Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 154

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

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The deaths in the summer and autumn months also show a great increase over the corresponding months of last year. In 1909, 20 deaths occurred during August, but in 1910 this

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lem of Typhoid Fever in Baltimore. (Illustrated.) WM. W. FORD, M. D., D. P. H., and E. M. WATSON, A. M. 351

nt Epidemic of Diphtheria in the Johns Hopkins Hos- and Medical School : General Procedures Adopted. WM. W. FORD, M. D., D. P. H. 357

of the Urinary Tract by the Bacillus Lactis Aerogenes, a Consideration of the Mode of Entrance of Bacteria the Bladder. (Illustrated.)

JOHN ARTHUR LEUTSCHER, M. D.

361

352

JOHNS HOPKINS HOSPITAL BULLETIN.

rose to 30. For September the number rose from 24 to 49; for October from 23 to 42; for November from 10 to 37; while in December the deaths rose from 9 to 26, as is shown in Chart III.

CHART II .- Typhoid fever in Baltimore. January, 1910, to June, 1911. Case incidence.

JAN

FEB

MAR

APR

MAY

JUNE

JULY

106

SEPT

OCT

NOV

DEC

JAN

FEB

MAR

APA

MAY

473

398

359

251

110

CHART III .- Typhoid fever in Baltimore. January, 1910, to June, 1911. Mortality.

JAN

FEB

MAR

APR

MAY JUNE

JULY AUG

SEPT

OCT

NOV DEC

JAN

FEB .

MAR

APA

MAY.

While these figures indicate an increase in typhoid fever during the year just past, compared with preceding years, it must not be supposed that this predominance of the disease in

any one particular period has not previously been noter in the year 1907 there were 230, and in the year 19- deaths. As can be seen from Chart IV, typhoid for always existed in the city of Baltimore. Deaths from : first reported officially to the Board of Health abox: ts 1875. At the end of this year 187 deaths were de this cause. Since then statistics of the Department a constant recurrence of the disease from year to ver: the earlier years the diagnosis did not rest upon su' . grounds as at present, the possibility existing that case : laria and early tuberculosis might be included among to diagnosed as typhoid. Gradually, however, as the spurs tology of the disease became better understood, as the ize of malaria and tuberculosis was more frequently med :, evidence of the parasites and not merely upon the se and finally as the Widal reaction was introduced, t .:

CHART IV .- Typhoid fever in Baltimore.

Average deaths 1875 to 1880

Average deaths 1880 to 1885

Average deaths 1885 to 1890

Average deaths 1890 to 1895

Year.

Cases Reported.

Deaths.

Per cent.

Pope s.

1895

260

173

66.53

1896

472

188

39.83

1897

363

189

52.06

34.68

1899

462

153

33.11

1900

871

189

21.70

1901

792

141

17.80

1902

1086

220

24.61

1903

768

189

21.72

1904

916

199

19,33

1905

.1019

197

1906

1215

183

15.06

1907

1417

230

16.23

1908

1426

180

12.63

1909

1069

136

12.72

1910

1890

235

12.43

the recognition of typhoid infection much more carz. returns made to the Board of Health have become 2 more accurate. Despite the fact that some of the (f- merly considered typhoid fever would now be sepax . this group, the figures indicate that there has been t!" diminution in the amount of this disease in the city " more, as compared with our increasing population. we had possibly the largest number of deaths fre ever known here, 247 in an estimated population of : But since then the number of deaths has diminisbei the smallest number being reported in 1909, 135 i: - mated population of 580,000.

Beginning with the year 1895 typhoid fever becsz : 1 able disease in Baltimore, and since then our inform:" become still more exact. In that year 173 deaths i ported, and 260 cases, a mortality percentage of ONE: notifications sent to the Board of Health have increts ally, the ratio of death to case incidence constantir f:' in the year 1908 it became 12.62%. That is, durit ::

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167 per Far

162 per Fax:

207 per fer

1898

545

189

20.26

641

183 per Fer

from 7 to 20% and in private practice from 5 to 12%,

e usual figure for estimating the number of cases of ., based upon the number of deaths, is 10%, it is evident

: have in Baltimore at the present time very complete for this disease.

officials of the Board of Health, particularly Dr. Jones . Stokes, have been interested in this complicated and problem of typhoid fever for some time, and in the report issued by Dr. Bosley for the Health Department 7, Dr. Jones has considered the matter at great length y observations that can be made upon the disease here art with his paper as the basis.1

scussing this question, Dr. Jones came to the conclusion possible sources of our typhoid might be named :

1. Bathing in polluted water.

2. Privy wells.

3. Flies.

4. Importation.

5. Contact.

6. Hydrants in yards.

7. Water wells.

8. Raw foods.

9. Milk.

LO. Drinking water.

I we now come to a consideration of these possible we are confronted with apparently a hopeless task. tors which enter into the situation are so diversified, ormation concerning the disease in general is so de- n those very points which are of prime importance in ing the problem, especially the conditions which gov- life history of the responsible parasite outside the body, that with the evidence at hand it almost seems ;h any deductions which we can make must be based sufficient grounds. Investigations of typhoid fever in ies where the conditions are not unlike those in Balti- pecially in Washington and in Richmond, while fruit- tifically and slowly solving the problem for those com- , nevertheless do not give us conclusions which can d without great caution to our own city. The prob- entially one which must be worked out by each center ation for itself.

phoid fever may be said to present three definite as- 'irst, it has existed in Baltimore from the earliest .ctuating somewhat from year to year, never falling certain level, but occasionally rising above this level t, as in the year 1910, where it may be regarded as

Secondly, the disease arises essentially as a result conditions. There is little or no evidence that our ever is imported from other districts. We have in the very influences which lead to its continuous prop- Thirdly, with the exception of the year 1906, when all epidemics occurred during the colder months and ly due to polluted milk supplies, the cases occurring

untue winter typhoid compared with our marked summer rise. Chart I for the year 1910, prepared from the Board of Health Reports, shows this very clearly. But it must be remembered that the variation here represented is not characteristic of any particular year, but represents a distri- bution of the disease by months which is peculiar for our typhoid. While we usually have but few cases of the disease in the winter months, it never disappears entirely. Typhoid fever with us is a winter as well as a summer disease. With the onset of warm weather, however, the case incidence and the number of deaths show a very rapid increase. During July the figures for both run up rapidly; during August they in- crease still more and the maximum is reached usually in Sep- tember or in October. With the beginning of cold weather in the autumn the number of cases begins to diminish; this di- minution becomes marked in November and December, but at no time do the cases entirely disappear. During the months of January, February, and March the disease remains quiescent only to break out again during the next warm season with the most dreadful certainty. A repetition of the summer epidemic each year can be predicted with absolute confidence.

We have thus two constants, the continued presence of the disease in Baltimore, and the marked seasonal variation. Dr. Jones, in considering the ten possible sources of typhoid fever which we have previously mentioned, has been able to eliminate such factors as bathing in polluted waters, well water, hydrants in yards, privy vaults and importation, from responsibility as epidemiological factors. Five possible sources of typhoid remain for us to consider.

1. Raw foods .- A number of articles of diet which are eaten raw, such as shellfish, vegetables and fruits, are popularly supposed to be intimately associated with enteric fever, and there can be no doubt that the typhoid bacillus may be carried by uncooked foods in certain special instances. Typhoid due to oysters polluted with sewage has been reported by Conn' and recently Buchan ' has called attention to the serious con- tamination of the shellfish sold in Birmingham, England, and has indicated their importance as a possible source of the dis- ease. As far as oysters are concerned in Baltimore, they may probably be eliminated from responsibility. Our typhoid is at its lowest ebb at the very time when oysters are consumed in the greatest quantity and has its especial prevalence in the months when the sale of the bivalve is forbidden by law. While raw fruits and uncooked vegetables may play a part in the spread of the disease, no satisfactory proof of this has thus far been presented.

2. Contact .- Our knowledge of the " chronic bacillus car- rier " and the disastrous results which follow his entrance into a family or into a community has served to again emphasize the importance of contact infection in enteric fever. The many investigations in Germany, England, and in this coun- try, especially in New York and Washington, indicate how many of our typhoid patients have previously come into close association with cases of the same disease, especially in its milder forms. They also serve to show that many attacks

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354

JOHNS HOPKINS HOSPITAL BULLETIN.

which on first consideration cannot be explained on the basis of contact, on careful study and search are apparently clearly the result of a more or less intimate connection with previous cases. In this city we may probably have underestimated the proportion of cases of this character, and Baetjer ' has recently called attention to the important role which contact may play in our country typhoid, reporting 17 cases in two houses. Dur- ing the past summer direct infection may have had a very sig- nificant part in spreading the disease, especially in the poorer sections of the city. The newspapers frequently stated that several cases had been found in one house or in one family. In a certain instance an extraordinarily large number was re- ported from a block of houses on East Chase street, and here the infectious material seems to have been transmitted directly from person to person. In general, however, the records of the Health Department indicate that in the majority of instances the cases of the disease occur singly in houses, but a small number of two-case and three-case houses having been discov- cred. Furthermore, we have typhoid summer and winter alike and the factor of contact infection will not explain the great increase of the disease in the summer months-that is, the marked seasonal variation or summer rise.

3. Flies .- One of the most attractive and plausible theories to explain a great prevalence of enteric fever in any community during the hot days of summer is to attribute the spread of infection from individual to individual to the agency of flies. The work of Levy and Freeman ' in Richmond, where a cam- paign directed against the fly seemed to be effective in limiting the cases of typhoid in that city, has been quoted far and wide and the conclusions reached by these authors frequently applied to such cities as Washington and Baltimore, where the cli- matic conditions and character of the population are almost identical with those of Richmond. The importance of the house-fly as the carrier of infection has also been emphasized by Jackson ' in New York, in seeking an explanation for the cases which appear in that metropolis. Still it must be remem- bered that in this city we suffer from typhoid not only during the fly season but during many months of the year when re- sponsibility cannot be fastened upon these pests. During the year 1910 we had 26 deaths from typhoid fever and 106 new cases reported to the Board of Health for the month of De- cember. While flies may be carriers of infection during the season when they are especially abundant and may thus explain the increase of the disease during July, August and Septem- ber, they can play but a subsidiary rôle in the cases which occur during the winter, the early spring, and the late fall. Further- more a great deal more knowledge as to the life-habits of these insects and the occurrence and distribution of the various species in Baltimore must be obtained before we can justly conclude that their activities are important epidemiological factors in this community.

4. Milk .- The milk supply of Baltimore comes from a wide district of farming land in the more or less immediate vicinity of the city. It is handled by a number of dairy companies w!' ' .ither produce it on their own premises or collect it

from small farmers, and then ship it in bottles or in irat holding a number of gallons, to the principal railmed sr. During transit no attempts at refrigeration are made. : the stations in the city it is distributed in wagons fre: to house or sold directly to the consumer in the little the persed through the poorer sections of the community. siderable time necessarily elapses between the hour of and the ultimate consumption of the product. The tra dairies often handle milk from a number of different s. this milk being mixed in bulk and again parceled out 2 5 quantities. As a result the individual samples sold (=r. counter may sometimes represent milk collected INEr scattered areas. The inspection of milk in the city l :- wisely carried out by the officials of the Health Dpa and is as effective as the present laws permit. Still s- and thorough regulation of the traffic at the proper pe .. is, on the premises of the farmers who make a business: ducing the milk, is not possible. The larger and more y. ous milk dealers have adopted the modern sanitary re ;- which ensure cleanliness and are making conscientious to furnish our citizens with a product which will L present-day demand for milk of a proper chemical cic ;. and a low bacterial count. In many of the small step. ever, where milk is sold by the quart, pint, or eren byl the filthiest conditions prevail. Refrigeration is eite :: regarded as necessary or the measures which are car: are of little value in maintaining the milk at a low 1. ture. The milk cans are frequently opened as the milk : out to the consumers one after another, and since for - where the milk is sold are often the living rooms of : family, it is thus exposed to contamination of rar. scriptions.

For a number of years now we have been making examinations of the milk found in the poorer quarter city in the vicinity of the Johns Hopkins Hospital these examinations have not been made through the year, nor with sufficient frequency to furnish posit: clusions, they indicate clearly that much of the milk s. poor people is badly polluted. The bacterial count fte. runs up into the millions and is uniformly above % liberal standards of purity. Recently one of our &. students, Mrs. de Angulo, has been making weekly tions of samples of milk collected in East Baltimore. instances she has found 50,000,000 bacteria to the e. meter. In a number of cases the count varied from i". to 25,000,000, and in nearly every sample obtained s:" shops where the milk is sold from milk cans the cocm? 3,000,000 or over. If such a degree of pollution is ! : ing the winter months, what must be the amount (! life in this product in the hot summer weather? : tremely dangerous conditions are found, of course. certain regions and in the small shops. The bett furnished by the better dairies shows usually a los count, and indeed certain companies furnish milk wii

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'ater .- The far-reaching importance which must be at- to the Baltimore City Water Supply as a source of our I fever has previously been indicated. Our water is from two main streams, the Gunpowder River and Falls. For many years we have made a study of the vder water and have demonstrated with great regularity is and constant pollution in it.' Bacillus coli can always ined in the majority of 1 cc. samples examined. It is itly present in a dilution of 1/10 and rarely in higher Is, 1/100. Together with this organism there are many acteria of intestinal origin. Bacillus alkaligenes, which ly resembles the typhoid bacillus, is often found on the und certain liquefying bacteria such as Bacillus cloacae, may be regarded as characteristic of sewage, are oc- lly encountered. The bacterial count varies greatly, ap- y bearing some ratio to the rainfall and amount of 1 the reservoirs. It is usually somewhat under a thous- the cubic centimeter, but may exceed this number,

V .- Pollution of Gunpowder water. Fermenting organisms. October, 1910, to June, 1911.

OCT 24

OCT 31

NOV 7

NOV 21

NOV 28

DEC. 12

DEC 19

JAN 2

JAN 9

JAN 16

JAN 31

FEB&

FEB 13

FEB 20

MARK

MAR 21

MAR 28

APA 10

APA 24

MAY 1

MAY 8

MAY 22 MAY 15 MAY29

up to between ten and fifteen thousand. The tion of the water taken from the spigot thus shows ;ion which is of a decidedly serious character and lly permanent. The findings at the tap are amply d by the conditions which prevail along the water- the Gunpowder River. The sewage from numerous uses and small settlements of working people passes into this stream or into its tributaries, certain of otably Western Run, Beaver Dam Run and the Ore- ich, are grossly polluted.

;okes at the Board of Health has obtained much the ults as ours in regard to the Gunpowder water. In he has made a special study of Jones Falls and Lake and he and Hachtel have even succeeded in isolating oid bacillus from Towson Run, one of the small which passes into the latter body of water."

ing in October, 1910, when typhoid fever was raging

uuupuwuer water, estimating the extent of pollution by using the fermentation tube and by counting the number of colonies. The bacteria present at various periods have been isolated and submitted to careful study and identification, largely in the hope that we might determine the value which should be as- signed to the presence of various liquefiers. As can be seen from Charts V and VI, the pollution of the water in October had reached a most dangerous grade. Bacillus coli or some other fermenting species was constantly present in a dilution of 1/100 and on one occasion in a dilution of 1/1000. The num- ber of microorganisms was also much above that usually ac- cepted as the standard of purity. At this time Maryland had been suffering from a prolonged drought, and the water in

CHART VI .- Pollution of Gunpowder water. Bacterial count. October, 1910, to June, 1911.

OCT 14

DET IR

OCT 24

OCT 31

NOV 7

NOV 14

NOV 38

Dec 5

DEC 12

Q.EC 19

JAN 2

JAN 16

JAN 23

JAN 31

FEB 13

FEB 20

FEB 27

MAR

MAR 21

APR 3

APR 10

APA 17

APR 24

MAY 1

MAY 8

MAY 15

MAY 29

5000 -CC

4000 - CC

1200 - CC

1400 - CE

800.CC

200 - CC

Loch Raven and in the Gunpowder was at the lowest ebb it had reached for years. The filth which is regularly present in the stream had evidently been greatly concentrated and the appearance of several thousand colonies to the cubic centi- meter and especially the extraordinary degree to which the water could be diluted without causing the disappearance of the intestinal bacteria indicate how totally unfit for use the Gunpowder water was at this time. The pollution of this stream, which was then the main supply of the city, Lake Ro- land having been temporarily eliminated, continued excessive during the autumn months and early winter. Not indeed till February of this year did conditions improve, the bacterial count come down to normal and the intestinal microorganisms disappear from the fermentation tubes. Recently, however, evidences of sewage contamination are again shown by our studies and during the month of May, 1911, the Gunpowder water reassumed the filthy character it presented last October.

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NOV 14

DEC 5

DEC 26.

JAN 23

FEB 27

MAR 13

APA 3

APA 17

MAY 22

OCT 17

NOV 31

DEC 2L

JAN 9

FEB 1

MAR 13

MAR 21

356

JOHNS HOPKINS HOSPITAL BULLETIN.

[Sa

DISCUSSION.

It may thus be seen that with the evidence at hand but an unimportant rôle can be assigned to raw foods, to contact in- fection, and to flies as epidemiological factors in our typhoid fever. While a certain proportion of our cases may be due to contact and while the number of cases may be augmented through the agency of flies in the fly season, the activity of these insects cannot be made to explain our winter typhoid, nor can the agency of contact explain our great summer rise. A combination of the two factors might be suggested to ex- plain summer and winter typhoid alike, but the problem is not so simple and two other possible sources of infection must be considered. These other possible sources are milk and water. The milk supplied to the people of Baltimore, especially to the poorer classes, is frequently loaded with microorganisms and would not meet any reasonable requirements based upon a bacteriological examination. The regulations adopted by other cities if applied to Baltimore would probably stop the sale of much of the milk now offered in certain of the crowded dis- tricts of the city. This milk pollution is amply explained by the conditions on dairy farms, along the route of travel, and in the shops where the milk is sold. In the long and tortuous journey which the milk drunk in Baltimore must travel from the udder of the cow to the mouth of the consumer, this valu- able and almost indispensable article of diet is exposed to fre- quent chances of contamination with dust, dirt and filth. The abortive attempts at refrigeration are manifestly insufficient to prevent the growth and multiplication of those micro- organisms which find accidental entrance. If milk can serve as a source of typhoid fever, we have in the city of Baltimore at the present time ideal conditions for the spread of this disease. Furthermore, the very months of the year when the cases are at their maximum are those months when we can reasonably suppose that the life of the typhoid bacillus in milk will be considerably prolonged, namely, in the hot summer season. Moreover, several outbreaks of the disease in the win- ter months have been definitely traced to certain dairies, as in the year 1906. Whether the uniform distribution of the cases of typhoid over the entire city which is characteristic of Bal- timore can be brought into harmony with milk-borne infection is not quite clear. It must be said, however, that the typhoid of Washington seems to bear a direct relation to the city milk supply, and yet the distribution of the disease in that city is fairly uniform and is similar to the distribution which has been noted here. Thus the utmost stress must be laid upon milk in considering the epidemiology of our typhoid and next to our water supply milk must be regarded as the factor of the greatest importance.

The serious and dangerous pollution of our city water, which has been emphasized by Dr. Stokes and by ourselves, may well be pointed to whenever the subject of typhoid fever is under discussion. That the contamination has been increasing markedly during the past two or three years is evident from the results of the many examinations which have been made. experience in both Richmond and Washington, how-

ever, indicates how dangerous it may be to attribute czs fever to water supplies, even though the filtration of ver other cities or the change from a polluted to a pure says: been followed by a marked reduction of the typhoid. & point of great importance has been brought out by the gations of the past year. The extent of pollution of ti .: powder water, or the concentration of the sewage priset it, shows the same variation as does our typhoid fever. It typhoid was as its height in September, October and Va ber of last year, and at this time the water used in Be'z was showing its maximum pollution. By December the = ber of cases had come down markedly but not to anything our normal for this month. At the same time, thep of the water had diminished in quantity. During the winter months the typhoid almost disappeared from ou. . and for this period the water showed comparatively little - age. With the onset of hot weather the pollution of fre r. supply has again become excessive and the returns total partment of Health indicate that our typhoid is also be- prevalent.

( 1

Whether this close correspondence or parallelism ber- the amount of this disease in our city and the extent a: v our water supply is polluted is anything more than a: cidence cannot be decided with the evidence at hand. ! parallelism is no proof of etiological relationship, and r. are able to eliminate water as a factor in the eristes: typhoid in Baltimore by the adoption of filtration plans." its sterilization or disinfection we will not be in a p .: explain the disease satisfactorily. For the present the c.". has only a theoretical interest. Our constantly and pr tently polluted water must be regarded for the present i- main source of our typhoid fever. It is absolutely ess. for the health of the citizens of Baltimore that the me. .. gent regulations be enforced in controlling our water and that every effort be made to hasten the constructien . sand filters now being prepared for the Gunpowder v: Until these filters can be utilized the water should be str by the addition of some chemical disinfectant, preferi the hypochlorite or bleaching powder method.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 154

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189