Popular Science Monthly/Volume 14/February 1879/Typhoid-Fever Poison
By ELY VAN DE WARKER, M. D.
ON the 4th of September, 1876, Otto Schmidt, an industrious and thrifty German, reached his home after an absence of a week at the Centennial Fair at Philadelphia. How and where he lodged, and what he ate, during the five days he was at that city, we have no means of knowing, for, by the time he had exhausted the marvels of the exhibition in his voluble German tongue, he had lost all idea of unity of place, and was wandering mentally amid the busy wonders of Machinery Hall. The reason of his mental migration was a very simple matter. Otto was sick. On the 8th he complained of headache, bodily prostration, and mental lassitude. The next day the distress in his head was very severe, with pain in the back and limbs, and chilly sensations. The day following there was fever with loss of appetite, and toward evening he vomited the only food he had taken that day. On the 11th he thought he was better; but on the 12th the fever, both morning and evening, was marked. The next day he was seen by a physician, and the disease was recognized as typhoid fever. And here, having given in brief the history of the misfortune that had befallen Otto, let me describe the little segment of the world that held all that was dear to him in the way of family and friends. In order to appreciate what follows, every point and detail in this miniature survey must be understood and remembered.
No reader of history can follow the marching and countermarching of hostile armies without his map; and here also, upon a space of ground one hundred and sixty-five by five hundred feet, we have the invasion of an active, subtile, invisible foe after due declaration of war. To the reader and myself this narrow limit of ground is historical. Here was fought one of the most destructive battles ever recorded in the annals of human misery—a campaign between this imponderable invader and the vitality of a score of human beings. This conflict was waged unheeded by the dense population around, which seemed bent more on enjoying itself during the pleasant harvest weather than witnessing an unequal fight.
The —— ward of the city of Syracuse is bailt in its northern extension upon a series of parallel hills and valleys. These hills, with steep eastern and western flanks, govern in a measure the direction of the streets. There are three of these crests, with corresponding valleys. The locality indicated in the cut is situated in the central depression. Directly to the west it is commanded by the second ridge, the sides partly built up, partly terraced, and the summit is crowned by Lookout Park, a pleasure-ground of doubtful promise, its scanty verdure being checked in its growth by the stony soil and the violent winds that sweep the summit. The slope of the hill east of the infected locality is of much lighter grade than that of the western ridges, and is thickly built up with small frame houses, except that about one hundred yards south of the group of houses, shown in the cut, the slope of the ridge is covered to the extent of twelve acres by the city cemetery, filled by
Explanation.—a, b, c, d, e, f, g, h, i, k, houses; L and C, streets; w, w, sewer and house drains; p, privies; s, f, u, v, wells. The Arabic numerals attached to the houses indicate the number of cases of fever in each. The Roman numerals indicate the order in which each house was invaded by the fever. n, sewer opening in the street gutter. M, uninfected houses.
eight thousand interments, and still used as a burying-ground. This second valley differs from the other in being gradually narrowed in its northern extension, so that the streets L and C gradually approach and enter each other at an acute angle about one hundred yards north of the scene of the infection. The little group of houses shown in the map are isolated by vacant lots to the north and south. The houses were one story frame, gable ends faced to the street, neat and comfortable, and were, with one or two exceptions, little freeholds, occupied by their owners, tidy and industrious Germans, except that the houses f and g were occupied, one by English and the other by Irish-American families. The houses were built two upon each city lot of sixty-six feet front by one hundred and twenty feet deep, and separated from each other by light picket and board fences. Several of the owners turned their ground to account by growing vegetables. At an average distance of twenty feet to the rear of each house were the usual privy-vaults, all of them too shallow and badly cared for. The water-supply was very defective, as this portion of the city was not supplied by the city water company. Well-water was therefore used for drinking and cooking purposes; while for washing, rain-water was caught either in cisterns or hogsheads. The water for culinary use was obtained from three sources. The houses g, h, i, c, and d obtained water from the well t; the houses a, b, k, from the well v; while the people in houses e and f crossed the road and patronized the well at s. This was the customary manner of supplying their wants. The source of supply at s was cut off during a short time, but, as this incident gave a clew to one of the most interesting facts of the investigation, I shall consign it to a later period of the narrative for the sake of what the critics call the dramatic unities.
Assuming that the details of the locality are sufficiently clear to enable the reader to understand the different steps of the search, I shall give at once the marches and halts of the fever in its invasion, and the amount of damage it inflicted on the population of our intra-mural hamlet.
As the reader knows, Otto Schmidt was taken sick on the 8th of September, and, as we have given him all the importance that belonged to him individually, I shall designate the other cases by the letters indicating the different houses. On the 4th of October a young woman was taken sick in the house g, the only case in a family of four; six days later the first case occurred in c, a family specially afflicted, as here four persons were stricken, leaving but two of the family, girls aged ten and fourteen years, untouched. These four cases were taken sick in the following order—the 10th, 14th, and 23d of the month; on the 20th and 26th we have two other cases in the house d, and two cases, at intervals of eight and twelve days later, in the house h, near neighbors of the Schmidts. In the house f, at nearly the same time, a case of the fever occurred. The last family attacked resided at e, and here the disease seemed to linger with special animosity, the first person being attacked on October 28th, and the last on November 8th. At this place and date the disease expended its force. In Otto Schmidt's family there were two additional cases taken on the 16th and 20th of October. In the total there were seventeen cases; five were very light, what some authors have called "walking cases." In the remaining twelve cases there were three deaths, one from an intercurrent pneumonia, or lung inflammation, one from intestinal hæmorrhage, and the other, without any special complication, gave way before the onslaught of the poison.
In an investigation of the kind before us we must have a knowledge of all the circumstances, and therefore, even at the risk of weaving such a complicated array of events around this drama of disease that it may need the skill of a professional novelist to disentangle us from the meshes, we must glance for a moment at the condition of the weather during at least the early part of the outbreak. From about the beginning of September a period of continuous dry weather characterized the month; there may have been one or two slight showers, but not sufficient to change the general condition of dryness of earth and air. During this drought the well at s gave out, and continued dry until replenished by the late fall rains. The wind, blowing generally from the west and northwest, served to keep the temperature down, but not to lessen the unpleasant dryness of the air. This was changed on the 20th by a thunderstorm from the west, repeating itself from the east after a brief interval with nearly equal force. So violent, however, were the wind and rainfall, that the water was carried off by surface-wash, filling up sewers and cellars and tearing out gutters, but doing harm rather than good to vegetation. The drought was ended, however, as this was followed by a series of easy showers. During October there was much wet and cold weather, the meteorological complexion of the late fall being decidedly unpleasant.
Now that we are ready to begin the story of our search, what shall we look for? We have here a circumscribed outbreak of typhoid fever, a disease admittedly of an infectious nature, but proceeding from what kind of infection? Shall we content ourselves with finding a heap of decomposing vegetable or animal matter, or rest satisfied by discovering an escape of sewer-gas from some untrapped drain into one or more of the houses? Since we—the reader and I—are scientific and reasonable people, we can not adopt the theory that the disease is contagious—an opinion held by some able but rather easy-going physicians—and having once effected a lodgment in the community is capable of infecting all who have systems favorable to the development of the poison. The disease is not contagious in the sense that small-pox and scarlet fever are. We have proof in the outbreak we are studying that it is not of such a nature; but we have further proof. Liebermeister says that he had never seen in the hospitals of Greifswald, Berlin, and Tübingen a single hospital patient, physician, or nurse attacked with typhoid fever, although such cases were placed in the general wards. Dr. Murchison states that during a period of fourteen years 2,506 patients were treated for typhoid fever in the London Fever Hospital, and yet during this long period, and notwithstanding this vast number of patients, only eight cases originated in the hospital. It is needless to cite further evidence, and, since we can not save ourselves hard work by the slipshod theory of contagion, we must explore further.
Sewer-gas and decomposing matter we can not dismiss in this summary way; for here we are entering upon the special preserves of boards of health, sanitary engineers, and all others who advocate the gospel of cleanliness. In admitting or excluding sewer-gas as an element in the spread of the disease, we need a more complete array of conditions than is furnished by our group of houses; but such evidence as is wanting we must procure from other sources. A glance at the cut will show that but three houses in the fever-group were connected with the street sewer. Two of these, e and f, were drained from the cellars by cement pipes four inches in diameter, the slops from the houses being thrown upon the ground. The house g was drained both from the cellar and by a branch pipe, untrapped, leading to an open sink by the side of the kitchen door. Two of these houses were the sixth and seventh in the order of invasion by the fever. There can be but little doubt in the event of heavy rains and sudden change of temperature that sewer-gas escaped into these houses. I never was able to detect such an escape of gas, but I concede the fact from what I know of city sewerage. If, however, we accept the explanation of the propagation of the fever after its first introduction in the person of Otto Schmidt by means of the sewer-gas, we leave unexplained a very important circumstance. In the group of infected houses but three out of seven were connected with the street sewer, so that in this particular outbreak sewer emanations are not competent to explain the extension of the disease. We may throw yet further doubt on the sewer theory by the fact that in the cottages M, containing numerous inmates, we have a group of uninfected houses, three of which were directly connected with the same sewer. If we were seeking for the cause of typhoid fever in defective drainage we should select these uninfected houses, as they not only had untrapped sewer pipes in the kitchens, which were practically the living-rooms of the families, but they were built at the foot of the slope and received the surface-wash of the rich alluvium of the hill to the west. Notwithstanding these unhygienic conditions and the actual existence of seventeen cases of the disease on the other side of the street, we find here complete immunity. When we have considered what this fever-poison really is, we shall be in a position to understand the origin of the disease from this source.
In seeking for a cause of the rapid spread of the fever in decomposing matter we are still at fault. The houses were all new, none of them having been built longer than five years. About none of them was found anything like an accumulation of refuse matter. They were careless about disposing of the water from wash-tubs and what is familiar to every housewife under the name of "dish-water"; but these were disposed of with more care than usual, as owing to the dry weather they were scattered over the gardens. In the condition of the vaults a critical inspector could find fault, yet they were in as good condition as these very defective household appendages usually are. Admitting a focus of infection at the house of Otto Schmidt, it is difficult to conceive of such a wide diffusion of the virus as to suddenly establish a focus at each of these seven points. This, however, is one of the least of the difficulties met with in tracing the disease to the decomposition of animal or vegetable matter. In typhoid fever we have a specific disease; that is, it exhibits a well-defined and uniform manner of beginning, a culmination and decline equally well marked, and, taken together, a group of symptoms and anatomical lesions that define typhoid fever and no other disease the world over, and under all conditions. The question comes up—and the pythogenic (putrefaction) theory must be competent to afford an answer, or it will have to be abandoned—In what way can an infection, which must be composed of many heterogeneous and opposing elements, and produced under widely different conditions, be capable of producing in different individuals, each affording a nidus for the development of the poison under an almost infinite diversity of circumstances, one uniform train of symptoms, one specific, well-marked disease? The answer to this is, that it depends on the kind of matter decomposed. To human excrement, above all others, has been given this fatal power. To this recently sewer-gas, which we have already excluded from the chain of possible causes, has been added. But typhoid fever has never been produced by experiments with decomposing substances, nor by products of decomposition accidentally introduced into the human body; and, further, it is opposed to our daily experience. There are vast numbers of houses in which the affluvia of vaults may be detected in all the rooms, others in which the inmates are constantly inhaling sewer-gas, and the fixed as well as the transient inhabitants escape the disease. It is safe to say that cities with defective sewerage are the rule; that some cities and villages are more filthy than others; that in some quarters of a city the decomposition of organic and excrementitious matter is constantly going on; and yet we find typhoid fever prevailing independently of all these theoretical sources of infection: we find it localized in one section, even in one block of buildings, while others presenting equally favorable conditions have not produced a case within the memory of man.
The theory has been seriously damaged by its friends. Not only typhoid fever, but a series of specific diseases, of the origin of which we are in a measure ignorant, have been referred to the decomposition of organic substances. Dysentery, yellow fever, cholera, typhus fever, and the plague have been assigned to this cause. Liebermeister says that this "very circumstance shows that to explain the origin of typhoid fever by a general and indefinite assumption of a decomposition of organic substances is not satisfactory. It is not every kind of decomposition that can produce typhoid fever; it must be some specific form of decomposition which elaborates as a specific product the poison of that disease."
In the epidemic which we are studying we have excluded the theory of contagiousness. We saw in the conditions reasons for excluding the sewers as a means of extension; and I trust, from what I have said of the nature of the disease-germs, the reader is willing to admit that I have some reason for the belief that we can not find an origin de novo in the house-vaults.
The atmosphere in this epidemic is not a probable means of the extension of the germs. We are not able to say positively that the air will not convey the poison, although it is safe to say that the area of its diffusion by this means is very limited. Instances in which sewer-gas has been known to be the means of conveyance are numerous, but the cases were confined to one or more rooms directly communicating with the sewer, or to a limited part of a building. But the typhoid fever poison is not a gas. In such a shape we can not conceive that it will lie dormant in suitable soil, that it will undergo phases which so closely resemble germination and growth, or that it can be transmitted to long distances when given a proper vehicle. We have here a right to make a scientific use of the imagination. We can not imagine it a gas, but we can form an idea of it as an atom, a germ capable of preservation, growth, and infinite multiplication. It has never been seen; it may be that it will never be seen. In the physical sciences we project ourselves ideally into the midst of many things unseen, yet with perfect theoretical conviction in the reality of their existence.
In the group of cottages to which the epidemic was confined we observe a certain order in the arrangement of the infected buildings. A close examination of the plan is nearly sufficient to convince one that this order is not due to chance. Nor can we explain it by a conveyance of the disease-germs in the clothing of the inmates. We have in the exempt houses a sufficient warrant against this supposition. The inhabitants of the exempt houses, as the outbreak of the fever extended, assumed generously nearly all the care of the afflicted families. They were daily and nightly in attendance upon the sick, and in many cases assisted in washing the linen. If this were true of the inhabitants of the houses that were exempt from the scourge, we are nearly safe in excluding personal conveyance of the germs by those who inhabited houses showing a sequence of infection.
During my attendance upon several of the cases I repeatedly looked over the ground and studied the habits of the different families, but, I am ready to confess, without discovering the clew to the extension of the disease from the single focus in the person of Schmidt; that is, to discover a clew that would meet the demands of the scientific germ theory. However, I became convinced that if I were able to find some domestic arrangement or prevailing condition that linked the infected families together under a common liability to the disease, I should become master of the position. Such a connecting link I found in the water-supply of the different families. I did not make the discovery accidentally, but only as a result of a systematic investigation. In all researches of this kind I believe that it is rare that the truth is stumbled upon in the course of a careless search. If we do not exclude cause after cause in the course of the search, we are almost sure in the end to halt midway between two probable conclusions without being sure of either.
It is necessary to recall the fact that five houses, g, h, i, e, and d, were supplied with water from the well t—an open curb-well, loosely stoned up, belonging to Otto Schmidt. All of these houses were invaded by the fever. But it is necessary to account for the contamination of the water. Here comes in the fact that gave me the key to the mystery. On the 20th of September, as I have already stated, there occurred a severe thunderstorm. It was so violent that a large amount of the rainfall was carried off as surface-wash. It did considerable damage to the gardens, and, among other things, filled up to overflowing the vault attached to Otto Schmidt's house. Here was deposited all the excrementitious matter from this severe case of the disease. It was easy to observe, from the appearance of a board walk, of the grass and ground, that the overflow had scattered material of this kind in the neighborhood of the well. Whether it ran into the well, or filtered through the ground, it is difficult to say; either could have occurred, or possibly both.
Now observe what occurred. Fourteen days after the shower, the 4th of October, a case of the disease broke out in the house g. Twenty days after, the first case was taken down in the house c; thirty and thirty-six days later, two cases in d, and two cases at intervals of six and twelve days later in the house h. These were the families habitually dependent on the Schmidt well for their supply of water.
Admitting that I am right in tracing these cases to the contamination of the well t, by the shower of the 20th of September, we have left two families in which occurred five cases of the fever who did not make use of this well. On questioning the people in the houses e and, f, I learned that they crossed the road and drew water from the well s. This missing link in my chain of cause and effect made a halt in my investigations. I had fancied that I was so near success that I took this disappointment as a sort of personal matter, and was half inclined to give the whole thing up. I made another effort; I crossed the road and investigated the well and its owner. There was no fault to be found with the well, which was a "drive well"; but the owner told me that it occasionally became dry, and was in that condition before and for a week or two after the great shower of September. Back I went to my fever-houses, and exploded this question like a bomb-shell in the midst of their inhabitants: "Where did you go for water when the Bogert well was dry?" "Oh, we went to Mr. Schmidt's well."
After this testimony let us trace the course of the invasion a step further. The fever appeared among the inmates of the house f on the 20th of October, and of the house e on the 28th. Had we no further evidence, here is sufficient to render probable that these cases were due to drinking the infected water from the Schmidt well. But we may strengthen it by negative evidence. The inhabitants of the uninfected group of houses on the opposite side of the street at M never used the suspected well. When the well s became dry they resorted to the well at x. There is one other group of uninfected houses, two of them belonging to the same block as the infected houses, and one situated on the opposite side of the street L. These three houses contained fifteen inmates, all of them coming into frequent contact with the sick. These people were supplied with water from the well at v, and were throughout the epidemic exempt from the disease. Thus, to sum up, all the families that were supplied from the Schmidt well after the 20th of September had one or more members attacked by the fever; all the families that were furnished with water from other sources escaped. The conclusion is reasonable that in the drinking-water we have the means of the diffusion of the germs.
I have here shown a direct connection between the case of Otto Schmidt and that of every other infected person. This connection, traced through the drinking-water, was a discovery in our own epidemic; but it is by no means a discovery as a means of diffusion of the disease. This has long been known, and the literature of the subject is full of instruction.
It must be borne in mind, however, that not all water contaminated with organic impurities will cause typhoid fever. There must be among these impurities the specific poison of the disease. And this, as we have been able to prove, can be traced to former foci of typhoid fever. Other fluids may be contaminated in the same manner. An interesting report of an epidemic of the disease in England was given in the "Lancet" several years ago. A pasture had been manured by sewer products. Here were fed a large number of milch cows. In a neighboring town typhoid fever became rife. The victims, it was discovered, all used milk from this dairy; those who did not make use of it escaped. One can not help speculating about the way in which the disease-germs entered the milk. The more probable explanation is a mechanical one: that the germs adhered to the udders of the cows and were brushed off in the act of milking. It hardly seems reasonable that the germs passed through the organism of the cows and thus entered the milk. The theory of a contagium vivum is further fortified by the circumstance that, by boiling, the power to harm is taken away from the infected fluids.
It must be observed that between the entrance of the infecting elements into the system and the breaking out of the symptoms which define the disease, a varying period of time intervenes. This is called the period of incubation. It is a feature which distinguishes the entire group of infectious diseases. In determining the length of this period there are two elements of uncertainty: first, it is difficult to fix the exact time of infection; secondly, it is often impossible to define the exact beginning of the disease. In typhoid fever, especially, the onset is insidious and slow. Days and even weeks may be passed in a depressed, languid state of the health, before the disease is recognized as typhoid fever. Among business men these initial symptoms are often explained by taking cold, or by overwork. During the epidemic at Basle a few persons were attacked after a residence in the city of from seven to fourteen days; others after sixteen days. Haegler found in three cases caused by drinking-water a period of incubation of twenty-one days. In our own epidemic one case occurred in fourteen days after drinking the water, the average time being about twenty days. The general experience at the present time points to an incubation of about three weeks; but it may vary from two to four weeks, or even longer.
It is an interesting question, but one to which I cannot give a satisfactory answer, Why do not all who are exposed to the infecting cause suffer from the disease? In some cases it may be due to idiosyncrasy. Some people resist powerfully the encroachment of all infectious diseases, while others seem fated to have an opportunity of testing in their own person every prevailing malady. Experience teaches, however, that typhoid fever, unlike many other diseases of the group, is favored in its development by unhygienic surroundings. Bad air, bad food, uncleanliness, and over-population of a house or quarter of a city, create a condition in the system favorable to a rapid and virulent development of the fever after an infection by the germs. We know nevertheless, that no house nor person is exempt from the disease after receiving the exciting cause. Prince and peasant alike have to bow to the malignant potency of these infecting germs.