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J. A. (Joel Asaph) Allen.

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culture medium for these bacilli. They retain their vitality and
perhaps multiply in damp soil. They may dry and in the form of
dust be found in the air, but here they certainly do not increase.
Sunlight depresses them ; excessive heat destroys them ; but
they live for months in ice, as has been demonstrated by
Prudden,

Finally, to complete this brief bacteriological description, these
bacilli produce, as a result of their life process, various poisons, of
which Breiger has described a ptomaine, — the typhotoxin ; and
Breiger and Frankel a toxalbumin, and Vaughn a ptomaine which
when given to dogs produces vomiting and a rise of temperature.
It is probable that these and analogous toxic products produce the
constitutional symptoms in man of typhoid fever. Unfortunately,
the detection of the typhoid bacillus cannot be made an ordinary
clinical practice, as we at present obtain the tubercle bacillus, for
it requires special experience and elaborate bacteriological equip-
ment, and must, therefore, be delegated to experts.



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CAST : TUB CAUSE OF TYPHOID FBVBB. 643

To understand how this bacillus gains entrance into the human
body, will be our next inquiry ; but we shall limit ourselves to
statements regarding only the most common vice. As has been
stated) the infection is discharged mostly with the dejecta, and
owing to its vitality it finds its way through our sewers or soil
back to our water supply, to our milk, or perhaps as dust in the
air, or still more rarely as food contamination. The disease is not
contagious in the ordinary sense of the word, as there are no ex-
halations from the skin or lungs which can impart the disease.
It may, however, be present in the material vomited or expectora-
ted, or it may remain in the body after death, and it is only, there-
fore, in the careless handling of these materials and the dejecta
that we can explain those cases of typhoid fever apparently due to
contact. Our literature teems with instances of typhoid epidemics
caused by water contamination, and the knowledge of this particu-
lar source of danger is not limited to the profession, nor even to
the well-informed persons of an American community, but in an
imperfect way it is realized in all grades of society.

As an instance, however, of this common cause of infection, I
will recite one of the most remarkable epidemics of modern times,
and one which is extensively quoted in standard works in medi-
cine. It occurred in Plymouth, Pa., and was studied by Taylor
and Shakespeare. In this instance a mountain stream, supplying
a population of 8,000 people with drinking water, became infected
from a single patient living close to the water's edge and some
miles from the town. At the time of his illness with typhoid
fever his attendants threw his evacuations on the ground and into
the stream. As a result, 1,200 or nearly one-seventh of the entire
population became infected, and these cases developed at the rate
of from fifty to 100 a day ; about 100 persons perished.

Bronardel, in his paper before the Academy of Medicine of
France, stated that the deaths in that country from typhoid fever
Aggregated 23,000 per annum, and he stated that the liability to
this disease is directly in proportion to the defective water supply ;
that when the water is improved the fever abates. He cited as an
illustrative case Vienna, where the typhoid mortality was 200 per
100,000 so long as the inhabitants drank surface water, and it fell
to ten per 100,000 when the water was improved. At Amiens the
typhoid mortality of the military population was reduced from 111
per 10,000 to seven, by establishing artesian wells. At Rheims,
typhoid fever was epidemic while the surface wells were used, and



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644 CARY : THE CAUSB OP TYPHOID FBVSB.

fell from forty-three per 10,000 to two, when thej were abandoned.
Van Fordor, of Buda-Pesth, reported an epidemic occurring in a
Hungarian community of 34,000 people living on the side of a
mountain, in which 1,228 persons were attacked, and ninety-three
died. He states that 40 per cent, occurred in young persons. The
preceding summer had been hot and dry. • Late in October there
was a copious rain-fall. Cases of enteric fever began to accumu-
late in the first week of November, the number became greatly
increased in the second and third weeks, then rapidly declined,
remaining, however, larger than usual. In the second week of the
following February, after the melting of the surface snow, the
. epidemic again broke out, and continued for several weeks. Privy-
wells were universal. Bacteriological examination of the moun-
tain water supply showed it to be abundantly infected with bacilli
having the essential characteristics of the typhoid bacillus.

Guimbretiere, of Boussy, reported the occurrence of a small
epidemic of typhoid where all but two of the eighty-five persons
affected had partaken of water from a well connected with a
church in the village. On examination the water was found to be
chemically impure, and to contain Eberth's bacilli. The two
exceptional cases had nursed other persons suffering from the dis-
ease, and developed it after the subsidence of the epidemic. The
source of the contamination of the well was obscure, but the
church itself occupied the site of an old cemetery. The recital
of these epidemics will suffice to illustrate infection from water
contamination. The examples might be multiplied indefinitely.

Infection by milk is by no means uncommon, and ten years ago
the British Medical Journal showed that up to that date fifty epi-
demics of typhoid fever had been traced to this cause. This con-
tamination of milk need not necessarily be the result of premedi-
tated adulteration or dilution, but may take place from the legiti-
mate use of water for ordinary cleanliness ; for, be it understood,
milk contamination commonly occurs from infected water.
Sedgwick and Chapin detail an analysis of an epidemic of enteric
fever in the City of Springfield, Mass., and Sedgwick reports the
results of an epidemic in Sommerville, Mass. The number of
cases discovered and investigated in the first of these two, was 150,
and the deaths twenty-five. The milk was contaminated by placing
the cans submerged in a well which contained dejecta from cases
of enteric fever. The cans were not so hermetically sealed as to
prevent the entrance of water. The milk was placed in the well



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CAST : THE CAUSE OF TYPHOID FBVSB. 645

for the purpose of keeping it cold. The other epidemic occurred
among the customers of one milkman, and the investigation dis-
closed the fact that the son of this man handled and delivered the
milk while suffering from an attack of enteric fever. The disease
was at first unrecognized, and he continued his work until thirty-
two persons became infected.

Mitchell reports twelve cases in persons who drank milk from
a common source. There was typhoid fever in the dairyman's
family, and those who milked the cows nursed also the typhoid
patient.

Caton, of Liverpool, has directed attention to the possible dis-
semination of typhoid fever from the use of liquid manure
obtained from cess-pools, in the cultivation of lettuce, celery and
allied vegetables.

Henry £. Armstrong, medical officer of health of New Castle-
on-Tyne, in his article on the different diseases communicated to
man by milk, states that epidemics from this source appear usually
as a sudden outburst, and that with the modern method of report-
ing to the Board of Health all cases of infectious diseases there is
at present no difficulty in fixing the source of contamination to
milk.

Finally, not in the form of an epidemic outburst, but simply
as isolated cases, filthy clothing may be the carrying medium, and
was the cause assigned to the continuance of typhoid fever in cer-
tain military quarters in Germany. Among contributing causes
climate exerts a certain infiuence. The disease occurs in all
climates, though it is most abundant in the temperate zone. It is
not uncommonly found in the tropics, is common in Iceland, Nor-
way and Finland. Season, again, exerts a marked influence and
though constantly present with us it is far more frequent in the
late summer and autumnal months. It is more common after hot
and dry summers, and Pettinhoffer and Buhl say that the disease
was most common when the water was low, it being believed that
when the water level was low, the greater must be the solid matter
suspended in it. Also dust of dry seasons may disseminate the
germs. It is also probable that when the dry season breaks up,
the changeable weather brings with it intestinal catarrhal troubles,
which favor the lodgement of the germs in the intestine. Sex
does not influence the disease, but age does in a marked manner.
This is the disease of youth and adult life, the greatest suscepti-
bility being between the ages of fifteen and twenty-five years.



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646 cabt: the cause of typhoid feybb.

Lastly, there is, as would appear, an inherited predisposition,
for some families certainlj contract the disease with greater readi-
ness than others. This cause is probably anatomical.

To summarize, then, the causes of typhoid fever, the one only
true existing cause is the typhoid bacillus, which finds its way
into the body through the mouth, with the drinking water most
commonly, more rarely with milk or dust or food contamination ;
in still more rare instances by the careless handling of typhoid
material, and in perhaps one case which has come under my
observation, by direct transfusion. The contributing causes are
age, climate, season, soil, individual and inherited susceptibility,
unclean habits and intestinal disturbance.

In conclusion, I am asked to assign the cause of this particular
epidemic — our epidemic — of 600 cases in very nearly one month.
This, like any other, must be caused by the typhoid bacillus. The
inquiries into the mode of its conveyance and wide distribution in
our city have not been completed, though the investigation is
still being carried on, so that we may hope to profit fully by our
hard experience ; still it may be said that the epidemic was without
much question caused by temporary contamination of our water.
Spread as these cases were rather evenly throughout the city, it is
not probable that the cause could be milk or food supply, for there
is no one source from which they are derived. Soil and air have
never been the cause of an epidemic of this character, whereas
water is the most common of all causes, and with this knowledge
we turn to the examination of this commodity and find our suspi-
cions warranted, and proof almost fixes the cause here. The Bird
Island Inlet has been one of our sources of water for many years.
The Bird Island Inlet has been the source from which we have
drawn water frequently through this Winter. When the water in
the river was low, and just preceding the development of our
epidemic, then also was the Bird Island Inlet open and our supply
was taken from this source.

In confirmation, our City Bacteriologist, after careful examina-
tion, has reported the abundant contamination of the Niagara river
water at this inlet, and has found Eberth's typhoid bacillus in it.

Note. — The usual water supply is taken through a tunnel from
the crib in the center of the river. The Bird Island Inlet is on
the east bank of Niagara River and is separated from the Erie
Canal by the canal feeder ; both of these waters are foul.

340 Delaware Avenue.



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potteb: thb pbbvention of disease. 647

THE PREVENTION OF DISEASE— A PROBLEM FOR ALL

PHYSICIANS.*

Bt WILLIAM WARREN POTTER, M. D., Buffalo, N. Y.
INTRODUCTION.

The highest office of the physician of modem times is and ever
mast be in the exercise of his functions toward the prevention of
disease. This is neither new nor original, bat is, nevertheless, as
true as when it was first uttered in reference to modem physicians
and modern medicine.

In a medical society meeting it is far more entertaining and
even fascinating to describe a brilliant clinical success, either in
surgery or medicine, than it is to discourse upon the methods of
prevention as applied to the maladies of mankind. But it would
be unseemly to address this Academy in general session assembled,
composed as it is of men who are distinguished in all the special-
ties of their art, upon any one branch thereof expecting to attract
either the ear or the thought of anything like a considerable num-
ber, to say nothing of a majority. But every one is or ought to be
interested in the prevention of disease. Moreover, the time has
fully come for the discussion in all medical societies by all medical
men of the manifold questions relating to preventive medicine.

The problems that are involved in this department of medicine
must interest the general practitioner, whether of medicine or
surgery ; likewise all specialists in the several departments and
branches of medical science and art; nor can the laboratory
teacher, whether he be chemist, pathologist, physiologist or bac-
teriologist, escape the necessity of a knowledge of how to prevent
the diseases whose infection and contagion he is absorbed in
studying and analyzing. What man is there who bears the honor-
able title of " Doctor of Medicine," no matter what his specialty
in teaching or practice, who escapes the sometimes intelligent and
always persistent interrogations of his patients or friends with
reference to the best methods of preventing the spread of cholera,
smallpox, diphtheria, typhoid fever and the like ? He must be
prepared to offer an intelligent opinion on all such questions, as
well as on those pertaining to plumbing, sewerage, drainage, venti-
lation and every detail of house sanitation. Ignorance on, or
indifferent acquaintance with, these subjects is a confession of

1. Read by invitation before the New York Academy of Medicine, February 1, 1804.
Published in the New York Medical Journal, April 14, 1804.



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648 potter: the prevention op disease.

anfitness to retain his title. Happily, however, some of the exan-
thematous fevers have not now the same dread to humanity as
formerly, since the triumph of medicine in solving the methods of
their prevention and cure. But if this be true in a certain degree,
there is being added to the list a number of maladies that formerly
were not thought to be contagious or at least infectious, but have
now become well known to be so through the investigations and
studies of clinicians and men experienced in the science of bac-
teriology.

Permit me to illustrate by accentuating the importance of a
better knowledge concerning the prevention of the propagation of
a few of the more serious diseases of this class.

THE PRETENTION OP CONSUMPTION.

I may refer first to one disease — namely, consumption, thai
comparatively lately has become known to the profession as an
infectious disorder — a malady that is destroying more inhabitants
of the globe than almost any other known disease, and that last
year proved fatal to more than 6,000 residents of your own city.*

While it is true that much has been done of late to control its
spread and to abridge its ravages in localities, yet how many
physicians are ready to admit even now that it is an infectious
malady, and that it may be conveyed to a healthy person who is
habitually in the atmosphere of a consumptive ? If it were pos-
sible to apply the knowledge which a few of the more advanced —
a small minority — of our profession now possess with reference to
the propagation of consumption and to disseminate this knowledge
amongst the mass of physicians, it would be serving humanity in
the highest possible way to concentrate the efforts of the entire
force toward preventing the spread of this direful disease. In
order to do this effectively, it would become necessary at the out-
set to establish an absolute inspection of all foods of an animal
nature, as well as supervision of the care of all animals that furnish
food for mankind, with a view to a rigid condemnation and destruc-
tion of such as prove unfit.

Again, if we should undertake to prevent the spread of con-
sumption by the application of all the intelligent means at our
command, it would further involve imperious supervision over the
food that our cows eat and their stable care, as well as a like
supervision over the animals that are slaughtered for our daily



1. Report of Dr. Hermann M. Biggs to the Health Department of New York City.



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potter: the prevention op disease. 649

<^on8amption. It also farther involves the inspection, by a com-
petent veterinary surgeon, of all cows that afford milk supply to
our cities and villages and of all the animals that are slaughtered
for purposes of food, to the end that every tuberculous beast shall
be killed and its body cremated. I consider it essential that the
latter order shall be enforced with great exactitude. If any por-
tion of a tuberculous animal, excepting its hide, horns, and hoofs,
be permitted to enter the avenues of commerce, there is danger of
the propagation of disease, and I know of no way to effectively
abolish such danger excepting to imperiously insist upon the
incineration of all tuberculous carcasses.

But we must not stop here ; our food supervision must extend
to all domestic birds, fowls, and animals whose milk or flesh we
use for food. The quantities of tuberculous food consumed by
the people assuredly are enormous, and it will require the most
rigid system of inspection and supervision, by most skilled, honest
and well-paid officials, to interrupt, cut short or prevent traffic in
these dangerous and unwholesome aliments.

Besides this, the circumspection and control of railway and
steamboat travel, as well as hotel life, would become necessary,
and this would simply arouse an opposition from every traffic
official and landlord in the country, to say nothing of the indigna-
tion of the travelers themselves. Yet none such would complain
of the exercise of an absolute authority with reference to restrain-
ing the transit of smallpox patients, or those affected with diph-
theria or cholera. Nevertheless, these maladies, one and all, have
not at present one scintilla of the importance connected with their
destructive powers that has consumption.

Another most important step toward the prevention of the
propagation of consumption consists in the prohibition of the
intermarriage of tuberculous subjects. If a man has tubercu-
lar disease he should not be allowed to marry a healthy woman,
and thus subject her to the danger of contracting the malady from
cohabitation with her consort, to say nothing of the liability of
propagating tuberculous offspring. For like reasons, a tubercu-
lous woman should be prohibited from marrying a healthy man.
But, if there are cogent reasons why these should not intermarry,
there are also forceful arguments that may be offered against
the intermarriage of two tuberculous individuals, that is to say, a
man and a woman who either have tuberculous disease or who have
come from tuberculous families. I make this assertion at random



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650 potter: the pretention of disease.

without desiring at this time to enter into a discussion as to-
whether the laws of heredity govern in consumption or not. But of
this I am certain, that for a man with existing tubercular disease
to marry a woman of tubercular parentage would be tempting fate
with a rude audacity deserving a better cause. The offspring of
such a marriage, to say the least, would offer a favorable soil for
the growth of the tubercle bacillus. I earnestly hope that before
long an enlightened legislature will enact statutes that will pro-
hibit such marriages.

Still another step in the direction of prevention consists in the
establishment of separate hospitals for consumptives and the adop-
tion of measures looking toward their isolation. But here most
bitter opposition will be encountered from those who are governed
by sympathy, affection and kinship. Nevertheless, it were welU
nigh impossible to prevent the spread of this fateful malady, unless
the methods and habits of life of its victims assuredly can be con-
trolled. It is admitted by those most familiar with the methods
of the propagation of the disease that the sputum of the consump-
tive constitutes a focus of special danger. Hence, to deal intelli-
gently with the question of prevention, the sputum must be
sterilized as soon as it is thrown off. Nor will it answer to deal
with it in a half-hearted, indifferent or slipshod manner ; the steri-
lization must be absolute and immediate, and this can only be
accomplished under the eye of a trained expert who knows no law
but that of perfect cleanliness and absolute sterilization, and who
will not be diverted from the end in view by fear, favor or affec-
tion. I know of no way to effectively enforce rules to prevent
the propagation of consumption, except to remove tuberculous
persons from all possibility of contact, direct and indirect, with
the healthy community.

Without doubt, independently of the infection by food, the
most serious menace comes from the respiration of infected dust,^
and it needs no specious ratiocination to prove to such an audience
as this, that the one great means of infecting dust is through the
sputum of consumptive patients. It has recently been said by a.
writer in the British Medical Journal that it would be well for
the medical profession at large to recognize the infectiousness of
tuberculous sputum and the danger of letting it dry into dust.
Harpman ( Centralblatt fur Bacteriologie und Parasitenkunde^ Band
XLV. 8, pp. 228-234, Med. Chron,^ November, 1893,) examined the
dust of a frequented street in Leipzig and found the bacillary



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POTrBB: THE PBEYSNTION OF DI8BASB. 651

remains on aboat 80 per cent, of samples of dust examined. From
the researches of Marpman we are taaght that street dust may
easily prove a scarce of infection, and that people should be taaght
to desist from expectorating in thoroaghfares or pablic places.
Hoases that have been occapied by consamptives, too, should
receive the most thorough renovation before farther ase.

It cannot be denied that already much has been done to limit
the spread of tuberculosis, as a careful examination of statistics
would p^ve, but these we have no time here and now to enter
into, '^e results already accomplished have been outside of the
prevention of intermarriage, inspection of food, attempt at isola-
tion, or sterilization of sputum, 'and have been mainly achieved
through the adoption of improved sanitary regulations — better
nutrition, purer air and other influences of like character.

I stand here to plead for the enforcement, in addition to these
well-known sanitary measures, of the prevention of intermarriage,
of the rigid inspection of animals that furnish food and the isola-
tion of tuberculous patients, and I ask this Academy to stand to-
gether as one man until it has brought about such change in public
sentiment and wrought such improvements in statutory law as shall
make all these conditions possible. I believe it will be yet just as
possible to quarantine and control the methods and habits of life
of the consumptive as it is now those of a smallpox, yellow fever
or cholera patient. At all events, I certainly hope that an enlight-
enment of the people on this subject will lead to such results.

TYPHOID FEVER.

Turning from the consideration of tubercular disease we
approach another infectious malady which has attracted the atten-
tion of physicians and sanitarians for more than a generation. In
July, 1845, Dr. Austin Flint, Sr., then of Buffalo, and afterward
one of your distinguished academicians, published in the American
Jowmal of Medical Sciences an account of an epidemic fever which
occurred at North Boston, Erie Co., N. Y., during the months of
October and November, 1843.

It appears that in September, 1843, a young man from Massa-
chusetts stopped at Fuller's tavern in North Boston. He had been
unwell for several days, a diarrhea being among the most promi-
nent and early of his symptoms ; he was first seen by a physician
only six days before his death, who found him suffering from
diarrhea, low muttering delirium, sordes and other symptoms that



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Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 65 of 78)