between Basle and Olten shortly before coming to the great Hauenstein
Tunnel. It is situated in the Jura, in the valley of the Ergolz, and
consists of 103 houses with 819 inhabitants. It was remarkably
healthy, and resorted to on that account as a place of summer
residence. With the exception of six houses it is supplied with water
by a spring with two heads which rises above the village at the
southern foot of a mountain called the Stockhalder, composed of
oolite. The water is received into a well built covered reservoir, and
is distributed by wooden pipes to four public fountains, whence it was
drawn by the inhabitants. Six houses had an independent supply--five
from wells, one from the mill-dam of a paper-factory. On August 7,
1872, ten inhabitants of Lausen, living in different houses, were
seized by typhoid fever, and during the next nine days fifty-seven
cases occurred, the only houses escaping being those six which were
not supplied by the public fountains. The disease continued to spread,
and in all 130 persons were attacked, and several children who had
been sent to Lausen for the benefit of the fresh air fell ill after
their return home. A careful investigation was made into the causes of
this epidemic, and a complete explanation was given. Separated from
the valley of the Ergolz, in which Lausen lies, by the Stockhalder,
the mountain at the foot of which the spring supplying Lausen rises,
is a side valley called the Furjust, traversed by a stream, the
Furlenbach, which joins the Ergolz just below Lausen, the Stockhalder
occupying the fork of the valley. The Furlenthal contains six
farm-houses, which were supplied with drinking-water, not from the
Furlenbach, but by a spring rising on the opposite side of the valley
to the Stockhalder. Now, there was reason to believe that under
certain circumstances water from the Furlenbach found its way under
the Stockhalder into one of the heads of the fountain supplying
Lausen. It was noticed that when the meadows on one side of the
Furlenbach were irrigated, which was done periodically, the flow of
water into the Lausen spring was increased, rendering it probable that
the irrigation water percolated through the superficial strata and
found its way under the Stockhalder by subterranean channels in the
limestone rock. Moreover, some years before a {251} hole on one
occasion formed close to the Furlenbach by the sinking in of the
superficial strata, and the stream became diverted into it and
disappeared, while shortly afterward the spring of Lausen began to
flow much more abundantly. The hole was filled up, and the Furlenbach
resumed its usual course. The Furlenbach was unquestionably
contaminated by the privies of the adjacent farm-houses; the soil-pits
communicated with it. Thus, from time immemorial, whenever the meadows
of the Furlenthal were irrigated the contaminated water of the
Furlenbach, after percolation through the superficial strata and a
long underground course, helped to feed one of the two heads of the
fountain supplying Lausen. The natural filtration, however, which it
underwent rendered it perfectly bright and clear, and chemical
examination showed it to be remarkably free from organic impurities,
and Lausen was extremely healthy and free from fever. On June 10th one
of the peasants of the Furlenthal fell ill with typhoid fever, the
source of which was not clearly made out, and passed through a severe
attack with relapses, so that he remained ill all summer; and on July
10th a girl in the same house, and in August a boy, were attacked.
Their dejections were certainly, in part, thrown into the Furlenbach;
and, moreover, the soil-pit of the privy communicated with the brook.
In the middle of July the meadows of the Furlenthal were irrigated as
usual for the hay crop, and within three weeks this was followed by
the outbreak at Lausen.
[Footnote 29: William Cayley, M.D., _British Medical Journal_, Mar.
15, 1880.]
In order to demonstrate the connection between the water-supply of
Lausen and the Furlenbach, the following experiments were performed.
The hole mentioned above as having on one occasion diverted the
Furlenbach into the presumed subterranean channels under the
Stockhalder was cleared out, and 18 cwt. of salt were dissolved in
water and poured in, and the stream again diverted into it. The next
day salt was found in the spring at Lausen. Fifty pounds of wheat
flour were then poured into the hole, and the Furlenbach again
diverted into it, but the spring at Lausen remained clear, and no
reaction of starch could be obtained, showing that the water must have
found its way under the Stockhalder, in part by percolation through
the porous strata, and not by distinct channels.
Volz[30] refers to an epidemic which occurred at Gerlachsheim, a
village of Germany, some years ago, in which, in the course of three
weeks, 52 persons residing on one of the principal streets were
attacked by the disease. It was found, upon investigation, that they
all got their water from a well which was polluted by the stools of
the first patient. A. Pasteur[31] reports an epidemic caused by the
contamination of a well by typhoid dejections, and which ceased when
the use of the water was discontinued. Niericker[32] also reports an
outbreak which was found to be due to a similar pollution of the
drinking-water, and which likewise ceased when the water-supply was
derived from another source.
[Footnote 30: _Schmidt's Jahrbuch_.]
[Footnote 31: _Revue méd. de la Suisse_, Mars 15, 1881.]
[Footnote 32: _Schweiz. Corr. Bl._, ix. 1, 1879.]
An outbreak of the disease which occurred in a farm-house situated
about eight miles from the city of Philadelphia came under my own
observation. The first case occurred in a young girl of sixteen, who,
with the exception of an occasional visit to the city, had not been
away from her own home for several months before she was {252} taken
ill. The disease ran in her a severe course, and eventually terminated
fatally. About three weeks afterward four other members of the family
were attacked, one of whom died. Two other persons, living in a house
on the opposite side of the road, but who were in the habit of
drinking water from the same well, also took the disease. There was no
other case of typhoid fever in the immediate vicinity, nor had there
been for some time. The farm-house is situated in a cup-shaped
depression, so that water flowed toward it from all directions. The
cellar was constantly filled with water during the winter, and just
before the outbreak had contained not only an unusually large
quantity, but also a large amount of decaying vegetable matter. The
well from which the family drew their drinking-water is situated
within a few feet of the kitchen door, and at some distance from the
cesspool used by the family, so that there was no reason to believe
that there was any communication between the two. The wall of the well
was found to be very much loosened by the roots of two trees growing
in the immediate vicinity. As the ground was also very much cut up by
the burrows of rats, the water used for the various household
purposes, and which was habitually thrown into a gutter which ran past
the well, found a ready access to it. There would seem to be but
little doubt that the first patient contracted the disease in some way
during her visits to the city, and that the disease in the other
patients arose from their drinking the water of the well which had
been polluted by that used in washing her soiled linen.
Ballard[33] has shown very clearly that milk may also be a medium of
communication of the disease. He found that an epidemic which occurred
in the parish of Islington, London, in 1871 was (1) almost entirely
confined to a district comprised within a circle having a radius of
not more than a quarter of a mile; (2) that out of 62 families living
within this district, who were known to have suffered from typhoid
fever, 54 were constantly supplied with milk from a particular dairy,
and it was satisfactorily proved that at least three of the remaining
eight had occasionally partaken from the same source; and (3) that out
of 142 families, comprising all the customers of this dairy, and
living not only within the district above specified, but in other
parts of the parish, 70, or very nearly one-half, were invaded by
typhoid fever within the ten weeks during which the outbreak lasted.
Upon a visit to the farm from which the milk came it was ascertained
that a member of the dairyman's family had been ill with typhoid
fever, and that the water of the well which supplied the family with
drinking-water had been polluted by his discharges. Although the
dairyman denied that this water had ever been mixed with the milk, he
admitted that it had been used to wash the milk-pans. Murchison was
also able, in an outbreak which occurred in another district of
London, to trace the disease to the same source.
[Footnote 33: _On a Localized Outbreak of Typhoid Fever in Islington_,
London, 1871.]
Typhoid fever may be likewise propagated in consequence of the
contamination of the atmosphere by the typhoid poison. This may be the
result of allowing the undisinfected stools, or linen soiled by them,
to remain for some time exposed to the air, or may arise from
pollution {253} of the soil from the same cause or from defective
sewage. Hermann Schmidt[34] refers to several epidemics breaking out
in garrisons which he believed to be due to pollution of the soil. In
the citadel of Wurzburg typhoid fever occurred through several years,
and persisted in spite of the cutting off of the water-supply, which
was believed to be impure. It was finally found that the ground upon
which it was built was saturated with all kinds of impurities. Volz
refers to outbreaks of the disease from the same cause.
[Footnote 34: _Die Typhus Epidemie in Fusillier Bat. zu Tübingen in
Winter 1876-77, enstanden durch einathmung, giftiger Grundluft_,
Tubingen, 1880.]
But perhaps the most striking example of this mode of propagation of
the disease is that recorded by Budd,[35] and is as follows: Two
adjacent cottages, which for the sake of convenience may be designated
as Nos. 1 and 2, had a privy in common, which was in the form of a
lean-to against the gable end of No. 2. Through this privy there
flowed with very feeble current a small stream which formed the
natural drain for it. Having already performed this office for some
twenty or thirty other houses higher up its course, the stream had
acquired all the character of a common sewer before reaching the
cottages in question. About a quarter of a mile farther on it acted as
a drain for a privy, common as before, for two other cottages, Nos. 3
and 4. Notwithstanding the condition of the stream, which was so foul
that it was said that the stink from it was often enough "to knock a
man down," no evil result appeared to have occurred until a man living
in No. 1 contracted typhoid fever--elsewhere, it was believed. As a
matter of course, all his discharges were thrown into the common
privy. In this way for more than a fortnight the stream which passed
through it was daily fed with the specific excreta from the diseased
intestines of the patient. No further cases occurred until the latter
end of the third week or the beginning of the fourth week, when
several persons were simultaneously attacked by the same fever in all
four cottages. From first to last, the outbreak was confined to these
four cottages, and there was no other case of typhoid fever at this
time in the neighborhood.
[Footnote 35: _Typhoid Fever: Its Nature, Mode of Spreading, and
Prevention_, by William Budd, M.D., F.R.S., London, 1873.]
The mattrass used by typhoid-fever patients, their bed-linen and
clothes, have each been the medium by which the disease has been
communicated to others. This is, as has already been pointed out,
unquestionably due to the fact that these articles are generally
soiled by their discharges, and that time has been allowed for the
latter to acquire infective properties. It seems not improbable that
the few cases in which the disease appears to have been contracted
from the dead body may be explained in the same way. The statistics of
the London Fever Hospital show that laundresses are more liable to
contract typhoid fever than the immediate attendants upon the sick.
This liability is greatest in those cases in which the bed-linen and
clothes of patients are not immediately disinfected after use.
According to Budd, the sputa in cases of typhoid fever where
bronchitis is excessive may sometimes contain the germs of the
disease, and mentioned a case in which he believed they were the means
by which the disease was propagated.
The question naturally arises here, whether this is the only way in
{254} which the disease can originate. This is a subject which has
given rise to a good deal of controversy, and therefore demands some
consideration at our hands. On the one hand, it is argued that typhoid
fever never occurs in the absence of the specific poison or germ of
the disease, and that this is contained principally, if not wholly, in
the alvine dejections. On the other hand, it is contended that it may,
and often does, originate spontaneously, and that all that is
necessary to produce it is the presence of decomposing fecal or other
organic matter, and the consequent contamination of the food, drink,
or atmosphere. Both of these views have found able advocates. Among
the upholders of the latter view is Murchison, who cites the histories
of several outbreaks of typhoid fever which occurred in localities
which had not been visited by it for many years, and which, after a
careful investigation of all the circumstances attending them, he was
forced to conclude had no connection with any previous case of the
disease, and could only be explained by admitting that it might
occasionally have an independent origin. Among the more remarkable of
these outbreaks is the following, which we give in Murchison's own
words:
"In August, 1829, 20 out of 22 boys at a school at Clapham within
three hours were seized with fever, vomiting, purging, and excessive
prostration. One other boy, aged three, had been attacked with similar
symptoms two days before, and had died comatose in twenty-three hours;
another boy, aged five, died in twenty-five hours; all the rest
recovered. Suspicions were entertained that they had been poisoned,
and a rigorous investigation ensued. The only cause which could be
discovered was, that a drain at the back of the house, which had been
choked up for many years, had been opened two days before the first
case of illness, cleared out, and its contents spread over a garden
adjoining the boys' playground. A most offensive effluvium escaped
from the drain, and the boys had watched the workmen cleaning it out.
This was considered to be the cause of the disease by Latham and
Chambers, and by others who investigated the matter, and also by Sir
Thomas Watson. The morbid appearances in the two fatal cases were
described as like those of the common fevers of this country. Peyer's
patches and the solitary glands of the small and large intestines were
enlarged like 'condylomatous elevations,' and in one case the mucous
membrane over them was slightly ulcerated. The mesenteric glands were
enlarged and congested."
"A remarkable instance of a circumscribed outbreak of fever was
recorded by Sir R. Christison in 1846. It occurred in an isolated
farm-house in the thinly-peopled county of Peebles, N.B. Every one of
the fifteen residents was seized with fever, and three died. Many of
the servants who worked during the day at the farm were also affected,
but none communicated the disease to their families who did not visit
the farm. There was no evidence that the disease was imported from
without, and the only explanation of the outbreak was, that the drains
and sewers were found all closed and obstructed with the accumulated
filth proceeding from the privies and farm-yard, the effluvia from
which was very offensive."
"About Easter, 1848, a formidable outbreak of fever occurred in the
Westminster School and the Abbey Cloisters, and for some days there
{255} was a panic in the neighborhood respecting the 'Westminster
fever.' No case of fever had occurred in the Abbey Cloisters for three
years, and there was no evidence of its having been imported. Within
little more than eleven days it affected thirty-six persons, all of
the better class, and in three instances it proved fatal. Shortly
before its first appearance there occurred two or three days of
peculiarly hot weather, and a disagreeable stench, so powerful as to
induce nausea, was complained of in the houses in question. It was
found that the disease followed very exactly in its course the line of
a foul and neglected private sewer or immense cesspool, in which fecal
matter had been accumulating for years without any exit, and into
which the contents of several small cesspools had been pumped
immediately before the outbreak of fever. This elongated cesspool
communicated by direct openings with the drains of all the houses in
which it occurred; the only exception was that of several boys, who
lived in a house at a little distance, but who were in the habit of
playing every day in a yard in which there were several gully-holes
opening into the foul drain."
The following cases would seem, however, to furnish stronger evidence
in favor of the occasional spontaneous origin of typhoid fever than
any of those referred to by Murchison. The first is recorded by P.
Herbert Metcalfe,[36] and occurred in Norfolk Island in the Pacific
Ocean, 400 miles from the nearest inhabited land. The patient was a
gentleman who had come from England four months previously. To
Metcalfe's certain knowledge, there had been no typhoid fever on the
island for fifteen months. Three years previously a man is reported to
have died of it, and in 1868 there had been an epidemic of fever, but
he could not ascertain of what kind. Upon inquiry, he found that his
patient had been drinking water from a well which had the reputation
of being unclean, and that he was the only person who had done so. He
also found that at a distance of seven feet there was an open sewer,
and that just opposite to the well much of the sewage-water became so
stagnant as to form an offensive cesspool. The well was cleaned out,
and at the bottom of it were found four feet of stinking sewage mud,
the skeleton of a duck, a pig's jaw, etc. The well was so situated
that had there been any typhoid fever previously to this case the
water could not have been contaminated by the specific poison, as the
above-named sewer only conveyed water from the kitchen, which is a
building detached from the dwelling-houses of the mission, and is far
from and on a higher level than the open closets in use.
[Footnote 36: _British Medical Journal_, Nov. 6, 1880.]
In the second case, which is reported by R. Bruce Low,[37] Medical
Officer of Health, Helmsley, Yorkshire, occurred in a lad who had not
been away from his home for months. No stranger had visited his house,
and there was no fever in the district, the last case having occurred
eight months previously in a sequestered valley eight miles away. The
patient's habits and those of his family were revoltingly dirty. The
garden privy was in bad repair, the filth level with the seat, and the
smell from it very offensive. Thirty years before there had been five
cases of slow typhus in the house. In his remarks on this case Low
says: "This case did not owe its origin to direct infection, and the
question naturally arises, was this a case originating de novo, or had
the poison {256} been due to infection in some way or another from the
cases which occurred thirty years previously?"
[Footnote 37: _Brit. Med. Jour._, 1880.]
There can be but little doubt that in many of the cases cited by
Murchison as instances of the spontaneous origin of typhoid fever
there was an introduction of the germs of the disease from without. At
all events, the evidence to the contrary is by no means convincing.
For example, in the account of the outbreak at the Westminster School
it is expressly stated that "the contents of several small cesspools
had been pumped before the outbreak of the fever" into the large
cesspool, the emanations from which it was believed had caused the
fever. It does not seem that it was positively ascertained that none
of these small cesspools had been used by a typhoid-fever patient, or
that typhoid stools had not found their way into them in some other
way. Moreover, in diseases generally admitted to be contagious it is
not always possible to ascertain positively the source of infection in
a particular instance. But after the elimination of all doubtful cases
there yet remains a certain number in which it is reasonably certain
that there has been no recent importation of the typhoid-fever germs,
as in the case which is reported by Metcalfe and which occurred on
Norfolk Island, and in that recorded by Low. The assumption does not
seem an unwarranted one that in these cases the poison of the disease,
which had been present before in a latent condition, had been suddenly
called into activity by favoring influences. The following observation
of Von Gietl[38] shows the length of time typhoid-fever stools may
retain their infective properties: "To a village free from typhoid an
inhabitant returned suffering from the disease, which he had acquired
at a distant place. His evacuations were buried in a dunghill. Some
weeks later five persons, who were employed in removing dung from this
heap, were attacked by typhoid fever; their alvine discharges were
again buried deeply in the same heap, and nine months later one of two
men who were employed in the complete removal of the dung was attacked
and died." If we assume--and there is no reason to doubt that this
point was fully investigated by Von Gietl--that the patient in the
latter case had not been otherwise exposed to the causes of the
disease, the observation shows that the stools in typhoid fever retain
their virulence for nine months. If for nine months, why may they not
do so for a much longer period--for as many years, for example? No
probability is violated by this hypothesis. On the contrary, it is in
full accordance with what we know of some of the lower forms of life,
and will serve to explain many outbreaks of the disease which would
otherwise be inexplicable--for example, the outbreak at Clapham
referred to by Murchison. Admitting that the disease in this instance
was really typhoid fever--and this has been denied by some observers,
among whom is Sir Thomas Watson--the assumption does not seem an
unwarrantable one that the germs of typhoid fever had been present in
this choked-up drain long before it was cleared, but that in
consequence of their exclusion from the air their infecting power was
at a minimum. It was, on the contrary, much increased when the
contents of the drain were exposed to the vivifying influence of the
atmosphere.
[Footnote 38: Quoted by Cayley, _Brit. Med. Jour._, Mar. 15, 1880.]
On the other hand, it is alleged that an individual may be exposed to
the direct emanations of sewers or of foul privies, or even drink
water {257} contaminated by leakage from them, without contracting
typhoid fever, so long as they do not contain the specific germ of the
disease. Every physician in large practice, either in the city or
country, can call to mind instances in which the air of houses or the
water-supply has been polluted in this way, and yet no typhoid fever
has occurred. Let, however, the specific cause of the disease be
introduced from without, and this immunity almost invariably
disappears. There is no reason to believe that the contamination of
the water used by the family which suffered in the outbreak of the
disease which has been already referred to as having come under my own
observation last year was of recent origin. On the contrary, there was
evidence to the contrary, and yet no disease occurred until it was
imported by a member of the family who was in the habit of making
frequent visits to the city. Even more strongly corroborative of this
view is the history of the epidemic reported by Ballard, in which milk
was the medium of communication. The water which had been used with
impunity to wash the milk-pans, or perhaps to dilute the milk, became
a source of danger only after the occurrence of the disease in the
family of the dairyman.