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in the presence of a typhoid patient without fear of harmful results if he refrain from touching the patient or anything in the room that may be infected, or, in less technical language, poisoned. More than half a century ago Dr. Budd, a distinguished English physician, became convinced that this disease was communicated from the sick to the well through the excreta from the former's body, and now all physicians recognize the correctness of this view. It has often been demonstrated that both the urine and bowel discharges of typhoid patients are loaded with the germs, or bacteria, of the disease.
The disease is conveyed by these germs or bacteria finding access to the stomach of the well person and in time entering the blood circulation. In plain language, one must swallow typhoid germs in order to contract typhoid fever. It is not a pleasant thought, and yet the statement is true, that "we have typhoid fever because our food and drink have become contaminated with the excretions, such as the stools, urine or the sputum of persons who have previously been infected with these disease-producing bacteria” (Richardson). It is true, however, that not all who swallow these germs contract the disease. Some persons have greater powers of resistance than others, and the systems of such persons seem able to combat successfully the invasion of these poisonous germs, which may pass through the bowels without doing any perceptable harm. They may even develop considerably in the bowels, and, in exceptional cases, may enter the blood stream without exciting the general symptoms of the disease which usually follows their presence. Such persons may constitute what are called healthy typhoid carriers, and they constitute a menace, since they are capable of conveying the disease to others without having it themselves.
There are many ways in which the bacilli of typhoid fever inay enter the body. Drinking water may become infected by typhoid excreta being carelessly thrown on the ground or into streams and later washed into the well, spring or other source of water supply. These germs do not live long in water. It is supposed that they perish in about a week; but water in running streams along which large populations reside is apt to become repeatedly infected from the many typhoid cases so generally present in large communities from which the drainage empties into those streams. It is a well established fact also that springs and wells in the country are often infected through contents of privy vaults, manure heaps, pig styes, etc., percolating through porous soil or fissures in the rocky ground; or from surface washi gaining entrance to wells through cracks in the well casing or the covering of the wells. One-third of all typhoid fever is tracable to infected water. S. C. Prescott of the Massachusetts Institute of Technology, examined 202 water supplies on dairy farms within 25 to 40 miles of Boston, “in a long-settled, intelligent and well inspected region, probably rather superior hygienically to the rural districts of most of the country.” And yet of these one-seventh were found to be so badly polluted that the water was rendered unfit for drinking or domestic purposes, or for the washing of milk utensils. This impurity the investigator found to be due to the location of wells in proximity to privies, sink drains or other sources of contamination (American Journal Public Health, September, 1913). Outbreaks of the disease have been traced to the ingestion of oysters fattened in infected beds, but this cannot be regarded as a common cause. Fruits and vegetables eaten raw may cause the disease if handled by persons with infected hands or washed in infected water. Ice also may become a source of danger.
Not infrequently milk becomes infected. This may occur in the process of washing with infected water the cans and other utensils used in the handling of milk, or by diluting the milk with such water, which dishonesty we hope is not now frequently practiced. The germs live much longer in milk than in water, since milk constitutes what is known to physicians as a good culture medium, or, in other words, a good soil for the cultivation of bacteria which multiply rapidly and enormously in warm milk. Many outbreaks of typhoid fever have been traced to dairies. A method of milk infection somewhat recently discovered is from the handling of milk by persons known as “typhoid carriers.” As already stated the typhoid germs are sometimes carried for weeks or months, in rare cases for years, in the intestines, gallbladder and other organs of persons who have previously gone through an attack of the disease. The carrier's hands are liable to become soiled with some of his own excreta which harbor these germs, and, unless extremely cleanly in his personal habits, in the process of milking or later in handling the milk it may become poisoned, and, as just pointed out, the germs rapidly increasing in numbers, the infection of those using the milk becomes a quite easy and natural process. Epidemics from this cause are sometimes quite easily traced. It is found that of those attacked many are the young who use milk freely, and in the community where the disease prevails it is found that those who use milk from one dairy are victims of the disease. while the families procuring milk from other sources escape. Milk products also, as ice cream, butter, etc., may convey the disease.
A few words more as to the typhoid carrier. Dr. Bolduan of the Health Department of the City of New York says that as a result of his investigation he finds about three per cent of persons convalescent from typhoid fever become germ carriers. Others claim that the percentage reaches 4 to 6. Regularly repeated examinations of the stools of such persons have shown that the excretion of typhoid bacilli is not constant. A stool showing very few of these germs may be followed hy one showing great num
bers; or a stool showing an entire absence of bacilli may be followed by one having an abundance. There may even be an intermission of months or longer, and yet a person may continue to be a carrier for years, and during all this time he is a menace to those with whom he comes into intimate contact. The germs. are harbored in both the bowel contents and the urine, and hence it is quite easy to soil the hands and through these the food or utensils in which it is served. “The danger of a carrier to his associates and to the general public will depend upon his occupa+ tion and his habits of general cleanliness. Of 51 chronic bacilli carriers reported in the literature, 33 were known to have been the cause of disease in others. Of these 13 were dairy workers, 10 were cooks, y were housewives and 3 were laundresses. Hence those carriers who have anything to do with the production and handling of food, especially food which is eaten uncooked, are most dangerous. It is important to note also that about 90% of all typhoid bacilli carriers are women, who, in most families, prepare the food for the table.” (Gardner & Simmons, Prac. San.)
The common housefly has come to be considered a very frequent cause of fever cases. This insect is omnipresent, its reproductive powers immense, and hence its numbers are unlimited. It breeds in manure heaps and other filth, revels in garbage cans, privy vaults and other foulness, and comes fresh from its nasty revels to the kitchens and tables of the people. The germs of typhoid fever have been found on the feet and legs of these pests. How easy, then, to infect the family milk, meat or other food, especially of careless cooks and housewives, and how innocently and unconsciously may one take into his stomach the poison that lays him on a bed of lingering illness or puts him beneath the green sod of the church-yard. Only a little fly, but an insect most potent for mischief.
Last September the writer visited a village of about 225 population in which 23 cases, just one-tenth of the people, had been attacked with typhoid fever within a few weeks. There was no common water supply, each family having its own pump. There was no common source of milk supply, many having their own cows. There was but a single privy vault in the village, but the old fashioned country accommodation, a little house set on the ground, open in the rear and without excavation, was found on every lot. The weather was warm, the close of a warm summer, and fies were abundant. In the absence of a common water or milk supply the simplest explanation of this outbreak was certainly the open privy and the fly. One case that may have been imported was sufficient to start the fly on its mission of destruction. Flies, filth, fingers, food, fever; and farewell to many bright young lives. This too often is the sad sequence.
The profession is coming to recognize that while this disease is not contagious as is smallpox or scarlet fever, yet we may and do have many "contact cases.” This means that a person in attendance on the sick or visning the typhoid patient may, by kissing, shaking hands, coming into contact with bed or body clothing, drinking out of vessels that the patient may have used, get the infection into his system, with a resulting attack of the disease. The United States Public Health Service, whose surgeons are expert in investigation of this disease, attach much importance to this mode of infection.
Infected: water, ice, oysters, raw fruits and vegetables, infected milk and milk products, infection by flies and human carriers, and infection by contact with patients are the common methods in which typhoid fever is conveyed; water, milk, flies, contact and human carriers being the chief of these. Our aim, therefore, should be to apply constantly the knowledge we possess for the purpose of reducing the number of typhoid cases to the minimum, if we may not totally eradicate this grave disease.
Firstly, it is an absolute necessity to secure a pure water supply. In the cities this is a matter for municipal and not individual action, and usually it is necessary to install a filtration plant. In the country each family must have its own spring or well. In either case the source of water supply must be located at a distance from manure heaps, privy vaults, and the house drains, and when possible above rather than below these, so that the surface and underground drainage will be away from and not toward the sources from which the water is drawn. The spring should have a curbing around it and a covering over it. The well should have a cement or tongued and grooved board covering so that no filth from the surrounding earth or the feet of those using the well can get into the water. Many persons are extremely careless as to their well covering, and no doubt the water often becomes infected by such carelessness. If any doubt exists as to the quality of the water it should be boiled pending an investigation, which can now be made without cost at the State Hygienic Laboratory at Morgantown.
Pure water on a farm almost insures freedom from typhoid infection, but to make the purity of the milk doubly sure the cows should be milked in a clean place, should be brushed before milking so that no impurity may drop into the bucket, the cows’ udders should be cleansed, and the milker should be personally clean, especially his hands, and should wear clean outer garments. The milk should be reduced to a low temperature to prevent the multiplication of germs from which milk is never entirely free, and it should be at all times handled by cleanly persons only. Special care should be exercised that no flies gain access to it, for we can never know when infection may be carried by this insect, nowly commonly called “the typhoid fly.” And this leads us to impress the importance of having garbage cans at all times securely covered, filth of every sort reduced to