Preventable Diseases

by Woods Hutchinson

This last instance is peculiarly interesting, as illustrating how typhoid infection gets into milk, the second—though at a long interval—most frequent means of its spread. It does not come from the cow, for, fortunately, none of the domestic animals, with the possible exception of the cat, is subject to typhoid. Nor is it possible that cattle, drinking foul and even infected water, can transmit the bacillus in their milk. That superstition was exploded long ago. Every epidemic of typhoid spread by milk—and there are scores of them now on record—can be traced to the handling of the milk by persons suffering from mild forms of typhoid, or engaged in waiting upon members of the family who are ill of the disease, or the dilution of milk with infected water, or even, almost incredible as it may seem, to such slight contamination as washing the cans with infected water.

Health officers now watch like hawks for the appearance of any case of typhoid among or in the families of dairymen. The New York City Board of Health, for instance, requires the weekly filing of a certificate from the family physician of all dairymen that no such cases exist. And the more intelligent dairymen keep a vigilant eye upon any appearance of illness accompanied by fever among their employees, some that I have known even keeping a fever thermometer in the barn for the purpose of testing every suspicious case. How effective such precautions can be made may be illustrated by the fact that, in the past five years, there has not been a single epidemic of typhoid traceable to milk in Greater New York, even with its inadequate corps of ten inspectors, and the six states they have to cover. The moment a single case of typhoid appears, the dairy or milkman supplying that customer is given a most rigid special inspection, and, if any source of infection can be discovered, the milk is shut out of New York City until the department is satisfied that all danger has been removed. One or two lessons of this sort are enough for a whole county of dairymen. The danger of transmission of typhoid through milk has been enormously exaggerated, and, as in the case of all other milk-borne diseases, is entirely due to filthy handling, and may be prevented by intelligent sanitary policing. Even with our present exceedingly imperfect systems, probably not more than between five and ten per cent of typhoid is transmitted in this way; and, if the water-supply were kept clean, this would practically disappear.

Typhoid may not only be transmitted from the earth beneath and the water under the earth, but also from the heavens above, through the medium of flies and dust. The first method is bulking larger every day, especially in country districts and in camps. The modus operandi is simplicity itself. The fly lives and moves and has its being in dirt. It breeds in dirt and it feeds on food, and, as it never wipes its feet, the interesting results can be imagined. Just to dispel any possible doubt, plates of gelatine have been exposed where flies could walk on them, then placed in an incubator, and within forty-eight hours there was a clearly recorded track of the footprints of the flies written in clumps of bacilli sown by their filthy feet. More definitely, flies have been caught in the houses of typhoid patients, put under the microscope, and their feet, stomachs, and specks found swarming with typhoid bacilli. A single flyspeck may contain three thousand.

Fortunately, we have a simple and effective remedy. We cannot disinfect the fly nor make him wipe his feet, but we can exterminate him utterly! This sounds difficult, but it isn't. Like the mosquito, the fly can only breed in one particular kind of place, and that place is a heap of dirt, preferably horse manure, but, at a pinch, dust-bins, garbage-cans, sweepings under porches or behind furniture, vaults,—anywhere that dirt is allowed to remain undisturbed for more than a week at a stretch. Abolish, screen, or poison these dirt accumulations, and flies will disappear, and with them not merely risks from typhoid, but half a dozen other diseases, as well as all sorts of filth and much discomfort and inconvenience. It was largely through flies that the disgraceful epidemic of typhoid, which ravaged our camps on our own soil during the Spanish-American War and killed many times more than fell by Spanish bullets, was spread.

It is also believed that typhoid bacilli may be carried in the infected dust of streets and camps. Here again we are dealing with a dangerous public enemy to both health and comfort, which can and ought to be abated by cleanliness, oilings, and sprinklings. Typhoid bacilli are also occasionally carried by shellfish, especially oysters, on account of the interesting modern custom of planting them in bays and harbors near the mouths of sewers to fatten them. The cheerful motto of the oysterman is, "The muddier the water the fatter the oyster." And nowhere do the bivalves plump up more quickly than near the mouth of a sewer.

The last method of transmission is by direct contact with the sick. This is a relatively rare means of spread, so much so that it is generally stated that typhoid is not contagious; but it is a real source of danger and one against which precautions should by all means be taken. The only method is, of course, by the soiling of the hands of the nurse or other attendant, and then eating or touching food, or putting the fingers into the mouth before thoroughly cleansing. If the hands be washed with a strong antiseptic solution after waiting upon the patient, and the cheerful habit sometimes indulged in of putting fruit or other delicacies into the sick-room for a day or so, in the hope that they may tempt the appetite of the patient, and then taking them out and letting the children eat them as a treat, be abolished, and the nurse be not allowed to officiate in the kitchen, risk from this source will be done away with.

When the bacillus has been introduced into the stomach through food or drink, it rapidly proceeds to diffuse itself throughout the tissues of the body. Because the most striking symptoms of the disease are diarrhœa, abdominal distention, and pain, and the most striking lesions after death ulcers in the small intestine, it was supposed that the process was confined to the abdominal organs. This is now known to be an error, as cultures and examinations made from the blood and various parts of the body have shown the presence of the typhoid bacillus in almost every organ and tissue. This process of scattering, or invasion of the body, takes from three to ten days to accomplish; and the first sign of trouble is usually a feeling of depression, with headache, and perhaps slight nausea, before any characteristic bowel symptoms begin to show themselves.

The general invasion of the system throws an interesting sidelight upon the subject of premonitions. There are several well authenticated cases on record where individuals just before coming down with typhoid have been strangely impressed with a sense of impending death, and have even gone so far as to make their wills and set their affairs in order. Because these strong impressions appeared before any clearly marked intestinal symptoms of the disease, they have been put down in popular literature as instances of the "second sight," or "sixth sense," which popular superstition believes many of us to possess under certain circumstances. Now, however, we know that the tissues of that individual were already swarming with bacilli, and his fear of impending death was simply the effect of his toxin-laden blood upon his brain centres. In other words, it was prophecy after the fact, like nearly all prophecies that happen to come true; and the "premonition" was an early symptom of the disease itself.

As it is, of course, difficult to fix the precise drink of water or mouthful of food in which the infection was conveyed, we were for a long time in doubt as to the length of time which it took to spread through the system,—the "period of incubation," as it is termed,—although we knew in a general way that it averaged somewhere about ten days. But, about a year ago, fortune was kind to us. A nurse in one of the Parisian hospitals, in a fit of despondency, decided to commit suicide. Like a true Parisienne, she would be nothing if not up to date, and chose, as the most recherché and original method of departing this life, to swallow a pure culture of typhoid germs, which she abstracted from the laboratory. Three days later she began to complain of headache, and within a week had developed a beautiful crop of symptoms, and a typical case of typhoid, from which, under modern treatment, she promptly recovered,—a wiser and, we trust, a happier woman.

By just what avenue the infecting bacilli go from the stomach into the general system we do not know. Metschnikoff suggests that they can only penetrate the intestinal wall through wounds or abrasions of the mucous membrane, made by intestinal worms or other parasites. Certain it is that the average stomach has a considerable degree of resisting power against them, for in no known civil epidemic has the number of those who caught the disease exceeded ten per cent of the total number drinking the infected water or milk. In one or two camps in time of war the percentage has risen as high as eighteen or twenty per cent of those exposed, but this is exceptional. However, now that we know that intestinal symptoms do not constitute the entire disease, and may even be entirely absent, we strongly suspect that many cases of slight depression, with feverishness, loss of appetite, and disturbances of the digestion, which occur during an epidemic, may really have been very mild cases of the disease.