CHAPTER II

DISEASES SPREAD LARGELY THROUGH THE ALVINE DIS

CHARGES

TYPHOID FEVER

Typhoid fever is a sanitary problem of first magnitude, especially in this country, where it is unduly prevalent. In the United States typhoid fever stands fourth on the list of mortality tables: tuberculosis comes first, then pneumonia, cancer, and typhoid fever. The average fatality from typhoid fever being nearly 10 per cent., it would, therefore, take still higher rank on the morbidity tables. In 1910 there were 25,000 deaths from typhoid fever in the United States, representing at least 250,000 cases.

Our general attitude toward typhoid fever is inconsistent; familiarity has bred a remarkable indifference to the disease. Every case of typhoid fever means a short circuit between the alvine discharges of one person and the mouth of another. The physician has a dual duty in the care of a case of typhoid fever: one is to assist the patient, the other is to protect the community. On the other hand, the people should learn the lesson that a case of typhoid fever should be regarded as seriously as a case of cholera. These two diseases present many features in common. Both are intestinal infections of bacterial nature; in both diseases the alvine discharges contain the microorganisms which reinfect another person when taken by the mouth. Both diseases prevail especially in hot weather, both diseases are peculiar to man, so that the patient is the fountainhead of each infection. Water, food, fingers, and flies play a similar rôle in both instances. In the case of cholera the dread of the disease is an important factor in keeping it out of the country or in preventing its spread when once introduced. By strange contrast, there is a remarkable indifference to typhoid fever. A wholesome fear of typhoid fever would materially assist the health authorities in combating what may be considered one of the greatest health problems of the age. From the standpoint of preventive medicine, it is proper to regard an outbreak of typhoid fever as a reproach to the sanitation and civilization of the community

in which it was contracted. When the matter is better understood health authorities will be held responsible for this and other preventable infections, just as some one is now held responsible for preventable accidents. Much harm has been done by insisting that typhoid fever is infectious, but not contagious; it is both-that is, communicable.1

It

Typhoid fever occurs both in endemic and epidemic forms. may truly be regarded as pandemic. Normally, typhoid fever is a warm weather disease. It recurs as an annual crop from July to October.2 Epidemics caused by infected water occur especially in the early spring, late fall, or winter months. Milk outbreaks may occur at any time of the year. Autumnal typhoid in our cities is due partly to infection contracted at health resorts, and has, therefore, been called a vacation disease.

Typhoid fever is more prevalent in rural districts than in cities. In the United States there is more typhoid fever in the southern states than in the northern zone. The only explanation to account for this is the influence of temperature, rural conditions, and association with the negro. Typhoid fever is no respecter of rich or poor; it attacks those in robust health, all ages, both sexes.

Typhoid fever is a disease which ordinarily attacks the individual during the period of greatest economic value to the community. The economic loss, therefore, is appalling, and has been estimated to reach the sum of no less than $100,000,000 annually in the United States. Again, typhoid fever is an infection against which the individual alone canrot protect himself wholly without the aid of the community.

Prevalence. Typhoid fever prevails more or less in all countriesthe amount of the disease, however, varies greatly. It appears to be a disease of defective civilization, for those communities paying least attention to sanitation, as a rule, suffer most. In the United States there are comparatively few communities of 1,000 inhabitants or more which, during any period of twelve consecutive months within the last decade, have been entirely free from typhoid fever. According to the United States census report for 1900, the average typhoid death rate in the United States was 46.5 per 100,000 inhabitants. In 1908 the death toll from typhoid fever was no less than 35,000 in the United States. In other words, one person in about 200 in the United States contracted typhoid fever that year. It is estimated that in 1910-11 the number of deaths was reduced to about 25,000. The seriousness of these figures may be judged by estimating the probable number of cases of typhoid fever among persons handling the milk supply. Take, for instance, a city, as Washington, receiving its milk from a

2

1 For distinction between these terms see page 317.

In the southern hemisphere the typhoid season is during our winter.

thousand dairy farms. On the average there will be about four persons on each farm who in one way or another come in contact with the milk. That makes 4,000 persons among whom about 200 cases of typhoid may be expected to occur annually. No wonder that milkborne outbreaks of typhoid fever are common occurrences.

The rate of prevalence of typhoid fever in the United States in comparison with the rates of many other countries is very high. Thus, the annual death rate from typhoid fever per 100,000 population for the period 1901-1905 was: in Scotland, 6.2; in Germany, 7.6; in England and Wales, 11.2; in Belgium, 16.8; in Austria (1901-1904), 19.9; in Hungary, 28.3; in Italy, 35.2; while the rate in the United States during the same period was about 46.5.

A comparison between the prevalence of typhoid fever in this country and abroad is impressive. The following ten European cities with a total population of about 15,000,000 have an average typhoid rate of 2.4 per 100,000 during the 10 years 1901-10:1

ANNUAL DEATH RATES FROM TYPHOID FEVER PER 100,000 POPULATION IN 10 EUROPEAN CITIES

The following fifteen European cities with a population of about 9,000,000 had a typhoid death rate of 5.3 per 100,000 in 1909 and only 4.5 in 1910:

These facts and the following instructive tables are taken from: "The Necessity of a Safe Water Supply in the Control of Typhoid Fever," by Allan J. McLaughlin, U. S. Pub. Health Reports, XXVII, 12, March 22, 1912.

ANNUAL DEATH RATES FROM TYPHOID FEVER PER 100,000 POPULATION IN 15 OTHER EUROPEAN CITIES

The following eight European cities with a total population of 7,500,000 had a typhoid death rate of 13.9 in 1909 and 15.6 in 1910. These rates would be considered low in America, but the European officials consider the persistence of such rates to be a reflection:

ANNUAL DEATH RATES FROM TYPHOID FEVER PER 100,000 POPULATION IN 8 OTHER EUROPEAN CITIES

To recapitulate, in northern Europe the 33 principal cities, with an aggregate population of 31,500,000, had an average typhoid death rate per 100,000 population of 6.5 in 1909 and 1910. This includes such notorious typhoid centers as St. Petersburg, which had a rate of 33.7 in 1910. The rate in St. Petersburg is considered to be due to the water supply, which is partly filtered and partly raw Neva water. Let us now compare these rates with typhoid fever in America:

ANNUAL DEATH RATES FROM TYPHOID FEVER PER 100,000 POPULATION IN 50 CITIES OF THE UNITED STATES HAVING MORE THAN 100,000 INHABITANTS

These 50 registration cities in the United States have an aggregate population of over 20,000,000. The average typhoid death rate in these cities for 1910 was 25 per 100,000 inhabitants.