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Appendix B

Table of Contents

APPENDIX B

ABSTRACT OF REPORT on the Origin and Spread of Typhoid

Fever in U.S. Military Camps During the Spanish War of 1898

By

WALTER REED,
Major and Surgeon, U.S. Army,

VICTOR V. VAUGHAN,
Major and Division Surgeon, U.S.V.,

and

EDWARD O. SHAKESPEARE,
Major and Brigade Surgeon, U.S.V.

 


Washington: Government Printing Office, 1900.

Excerpts from Chapter XV (pp. 194-239), "The Etiology of Typhoid Fever." [Special reference to typhoid carriers.]

Typhoid fever is caused by a specific micro-organism, generally known, from its discoverer, as the Eberth bacillus. This bacterium finds its way with food and drink through the mouth and stomach into the small intestines, where it develops, produces specific lesions, and elaborates chemical poisons which induce the characteristic symptoms of the disease. In addition to its location in the walls of the intestines, this germ is usually found after death from this disease in the mesenteric glands and in the spleen. If proper bacteriological examination be made directly after death, the bacillus is usually found in pure culture in these organs. For this reason the spleen is generally selected for bacteriological study and for the preparation of cultures after death from typhoid fever. However, it seems to be possible for this bacillus to reach any part of the body and to find lodgment in various tissues, having been found in the lungs, liver, kidneys, bones, muscles, and brain. Its lodgment in diverse parts of the body and its long-continued existence in

 


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these localities are accountable for many of the varied sequelae to typhoid fever.

Typhoid fever may run its course and terminate fatally without causing the intestinal ulceration, generally regarded as the specific lesion of this disease. More than 20 cases of death from this disease in which post-mortem examination has failed to show intestinal ulceration have already been recorded, and it is probable that this number will be increased by future observations. It must be evident from the existence of these cases that the bacillus may penetrate the intestinal wall without leaving a marked lesion and that the elaboration of its chemical poisons is not confined to the intestinal tract. It remains for future investigations to determine whether, ordinarily, in this disease the intestinal lesion precedes or follows the infection of the spleen and mesenteric glands. The existence of typhoid fever without intestinal ulceration emphasizes the desirability of a classification of diseases based upon etiology rather than upon pathology. [p. 194]

The natural distribution of the typhoid bacillus is another subject needing careful investigation. Apparently trustworthy bacteriologists have reported the finding of this micro-organism in the most unexpected places. It has been detected in the soil of localities far removed from the habitations of man and has been isolated from drinking water supposed to be free from contamination. Furthermore, its presence has been reported in the stools of healthy persons as well as in those suffering from dysentery and simple diarrhea. It must remain for future studies to decide upon the reliability of those reported findings and to attach to them their proper significance should they be found to be true.

THE ELIMINATION OF THE BACILLUS FROM THE BODY.

It is important in a study of the etiology of typhoid fever to ascertain by what avenues the specific micro-organism leaves the body of the infected individual. The exhaled air from the lungs of the typhoid-fever subject is germ free, as it probably is in all infectious diseases. There is therefore no possibility of this disease being spread by means of the air exhaled from the lungs. This statement is true only when the exhaled air is free from sputum. In the pneumonias that complicate typhoid fever the Eberth bacillus is found in the diseased lungs and may be eliminated in the matter coughed up and disseminated through the air in the fine spray that accompanies severe fits of coughing. However, the spread of typhoid fever in this manner must be regarded as a bare possibility.

There is no positive evidence that the perspiration from one sick

 


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with typhoid fever contains the specific bacillus of this disease. It is true that this bacterium may be found on the surface of individuals sick with this disease, but in such cases the germ owes its presence in this locality to contamination of the skin with the stools or with the urine. It is possible that under exceptional circumstances this bacillus may find its way to the surface from the blood, as it occurs in the eruptive spots of typhoid fever.

The urine of one sick with typhoid fever may or may not contain the Eberth bacillus. Several observers have found the living virulent bacterium in the urine, especially when this secretion contains albumin. In some of these cases it is more than probable that the germ has found lodgment in the kidney and has produced more or less extensive structural changes in that organ. However, the bacillus may be abundant in the urine when this secretion contains no albumin and when there is no other evidence of structural disease of the kidney. Persons recovering from typhoid fever may continue for weeks to eliminate in the urine millions of the Eberth bacillus. It sometimes happens that a cystitis occurs as a sequel to typhoid fever. In at least some of these cases the inflammation of the bladder is due to infection with the typhoid bacillus, and this germ in a virulent form may after a long time remain in the bladder and render the urine a possible source of the spread of typhoid fever. Houston (British Medical Journal, 1899, vol. 1, p. 78.) has reported a case of cystitis of three years' standing due to the infection of the bladder with the bacillus of Eberth. An interesting point in connection with the report of this case is that the patient never had typhoid fever, but had nursed cases of this disease. Further evidence will be needed before we can accept the possibility of an infection of this kind. However this may be, the occurrence of the specific micro-organism in the urine in cases of typhoid fever is of sufficient frequency to demand that this secretion be disinfected in every case of this disease. Post-typhoidal abscesses way form in various parts of the body and may discharge the Eberth bacillus in virulent form for months and even years. It is unnecessary to add that infected material of this kind should be burned or otherwise disinfected. The necessity for this is evident whether the abscesses be due to the typhoid bacillus or to other bacteria.

The most important avenue for the elimination of the typhoid bacillus from the body is through the bowel. Long before the discovery of the specific micro-organism of this disease man had learned that the stools of typhoid patients contained the infective agent of the disease. It had been frequently observed that epidemics of typhoid fever resulted from the drinking of water contaminated with the stools of those suffering from this disease. The more intelligent members of the medical profession recommended thorough disinfection of the feces long before the bacillus had been dis-

 


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covered. The elimination of the typhoid bacillus in the stools probably begins soon after its introduction through the mouth. Indeed, it is quite certain that an individual may become the bearer and distributor of the infecting agent of typhoid fever without developing the disease himself. The specific bacterium finds its way into the small intestines, in the contents of which it multiplies rapidly, and this intestinal culture may he wholly discharged from the bowels without inducing any local lesions. Furthermore, as we have already seen, typical typhoid fever may develop and death result without intestinal ulceration.

We desire to emphasize the fact that the typhoid bacillus may grow in the intestines of an individual and pass from the same without causing typhoid fever. This is most likely to occur when many irritative saprophytic germs are taken into the alimentary canal along with a few typhoid bacilli. A few hours after infection with such a mixed culture the saprophytic germs may cause a profuse diarrhea, which sweeps from the intestines the typhoid bacilli. This is probably the true explanation of the unquestionable protective effect of diarrheas in certain epidemics of typhoid fever. We shall have occasion to refer to this later. Moreover, it is probable that a considerable proportion of adult individuals are to some extent, at least, immune to typhoid fever. The specific germ of this disease may be transported from one place to another in the intestines of an immune man, and when cast out in the stools may become a source of danger to others. It is probably in some such way as this that epidemics of typhoid fever sometimes appear to originate de novo.

The stools of individuals sick with typhoid fever constitute the most important source for the spread of this disease, and it may be stated in a general way that typhoid fever is due to the transference of some part of the feces of an infected individual to the alimentary canal of one susceptible to this infection. This transference in exceptional cases may be quite direct, as when a careless nurse soils her hands with the dejections from her typhoid-fever patient and eats her food without disinfecting her soiled fingers. Generally, however, the transference is more indirect and the germs in the infected stools may multiply through many generations and be transported by water or otherwise through considerable distances. Moreover, as has been indicated already, the bacilli may pass through an intermediate host, which may be man or one of the lower animals. An immune individual may visit a distant city, the water supply of which is infected with the typhoid bacillus, and he may carry this infection to his village home, where it may be deposited in his normal stool, may find its way into the local water supply, and cause an epidemic of the disease.

Typhoid bacilli are most abundant in the stools of patients suf-

 


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fering from this disease when there is sloughing of the intestinal ulcerations. However, it should be borne in mind that typhoid stools are infectious often before the individual shows any evidence of the disease. In other words, the stool of a man in the incubation period of typhoid fever may be laden with the bacilli of this disease. In this way every latrine in an encampment may be infected with the specific micro-organism of typhoid fever before the disease has developed sufficiently in the individual to be recognized clinically. On the other hand, the stools may continue to be infectious long after convalescence has set in. So great is the danger of the spread of this disease from infected stools that in all cases where fecal matter can not be removed by water carriage, or otherwise, from immediate proximity with human habitation, all stools, those of both sick and well, should be thoroughly disinfected.

Notwithstanding the fact that the typhoid bacillus is abundant in the stools of individuals suffering from this disease, its isolation and identification in the feces is one of the most difficult tasks undertaken by the bacteriologist. This difficulty lies in the separation of the typhoid bacillus from other bacilli, which it resembles in some respects and which are present in the stools in much larger numbers. The colon bacillus, always present both in normal and typhoid stools, grows so abundantly and may resemble the typhoid bacillus so closely that the separation of the two is difficult and often impracticable. It is unfortunate that we have no reliable method of detecting the typhoid bacillus in mixed cultures of this germ and the bacterium coli. Such a method would supply us with a more ready and sure means for the early recognition of typhoid fever than we now possess, and it is to be hoped that future investigations will furnish a practical solution of this question. Many devices dependent upon supposed cultural peculiarities have been proposed and success has been promised many times, but up to the present no reliable, easily applicable method for the detection of the typhoid bacillus in stools has been discovered. [pp. 200-203]

THE DISSEMINATION OF TYPHOID

(a) Transported by man.

Man himself is the most active agent in the dissemination of this disease. He may carry the specific virus in his alimentary canal, on his person, or in his clothing. In this way the germs of the disease may be carried hundreds and thousands of miles and may be widely distributed. An infected recruit may plant the specific bacillus of this disease in every latrine in his regiment before he is suspected of having the disease himself. So widespread is typhoid fever that in assembling a regiment of volunteers it may be as-

 


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sumed that among these men there are one or more infected with this disease. Practically, typhoid fever is always imported into military camps, and having been thus introduced it too frequently finds conditions favorable for its spread. [p. 210]

It is altogether possible for an individual to carry in his alimentary canal and eliminate therefrom the Eberth bacillus in virulent form without having the disease himself. The probabilities are that the majority of men who reach 40 years of age have at some time or another carried this germ in their bodies, and this may account for the fact that men of this age are less susceptible to the disease than younger men. It is also possible in the St. Clair epidemic that the infection came down the river from Port Huron, about 12 miles distant. Another possible explanation might be given by supposing that an individual who had recovered from typhoid fever recently, in visiting one of the houses above the intake discharged from his body into the drains the specific bacillus of typhoid fever. In some instances the typhoid bacillus continues to be eliminated with the urine for several weeks after recovery from this disease, and each cubic centimeter of such urine may contain millions of virulent bacilli. [p. 225]

(e) Transportation of the bacillus on the person or in clothing.

That the infection of typhoid fever is often carried on the hands or in the clothing of nurses and other attendants there can scarcely be any doubt. This is probably one of the chief means by which the disease is spread through a family after its introduction. The mother or other attendant on the sick handles the food of the well without disinfection of the hands. Superficial ablution with soap and water is not sufficient to destroy the vitality of this organism; thorough disinfection, with special attention to the material collected under the finger nails, is absolutely essential. At one of the division hospitals at Camp Alger in August, 1898, the members of this board observed the nurses, many of whom went directly from their duties in the typhoid wards to their mess tents and handled the food eaten by themselves and passed articles to their neighbors without even washing their hands. Another practice for which superior officers were responsible is undoubtedly accountable to a greater or less extent for the spread of typhoid fever among the soldiers at the various encampments in 1898; It was customary in some of the commands to take a fresh detail of men from the line each day as orderlies at the hospital. Each morning 100 men were detailed to attend those sick with typhoid fever, to place and adjust bedpans, and to carry the contents of these to the sinks and to disinfect them. These men, at least the majority of them, were

 


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wholly ignorant of the nature of infection; they had never had any training as nurses; they knew nothing about the desirability or necessity of being careful in order to prevent infecting themselves, and they knew less about means of disinfecting their hands soiled with typhoid discharges. At the close of the day these men were returned to their company tents, and the next morning a new detail of the same number went through with the same routine. A more effective means for the spread of typhoid fever could scarcely have been devised.

Many of the so-called cases of prolonged incubation after exposure to typhoid fever can be best explained by the supposition that the infective material is carried on the person some time before it finds its way into the alimentary canal. We shall have occasion further on to mention some of these cases. However, it may be stated here that undoubtedly a man may carry the typhoid bacillus under his finger nails, in his hair, or on his clothing for weeks, during which time he may travel across the continent, and at last accidentally introduce the germ into his alimentary canal and develop the disease. Some authorities lay much stress upon the period of incubation in the infectious diseases, and the International Sanitary Conference, which has attempted to prevent the spread of the plague from India, has based its most important measures upon what is supposed to be the maximum period of incubation of the disease. It must be evident that we know very little about the true period of incubation in most of the infectious diseases. If a hospital corps man who has been attending typhoid patients at Ponce, Porto Rico, leaves that place on a certain date, does not come in contact with other typhoid patients, and ten weeks later develops the disease, this certainly does not prove that the period of incubation in typhoid fever may be extended to ten weeks. This man may have carried the specific germ on his person or in his clothing for the first eight out of the ten weeks and then accidentally introduced it into his alimentary canal. The fact that a belief in ten days as the maximum period of incubation in the plague has been the cause of the introduction of that disease from India into Europe should cause us to hesitate about laying too much stress upon so-called periods of incubation. The period of incubation of an infectious disease is the time which elapses from the introduction of the germ into the body until the development of the first symptoms of the disease, and unless we know definitely and positively the day or the hour of the introduction of the germ into the body, we can not determine the period of incubation. The number of days, weeks, or months the patient has carried the germ in his clothing has nothing to do with the period of incubation.

Experimental evidence shows that pure cultures of typhoid fever

 


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bacilli will retain their virulence when poured upon cotton, linen, or woolen cloth for from two to three months, and it is altogether possible that the infection may be carried in a blanket roll for a much longer time. The evidence which we will bring forward in connection with the history of typhoid fever in our Army during the late war with Spain will show quite conclusively, we think, that infected clothing, bedding, and tentage had much to do with the spread of typhoid fever and will demonstrate the necessity in attempting to eradicate this disease from an infected command of disinfecting all the above-mentioned articles.

The personal and bed linen of patients sick with typhoid fever when soiled with discharges from the kidneys or bowels should be immediately immersed in a properly prepared disinfecting solution. When such articles are thrown aside without previous disinfection, flies may carry the infection from the stains to articles of food, and, moreover, after the material dries, handling these articles may scatter the infective material through the air in the form of fine dust.

(f) Dissemination by flies.

We are satisfied that the evidence furnished in our studies, to be detailed later, is sufficient to show beyond reasonable doubt that the most active agents in the spread of typhoid fever in many of the encampments in 1898 were flies. [pp. 228-230]