thefactthatthe disease is produced by an organismwhich istrausmitted from one case to another. This view, like thatof

M . Gaultier de Olaubry (who proclaimed the identity oftyphus and typhoid fever) in France, obta ined a holdon the medical profession in this country and has withconsiderable d ifi culty eradicated.As to the incubation period of t fever, Dr. Murchison

stated his conclusions in 1871ozpp

a

per

mwhich

in Vol. II . of the St. Thomas's Has follows

1. The riod of incubation of enteric fever is mostcommonly a uttwo weeks .“a Instances of a longer duration appear to be more

commonthan in typhus or relapsing fever.

“3. The period of incubation is often less than two weeks ,and, as in ttyp

hus and relapsing fever, it may not exceed oneor two days .

The usual period of incubation is now gen Wm ;be irom 11 t0 14 or 15 days (see pages“genandwag,

be longer. Nevertheless, I believe that the instances o f verylong incubation periods are due to the fact that the eflectiveexposure to the poison of the disease has takenplace nt alater date than the supposed exposure.With regard to the very short incubation periods referredto in Dr . Murchison’s third conclusion, I think thatthey areacc ounted for either in the manner suggested by Drs .

Bro uard el

gifial‘

ho

éggt in the

aix

éetr

tiat

ise

thznhe“ Fievre

Typhol‘

d e"

1 page 2 t t y are notgenuine cases of typhoid fever, or that the effec tive exposureto the poison has really taken place at an earlier date thanthat given.

In 1873Dr.William Budd produced his work on “TyphoidFever, its Nature , Mode o f Spread in , and Prevention,

” inwhichhemaintains thatitm proced agathat

‘Wypho idfever is inits essence a contagious o rself fever,

’

and he ad ds, " It is scarcely to the credit the medical

on the Practice of Medicine has not only lent his powerfulsanction to the doctrines o f the contagious origin and modeo f spread of typhoid fever, “but has venanexpositionofthem inthatterse and lucid style o f w he is so greata

master,”and I may ad d that in Sir ThomasWateon's small

work on the “Abolition of Zymotic Diseases, published in1879, he says,

ymho id fever, “When we reflect

how read ily this ori

referringof the (through watm

'

ormilk)may escape suspi on or may elude detection even when

81

described Dr. Budd, says How could a disease whoseare so severely demonstrable

imagined to be nono contagio us‘

l How could such a doctrine

bwcf

pllowed out, as ithas been to the destruction of human

8n

I may be allowed to

We ars, however.told thatthe intestinal d ischarges from a patia rtsuflerlng frornenteric iever are not infections whenhu hMome so after d ecomw ltionhu set in, and inmf otad vanced thatmed lcal attend ants d o not take lt thethatnurses d 0°not get it, and that other patlenta inthe aame ward .

alth u d ng thc nme utmsflg acarcely em take the d iseaae. Nowltm be admitted thatsuch cases are

no meaus unknewnflnd eed I find thatwhilc hfurchisonmnthe -w ond editionof his “'I‘ra the on

ecu -innaIly itis contaglo us.Thatftia and mo stviru lently so , I havenotthe nlighteat

amnbnt l und erstand whatthoee meanwho say itis notz

tbey meanthat if attend upona ent suflering irmnenterictem yo u u enothi

veggto get it, while tycu attend onone suflering

https://www.forgottenbooks.com/join

m of o utmeaks have beencansed inthis and other countries, beginning with those which have been connected with

panora m as-gm , and l shalLas tar as le.

quote the actual word s oi the reporters, as that l akethe infonnationmnch more valnable thanif l snmmarieedthe reports myself. lnthe sixth report(1863) of the med icaloficer of the Privy Co uncil is a reportby DnJ. 8 . Bristo weonfeveratWhitehaven. He satisfied himself thntthe oases

conclusion that the fever was 3 read by means o f generalfilthy cond itions. He says :

“ I ve no hemtationinaseerting thatthere is no Englishtownwith whioh l amacquaintedwhere the sanitary circ umstances (with one ortwo exceptions)o f the inhabitanta and especiall Of the r. are ina more

condition e houses of thelabouring popnlation(more particularly in the central partso f the town) are crowd ed together in a way which is

scarcely conceivable ; the houses are forthe most part dirtydilapid ated. and imperfectly

’

(ii at all) ventilated ; they are

overcrowded and cellars are habitually lot as

tionable as theirsituation; drainage scarcely exista.And itmust remembered that this is the opipionof a

metropolitan medical emeer of health. Under the heading"Oam o f Pever

”be says thatthe oond itiono f things d iso

closed inthe statement justmad e “amply m ounts for thetpresent epidemic of fever ; indeed it is d ifi cnltto suggestMm for producing typhoid fever so likely to

as tho se which have allowed Whitehaven to bed e

gad ed into its present filtby sta .

seventh report of the med ical omcer of the Privy

86

so urces ,

water as well as hy the water furnished b the company.

And he considers filthy conditions to have beenthe cause ofit and says : “Knowing well as we do that typhoid fever hasbeen shown overand over again to arise from the efliuvia o f

accumulated human excrement and that throughou t thewhole town o f Grantham such efiiuvia have revailed thereremains, I think, scarcely a doubt that the (fism mustbeattributed to this cause. The fact that the disease hasprevailed chiefly among the better-o i! classes is, on thewhole, confirmatory of this view, inasmuch as it is theirhouses chiefly which are connected with the im sewers

(and connected , too, by imperfectmeans) an it is mainlyalong the streets which“1

2ioccupy that the principal sewers

of the town pass with th (until recently) unta pped gullyho

n

In the same volume is another report by Dr. Bristovve onanoutbreak of typhoid fever at Debenham . He points o utthatthe d isease seems to bave clung to the easternportionofthe village and especially to the bo uses bord oriag oa thep oudor in its immediate neighbourhood. It would seem, and isno means improbable, that this stagnant receptacle forwas pestiferous and the direct cause of the illness which

prevailedOf the same d ate is a report by Dr. George Buchanan on

the sanitary state of Bridport, of which he says :“In h'rrth,

scarcely one London district really reaches the fever deathrate of Bridport, fo r those which appear to exceed it arechiefly those in which the great metropolitan hospitalsreceiving fever are situated. With London Oi withClerkenwell, with Marylebone and St. Pancras, d port

will not bear a moment’s comparison as to im fevermortality ; no, nor even with Holborn, or Bethnal Green, orSt. Giles.” He adds that the feverwas, no doubt, typhoid.

Dr. Buchanan puts down as the causes contaminated waterfrom shallow wells, described in a local broad aheet as“looking yellow, tasting strongly, with a nice good drainsmell. ” And “the retention of d ecom ordure anrefuse about the houses. The air of t townis pollutedserious and on a considerable scale."

Dr. uchanan, in his remarkable re Onthe results0 ' which have hitherto been gained various parts ofEngland by Works and Regulations designed to promote thePublic Health ,"states the general result of his observationsas regards typhoid fever as follows Many of the publicimprovements have coincid ed with reduction of typhoid .

Though notwith absolute constancy, drying of the soil of atown and md uctionin the crowding of houses have beenfollowed by reductiono f fever. Much more importantappearsto be the substitutiono f anample su y of go o d water forascanty and impure supply ; other inge being equal. the

87

towns in which this substitutionhas been completed havemade mostimprovement. Merthyr is a conspicuous instanceo f atownwhere.before any other immrtantchange had beenmade, typhoid felltc a notable extentas scon es inswction

f datmosphere mwm

f

themf go c matters

beenmost uniformly followed by a f in the prevalence oftyphoid . And this has o ccurred ually whetherthe purifiwtron has been brought about by e abolitim o f cesspools orby d rainage and drying middens . (Ninth Report of theMedical Ofi cer o f the Privy Council me) .In the tenth report o f the medical officer of the Privy

Council (1867) is an account of an investigation of an outbreak of epidemic typhoid feverat Winterton in Lincolnshireby Dr. Thoma Thorns. Of this he says : “The epidemicprevalence of fever in Winterton is undoubtedly to beascribed to the disgracefu l state o f the priviea cesspools,ashpits, and wells,

” and he describes these in detail. Healso gives an account of the water inthe well su lyingsome of the cottages where there have been cases o fmease

and says that the ple living in onem “and whohave always en

'

oy go o d health, not taste o f it,have d rawnth water from aneighbcur

’

s w Onthis heremarks : “Nothing could

hp‘ointmuch more conclusively to

the contaminated state of is water, and on examining it I

found it to be of a light brown colourand d ismble taste

and to yield a consid erable d epoeitafter shn for a fewhours. Under the microscope it exhibits a large quantity of

c matter, both animal and le, as well as

and animals of a low type. ” r. Thorns made anattemptto ascertainhow the fever criginated and onthis hesays : “ In some instances I endeavoured to ascertainwhetherthe fever could have had a spontaneous origin, butthe inhabitants all seem to be onsuch terms of intimacywith each other that they continually frequent the infectedhouses. there assist in attending to the sick, and thus comeinto contact with the bowel discharges, or else they d rinkthe contaminated water. My inquiries there fore failed toelicit any intormationon this subject, and owing to thefever having now existed inthe towntc a greater or less

extent fo r nearly sevenyears l was unable to ascertainthemanner in which it first originated.”Mr. J. Simon in his Report as medical ofiicer of thePrivy Council and Local Government Board for 1873(New

2) gives in an appendix“ Illustrations from

Inspecto rso Reports o f the fonr ears 1870—73. of the cir

which enteric ever is commonly foundprevalent.” There were 148 such reports during the four

cause. Form u llew mightonmhu hire) in1888

as the a igin o f the fiever prm b ce,”but that the

fiever was “ d ue in all probabflity to fire cond ificn

wanto f sufi cient dninage in the village the multitu d e and

itwas

water had got contaminated by drainage. He, however.ad d s ina note : “Though itwas very po d tively stated bynumbers o f persons that the never d rank the waw o f thestreams itis d iEoult to fee eure that a strict separationwould be mad e intheir use if two so rts of water were

admitted into a house." He was very evidently o f opiniongoo d d ealtc d o with the sprsad ingThe feverhas been most prevalent

also occurrcd in clean cottagea notovercrowded Butfew

cases have occurre d inthe barno ks.

Inthe seventh report of the med ical offic er of the PrivyCo uncil (1864) is a reportby Dr. H . J. Hunter onfever at

Harpenden. Es says : “The d isease was phinly typhoidwith diarrh ea

” and he distinctly attributes the cause of itto drinking-water. In describing the house where the firstease occurred he mys :

“The welhwith s totten structure

the family had beenobliged to desert their ownwell afterbearing with its horroru to o l a time. The wellwasnotonly ina filth yard , un near d rains and cesspo o ls,but the peopl Iie whc ved nearest to it were , ing

enerelterma accused o f d irty habits in us to the water. Andwith regard to ancthervillage w ere the fever ed hesays : “The firstfo urhouses inthe list ad jo and being

o f this water and thatamcngstthemonly of this group was

there mortality.also thatthey seemed to have aninstincto fone atleast amongthe causes of their illnees end eoughta

https://www.forgottenbooks.com/join

86

sources, “so thatif the fever has beend ue to any poiscno us

Ennisof water this poisonous quality must have beenby the canal water, the conduit water, and the well

water as well as by the water furnished by the company."

And he considers filthy conditions to have beenthe cause ofit and says : "Knowing well as we do that typhoid fever hasbeenshownoverand o veragainto arise from the efiiuvia of

accumulated human excrement and that throughout thewhole town of Grantham such efiluvia have vailed thereremains, I think, scarcely a doubt that the must hsattributed to this muse. The fac t that the disease hasprevailed chiefly among the better-o i! classes is, on thewhole, confirmato of this view, inasmuch as it is their

houses chiefly whi are connected with the im ect sewers

(and connected, tolcicm

by imperfectmeans) an it

pi;mainly

alcng the streets w tb

zoccu y thatthe princi sewers

o

f“the town pass with th (nutsm ently) untrapped gully

h a .

"

In the same volume is another report by Dr. Bristowe onan outbreak of typhoid fever at Debenham. He points o utthatthe d ism e seems to have clungto the easternportionofthe village and especially to the ho uses bord a

-ing onthepo udor in its immediate neighbourhood. It would seem , and isb no means immobable, that this stagnant receptacle forth was pestiferous and the direct cause of the illness whichprevailed.Of the same d ate is a reportby Dr. George Buchanan on

the sanitary state of Bridport, of which he says : In truth,scarcity one Londondistrict really reaches the fever death

rate Bridport, fo r those which appear to exceed it arechiefiy those in which the great metropolitan hospitalsreceiving fever are situated. With London Oit

g, with

Olerkenwell, with Marylebone and St. Pancras, rid port

will not bear a moment's comparison as to its evermortality ; no, nor even with Holborn, or Bethnal Green, orSt. Giles." He adds that the feverwas, no doubt, typhoidDr. Buchanan puts down as the causes contaminated waterfrom shallow wells, described in a local broadsheet as“looking yellow, tasting strongly, with a nice good d rainysmell. ” And "the retention o f decem ord ers andreMe about the houses. Ths air qf t towa ir pollutod

and on a considerable scale.Dr. uchanan, in his remarh ble re Onthe results

which have hitherto been gained various parts o f

followed by redu c tionof fever. Much more importantappearsto be the substitutionof anample su y o f go c d watsr forascanty and impure supply ; other tugs being equal, the

48

er another m caueed Mer imported from

Typhoid fever has beenvery neatly spread hy mnfi oa rhoaon Other instanceo o f

Privies “depth“?specifically polluted by the sacramental

Inthe Twelfth Beport o f the med ical cfiicer to the

Lo cac vemmt oard for- lfifia is anaccount of a

lo calised o utbreak o f typho id fever at Nor-wo o d , inthe

U BmaI Sanih ry District byMr W. H. Power

(now e chief med icnl omcer o f the hocal GovemmentBo ard ) .

e

The cause o f this o utbrmk m so clear-ly traced

by lin Power and is o f such great intereet that I maypc haps be excused fcrgiving his accountalmostta eu cm“V” early in the investigation it was noted that

the incid ence of the outbru k bestao cord ed with what is

knownof enteric fever id emics caueed by specificnllinfected water or milk. ilk causation of this ou

man% y

ard syard s d istant from one another and frcm the

seemed a highly improbable occurrence, andthns some time was t overthe air- hypothesis.

ties in enp the attacks o f

inmates of No . 13 (which is ona separate system of

cos pools) furnished a clue of much value. I twas foundMm No . I I I . which served houses No s. 13, 14.15. 16. 17. and 18 had atthe dats qf ths w tbnak bm fir e

44

{Maj fim thm pw u had bm ww ly mThis reduction in the number of pumps, and therefo re of

wells implicate d, d id not, however, greatly help towardsbelief in water-causation of the outbreak, for there seemedwell-nigh as much d ifi culty in accepting sudden andsimultaneous infection o f two as of three wells. In thisd ilemma I soughtto ascertainwhether pumd IL hadnot fo r some reason o r other come into tem andexceptional use sho rtl before the occurrence of eby the inmates of o uses 23 t0 30. But this suspicionhad to be aband oned . Both pumps had beeningo o d ord erthroughout the period in question, and pump No. I ., whichis separated from pum No. IL by a brick wall

,had

beenm i md so lely usedtby the inmates of houses fi to ao,all otwhich ho uses had beeninvad ed inthe outlneak. StillI was unable to accept a hypothesis of sudden and simultaneous infection of two widely separate wells far distantfrom the houses and from the cesspools—rather I was d isposed to regard the confident local assum espumps Nos. I. and II. su cking from separate andwells as open to d o ubt, and thus itcameabmcttlatI am u oedthatfir oomp lete belief inwater causationof the mstbreak itm m amry that pumps No . I .MI L sho uld mokfrona

single well. My surmise was quickly put to the proof byMr.

Freeman. the inspector o f uuisancea with the result—a greatsurprise to certaininhabitants of the terrace—thatthe suctionpipes of Nos. I. and I I . were found to lead to one and them e well .Here, then, in infectiousness of a particularwell water isexplanation in some sort of the outbreak. It accounts forthe limitationof the outbreak to the particular part of thetenaoe ccmprisinghouses 13t030as well as forthe intensityof the fever incidence onthese houses. But it does notexplainall the facts. There remains to be accounted forthe two months' interval between the August- Septembereeries o f oases and the outbreak of December, and ydoes the suddenness of the outbreak when it di occurrequire explanation.At an earl stage o f suspicion as to watercausation of the

outbreak s!) upon assumption of conservation in the cess~

pools of enteric fevermaterial d erived fromthe firstseries o fcases with subsequent thence of this materialthrough 600r 70 feet o f so to two or more wells, theabove facts d id not appear easy o f explnnation. But noso onerwas a particular well found to be alone inqumtionthana clue appm d that had been wanting. For thus con“dm d w““

233mam s

temm e

d ““m ay imp i m a c

walk such as might have resulted from fresh cmd ifionsnew] bmughtto bear onitand onitalone ; and inthis directionnow rcvealed the followingiacts. OaNoeJ flh,1881, cesspool cleansing was commenced in the terrnoe andwas repeate d onsu uentdnys up to early Decemberzm

45

the cleansingproceed iaysminclud ed transference d the content:

of thm ou rpu lr {e tha ne-8m mMMM, m hi9her

a

n thmM1inthe lim of mmmlsockeye to . the particular well which has been called inquestion. Now the main o utburst of the fever d id notoccur until the mcond week o f December, soon after thecommencement o f this cessp emptying. Then, be itobserved, and not till then, did any notable extensionoffever in the terrace take place, and this notwithstand ingthat the oesspoo ls must be regarded as having fostered eversince An

gstmaterial presumably

fever. inference is not to be avoided- namely, that thisexceptional transference o f cessm contents to a. hole inthe and near the particular well speedily brou ht about

0pollution o f the well water, and thus oned thesudden outbreak of enteric fever among persons using thatwell water.

They do not afiect the above conclusions, though they mayhave interest for the etiol t. Allowing for the incubation

period ordinarily observ in enteric fever, this outw it

llowed very quickly onthe procedure which is believed tohave fouled the well . It would seem, therefore, that eitherhighly potent infec tive matter transferred from the cesspoolsto the soil o f the gard enpassed atonce into the well ; or, inthis particular outbreak, the interval of time between theoccasion of infection and the first

egm tom of illness was in

many persons abnormally shorten ortening of the inoubetiontime may no doubt have occurred In

8would be in

accord with experience of certain milk outbreaks o f entericfeverwhere consumers of large amounts o f the implicated milkin a raw state have seemed to snfier from feverwithin a veryfew days of their infective meal. And what is true of entericfever conveyed by milk may be true also of enteric fever

ed by water, forinboth instances there is chance o fve matter o f great potency getting

and in abundance to the intestinal tract.there was inmanym es the usual d ifi culty inexactly fixingthe d ate o f atteck, butso faras l have beenable to awertainby personal mquiry case by case the early attacks occurredas fo llows :

Doubtfully onorabo utDec. 4th, seven d ays aftercommenwmento l emptying o f ceu po ols l ease.

lnthree d ays, Dec . 8th t0 10th. ll to lS d ays after como

monu mento f ernptying of eeu poo le “ la ses.

lnthrecmencemen of emptying o f ceu po o ls

The above facts are not, it will be observed, inconsistent

inw aooount before a d ecisionis arrived at. Ths holcMly u h h tu m fw the m fiu af m“Mu s ing .“ a u ll that m (Maud

whioh the suctiongg

e o f pump No. 2 had originally beenlaid, and following new course alongside that pipe wouldbe conducted directly into the well. Whether or notthe

mm "mm“m ‘

fMm ‘

iif“”

rimmm"m ”

e oesspo o e to e cannotnowbe .d cterrnined Mr. Freemansought to put this surmisealso to the test, buthe failed for the reasonthatthe umberwho had meanwhile been employed inla on theWater o om

tL‘supply

to the terracesuction pes o wel s. In removing the suction-pipe

theof

o. 2 the interval of and between theSepa lt-hole and the well had

ghzcome so femmaustworthy evidence onthe above t was not to be

ln1883Mr.W. R Powermad e animpoa-tant

outbreak atHitchinon which Dr. Bushmanmakes followingremarks inhisreportas chiefmed icd oflicer: “Inarepmt

gym. Poworonanepid emic pmvalence of enteric feveratitchin fresh illustration is givenof the now wewknown

factthatthe d ictributionof mteric fem oftenfoum bothinplaoe and time the d istributim of im waterinsuch a

way thatthe water cannot butbe “ conveying the

47

material otthe fever. The particularinterestof thenitchln

thus inf and thatthe impurity, certainly eonnected asMnPower’s report shows)) with the fever, yesthad notbe(m

anywise recogmsed as the cause of the fieveruntil his inquiry .

Inthese respecta and knowingthe ability of cholera to be oonveyed waterinthe same manner as enteric fever, the oased is of particularvalue to the presentreport.

"

Powerstates that blie water so ly le d erived fromthe Bath spring, situa at Oharlton, a mile south ofthe centre oi the town. This spring arising inthe chalk[lo v e into an underground chamber ad j oimn a cottage built

immJ“

p t roug a nmemented at interv’a

e

l

s

s between the iron pi inw h

izcourse from several ad d itional spsprings comin

lgto

therein) across the His into Priory ark. thismpoint

the water conduit, now consisting of clay-so cketted earthenwampipea is conveyed into the townbywayy our

/

flewchargesand, recrossing the flis againby ironpipes, finallyinto receiving tanks in connexion with the pumping wellwhich is situated close to the river in Queen~ streetThe water had

tgener

allyy beenconsidered to be not only

suficientin quan but unobjectionable in quality .

“But from the story that has been told respecting themethod of conveyance o f the water to the town there isobvious suggestion o f many chances of pollution encounteredby it on its way thither, and it cannot, therefore, be regardedas uniformly a safe supply . Flormer

ganrisks of pollution of

the waterwere even more abundant at present, and it“Mm “We?

“flit?

mm‘“the

“n“di by e tary u ty the lastfew

years certainprivies belonging to the hou ses at or neartothe Bath spring have been removed to a d isiance fromit, and their vaults have been made watertight. Earthen

KIMtoo, that at one couve the water

throug the spinney have beenreplaced iron pipes,

and inspection holes on the cond uit in the ey.whichatone fime wem leftopemhave beenfitted wi heavy stonecovers. Some other and serious risks to the water that stillremain may be particu larised as follows z—The cottage at

the spring is occupied by a laundress, who se cellar-kitc hen ,used by heras a wash-house, is withina few feeto f, and at

level than, the underground chamber containing theConsequentl there is , in the eventof this womanclothing or en fouled b enteric fever

md iwharges,

cally contaminatedyimperfectly drained floor of er cellar-kitchen

spring itself.to

, the spinney, where are theminor spring

e cmmng e surface and supplementing thepublic lu is not securely fenced against trespassers, and

{a ground here was, on my visit, observed to be

https://www.forgottenbooks.com/join

is easy to cred it for thia the first o utbrmh similar d h'

ect

relatim to the public water service. And inthis conna ion

that, on a hypothesis of water oausation,mighthave beenconcerned on each occasionwith the other

As regards the second, orJan outburst, discovery of the defaulting o verflow-pipe an arrest

of this so unce o f pollution o f the public

water eervice was followed some two weeks later by sud d encessation o f the fever, and similarly complete emptying and

by well-nigh commets disappearance of all fever that canbe consid ered as related to any common cause of the

December outburst."

In 1884 Dr. David Page reported onan outbreak atBeverley (Yorkshire Theborings into the cha whichpolluted by defective drains in their neighbourhood (therewere 185 houses supplied by a private waterworks company) other sani defects an outbreak o f typhoid feveroccurred inJuly, , consisting o f zal cases inmfihousehold s ; the mainfeature o f itwas thatthe general watersup ly ei the waterworks company d erived froma d eep wellin e chalk was specifimlly contaminated, the cornpany

’

s

well and reservoirbeing in immediate oonfiguity to a sewage

51

W field belonging to the East BiAsy um, inwhich oases o f typhoid hoverthe outbreak in Beverley.In 1889 Dr. J. Ashburton Thompson, chief medicalMoto r of the Board of Health of New South Wales, issued

a reporton an outbreak o f typhoid fever at Balranald whichhe trao ed to pollution o f water ina certaintank which wassupplied with rain-waterand was sunk in the marly clay andno t known to be puddled outside near it were severalcampite. It was shown that 14 households, in all 124

pers ona were supplied with this water, and ananalysls ofthe cases in those 14 households in which thatwaterwasregularly drunk, in comparison with that o f households the

e of which are not known to have drunk it, gave thepoottlmto f 12¢l persons who regularly d rank the watersll

per cent. sufiered ; while of 476 nsthe water cannot be defined (that who werenotknown tohave drunk it) only r oent. snfiered .

I am indebted to m (1Professor Byears Doyen o f the acuity o f Medicine of Paris, for the

oulars of three ou tbreaks of cid fever which hevestigated and repo on in The first occurred atPierrefonds. In August and September, 1886M

adpereo

from Paris and Versailles went to live in three jo inio

r

ighouses at Pierrefonds ; 20of these nacontractedfever more or less severely, and o urof them died.ascertained that cases of enteric feverhad occurred in thesehouses before, one o f them having beenvisited five times bythis feverbetween 1874 and 1883. The water-suppl w

hichthe

houses on both sides of the street was from we

communicated with one another through the veryfilmsoil . This was proved by the fac t thata few years are

a fruiterer who kept one of the houses on the other sid e o fthe street let fall a canof oil into his well, and three or

four days afterwards the oil a in the well of one ofthe houses in question. The en ilwater supplying thesewells either alongside o f, o r below, the cesspools ofthe erenthouses. These cesspools were notwatertight,being constructed of small stones without any cementOne of them, w ith which two of the infected houseswere o onnected , had a small d rain from its lower part

discharging into the neighbouring stream. This drain at

the time o f was blocked , the cesspo o l had

not been emp

n

W and it was almost fullof hard d epomt which to be remo ved with a spad e.

The wells for the two ho uses were d ug at d istancesof 9 and mmively from this cesspooland in such

20a the level o f the bottom

of the cesspool was

t

s little above that of the surface

o f the water inthe wells . To increase the d en the rainwater from the roofs was also discharged into e ,ceu po o l

so that wheneverthere was a ha vy shower the waterwashedthe meal matters into the subsoil and thence into the wells.

the organic matters ineolutioninit had beenalmo stcomplately oxid ised . 0f this Dr. Bronarflel remarks : “This isanobeervationof which the importance is eafily und ersto o dinthe d iscuseion of the questionof the purificationby thesoil o f sewage water charged with exscrementalmatters. Itshows thatthe d estrwa organic matters which come incontuctwith it; they und ergo nitrificationinit; butitisnotthe same forthe germs of typhoid fever. They persista longtim inthe earth ; th

zs

lived formore thanamonth inthew o f Pierrefond s." Be thengoes on

to show thata caee o f enteric fever had beenimporte d fromParis lnto on

izo f those houses at l’ierrefond s ata remote

period. As very usual insuch casee the intensity of theseaee varied v much a

gi

fonzgthe pereons attacked . Of

value would certainl have beenpoint he quotes P. lin-aim “DeHumain et de ses Variations“Perhaps there is a twhoid ette

u thm h a m loid . There is no reason why one

58

should not sdmitthis hypothesis, butitis a hypotheeis.Of this Dr. Brouard el says :

“Thatwhich Lorainconsid ered

and Redhill which Dr. Buchanansummarised as follows :

conclusive f of the manner of its d istribution and was ofsingular as demonstrating how limited a quantity o finfective material may sufiice under favouring circumstancesto do widespread mischief. In one of the wells o f the

formed and

by d iarrhma,

have become contaminated and there was no suggested wayof its contamination by any other means. For the rest,uite satisfactory evid ence

anyconnected the y of water

thls well withm fli

gfighepid emic extended

beyond Oatsrhamto and er localities supplied by

near which there was an old brick and mortar culvert

dischargee and thatno d oubtby l from itthe well

became infected . (Nineteenth report o themed ioal ofi cerof the Lo calGovernmentBoard .)In1889 Dr. David Page reported anoutbreak o f oid

feverat Houghton-leo Spring (Durham), the cause of w is

54

of exceptional interest. He traced the epidemic to the waterof a well or staple sunk to a depth o f 330feet into sandstone strata o f the coalmeasures, and the investigationis o fsuch it hatI quote atlen from the end o f the

report : “In looking around beyon the immediate viciniof the well for

‘

ble opportunities of contaminationhad visited early my inquiry the farmhouse of HerringtonHill. This is situated about three-quarters of a mile tothe south of Herringto n Colliery onrising und andabout 150 feet above the level of the s ace o f thewell. The farmhouse and buildings are upon the magnesianlimestone, the beds of which di towards the north . Owingto subsidmcee caused by the co liery workings below fissuresextend ingto the surface existinthis locality.

o f the farm build ings, o f a cottage, and of

itself (inwhich latter there is a water-closet) is conveyed toa tank. The overfiow fromthis tank escapes and d isappearsdown an adjoining fissure in the ground. To determinewhether a connexion existed between this fissure

“Sthree

quarters of a mile from the well) at Herrington H'

farmand the water-bearing strata eu plying the staple ’ I suggested that common salt shoul be dissolved and throwndown the fissure. Instructions were given to this efiectandtwo tons o f salt were acc ord in

ethrown downon May 11th.

At this date the discovery 0 the ‘feeder ’ in the ‘ staple ’

had notbeenmad e and te of the wateras pumped fromthe well did not give any conc usive indication of increase ofchlorides. On the discovery of the ‘ feeder’ a week later aclue to the excess of chlorides shown by it (as commred

with the body of water in the well) was apgamntl furnished

and, as will presently appear, the source 0 the c orides wasin the end conclusively demonstrated. From May 24th aseries of daily testings of the relative amounts o f chlorinein the water of the reservoir and of the ‘ feeder’ weremade. The chlorine in the water of the reservoir variedfrom2 °3t02 °8grains pergallon OnMaym , wima fimof placing beyond doubt whether the increase of chlorinethus shown was due to the salt thrown down thecrevice at Herrington Hill, five tons o f salt were washeddown the crevice with a hose-pipe ruaniu for twelve hours,during which time it was estimated t some 100tonsof water were discharged. On the following day thechlorine present in the water of the ‘ feeder ’

rose to 15per on. The testing was continued for a few

umyx

s

ml

‘

onger and 5th the chlorine reached theurnamount grains per on. During the next

few days it fell to the formergaunt. The connexionbetween the two ocalities, the farm tank and the ‘ staple,

’

was thus conclusively established and the source of excremental contamination o f the water-eu ply demonstrated.Specific contamination of the sewage m the farmhouseco uld not, however, be mad e o ut, no illness of a characterresembling enteric fever having been known to occur at

55

the farm during recent years. It remains to add thatsince the discovery of the ‘ feeder ’ arrangements had

been made byMr. Lishman for the supply to the afiected

district o f water for drinking purposes from wholesomeacumes. Warnings had been issued to the people againstm e to the tap

-water fo r drinking purposes and itwas fnrt er decided to abandon the Herringto n water as asource for domestic sup y. To meet the immediateexigencies of the case an to guard a

gainst d anger from a

continued distributionof thiswater the oughton servicewastnrned onand d istributed thro ugh the Herrington mains fortwo hours night and mo rning. But as this su

pply was

insuflicient to meet the requirements of the who of the

boiling the supply pumped from the Herringto n well beforeit entered the reservoir. boilers, which were fortunately athand , were emote and ad apted to this

and on June and these arrangements were comple and inOperation. Onthe occasion of my final visit to the districtonJune 7th I witnessed the remarkable and unique instanceo f the delivery to the mains o f a water-supply which hadbeenactually submitted to a boiling temperature. To fillthe watermains o f s town with water which had been allboiled was indeed a remarkable and unique experience.Dr. Theodore Thomsonreported in 1896 on an extensive

outbreak which occurred in the Boro

glb of Worth

'

(Sussex), where there were no less than 7cases with 1d eatm. Of the cases 1257 were inWorthing properand 58in West Worthing. The villages of West Tarring andBroadwater were also invaded by

‘

the disease. Thisepidemic was found not to be referable to general sanitaryc ircumstanc es, to sewerage or or to milkc supply.

The epidemic in Worthing and water, which have acommon water-supply, was shown to be caused by waterfrom a new heading which was contaminated by foul matterfrom leaky sewera and this water was shown by bac teriological examination to contain not only abundance of thebacterium coli butalso bacillus typhosus itself. The epidemicinWest Worthing and West T which were pro videdwith anotherwater-supply appears to ve been due to localinfection of the watermains .In 1894 Dr. Thomson also reported onsimultaneous out

b eaks o f typhoid feverand o f fever o f less definite sort atvarious plac es in the Borough of Newport, Isle of Wight. Hefound that these outbreaks were referable to a pubhc watersupply common to all the invad ed places. This water-supplywas derived from a well in the chalk at Carisbrook and wasfo und to be Open to us contamination from the leakyd rains o f houses near e waterw o rks and standing onthechalk, and also from a filthy mill-pond. There was, moreover, serious risk o f dangerous pollutionof the water in thedeeper strata of the chalk supplying the wells, from theexistence of am orous cesspools within the area drawn uponby the two wells.

56

break.

Ama t interesting and remarkable case of the pollntion

l novortheloss u csrtained that

pad to the house on certainobnrvo d uryself, a very fo ul smell was forced into

The explanation of this is no doubt as follo vm. Thewatcr iu tho well stand s as a rule consid erably higher

thanthat inthe pond . so thatthere cannotbe any d ire ctcommunicationbotweenthem, or the water inthe wellwould hak am d ownto the level of that inthe pond ,whloh lsnottbe caae. When, however, the level o f the wellwater has beenconsiderably reduced by pumping, as is

montb the onmif it so happens thatboth o f the sto pare runopen, the two suction-pipes must act as

siphonand tbo waterfromthe d be su cked over into the"unanimou s-inbo und that the wawr inthe wellhas notbeeninfrequmtly ccntaminated inthis way. (See(lync h )y friend Dr. Pisto l of Berlinhas kindl sent me two

N Monpo llnto d wellwaters. One by Dr. cwius o f GoselMa intenanoutbnak o f typhoid feverwhich occurred inttowna otobor, 1899, and was traced to the use of

lutod wator from the well of ome o f the hotels inthe

wn‘ ; aud tbo otherby Dr. Bloch of Beuthen(Silesiamonl 24 imm-mMrMou rh alheamte, Bolt19, 1901.

https://www.forgottenbooks.com/join

58

to ok plao e inthattownfroe me t-o October, 1397, and was iaao ed topo lhrtiono

f the town supply by exm'emental matters from

the mirws which filtemd thmugh the sofl into the wells d flie

pu blic water- supply liw a heavy flo od which swamped themines and washed the fmcal mfl aters c ut of ihe p fils inflie

My friend Professor Kubom q of Serning, Liege, thePresid ento f the Royal So ciety of Public Health o f Belgium,

has kind ly forward ed me a numher of mpm'ts to the m m

onriculture by the pro vincialmed ical o ommissions of thatcountry , from which l find thatthe spread of typhoid fevu

'

there is d ue (Report for 1891)“ for many plaoes to the

po llutionof the “ ta -supplies, for some to imporh tim andto d irect contagion; inthese the 1elafi ons of canse andefiectare precise. Lastly , ina more vague sort o f mannmo vercrow d ing moisture . and want o f cleanliness are alleged

causes " Thatit is d u e to polluted well-wata is not to be

surprised at c onsid ering that the following is gim as a

descriptionof the wells supplying the w orking d ames inoneo f the greattowns :

“ A well Sin-ro unded with privies, hnpsof manure , and goat-stables fumishes waterto allthc inhabitants. These c ome there to obtainthe water wiih vesselswhich have served for all sorts of purposes. l ost of theinhabitants are w orkpeople employed inthe city—a factwhich explains the rapid spread of the disease ”

Inanotha '

reportwe are informed that while the water is at fault insome places inothers “it is the hou ses which are at fault,whetherby overcrowding or by filth .

”

InLuxembo urg I find from the report of works carried

o ut d urinnQZ an acconnt of an o utbreak at llamo ur,which has forthe last 15 years had a public water-supply

and which during thattime hasnotbeenvisite d by typhoidfever, but the water-supply to the inhabitants was c om

pletely spoilt onacco untof the droughtwhich had laid d rythe openend o f one o f the main pipes drawing water froma stream ; various animals having found theirway into thispipe died there and the decompo sition of their bod ies

cause o f po llution was withdrawn a stop was putto theepid emic. And in another place called Bastogne, wherethere had not been a single case o f feversince whenthe public water-supply was established, the droughthaving diminished the quantity of water available, thecommunal authority allowed resort to be mad e to old wells,recommending the people by placards not to use the waterfordrinking . But a certain number of the inhabitants to okno no tice o f this warning 20days after the reopening ofthe wells there were 30cases of typhoid fever ; a monthlater 100cases, of whom 10died .

”

Again, in the report for 1893 we are told that “inthe

3 Deuteche Vierteljahrschrift, 1898

59

greatmajorit o f cases it has beenpo ssible to trace the

origin of the and the causes of the mme, which werefound almost alwa

ys indicated. The most frequent by far

consists inthe po utiono f the d water d ue to theW on d er-gu mmatters through their walls, the mixture of spring or riverwaters with waste waters in a state of putrefaction, ofmanure deposited on the fields or in the proximity of houses,especially after heavy rains have washed the country,cleansed the streets, and made the cesspits and the waterco urses overflow. Next to this came the importationof thedisease by individuals, most frequently workmen cominghome from an infected locality ; direct contagion operatinghabituall between persons o f the same family or livingtogether small apartments ; emanations from foul sewersand the want o f disinfection of the stools of typhoidpatients. In the report fo r1900 I find it stated that“sometimes typhoid fever is also spread by means of thebw habit which farmers have of throwing typhoid excretaon the dung-heaps. It has resulted that in the spring whilespreading the manure onthe fields the workmen who hadcarted the wintermanure were infected by the bacilli whichhad beendeposited in the autumn. The manure in pas ser-viits temperature, its humidity, and also certain salts analbuminoids, supplies them with an excellent cultivatingmedium.

"

Water-supplies have sometimes beenshown to be pollutedat or am their

‘

ngs by infiltration into them of excremeutal matter, an outbreaks of typhoid fever have tamplace when such matter is specificallythese are the following.

Bricksworth (Northampto nshire) .— Dr. Thorns in 1874reported that this fever was habitually prevalent and thatt

he water was liable to surface and excrementsl pollut on.

Dr. Hubert Airy reported onan outbreak o f enteric feveratBlackhuru inLancashire iu 188l as follows : “Thiamsupply of Blackburn runs the risk of pollution at its severalsources. There is risk at the ering ground above PickupBank there is risk at the Wh te Birk colliery of some accid ent similar to that which befell the Oaterham well ; andthere is risk atths well onRevid ge, for ho uses are tynumerous round about and the soil is a porous sau tonerock. Moreover, as regard s the water from Pickup Bankthere is risk at very many points along the route by whichit is cmveyed to the to wn. The stone culvert isof rough construction, built o f the ragstone of the districtin rude w shaped lumps, fitted together without mortaror cement, t well bedded in thick puddle ; and rememberingthatthis culverthas lainfor more thanao years, onlythree or four feet deep, on the slope o f the

film“with a

on e upper side,

and lessening of pressure on the lower side, it can hardly be

3 8 id uimwhicmwhend eeired . canbo set openso

theMormtof itinto anopenby-channelwhich runsd own between the Guide embankment and the public roadnnd is finnlly tumed into the lower (Fishmoor) r-eeervoir. Inits coume it receives the contents of a d itch which, whenMced bwh is found to take originatthe back o f somedwellings in the upperpartof Guide village, whence it comesalmg a cu twuy uo d d enm d befo uled by cattle pu ta fnrmMm d thmugh a field , d posed inito who le length to theriek o f pollution. I heard tnles also of miachievoue fellows

Thesix-too t mcloeure wull is eu ily climbed.

”

Dr. wm ww s how me of the privies hnd beenshortly ore the outbrenk infected by the sto ola o f a mnn,Aspd en, who had typhoid fever end go ee onto suy :

“Thiscase was not visited the medical ofi oer of healthnor by the inspector o nuisances ; the dnnger to the

public henlth attnd iag tbc pnm o o qf a m e offm w w tbe fl atw o rm-

y qr‘

tke m terw ly moverlo oked . An unskilled labourer who works under the

front of the ho use. Either channel would curry them, ae

already described, immediately over the water-culvert. atpoints when it was evident on internal examination thatfluid was inthe hubitof oouing into the culvert. Any suchrid it to occur. wo uld be infinitesimal incomp rison the quantity of waterflowinginthe culvert.m d thatngaimin compurioonwith the whole bo d y o f waterin the reservoir which received it, would be butus a riverflowing into the sea. It certainly taxes the imagination toeu thnt oo minute a portionof infected mstterwould

to give a poieono us tnint to so lnrge a bo dy of

water, unless it possessed the pro of self-multi lieution." (Eleventh reportof the cal oflicerof theGo vernmentBourd , 1881.The second report, or which I have to thank Dr.

spa t. Theee o uthlmh " had the eame com e inthe two

Moa emnd ut thetoward ethemid d le offound in the waterinbeentyphoid fever d urii

zgthe second outbreak. This cistern

had notbeenclenned or two yenre nnd a young girl whod rank weterfromithad anattuck of typhoid fever.The third kind ly forwurd ed me by Dr Brouu d el,was on an veetigation made by himself and Dr.

Ohautemeeae in1887 into some o utbreaks o f the d ism e

in the barracka of the Marines at Lorient. Theythatultho ugh the fever ruged among the trwpe

68

hospital on which thestantly being thrown.across thatgard en the cond itiins are such that it is notpossible that the drinking-water should not he sometimeslluted . The secondary cause o f pro

tgagatim of the

is the infection of the air due to e installationo f

under the windows of the buttock-rooms. As soon as theselatrines are infected by hoid excreta they can spread

Onthe firstand secondks one window is more 1

above the tubs ; the three placedby the sid e o f this wind ow o u the firstand wcond floors

have beenoccupmdwith typhoid fever. Aro und them inthe same messes of the

burrscks the victims of the d isease were much more wid elyseparated Thus twice a year humanexcrementis fiircwn

game meadows where the source of waterwhich supplies

te mcks o f the arsenal springs and twice a year anic of typhoid fever bursts forth . The manuring takesWMfirstinJanuary and February and theninAg‘gust; theid emics inMarch and inOctober or ovember.

o rs in is e bond which closely unites these two facts, themanuring o f the land and the explosiosiono f typhoid fever.

Further prmh if any wm necesaars to be found inthe

https://www.forgottenbooks.com/join

the smallstreamfromwhichthe Bangorwater-supply isand in this manner no d oubtinfected matter fo und its way

tive plugs inthe filtsrsthemselves fully a third of the waterwas passing d irectiuto the watermainwithout auy filtrationhatever. The filtering sand has not beenrenewed for agreat a of yeam. altho ugh l und erstand thatitund ergoos e certainamo unt of cleansing from time to tims. Iwas further infcrmed the clerk to the urbunsanitaryauthority, who is also waterworks manager, that fromthe pesty character o f the water the filters frequently beoomeclogged , and atsuchtime the water cannotbe filtered rapid lyenough to meetthe d emand , hence the water is paesed intothe mains withoutany twhateveratflltration. Here,then, we have established a means of communicationbetween the consumers of waterand the specifi poisonedcontents of a d rainatLlwynrband ir ; further, we ve cases

o ccurringsimultaneouslymiles apart from oneanotberwhich,with the exception o f the water-supply, had no circ umstances incommomthere being also anentirs absmce ofcases in houses not so supplied. I have, therefore, now nobed taficninattributingthe primary spread of the d iseasetothe water-sup y.

"

After d escn’

the co urse of the outtseak he concludes as

1

pollution accounts for the dropping natureo f the ceses up to July 7th. Thatthe special outbneak in

67

the second and third weeks o f thatmonth was d ue to thecommunioationof infected matter ina concentrated formowing to the disturbance in the reservo ir and filter-beds,resulting from the accident to the main onFinally, that a certain number of the cases which haveoccurred fromthe end of the m-stperio d to the presenttimesre dne to the direct introduction o f infected air from thesewers into which the dischargm from cases ofhad beenreceived .

”(Twelfth report of the m

to the LocalGover-nmentBoard for lm )An outbreak at Mytholmroyd (Yorkshire) in 1888 was

Fever in the Valley of the River Tees in IMO- 91. in

amongst the users o f water from the river for d omestic

periods to gether for every single person who contractedenteric fever amongst the population not using the Teeswater 15 contracted it amongst those who were suppliedfrom the river. This river was liable both habitually andstill more during floods to fouling by human excreta and otherfilth fromthe town o f Barnard Castle and some 20villagesand hamlets. Commenting on this the late Sir B. Thornsremarked Over a wid e area covering 708,080aores, or

1103 square miles, and containingMGMinhabitants,enteric fever

each o fas

large amount, the remaining area meanwhile exhibit

m a

nconsfituent sanifi ry districts, com .

manly t ‘ fever’rates. One of the out

at a time of year when, apart from someceptional and unusual factor enteric fever is not apt to

prevail in epidemic form in this country. Within thedistricts invaded by the two epidemic prevalences

some coalities sufler heavily whilst others escape excepfioual incid ence to the disease . One factor alone is foundto be commonto the places thus suflering exceptiomlly fromentesio feverand this is the use of water umped fromthe

times subjecttoconditions o f the gro sewtf by reasonof d re factthathuman excreta and other d lth are owingly and deliberatelyconveyed to it. Opportunities for the access of the specific

68

material of enteric fever to the

beenaccumulating onthe banks o f the river d ownup to and pastthe points of intalre fromwhich

the foulingso

of water intended for human consumption, soglues pemistently maintained, come within them

mof the medical department, and eeld cm, if ever,

has the pro of o f the relationof the use o f water so befouled

to wholesale occurrence of enteric fever been more obviousand patent.” (Report of the medical oflicer of the LocalGovemmentBoard forlM—QS.)In1891Mr. E L Jacob traced ano uthreak o f fi cases at

Catteshall Paper Mills, near (im age the temporary

use o f thewaterof the riverWey for “Atone of theho uses inthe boro ugh of Go d almingwhich d rained into theriverWey above tbe mills there were some cases offever inApril and May ; the speoiflc po isonof the ever,therefore, was probably w ing into the river from thatho use atthetime whenitwas d istributed to the cisterns inthecla «ro om atthemillsfi (1

’t o vol. iv., p.outbreak of typhoid feverat

Lynnand Gaywo od(Norfolk) was reported onin1892 Bruce Low.

fact that the water-en ly o f the town was derived fromGaywood river which through cultivated fields and

ens. The intake of the water is within theund ary and the filtration ado is very insufi cient.

before the time o f the o utbreak onpartof a market gardenabu tting on the river and abo utamile above the intake ofthe water-supply and the " excreta from a house outsideGaywood wherein eight persons were attac ked one after theotherwith typhoid fever between November andMarch hadbeen ina pitinthe gard en. fromwhich itwas washedinto river above the intake by the melted snow and heavyrainfallthatoccurred inthe third week inFeln'

uary.

"

Dr. Bruce Lo w reported ln1898 onanoutbreak atthe

chief intenstinthis o utbreak is thatitwas cnt shortby all

69

the water used for all domestic purposes being boiled .

In 1895 Dr. Bruce Low reported on an outbreak o f boidfever in September in certain riverside villagesHelmsley, just after the outbreak at that town caused byinfected milk (see page This outbreak was “confined to tho se persons who d rank raw river water takenfromthe Bye atpoints below thatatwhich it is po lluted bythe sewage of Helmsley.

"

Dr.MacieanWilsonreported inlBQS ona sud d encutbreakof typhoid fever at Chester-le-Street (Durham) which wasfollowed after a short interval by another equally sudden.

The suflerers in both cases were almost entirely personsusing one public water-supply which had before the commencementof both outbreaks been contaminated by entericfever discharges from some cases in a grcup cf cottagesabout three miles above the intake of the watercompany.

The sewage from these cottages ranby means o f a covereddrain into a small stream, s tributary of the Stanley burnwhich supplies the filter-beds of the company, but thesefilter-beds were quite inmoientfor the urpo se of preventingany germs of enteric fever contain in thatwater fromgain ac cess to the stmeetmains of the com y.In Dr. F. StG.Mivartreported ona sugigno utbreak o f

ind iflerently throughout both plac es . The water-eu y was

d erived frcm the riverGa co d “which is exposedrit

e

pollution of all kinds bo ut its course. ” The ver

water was delivered without tration, an abundance of contaminatingmatters having been washed into the riverby theexcessive rainfall on t. 29th.

In 1899 Dr. 8. W. eatenreported onan outbreak in theborough of Ilkeston (Derbyshire) as follows :

“Fever prevalence ih all hability d ue to pollution of the generalwater~en ems town, which is derived from the Nutbrook an im ectly filtered The water of the Nut brookis grossly po utc d by liquid refuse from dwellings at Honor,effluent from the Honor sewage farm, and numerous othersources of contamination.

”

Inthe twenty-second annual report of the State Board ofMassachu sets for 1890is a reporton ho id feverinits relatiomto watero supp byMr. IIiram .Mills, inwhich itisstated : “Twen ve years c

d eaths by typho i fever in 10.which are now cities in this State was 78, the numbernow

the same places is 4 '0inactual number of deaths

from this d isease ZByears ago inthese placea whentheir

populationwas cnly six -tenths as much as atpresentwas asmatas it is now, and if mmsures for its prevention hadnotbeen takenand the death-rats had continued as it was 25years ago we should now have 1000deaths early, when theactual number in the cities is about 800. carefully plot

d ownstreamfromwhere the Lowell sewage enters the rim .

d isease prevails inthese cities are laterthanthoee o f other

citiea and inthe lower city onthe river later t intheupper city, ata seasonwhenothertbe d ieease and atthe time whenitby the sewage from the upper city ; further. that

71

water o f the riverwhich passed the upper city and recelvedits d uringthe greatc st valence c f the d isease therehad the sa vice o the lowercity, and there wasthe greatestprevalence Md isease inthe lowercity typhoidfevergerms were found in water from these service-pipes."

is given by Dr. JohnLee ], health officer, Paterson, NewJersey, o f an outbreak of which he says "No posd bleccmmenmeans of infectioncculd be found exceptthe blic

water-supply, uponwhich all of those affected, v i thepossible exception of two o r three, were dependent for at

leesta porticno f the mhours. Italso thatthe

only secfionof the city which d id notccn e caee o f

the d isease was also the only section not furnish with thelie water supply. It appears that “a resident ofFalls (a place on the river above Madison)

returned from a summer rmort ill with typhoid fever onAugust 28th. The fever subsided about Oct. h is buta relapse followed , lasting from about Oct . 8th to the

end of the month, when finally convalescence began. Thewater-closet receiving the d ischarges o f the sat wasconnected with a series of cesspo o ls, conn with each

other by o verflow-

pipes, and the last cess l of the series

throng hidden pipe into e river. Thesehaving thus become infected about Sept 1st.

nod to receive fresh infection until about Nov. lot,when the patient was actually convalescent.” Bacteriological examination o f the water above Little Fallsnegative result both as to bacillus coli and bacillus typ cans.but below Little Falls the chemical evidence o f harmfulpollution was found, the sump

“number o f bacilliper cubic

centimetre was SOO, and in cent. of the specimensexamined colonies of the common

perm “bacillus a

Ona specimentakenatthe intake onSe 23rd Dr.

reported as follcws :“Tests for typh bacillirevealed the

from that eource and . Notmore than28 0ases wereintected after d atc and cf the ZS cases IS were

infected within the first week and seven within tbe

second week after it. Thus it s. that withintwo

weeks of the shutting off of fres infection the typhoidbacilli already in the river had prac tically disappearedowing to surrounding conditions notpbeing so favourable asinthe Is and to the effecto f the downward flow of thecurrent t seems reasonable to believe. however, that theinfectionof the river and its attendant results might havecontinued indefinitely, owing to the conditions favourable to

https://www.forgottenbooks.com/join

75

Parish o f St. , fr m which it ba conion“ Oau al rmm mm

o

emJunction y d urlng December lu twas of inferior This

y oppoeed to the opinionwe have arrived at

extensive experience of the cond itions o f thawsteb supply fmm d ay to

to the orgenie matter he s thatthe coincid encemaybe e buted to the e clical encess o orp nic mattcr which occmd th

uzgwintermont

ch h i 0facts are against any su ypothes s. ur reoord sda o f the Thames-d erived waters since lBSl , wgether v-1th the

s statistics o f enteric tever, enable us to stsmthatthere u no caunl relationbetween the m . Ind eed , this mnst

76

This was referred to me by the committee of works, and Ithe fo llowing answer to ‘

which issuedp‘m Spscial ltepor

-tontheWanter-supply

v'

v’i

as a

77

thatthsy varied from wpw per oubic centlmetre d ownto nothing.

33mm“it.m assgaira mu m?

“

they eho uld notexoeed lmpercubio Onto f theMtgexamination Bir k lfrankland there were bb d a inbanter-la m! thh stand ard and for the waveraged 783mierobes per cnbic centlmetre w thatza

ba

pu u na o f

the results of Sir Bd ward Prankland s exam tend to ahow that

cornplaints inthe late summer, to which some referencs has besnmad sabove , to be d eservin

fo fmore prolonged and d etailed investiga

tion.’ italics aremine.“As to the factthat

‘c orgnnisms

'have notbeenfonnd in

the water lled by e T companies lnsed ma 'ely say thatthe bacillus o enteric feverhas rarely , if ever, beenfonnd inany wateran . .ltwas not found forinstance inany sample o f watm ued

and onthia t Dr.Washbo urnaaid inhis that‘ao tmpog

om caa bc a to the foam to doiseooer the iwhoid

typhoid jeoer.

mi tgflis so ,

“sw ift; y

anggegmag

bacillus wonld be foundo und inwata- which is meusll

y suspected

m ainta in- inintho se us o f the community who are

susceptible to it. In , the test which shows whetherawater contains typhoid pciaonianotthe d iecovery inito f the bacilluao f the d ieeaae, butthe factof itapro d ucing or notpro d ucing thattsverm o

ggthe peo o le who d rink it.Wm. Omokes and Pro fessor Dewar allud e to theMaid stone

inquiry and say that‘itwas proved beyond all d o ubt that one of the

‘ 79

thatths gm ier part of llond onis thenmpplisd with water whiohcontains ancxcess o f matier.

’

it

{ou tc a remarkable coineid ence that

l am able thia mw h to repon you that the number o f casea o fver inLond on has very c onsid erably d iminished and the

d eath-fate fmmitgone d ownto itsnormaiamo untnow thatthe watsro f contaminationto which I havea E é i

is

advisers

I haveno d oubtfromthe abo ve facte thatthe unseasonableprevalence of typhoid fever in November and December inim d on is d ue to the distribution o f inemciently filteredriverwater conminingthe poisono f the d isease, intamount, however, only to attack the

Dr. 8. Davies, the medical oficer of health of Plnmstead ,

reported in1893 thatthe cases of enteric fever among themenemployed in the Arsenalwere caused by theirhabitofdrinking water used for an and drawn from theArseml canal. This water is e to be po lluted with theu m fi of labouremand isvery liable to containthe infectionof entexic fever. This ramind s me of the acco unt venbyDr. d e Benay otthe prevalence od typhoid feverat

the Thames. On supplying the prison by means o f anartesianwell the d iaease became as rare there as it was

among the employee on sewage farms, even when theyd rinktbe waterof wells onthe farm, which is frequently the

municated a paper to" Public Health in July, 1873,

enfitled “The Danger of anIntermittt aterSupply whend elivered

"by ho use services designed for use under constant

He had noficed that cases o f d cknem d ianhwa andtyphoid fever bro ke out in ho uses in cro after the

constantwater service had been tem‘

y replaced by

plained of asnotbeing goo d ; he fo und thatwater fmm the

soil was sucked into the water-mains h defective

joints, and also that fo ul matters were su c into thmrm s sm m m u om wm em .

At Lewes (Sussex) Dr. Thorne reported in 1874 that

sewage, and mainly spread by suotiono f polluting matterinto the water-pi of an intermittent water service "

Of the cal ofllcer o f the Privy Oo uncil and Lo calvernmentBoard , New Series, No. W. , for He also

reported as follows on an outbreak atWolverton: “Watersupply exposed to risk of pollution by suction of foreignmatters from clo set-pans into mains o f anintermittentservioe

”

mno f the med ical emcer o f the Pri Council andGovernment Board, New Series, No.

And on another at Tideswell, Derbyshire : "Spread ofdisease favoured b conditions in an intermitting watersurface allo o suction of foul air into water-pipes "

§Sixth Report themed ical oficer of the Lo calGo ver-nment

for Dr. Theme also reported on an outbreakin the Dewsbury registra tion district as follows : "Watersnp

o

l

gifor some dish-lots liable to pollutionat its sources and

pert!

cally fo uled ind eliverymains d uring intermissions inthe service. And again in the Dewsbury Urban SanitaryDistrict : “Water-supply subjectto pollutio n at, and

‘pr

obablyon its course from, the gathering ground. 83m

intermittent and liable to be fou led suction th intomains CEighth Beport of the ofi cer of the Lo cal

GovernmentBoard for 1878).In 1874 Dr. F. R. Blanll onanoutbreak at

% erborne (Dorset) as fo llows : e influence of milk inthedistributioncould be excluded, but respecting the circumstances of the water-supp] the following facts were ascertained . During December, 872.and January, 1873, the water

https://www.forgottenbooks.com/join

82

o u ano utbreak which occurred in 1873 at Caius Coll e,Cambridge, from which 1 extrac t the following : “Allmore usual ways of enteric feverspread have now been consid ered and none o f them have a peered adequate to accountforthe intensi of incidence of ever uponCains or

fo r its remarka ls incidence onTree Court. Holding waysin view the special character o f these occurrences let us

observe that the W au

gh to the college is taken

from a surrounding five-ih main at six d ifiereut places,and that one of them, at the Gate of Humility , is forTree Co urt and for no part but Tree Cc urt What ifthere should be something wrong with this one local

my ? Eveu pfimé faois there is something to be said forview. The suddenness of the outbreak inthe college

was such as at once to suggest to Dr. Pagetand Dr. Bradbury, and equally to myself, the thought

‘ that it might bedue to the contamination of the waterormilk.

‘ The area ofthe particularwater distribution is exactly the area of thefsmg

least of Izuioi

ut of 11

5311l

onem boot the

re cases req ng ro y no exp yondevery-day circumstances. The character of the compan ’

s general waters upply w d not avail as an argumentagainst a local contamination in a local service. And at anearly period of my investigation I was struck with the circumstance that while every water-closet in the old part o fthe building was ed with a c istern proper to itself,the closets in the Court buildings were supplied withwater direct from the high-pressure constant-service pipes.Complete intermission of supply m found to have actuallyoccurred ontwo occasions at leastduring the last term. Theearlier occasion can be defined as the cv of thesecond day o f an October frost, and thus“ht havebeen either on Oct. a5th or on Oct. 3oth. but otherassociations suggest Oct. 25th as being the more probableof the two d ays ; onthis o ccasiononly the particularservicethrou the Gate of Humility was stopped. The latteroccas was when the water company’s servants, having,

for the purposes o f piépe r

'eérair, o ut ofi the water-supply of

some half of Cambri ge, ere was hu to restore theeu ly in orde

r to gain water-power to ow the organ ofK&s College Chapel fora musical service. This fixes thedate of the second known intermission at about AM. onAll Saints' day, Nov . 1st. Now a fortnight is about theincubation time of enteric fever. A fortnight afterOct 28this the date of the first attack in Tree Court. A fortnightafter Nov. let is the date o f the second, third, and fourthattacks. And tho h it was known thatothercases of fever

in til the end of November the coinc idence ofwith these ascertained intermissions was not

tbe less suggestive as ind icatin the direction that furtheruiry should take." Dr. Bu ananthenshowed thatthein that main was oontaminated by suctioninto it,

during the periods of intermission of the su pply, of foul air

In the annual report of the medical officer of the LocalGovernment Board for 1887 is an immrtantre rt on anepidemic o f t fever in the Mountain Ash rban Sanitary District, organshire, bMr. John Spear, in which,after the evidence, Spear continues : "Thefacts all tend to bring into more and more prominent reliefthe t of s

‘nitr’al contaminationo f the water, and , inviewof now clearly established mises of my argument, thesnot condition of the Oxf «street main and its relationto immediate surroundings become matters of exceedinginterest and importance. I have shown that the water, asit passed into the main and for the first 160yard s o f itscourse there, used no ilLefiects in its consumers ; and Ihave id entifi that int just at the Henry -street bifurcationas the one pointi osted by the fac ts o f fever revalencewhere specific contamination o f the water main in alllikelihood habitually occurred. Fo r the purpose o f thisinqu the two pipes were laid bars as little above and fo rsome ce below the pointindicated. The Henry-streetpipe was laid some 25 years and has been found to bemuch corroded. Thatof Oxfo -street was relaid , as I havesaid , in 1885. Thors ic rw d o ubt that the re

‘

ng muwry carelessly, not to my reolclm ly, d emo . ng tothe exigenc ies of water-supply it was done mostl

yat

night, and the work being in private hand s was anjeotto no supervision on the part of any offic ial o r authorityhaving concern with the public health. Accordingly, the mainwas carried. without any special precaution, émmc d iatslyabove, a! rid e, and soonthrou Itthe old rubble d rains :and when n the course of trenc g pipe-drains were o ut

through no trouble appears to have been takento replacethem. I find the mspector of nuisances reporting inSeptember, 1885, a third case of in

'

ury and stoppage of adrain from this cause. Although 0 old stone culverts towhich I have referred are notostensibly sewage-carriers nowthey formed the sole sewage system some 20years ago andeven now refuse matters are often poured, as I saw myself,into the roadside gullies that are connected with them. Oneof the culverts through which the Oxford-street main wascarried (a

‘collar’or junction between two pipes being in

the interior, was found to contain a quantity of exces

sively foul sewage deposit, a slaughter-house apparently,amongst other places, d rainin into it. It may be said that,as one result of the careless ying of the main, the latterwas at d iflerentpo inmfrom time to time bathed inrefusematters and habitually at certain points in sewage-con

mach air coming with much nnisc snd torcs had to bs

Months fint rmw al o f

giply) for ccnsumptionas

‘ d rinkingwwater.’

law W ha m ,

isnotby any mm essa tial to tbe intro d ufi onof fineign

An outbreak of typhoid fever at Fareham (Baum) was

https://www.forgottenbooks.com/join

which there were cases of enteric fever, 22 had the sanid efect inquestion; while there were ll otherhouses witthe same d efwtinwhioh cases of low fever, or some otherill-d efined d isease, were found. It may be mentimed thatdiarrhe a frequently breaks out in su ch houses. ’ The waste

pipe being a ventilator, and oftenthe only one to the d rain,

the foul air, which may contain.suspended in it, some o f

the poisonof the d isease, rises up this pipe into the space

betweenthe water inthe cisternand the co ver, and thes

gzpend ed particles fall into the water which is drunk,which may,

partl andoften does , give rise to enteric fever in

persons d rlnking it. There can be no doubt that theremarkable diminution in the number of cases of ty

phoid

fever in London d recent years is very largely. i notchiefiy, due to the nnection o f the waste pipes of

Wenow come to the d istributionof the disease by meansos cted stilt. In 1882 an investigationwas mad e byPro fessorJohn cnOattle Disease inRelatiori to theSupply of Meat and ilk, and his report was published in thefifth report of the medical ofi cer o f the Privy Council. Hecame to the conclusion that the cause at present.operating

cattle to man have been observed either from the virus penetratin a wound or into the system with the milk.

Sir J Simon ad d s to t seems to haveestablished as certain that, at least undersome circumstances,the human afiectionmay be caused by the consumIJtionofmilk d rawnfrcma d iseased animal. ” And itis ststed ina footnote that mo re thanZOyears ago ProfessorHertwigpublishedparticulars of such experiments performed by him on himselfand two friends with the result of producing a very definite

I insert the folio lengthy quotations from his reportThe general resulto aninquiry into the milk-eu of the

families withinthe quartermile rad ius into I asesttained that fever had entered was this—via z Thatit occurred the ho use o f the milk vend or where the

businm was carried on. Bo d ied and sevenotherpersons,members o f his family or boys employed and living onthe

87

premises, had cid fever and one of the latter died.That it in the family of a personwho dweltina small cottage inthe cowyard distant about 100yardsfrom the last-mentioned and dairy, three personshaving fever here. The first case here was in a

xrl,

who , a fortnight before she actually fell ill, had l

situation at a public-house supplied with milk from thisd airy and since then had been resid ing at home. Thisfamily, the mother of the girl told me, rarely took milk,except on Sundays, being poor, but when the wasmilk was givento them fromthe dairy. The m erherself,and subsequently a little boy, had boid fever when thegirl was convalescent. That, in ad tion to the two boyswho had lived in the house for a longer or shorter time,two men engaged in the business who did not livein the house had boid fever. One o f these was the00m engaged te ;r the master was taken ill theother was a man who worked at the cowyardand carried o u

yt

o

m k and who to ok all his meals at a

coffee-eh sup lied from the dairy and where two familiesalso su

ppthe dairy had fever. That a fifth man

employ at the cowyard and residing at home had fever.He also occasionally had his meals at the above-mentionedcofiee~ sho and his tea at his mo ther’s who was suppliedfrom the His family being pg

o r he bought no milkfor them anywhere and he was e only member of itattacked Thatanother lemanresid ing within the radiusin a wholesome house an engaged as a coachman ou tsidethe radius, who habitually took his meals atthis same co d eshouse, had an attack o f typhoid fever. That (omitting thegirl who came ill from the country) out o f 62 other familieswithin the d istrict which are known to have sufiered fromtyphoid fever, 54, o r fully 87 per cent, were co usmntlysupplied from the dairy with the milk they required, twowere occasional custo mers, and five only stated that they d idnot deal there at all. I am not quite sure that completereliance canbe plac ed on this last statement ; oertainly Jdoubt itin one case of the five. All five resided close to thedairy and it is very probable obtained there, as the mostconvenient place, any extra milk their families required. Inanother instance a l was attacked in a family not suppliedhy the dairy, butit a

peered that on N o consecutive d ays

in the beginning of JPu y she had taken tea with a school

fellow who, with herbe

mother-, hadmo ld fever a few dayslater, this family be supplied the dairy. No oneelse in this girl’s familyOn inquiring into the fa

f

tal cases happening infamiliesresiding in the quarter-mile radius from the dairy he found,That the members of 142 families were eu lied with milkfrom the dairy in question. The district wi the quartermile rad ius alone mustcontain over 2000families. 80, afterall, no very consid erable ppwrti t their sup ly fromthis source. Out o f these 1 famili

80

(which incgud e

“ Wa n-s a w h s d a mm er thatnot

with enteric fever within his and that of his professional friends, obtained their from the same dairywhich “PPMhis ho uw ho ld . The was r' Mn"? hadm d e it ca b inthat the milk of six o uto f the serenfarms

https://www.forgottenbooks.com/join

91

forms the subject of inquiry was caused by milk infectedwith w teric fevermaterial ; (2) that this milk onme froma

particular farm ; and (3) that the water used for dairypurpo ses onthis farm contained excremental matters fro m apatient su ffer-in from enteric fever immediately before andat the time o f t e outbreak (Report o f the medical officerof the Privy Council and the Local Go vernment Board, NewSeries, No. IL ,

In the seventh annual report o f the medical ofi cer of theLocal Government Board. 1877, is a report on an unusualprevalence o f enteric feverat Ascot during a cd of fouryears and a half by Dr. E. Ballard , from whio I ucto thefollowing : “ In the midd le of 1873, at the very me thatthe outbreak in Marylebone which was traced to the milksupply of a particular dairy was in progress. three cases ofenteric fever occurred almost simultaneously on the to p o f

the rid ge of hill onwhich the village o f Ascotstsnd s.“The three cases occurred in persons who had recently

beeninLond om cnd £900 0m kad osrtwialy when“aro used m auve of the pad imd ar d airy. I failed to

lget

evid ence o f the third case having partaheno f thatmiDr. Ballard makes the following interesting observation

Wharf: to bagatko red fi om ooinoa’d em f— Inau inquiryintom emic such as this, where the cases of the diseaseare buted about a d istrict having certain commonfemxres, there are four sources which are ordinarily lookedto as those whence the contagium of the disease is mostlikely to have pro ceed ed and the med ium o f which itmayhave beend istributed , vis. : (l a common source o f water

supply, such as some particularwell or stream or the mainsof a system o f public supply. in which case infection of thewater, either at its source or in its regress fordistribution,may result in the distribution th it of an infective

a sewerbecomin infected may be the means of distributing,through the m um of the sewerair, infective matterto thehouses in relationwith such sewer ; (3) where there is nocommon water-supply and no common system of drainageto account for a wide distribution of fever, the cause ofthe spread may be found in the progressive infectionof

independent privies, kc , and soakage from thm intoindependent wells or other supp ice of drinking-water ; or

(4) the cause o f the spread may be found in the distribu tiono verthe district of some particular article o f food, such asmilk, which has become infected.

"

Dr. Ballard then shows that the first three sources werenot o mthis casa butthatthe fourth waa almo stall the fami es infected being supplied with milk from a

farm known as the Brick-kiln farm, and he comes to thefollowing conclusion “The facts which I have detailed canleave, l think, no doubt upon the mind thatthe use of milkdistributed from Brickokilnfarm was in some way directly

“ g a m ma -anthe m “

https://www.forgottenbooks.com/join

breaks. The great interestand importance cf this con

mentwith the use o f milk {nom a d airy situated onthepolluted brook and witho utwaterwupply on the premises.In1886 Dr. J. Ashburton Thompson, then an inspector

the Board of Health o f New South Wales, presenteda on an o utbreak o f typhoid fever- inthe municipal

of Leichhardt, which he had traced to polluted milkand in which he draws the following conclusion as to thecause o f the outbreak “All possible causes have now inturn been examined Ithas been shown thatits attack anddecline were alike sudden ; that it occurred at a time whenthe district affected by it was practically free from fever ;and that it was almo st entirely confined to customers of aparticulardairy, w es of fever among others thancustomersbeing very few. and two having had ample opportunity atleast of sharing the milk. It has been shown further thatthese customers lived under eral conditions which wereequally shared all the i bitants o f the district, theirnumberbeing 61 and against very nearl who werenot customers. It has beenshowu , the one, that the condition common to the persons attacked must have beenoneto which the persons who escaped were not subject ; andthat the only condition answering to this requirement is theconsummiono f milk supplied from the Helsarmel dairy tothe former." At the dairy the well waterwas shown to bepractically sewage and it was highly offensive at the time o f

calling— infact, the sewage of a number of houses and thedrainage water of a cemetery soaked into it. and Dr.Ashburton Thompson was able, moreover, to show that itwas specifically infected from the excreta of a recent case o ft ho id fever in the neighbourhood.

1887 Dr. B . A. Whitelegge. then medical omc er o f

health fo r Nottingham, reported on a small outbreak o f

cid feverwhio he had traced to a cularmilk supply .

he interest of the case c onsists in the ct that the customerswere partly supplied by milk fromthe d airyman

’

s owncowa,

which was taken round by cart, and partly b milk obtainedfromthree othermilk d ealers inthe town. w h was serveddirectly by m from the dairy . It became evident fromthe preliminary enquiries that a diapto to number o f

the attacks were among those hou seho d s supplied by cart.Oithe Sl cases itfinally appeared thatIQ were inho usehold s

exclusively by cart, and only 3 in those suppliedex usively by can. Suspic ion was thus directed to the dairymsn’s ownsupply, and was confirmed b finding an almostcomplete absence of cases o f enteric ever in households

95

supplied b the three dealers from whom the milk wasobtained . s o f the six farms send ing milk to these

dealers also supplied other dairies in the town. but withoutany occurrence of enteric fever among theircustomers ." Onfurther investigation Dr.Whitelegge “came to the conclusion that the milk was probably infected by some personemployed in its distribution ,

"most likei a hel who camefrom the Unionatthe d ate of the proba e begfihing o fthe

Dr.Page reported in 1888 that an outbreak of typhoid feverat Spennymoor (Durham) was associated in tims with prevalence o f fever at a farmhou se whence milk was distributedto a considerable number o f the persons attacked. Dr. BruceLow reported on an outbreak at Shildon and EastThickleyDurham) in 1893. There were scattered im rted casesuring May, June, and July, followed by a co d erable o ut

burst o f the d isease in August and September, the number o fcases gradually diminishing in Octoberand November. “Theearlier cases were mild, anomalous, and irregular, the latercases typical and severe. Many cases admittedly escapeddisinfection and established foci of infection. A large shareinthe d ifiusiono f the d isease was attributed to a particularmilk service. “ In the milk-seller’s house there occurredthree or four unnotified cases belisved to have been entericfever. The dairy where the milk was stored communicateddirectly with the sewer, without a bend o r trap, by means ofa four-inch pipe inthe sink stone. History of flooding ofmilkman’s cellar by sewage on two occasions in July afterheavy rainfall. The public water-supply had nothing to do

In 1895 Dr. Bruce Low reported on a sudden outburst o ftyphoid fever in An in the town of Helmsley, NorthRiding (Bu ffs ), con ed to the customers o f amowermilk-seller, a memberof whose family recovering thisfever came on a visit to his house from July 11th to

August 24th. The outbreak suddenly terminated inSeptember on the stoppage of the sale o f the linted milk .

At the International Medical Congress o f 1 Mr. ErnestHart read a paper onthe Infiuence o fMilk inSpread ingZ otic Disease in which he placed on record 73 outbreaksordisease as having been traced to the agency of milk, andof these no less than 50were outbreaks of typhoid fever ; andin 1897 he published another report onthe same inthe BritishMed ical Jo urnal, givin short acco unts of moreoutbreaks (occurring between and of which 48were those of typhoid fever, making together 98 outbreaks o ftypho iég

ever traced to the agency of milk by the end of the1”D

r

u D. 8. Davies, medical officer of health of the city ofBristol, read an important paper before the EpidSociety in March, 1898, "On an Outbreak of

Enteric Fever in Clifton.

" In this outbreak the cases variedfrom the mildest, which would not otherwise have been

Dr. P. Buchanan. the

d huMhad d m d y s oertained that

https://www.forgottenbooks.com/join

LECTURE III.

Delivered onFeb.37th,was.

Ms. Passmmvr AND Gu nm an—Other foods havebeen proved to become occasionally the vehicles for thepoisonof typhoid fever.In 1881, at the mestin o f the British Medical

tion at Cambridge, Sir les A. Cameron readentitled Sewage in Oysters, in which he pointedsewage which might perhaps contain the microbe o f boidfever was sometimm present ino ters, and he oftenfound it inoysters taken from thefi res of Dublin Bay.

On m m 1894, Dr. Newsholme, the medical ofi cerof health of Brighton, to the Sani Committee ofthat town “particulars 8 cases of enta ic ever whichhadoccurred during the preceding quarter, and which were

excrement. ’“OnDecember7th inthe same yeara d eputationfromthe

BrightonTown Council waited upon Sir WalterFoster, thenParliamentary Secretary of the Local Government Board, andbrought the matter to his notice.”

OnDecember11th, 1894 , in the Seventeenth Annual Reportof the State Board of Health of the Sta te of Connecticut,

Professor H. W. Conn reported onan outbreak oftyphoid feverat theW an University there. Afterexcluding the d rinkin water, e ice used inice-water,the milk,the ice-creams, emeatand the gro ceriesd twas found thatoysters obtained from the dealers at Middletown were thecause of the d isease. These oysters were served at certainan at which were a number of persons who were not

to of the college,also appeared at theFor instance, of fivebanquettwo developed typhoid fever. It was found thatthose only suflered who had eaten the oysters raw. One

https://www.forgottenbooks.com/join

108

afi hours inthis water he removed

time theywould take in delivered to the oonsumers.Afterthis time they were living witho utany particularsmell and were o f goo d Neverthelm bacterio

logical enmimtion show0d that contained in their

In169'

l Dr. .G . Buchanan onrecent oases of

typhoid fever at several urbanand rural

sanitary d istricts in and SuRo lk. There were flBoases

oysters oame from“layings ona foreshore inBrightlingsea

Creek conspicuously llution the ofaewageBrightlingsea which is lschargeg

o

un into the creek.He further asoertained that “at sund ry d iflerent perio d sd uring 1897 infeotious matters from enteric fever oases in

sewer outfalls."

find fromMr. Shirley Murph s annual report for 1897. asmedical emeer o f health to the County Council. thatthe fouowing cases invario us Iend ond istricts were referredinthatyear to the eating of oysters or otbor shsllfirb. Themedical w oer o f health o f Pad reported thato f thedo esses (of typhoid fever) d uring the year three

appeared to have beend ue to the‘

tients nursing other

cases and two tomu

oysters unknown) Intwocases thsre were of consnmptionof ice-creamandmussels, but the information was to o umeliable to be

accepted withoutreservation. AtPulham inthe same yearthree caseswere thoughtto havebeend ue to the consumptionof shell fish. InMarylebone one csse

“pointed specifically

to the pticonsum on of oontaminated oysters.

"

Herringtonfive cases“were ascribed by the sufferers to the

eating o f oysters."

Inthe Strand at least six o f the lBto have arisen out of eating uncooked

shell five of them at a seasid e rssort At Ho lbor-nthree out of the seven cases, which were contracted outside

Oh ve’

a and three inWand sworth. Inone case atPlumstsad“the enthad eatenwhelks eight before his attack "

m asorihsd to shelL-fid r.’

In l arylehtme‘ in seve

cass flrsre appm ed to be go o d evid ence thatthe infecdwas h keninv ith u ch too d s asMMor otl

fire consumptien ol oystsrs inmo d rer caee.’InHolbo

of ahell fish sha tly beforc .

’

InGmu rwich ‘ itwas ion

m‘ in two cases eating insufllciently—cooh

musselsmayhave beenthe cause and inone m e oysters."

The foll cases were described in T3! m m'March 3rd . l . :p. 638"Two servants, a to otmanand

maid-servant, employed at a. country seat in Cornwall, in

oysterl here inquestionwere procumd fromthe seme sourThe su o rs were laid d owninthe l’em

river ofi themd

of ushing and opposite to the townFalmoutli ” ; into this rivermuch sewage is d ischarged s

Dr. Bulstrode consid ersthe oyster layinge init"as occupyi

a dangerous position.

https://www.forgottenbooks.com/join

. d r mese fihd y thfl mog if not amof the casa ef

pre ved matthis had beenthe u uae of the illneee. Of cases

InMr. Shirley Murphy's ninth annual report as medicalafi cero f health of the Lond onCounty Council is a reportbyDr.W.H.Hameromcutbreaks of d feverinStGewSouthwark, Lambeth and inSeptember,Dr. Hamershowed thatthe o uthreaks werenotd ue to wateror to milk-supply or to d efective d rainage orto the use of acertainswimming-bath. to which the cases inSouthwarkhad beenattributed . orto ice-creams, orman other-toadswith one cnrious exception. “The only axfi c of feed er

107

d rink emanatingtrom oue so urce which hado omumcd by persons d uring the outbreak (was friod -fich. The circle of a natter of a mile radiuscoveringthe ama specially attac had atits

fish shop,” and Dr. Hamer showed that "49 cent. or

justabo uthalf the families in the portions 0 the area inwhich a house-to-house inquiry was mad e, contained oneormers members who ate fried fish from that shop, and o f

the whole population of those two areas 48 per cent. did noteatfried f fish, 16 per cent. ate fried -fig) not obtained fromthe particularshep, and 42 pe

r cent. ate fried »fish obtainedfrom that shop. Similar inquiries umd somewhatsimilarresults in Lambeth and in Town, and in bothd istricts itwasnoticed that persons attacked by the d isease

clearly traceable, but a number of those attacked purchasedfish or shell-fish at a certain general fishmonger

’

s shop.AsMr. Murphy says in his remarks on Dr. Hamer’s report :“The on how fried-fish should be capable o f conveyingthe eetion o f enteric fever is one to which no answer canatpresentbe given. If d ue to surface contaminationbefo recooking it is bable that this would destroy theinfection ; if ne to infectionwi the fish itis improbablethatthe fish would be sterilised therehy. These points co uldbe determined only by experiment. With respect to thequestion y as to how the fish acquired infectiveproperty Hamer found no reason for thinking that

specific contamination occurred onthe Southwark premises,and if both the Southwark and Lambeth outbreaks weredue to the consumption of fish this fact would stronglmitigate against the view that such contaminationoccurred in either o f these d istricts, and po ints to someearlierperiod at which the fish became infected."

A report by Dr. Turneron an outbreak of typhoid fever insouth-east Lo ndon drew attention to “m ore“ : as a

w e means of typhoid infection. The occurrence ofnames amen the sufferers led Dr. Turner to ascertain

the so urce from w h the makers of ice or ice-creamsobtaincd the milk used in their business. Later he foundthat87per cent. o f the pafients had eaten ices purchased o f

itinerant Italians. The centre about Coldbath-street being

ices, where the ices were purchased. and whether the feverattacked those who consumed the loss sold by any particularvendor. Seven streets were selected for this purpose. Thesewere adjoining streets. in some of which there were manm inmme few, and inone there was no fever at

The msult of this inquiry may be summarised thus. Thenumber o f inhabitants atall ages inthis area was 1561. o f

https://www.forgottenbooks.com/join

110

‘

s‘;

They were cases of a, mo ' Of the fever to the

has?

111

had been fever at some houses in St. Peter’s-street with

visited and itwas found thatthe d rainjusto utsid s the housewas atfo ur o f thempractimlly untrapped, butwas efi cientlytrapped atthe otherthree. Io none o f the latter had there

beenfever, butthis d isease was present last inthreeout of the four former. 2. Howard and Emmetreads,South Norwood, were visited because of a d ifierentprevalence o f fever inthe two . 13 houses inthe formerroad , includ ing seventhathad had fever, were examined ,and eighthouses inthe latter, includ ing one of two thathad

had fever. Few of the houses were found with their

overflow pipe going direct into the sewerfrom a cistern thatwas usually placed in a very confined situation undera bedroom floor. In the Howard-road this arrangement was seenin eight houses, the cistern furnishing more or less of thed rinkmg-waterinthe case of seven of themand insix out

o

fi

f “10?e

sevenh there

onlhad been fever. It was notseen in the

ve er ouses, y one of which ving awater-closet) had had fever. In the Embanger-road

defect was witnessed intwo houses onl out of theeightvisited and one o f the two had had a case fever ; thehouses where there was no such arrangementhad escaped .

(Facts as to the second fever house were not obtaimble.)Otherways less direct than the foregoing by which snoremental products hearing with them the contagium of ented cfever have produced the disease will immediately comeunder review. But there can, I think, he no doubt that thechief way inwhich enteric fever spread last year in Croydonwas the most direct and commonplace way of all—via , bythe escape of infected air from the sewers and its inhalationby persons susce

‘

ble of the disease."

And he adds following very definite and very importantstatement “The great intensity and simultanco usness ofthe feverepidemic overCroydon should be no hind rance tothe acceptance o f this view. Where sewers are small andill-ventilated they constitute perfectly sumcientmeans forthe rapid d istribution of fever infection, and places havingsuch sewers may not only show fever-« ates maintained ashigh as before the sewers were made but they may show assmart outbursts of feveras are witnessed where conveyancethwh water or milk is inquestion. Croydon itself afterit made its sewers and before it attempted to ventilatethemhad this experience. So in other instances that have

https://www.forgottenbooks.com/join

115

fever infectionwith it, unless there be fever inthe houseitself. But in efiectment under its mostsmall whatever fromare ingoo d ord erithabitually acts as an inlet forair that

holders to ventilate public sewers ; that is the affair of theauthority inwhom these sewers are vested . In on thedirect connexion between public sewers and the pea thatrunup the sides of houses is not only dangerous to thehouses, but in relation to public sewer ventilation. thearrangementis little more thana sham.

”

Dr. F. R Blaxall repoxted thatinTruro in1874 anout

break was caused by"entrance of foul air from the sewers

into ho uses.”

Dr. Ballard reported in 1875 on enteric fever at the WestRiding House of Correction. He says : “ Interior of prisonpolluted by sewer air in consequence o f faulty constructionof sewers and d rains. Infectionprobably spread by the useof infected earth supplied to earth-closets .

"

Inthe seventh report of the medical Officer o f the LocalGo vemmentBoard fo r 1877 is anabstract o f a report by

feverat Padstow ininfected sewer air

”

and unpro vid ed with

a tahle showing the incid ence of the fever onvarious streetsand ad d s : “ Itwillbe observed fromthis table thatonthreeor four ocoasions there was a simd mneous appearance o f

https://www.forgottenbooks.com/join

118

i t em -nm h fi e d inm e.”Foraaother

119

the waterwhich next came into it. This is aninstance o f

was as follows : “Various fom s of enteritis are commonin

the subsoil watsr, and he came to the concluaionthat

invol.and a copy o f Pettenkofer’smnrt

by excrm tal m tterind rinki

any outbreak o f enteric fever. V

tion “where the supply cf d rii

the eoil cnwhich it stand s.”

fever in Munich under von lranarkabla as seenby a table a

houses inthe city inlm It intionof the subsoilmusthave brpurificationo f the waterof the v

th thanPettmkoferthere

Inthe tenth report of

https://www.forgottenbooks.com/join

inthat mty. To qm fm his own report on themoloy of typho id fever : The emetic death-rate has

128

greatly declined but still typhoid fever more thanholds itsown. I canonl account for this by assuming thatthe

microbes of the have established themselves in wesoil, that they multiply therein, and that they issue occasionally from it into the atmosphere , which consequentlybecomes infected . Itis only inthis way thatwe canreasonably acco unt forthe period ic character of the d ism e. for its

seasonal intensity, for its epidemics. In the soil therefore we must look for the cause of the endemicity of typhoidfeverinDublin and inother pm This theory is greatlystrengthened the factthatthe so ils are to amuchgreaterextent to be the hab tat of the organismthanmo stifler clays. e cond itions o f existence forall kind s o forganisms are more favo urable in loose soils than in adhesivedense clays in which aircannot freely circulate.

mlThe action

of strcngwind s and the rising andwatermore readily cause movements of in

m1grav

loose so ils thaninclays, and the escape o f microhes fromthe

formerunder su ch circumetances mustpa

the more freely occur.The streets o f Dublinhave lately beento a large extentpaved with stone setts, which circ umstance may, perhaps.account to some extent fo r the increase of typhoid fever.The underground air cannot now diffu se into the atmosphereover the roadway, and therefore may be d rawnin largerquantities into the houses, the basement floors of which are

rarely concreted.”

In his annual on the public health of Dublin for1891 Sir Charles eron gave a map showing the distributionof 1988 cases of typhoid fever in that city. Hepointed out that ongravel soil the ratio of cases to the

gopulationwas l in98 8 and on clay 1 in 1453. Thus theisease is much more prevalentongravel, as is usually thecase . He expresses his belief that

gmthese facts appear

show that the organisms thatpro d u ced tiphoid fever sunspot;

into the air more read ily fromthe grave thanfromthe stifiand usually moist cIn a very in g, though short, report on boid

feverat Lawrence, Otsego County. New York. in , thecause o f the outbreak was described as follows .

“We haveangid emic of sudden development, lasting through twooccurring now at one Village and now at another,

without a central focus. It occurred in a place havingno common source o f water ly, no common mof and no common bo tiou of

other ole of food. It appeared upon an infectedsite, one in which the d isease is regularly recurrentand end emic, and in a locality where cid feveris common, other epid emics of severity ha withina

recent period occurred in neighbouring communities. Thefactor which determined this fulminant outbreak does not

surface. That it was one of general applicaThe only one that cannow be cited is in

connexionwith the soil water and the influence upon it o f

https://www.forgottenbooks.com/join

of typhoid fever (1 severalgaears in

istrictof Swintonand l’md lebury ca ).the d eathwaie from fever and continued fever dnringthe lOyear8 1888to was “more thand onble thatinthe

onthe cond itions of the city of Chichester, Sussex,w "has onwveraloocasions attracted aweutionby reason

127

c f itsliabilityto repeated occurrences of enterio feverineeriou s

that it “may be consiclered endemic." After inm mthe conditions favourable to the spread o f typhoid feverthe

favourable to the viability and growth of theective material of this d isease is notinconsistent with the

knowledge o f so il cond itions in their relations with

fever prevalen0e may account for these features ; withoutthat lmowled ge it is not

1

ble to arrive at d ed uite”

(see alsobmm )

The mostremarka ce o f the passage of typhoid

poison a ccnaid erable d istance underground occurred atthevflhge o f Lam nearBasla inSwitaerland . and was inves

t

Ayp fever, just after his return from a

girl was attacked in the same house cn 1oth ;and in a the farmer’s wife and sonsicbened o fdisease. was nc communication, so far as could be

On 7th, 10of the villagers inLausenwereattacked byfever, and within nine days the number of

cases had risento b’l, o uto f a populatitiou otm um msohouses. Withinthe first fo ur weeks o f the epid emic the

rose

s i

https://www.forgottenbooks.com/join

of miningpopulatien.Inthe same yearDr. R D. Sweating reported on sn outbreak at Temple Cloud, Cameley parish (Somerset). Inthisdistrict the early cases were "

u nd ated with grossly unwholesome circ umstances of water-supply and excrementdisposal,

” but the later cases were “probabl directlyinfected from the earlier o to nomd is ection o f

stools ”

(azad Ann. Be Med. 0 L . G. B .)In 1889 Dr. J. burtc hom m chief med icalinspecto r of the Board of Hea th New South Wales,submitted a report on an outbreak of typhoid fever inthemunicipalities of Newtown andMacd onald towu , in which hegave a number of "exammes of the spread of typhoid by thewhen o f air.

”Inthe first example a womansuflering

the d iaease intro d uced the poisontc the ceespitof a

certainhouse which was generally ina very insanitary condition and the disease spread among that family. On theirmmoval to ancther houu inanother str'eet also ina veryfilthy condition, they conveyed the poison there and thed isease spread inthat family also . The second example wasvery like the first, the filthy surroundings o f the house

“didnot.as far as was u cmtainabla oause d isabling illness untilthe firstcase of typhoid fever had bew produced outsidecontagion ; when that had nearly it beganto spread through the old rapidly. The othercasesare somewhatsimilar.Dr. Sweating reported in 1893 ona localised outbreakofgphcid fever “m m

?the first four months

of e year on the ou o the town at Amlwchthat there was no common water

https://www.forgottenbooks.com/join

185

of his great experience Dr. Goodallsure that those are wrong who teachtaughtby the lead ing text-books that there is no

in nursing typhoid fever patients and that there isnoil

knecessity for removing an enteric fever out from hishome to ho spital.

”lnfact, the result this d iscussion

showed thatthere wu greatunanimity of opiniomnotcnlyamongW of the Local Go vemmentBoard but

among ofiicers of health throughout the country,that communicationby d irect oontagion is a much morecommon cause of the sp eed o f typhoid fever than iscommonly supposed .

We now come to the consid erationof the actual n ofthe d isease. I will firstgive yo u lfir. (afterwards John)Simon’s views inhis ownword s. He said inhis supplementary report for ‘While, however, thus far thereis only the familiar case o f the ao -called som eh owpoison, which hurts by instant action and in d irect

recognise infilth are such as apparently mustbe attributed

to m bific fe or oomMmatters which notonly are not gw eo us, but on the contrary, sc fnr as we

part of it, in certain solid elements which the microsecdiscovers in them—ih living organisms, namely whichtheirlargest sizes are but very mw o te microscopical obisch ,

and attheir leastsises are

probably unseen even with the

micro scope, o ms whio in virtue of their vitality areindefinitely -multiplying within theirrespective spheres ofoperation, and which, therefore, as in contrast with commonpoisons, candevelop indefinitely ulterior efiects fromfirst doses which are ind efinitely s“inp

arent'lgn

itis by these various agencies (essentialnad inci N ) tfilth pro d uces

‘otic

’d isease, itis

important not to confound them wi the fe tid gases oforganic decompo sition, and the question what infectingpowers are prevalent ingiven atmospheres shou ld never beregarded as a more question of stink . It is of the utmost

practical importance to rmnise yinregard o f filth thatagents which destroy its ma yet leave all its main

era of disease-production undiminished. Whether theerments of dm if they could be isolated in sumcientquantity would prove themselves in any degree odorous is apointonwhichno need be hazard ed butitis oertainthatin d oses inw ch they canfamlly infect the humanbo d y they are infinitely out of reach of even the mo“cultivated sense o f smell, and thatthis seuse (tho ugh its positive

ble sanitary service) is not able,sireeptg

‘

y

are

indirect an quite insumcient perceptions, to warnus against risks of morbid infection.

And further, in the same report : “It must be remembered that gases on the one hand and the particnlate

186

ferments on the other stand in widely d ifierentrelations toair and as their respective media of diffusion. Thefermenta

w

w faras w

gfixgt

fiem, s

t

l

l

i

l

ow ntohpower o f ac

v

tr

e

r

ie

d ifiusionin t o y as e are passi ythenmpr

obably, if the air be freely open, notcarrying

mtheir vi butas moisture ia theirnormal

medium currents of hmnid air (as from sewers and drains)can doubtless lift them in their full effectiveness, and if intoho uses or confined exterior spaces thenwith their cchances of remaining efiective ; and ill-ventilated low-lyinlocalities, if unclean as regards the removal ofrefuse, may especially be expected to have these ferments present in their common atmosphere as wellas, of course, teeming in their soil and ground water.Considerations like some which I have stated inregard of infective air apply equally to infectivewater. In the latter, just as in the former, the zymomemalignity is but indirectly and most imperfectly suggestedto us by qualities which strike the commonsense, or bymatters which chemical analysis can ify. As any uhbrutalised sense of smellwillturnwith from certainairs, so will it, and common taste and srght, be repelled bycertain waters, and as the chemist no show certainfoulnesses in the one, so he can show certain foulnessesin the other ; but these tests, it must always be remembered , are tests only of the most eral kind . Confessedlythey d o not touch the some: d o stcti, but only certaincond itions to which it is ormay be collateral ; and theirnegativefindings are consequently not entitled to the same sort ofconfidence as their positive. Chemical demonstration ofunstablenitrogenous compounds in water is a warning whichof course should never be disregarded ; but till chemistryshall have learnt to identify the morbific ferments themselves, its competence to declare them absent in any givencase must evidently be

qud ged incomplete, and waters which

chemical analysis wo ul probably not condemn may certainlybe inthem very fatal seed s of infection.

"Mr. imon continues : “Since the year 1849, when Dr.(now Sir William) Jenner made known his conclusive andmasterl discrimination of this specific form o f fever,success ve studies have tended with s uniformity toconnect it inregard of ite originwit nuisances of anexcremental sort.‘ In illustration of that fac t in the naturalhistory o f enteric fever 1 may refer to an abstract which I

d of the ence o f the Med ical Department duringtilie ffour years

l'i

73 inthis particularbranch of diseaseroduction, and

1

such illustrations might be multiplied to any

gesired extent. The experience is.notonly that andvy d rainage, with theirrespective stinking: makings,

and the pollutions o f airand waterwhich are thus produced,

1 a The able writings c l Dr.Murchison, d ati a paperbhim inthe glad ico -Chirurgla l Transactions o f 1&

mhm bm of

y

particularinfluence inthatcontention.

https://www.forgottenbooks.com/join

189

thatwhencultivated outside the bod y they never becomecauses of putrefaction, “ far as my researches permitof a jud gment l have carried out a number of

cultivaticns in succession with those ved from 13dilu ent cases and the bacilli neverproduced putrefaction insubstances extremely liable to putrefaction in to of theirluxuriant growth. Even when cultivated on de the bodyformore thana yearncthing c f the sort has occurred . Asthe bacilli always form the same masses in the internalorgans, whether one examines fatal ow es o f typhoid fever inRussia.German Switzerland, or England, so in the sameway, cultiva outside the body on the same nutrientmatter, they have hitherto always d is ed the same mannerof growth and the same mode of spore evehpment.whetherl obtained the cultivations fromtyphoid organs inBerlinor

from theWitteubergle demic."

M. A. Rod etand . Roux (of Lyons) considerthatthereare intimate relations between the bacillus coli and Eberth

'

sbacillus ; thatthe latteris, infact, the former "ina state o f

attenuation ordegeneration they “think that the bacilluscoli becomes virulmt.tMyers“, without notably changingbotanicalchm ctm'

s ;an thatitiswithintheorganism,uotablyinthe spleen, thatittakes the cf the bacillus o f Eberth,degenerating no doubt e destructive acts o f theorg

-mien.

”And they ad :

“ Itisnotnecessary to insist on

which has not been generally accepted.Fora d etailed description of the characters and methods

of isolating and cultivating the typhoid bac illus I only needrefer you to Dr. P. Horton-Smith’s excellent Go ulsto uianLectures,’ delivered inthis Co llege il OO, but l wish tcrefer more particularly to a specially interesting account

onin those lectures of the persistence of the boidus in the body, especially in the bile o r the e

marrow, where ithas been now shown it may remain for

gum Dr. Horto n-Smith quotes some cases from a paper byunner in the Johns Hcp kias H ospital BulletinforAugust

as follows : “ In one case the bacillipure culture in the inflamed gall-bladder

3 Publlc vo l. il. Im morlnccsnptesnend us d e la swete

law .

‘I

(1°0a sits (p . , sgei

msist (new).and April 14th

140

the blo o d o f the li°

typhoid fever patientbut incertaintissues of the bo d ies o tho se who had d ied from the d isease

he never failed to find it especiafly inthe mesenteric gland sand inthe spleen, and he d eecribes its d iflerences fmm thebacillus coli. The next year he reported thathe had mad eexperiments with this bacillus onmonkeys. Two monkeysto whose

d ld

fo o d had bee

igad d ed a culture o f th

ghbacillus nct sufier any way ; n0 patho logi esionswere found inthem aiter they were killed , neither could thet oid bacillus be d etected intheir blo od or spleen. Onother hand, eight monkeys having been inoculated with

cultures of the bacillus the true typhoid bacillus was fo und

inthat o f another, and “a ncnd bacillus exhibitingcharacters

dpertaining some o f them to us co lL others tobacillus

"was found ina third . Inino culated

3man d ifierentwaters this bacillus may persist longer than

thi

s this?beend

se

orntohnsu-

a

ttedofbut also that incertaincf

em w are to t as affording pabulum forthe microbe the typhoid llus is able onpro liferate in abundant fashion.

With regard to the relative frequency oftyphom inthe intestinal d ischarges and inthe urine I may

https://www.forgottenbooks.com/join

142

oftenoheerved . via .thatatthe autopsy the d rgesti'

ve canalie found filled with bacilhu ooli to the eaclusiono f the

this factitseems to us thatthe bacteriological examinatio nthe urine o ughtnotto be neglected inany d oubtful case

is suspected . ltis hard ly neceesaryd o mcre thanmerely ad vertto the hygienic aspect of the

was only a natural outcome c f the intestinal

recent observations on the almo stconstantabsenceWfromthe stoo ls are to be trusted, the eetionof the fmoes willhave to ranknotas anarticle o f faith , butas a more ‘

oo unsel o f perfection.

’ On the other hand, themostcarefulattmtio u willhaveto begivento the d isinfectionof the urinc . Insome oasesthe urine evenbetore incubationis absolutely turbid with bacilli ."

DnEdmund Oau e a research onthe behaviour ofthe d bacillus milk and his accountof itwill be(bun the report o f the med ioal omoer o f the lrocal

Government Board for 1896- 97. He found that in unsterilised milk to which the typhoid baoillus was ad d ed it

was recovered inconsiderable numbers from the milk whichhad beenkept for six or seven and had turned com

eo ur; and insterilised to which the idus aud some othermicro bes were ad d ed he i

’

thatthe typhcid bacillus will live inthe of the bacillus

lactie fcra week but willnotact y multiply und er theseconditions. He says “that the prerence of the oidiumlactis insterilised milk does not interfere with the growth and multillcationo f the typhoid bacillus

”and thatyeastd id notinter

withthe growth cf the oid bacillus, as“bothmicro

organisms increased in num and neither appeared to bemodified inits growth by the resence o f the other." Heconsid ers that “the typho id us will live in milk und crconditions whichW in a household. Whenthis baoillus has been ad d ed inlarge amo unttomilk inthe ccnd itioninwhi it comm reaches theconsumer the presence of the microbes in living state

148

may be d emcnstrated after the milk thus treated has beenkept for several days. There is no indicationabove in tions thatthis microbe is capahleplication unor the conditions in question. Judging fromthe results obtained it is very bable that the numberpresent rapidly diminishes in which isobservations with regsrd to the bacillus lactis

milk ‘ indicate that it is quite possible for the typhoidbacillns to existincurd -cheeses."

Ina reportby Dr. Kleinonthe behaviour o f certainpathogenic microbes inmilk, cream, and chesse he says :

“itiswell known that the typhoid bacillus grows luxuriantl

gin

milk both atEO° Q and at37°0. it d o es notalterthe uidchm cter cf the mflh althcugh it pmd uces acid , as is wellknown red d eningp

rcd uced whenlitmus milk is usedasthe c ture med ium. His experiments oncream shcwed“that cream keptat as high a tem ture as 37°0. is

not a suitable medium ior the gro and multiplicaticnof the typhoid bacillus, but that it is a suitable mediumwhen kept at 2O° O. He further found that the typhoidbacillus d oes not grow and mriltipzp

w

he

?Tplanted on

Ohed dar cheese eitheratw o or at (Twenty-ninththe Local Government Board

search made M. J. Grancherand hi. E. Beacham on thebehaviour of typhoid bacillus in the soil. Th conclusions are as follows : “1. ltd oes not pass through soil withirrigationwater. Z. Itis stopped by fromm—lwcentimetresof thickness of soil. 3. Itretains its liie inthe mid stcf allthe organisms soil contains, five and a half months after ithas been sown. 4. It does not penetrate into healthy vegetables.” (P ablic Health, vol. ii , 1889Amostinterestin series of inv tions has beenmad eDr. Sidney H. . Martin onthe wth of the Typhoidus inSoil and

O

his acconnts ot them will be fono a lathe reports of the medical ofi cer of the Local GovernmentBoard for 1896—97and onwards . He first found that thebacillus when planted in organically polluted soil, as, for

instance, the sammee of earth from Ohichester,

“

my!increased and abroad, whereas in anunpollutedfrom anuninha ited and cultivated area “itlanguished andquickly died out ” und erlike conditions of temperature and

so il of both classes the ability of the typhoid bacillus tocontend with the othermicrobes alread

‘Epresent in such soil

and Dr. Ho ustonwas aseociated wi Dr Hartininthis

coliwere io und and iniouroi these the typicalbaoillus co liitself was present ; these four soils, however. were shown

https://www.forgottenbooks.com/join

146

wells of several towns having e id emics o f t hoid , theso il and d ust from d iflerent es, the d isc

the ve tracto f personsnotafiected with typhoid, kc ,

and s us ving all the pal laboratory reactions ofthat of typho i was cbtain from all these sources. The

following illustrations are of special interest. In 13samples of soil and dust the bacillus typhosus wasfound seven times, (a) in the refu se from barracks wherethere were some cases of typhoid ; (b) in dust from the

laboratory floor ; (a) in the spac e betw een the joists of aroom in otherbarracks ; (d ) infour specimens of soil, bothsuperficial and a metre ind epth, from the co urts ando f Val-de-Gréco . These in three instances were paforauimals. Inthe examinationof the faces o f 10treated at the hospital for affections which had 11 g incommon with typhoid, five reac ted like the bacillus ho sus.

Thus (a) in a case of leukemia specimens ed at

After some remarks illustrated by comparisons with thevariations of the cholera vibrio, these investigators state :" Itis allowable to suppo se that facts o f a similarkindd uoe themselves in connexion with the bacillus osus.

species of the bacillus o f Eberth comprebens, perhaps,varieties more or less numerous which do notpro bably reactsimilarly under the influence of the serum of an animulimmunised againsta d eterminod variety. The belief in theinvariability of type in pathogenic microbes is to-d aymuohweakened by many facts. The quew onof race, descendantsfrom a commonstock but differentiated by unknown vicissitudes , acquires an immrtance which must not be underrated.Why shou ld not this theory, which is acknowledged to betrue for certain pathogenic bacteria, a y to the bad llus

gghosus ? We incline to thinkthatbac

‘

notpath o andtto the serumtestwhich are encountered water.

soil, ho , are only varieties of the bac illus typhcsus ; at least,the parentage is evident even if the ideati is notabsolute.This diversity of fundamental ty

ge perhaps serve

to explain the variable forms of cid infection which areIf this terpretation of facts isW ha

m will result. The bac illustyphosus is distributed in nature outside the human body ;it is found in potable waters, in soil, in the intestines ofpersonsnotattacked with typhoid, and without doubt forms

147

a part o f the microbic flora o f the med ia whioh snrroundus. This id ea isnot subversive of recognised taots as to the

inrelief the pa layed by contagion in the formation andextension o fm epidmnlc centres ; their value remains.Mf

o d

ielr

l

nresearcheshare i

d erzrdonsxted the

primeimportar

tihc:o waters ts cv pment an spreadshaming?”the pro of defies all .question. But all the casesmust originate from contagion o r water polluted with thedejections of typhoid patients. Many times it breaks o ut

in patients or

azzups worn out with fatigue, overwork. o r

privations, or eating various foods, without its beingble to trsce the originof the contagionor the use of apolluted water. The facts conform more easily with

the idea of the widespread presence of the bacillus hosus,which accounts for its dispersion in surroundingits presence eventually in o ur natural cavities. A water

assw iated miorobe wiIlOpento ita careero f action.Dr. John Robertson, the medical ofllcer o f health of

Bhefi eld , mad e anumber o f experiments with soil “out-oidoors.” The results o f these ts “

pro ve that the

typhoid organism is capable growing very rapidly incertain soils and that ap tly under certain conditionsthe organisms cansurvive m one summerto another. The

According to Liebermeister “the curves representing thefrequency o f typhoid co d to the curves o f a7011 88temperature, only with this d reuse—the d iflerentpo ints o fthe typhoid curve fo llow those of the tempemture curve by aninterval of some mon ”

and he suggeststhatittaloes two or

three months forthe changes o f temgerms? penetrate to

the breedingp o‘g

the typ (Ziemssen's

L poyThe present war in South Africa has lent add itional

interestto the question of id fever in armies and theways inwhich it spread s uner the circumstances o f camplife. Inau article onMm Fever in Ai-mies inthe

t,Bi 8 rgeon r pro femor agrégé at Val“ $ 119s “the pred isposing causeswere

https://www.forgottenbooks.com/join

m hyM —W K R O-flh u l c , senior

he shonld notad vance his Opinion onthematterif he “d id

151

not feel that the growing tendency to attribute enteric towin d flies was not becoming a source of danger.” Hemaintains fi-cm six years' experience “thatthe causation ofepidemics in South Africa is practically similar to thatwhich givesrise to the m

fi’

o rity of cases in England—via , apolluted water-supply.” e states that onl onone occasionhas he “had any grounds for“

fle eing td ustwas con

corned in the production o f typho and on that occasion the

says thatitis rare.“As amatter o f fact, ho id cases are

less frequently met with just at the peri at which d u trtom prevail and are more numerous when, onaccount ofboggy

rain, dust is less troublesome. This, to my mind, isco neive proof that d ust does not exert much injuriousinfluence as typhoid. As regards flies I canonly say that I d a similar Opinion. The possibility o f

the conveyance o f enteric through these posts is undeniable, but in this instance also the su cause, theflies, begin to be troublesome long before typ cid prevails andcontinue to annoy us long after it has subsided. If the flieswere really immrtantagents in the spread o f typhoid feverone wo uld expectthat even if the d isease d id notcommenceto prevail soon after these nuisances commenced to benumero us, because it is conceivable that at theMetyphoid-infected stools would be rare, yet when once oid

became common the flies should carry on the ectionwhich should continue as long as, or longer than, the fliescontinue." Finally, be stro ngly maintains that "typhoidin South Africa is almost entirely due to polluted water.He admits that filters were sent outwith the tr00ps butstates that they were not generall used ; while, on theother hand, "where the commanding omcer had a ‘ fadabout water ’ the case inc idence of typhoid was insicant.” To show that he does not underrate the dimo ty ofso lying au army with water when on the march he adds :

y private opinionis thatif the army had been suppliedwith the bestW advice on the march fromPaard to RI ingshave ted, either the army would never have reachedBloemfontein or it would, as it did, have sufiered fromfever ; one or other of these results was inevitable.

” The

contained in it for the purpose of this lecture. I have, however, Professor Lane Notter

’s sionto state as his own

personal opinion that he co era" that while water was

a vegyfrequent cause of typho id fever among the it

coul not, I thh h be said w be themly cause of it.hmu

were the aggregation of men onlimited areas—density of

152

tion—withou t any of the usual methods o f drainagethe d ispoeal of excr

'eQ and refu se which exist where

o f the Orange RiverOolony and

’

l‘

ransvaal.I intended the subject of these lectures to

the “Etic i of Typhoid Fever." and this would

beenquite out. but1 afterwards tho ught that itd add to theirmm if [ showed how the mortalitytlns d isease has beend iminished inthis and insomei

ii

“

around them mustbe kept pure by the adoption of methodsfor the removal of excreta from the vicinity of habitations

md fly and continuo usly. The late Sir George Buchananwed us that the death-rate from typhoid feverwas especially

lowered in towns where refuse matters were removed mostquickly. Am these methods for the prevention of the con.

taminationof t e soil and the airare the provision o f watertight house drains, their d isconuexionfrom the public sewersor cesspools, their preper ventilation. and the provision ofanal ap iancee and pipes which insure the speed“momof file foul matters from the houses and prevenithe escape into them of any fou l air from the drains or

sewers. All these matters have been so thoroughly discussedby me inother public lectures that it is quite unnecessary forwe further to on onthem here.

m d ifl‘erences of opinionwith regard to

the disini of typhoid excreta ; some advocate mixing

https://www.forgottenbooks.com/join

155

Tsm I ll — Lond on.

Years.

1851- 1870

Nuisance RemovalAct. 1855.Sanitary Act, 1866.

000 000

0“ 000

In Table IV. the corresponding figures are shown withregard to the general death -rate in England and Wales.The average from 1849 to 1875 was 22 4 per 1000perThe Public Health Act was passed in 1875 and after that thetable shows a steady diminution of the death-rate until inthe quinquennium 1898to 1900it was only 178.

mam lit—England and Wales.

1848-1875

Public HealthAct, 1875.

and 1881-90. They show “that whilst enteric feverhasMeneno rmo us diminution in this country, the areas

of bo its maximum and minimum incidence have remained

https://www.forgottenbooks.com/join

159

rats of mortality from t

flphoboid fever (not inc

continued fever) per milWales and in London from 1 t0 1900,

Vinw ch

in a graphical manner the remarkable diminution o f thedeath-rate from this disease in England and Wales since1875, and inLond onsince 1883. It will benoticed thattheonlgyyears in which the typhoid death-rate in London wasor than that in the country generally were the three

years 1881—82—83.

I have alread referred to thethe death-rate typhoid fever at Munich to theimmovements carried out under the advice o f e lateProfessorPettenko fer, a diminution which is even far more

country generally.The diminution at Munich was. in fact(in the mean annualmortality permillion inhabitants). as follows

am on the “Diminution o f hoid Fever inParis,

”

pu ed in the Bow sMunicipala of 29th, 1900.I find thatthe dmth-rate from that d isease per

personi'

inthatcity has d iminished ina ve notablemanner. as s own by the folio figures. In 1 it was143) ; from 1883to l888 itwas 1 ; from 1889 t0 1894 itwas 298 ; and from 1895 t0 1900itwas l72. And this inspite o f amcru d escence in1899 and 1900.which was bro tinto prominent notice on account of the t Ezhi onheld inParis in1900, butwhich was s by Lond onand

and would not have beenforthe Exhibition.

I ho thatthese lec be o f some permanent use.es y as a conciss summary of r

gprts o f outbreaks of

typhoid feverscattered throughout pu 0 health literature .

M‘ This flgurs has bsenldnd ly su ppllsd to me by fi o fm or flahnmf

Printed atThe LancetOfl ca, 428,Strand ,WU .