Typhoid fever in Philadelphia. 
Ir 
BY HENRY LEFFMANN, M.D., 
Port Physician at Philadelphia; Hygienist to the Pennsylvania State Board of Agriculture. 
Read before the Philadelphia County Medical Society, Nov. 24th, 1885. 
It appears from a study of the mortality re- 
turns, that the chances of life are a little better 
in Philadelphia than in many other large cities. 
The rough conclusion drawn from inspection 
of comprehensive totals gives, however, a very 
incomplete notion of the degree of sanitary per- 
fection or imperfection in any community. To 
secure an insight into the extent to which so- 
called preventable disease prevails, we require 
a careful topographical and statistical study. It 
was intended, in the present paper, to give the 
results of such a study of all the principal zy- 
motic diseases in Philadelphia for a given time, 
together with local and social features bearing 
upon this subject; but the task has proved too 
extensive for the time at disposal, and I am 
compelled to lay before the members the results 
of an incomplete investigation ; but I think, 
even in this form, it will be not unimportant. 
A topographical study of the location of con- 
tagious or infectious disease is no new sanitary 
method. Even with reference to Philadelphia, 
this has been done several times. A committee 
of the State Medical Society* presented such a 
report some years ago, and Dr. R. A. Cleemann 
made a similar study in 1876.! The epidemic 
of yellow fever in 1870 was also carefully ana- 
lyzed. X 
In view, however, of the great progress that 
has been made lately, in the methods of study 
of infectious disease, and of the intense local 
agitation concerning the sanitary condition of 
Philadelphia, it seemed to me that the investi- 
gation might be again undertaken, and profit- 
ably carried much further than in the previous 
attempts. Compelled to limit my work, I se- 
lected the cases of typhoid fever in 1884, and 
of the last six months of 1885, and carefully 
transcribed from the records the sex, age, nativ- 
ity and residence of every person reported as 
dying from typhoid fever in this city in that 
period. The records of the Health Office are 
kept in admirable order by the Registrar, Mr. 
Geo. E. Chambers, and 1 take this opportunity 
of expressing my indebtedness to him for the 
facilities which he afforded me, and for the pa- 
tience with which he has endured my presence 
for hours at a time during his office work. 
The disease in question has been gradually 
growing in frequency, at an irregular rate, in 
this city, and is now, if we take the general 
mortality returns from various foreign and 
American cities, out of proportion to our popu- 
lation. The figures, as given in the Health 
Reports, may be rendered more intelligible by 
means of a diagram :— 
The high figure for 1876 (761 deaths) is ex- 
plained by the peculiar and overcrowded con- 
dition of the city in that year, but the rapid and 
sustained increase from 1880 to the present 
time is not susceptible of such explanation. 
The figures of these years show the disease 
to be more prevalent in Philadelphia, or at 
least more fatal, than in most large cities. It is 
not advisable to burden the reading with an 
array of figures, but I may take, as illustration, 
the city of Paris, from which I have for the 
present year weekly returns, covering a period 
of fifteen weeks, beginning June 15th, 1885. 
The total deaths from typhoid in Paris, with a 
population above 2,260,000, was 389. In Phila- 
delphia, with a population of about 925,000, the 
deaths were 193. If the proportion of deaths 
was the same in both cities, those in Philadel- 
* Transactions Medical Society of Penna., 1876. 
t Proceedings College of Physicians of Phila., 1876. Report 
of Board of Heal'h of Phila., 1876. 
t Report of Board of Health of Philadelphia for 1870. 2 
phia would be less than 160. Comparisons 
with other cities show substantially the same 
fact. 
In judging of the cause of this condition, we 
must consider and examine into many points. 
In all sanitary examinations, I think it well to 
keep in view the remark of a sarcastic French 
writer, " that nothing can lie worse than figures, 
except facts." 
The city of Philadelphia is peculiar in several 
ways. It is spread over a large extent of terri- 
tory, perhaps larger than any other city. It is 
claimed to constitute the largest manufacturing 
district on the continent, and although this has 
been disputed, being claimed for New York, 
yet there can be but little doubt that, in pro- 
portion to population, it is the larger. Mr. 
Lorin Blodget, who is thoroughly familiar with 
the industrial statistics of this city, informs me 
that the northeastern section, including princi- 
pally the Nineteenth, Twentieth and Thirty- 
first wards, represents an extent and rapidity of 
development unequalled by any city of the 
world. • 
The topography and soil conditions are very 
different at different points in the city limits. 
The southern and eastern portions are located 
on alluvial deposits, while the northern and 
western portions are upon the original conti- 
nental rock basis. Considerable variations, 
therefore, in elevation and drainage facilities 
exist in different parts. We must remember, 
also, in comparing an American city with a 
foreign one, that the former will contain a 
much larger proportion of persons unaccustomed 
to the habits and climatic conditions, and that 
malarial and typhoid disease are more likely to 
affect such persons than those born on the 
soil. 
The complete investigation of the subject in- 
volves a large amount of labor. The records 
of the Health Office, although collected with 
care, and sufficient for the practical purposes 
of the Board, are yet but a skeleton of the body 
of facts necessary. We would need, above all 
things, a complete record of cases, whether fatal 
or not, a verification of diagnosis in a certain 
proportion of cases, an outline of the sanitary 
surroundings of each instance. 
In the actual performance of the task I un- 
dertook, I have been thwarted by some minor 
difficulties, but not to such an extent as to in- 
validate the general conclusions. In a few 
instances, the residences were not recorded, in 
quite a number the streets were obscure, or 
their names duplicated in different parts of the 
city. I traced out a fair proportion of these 
cases to a certainty. I have, however, learned 
of a source of error which must seriously im- 
pair any attempts at topographical study, unless 
the method of reporting deaths is radically 
changed. Among the points of interest in the 
work, was to ascertain how frequently two or 
more cases would be found in the same house, 
and especially if fatal cases so occurred. I 
found several instances. From 1139 North 
Third street, 1215 Girard avenue, and 1002 
South Fourth street, three deaths were report- 
ed. I expected that a sanitary examination 
of these premises, would be of value, but 
was rather surprised on discovering that the 
first two were residences of undertakers, and 
the residence given in the return was, there- 
fore, merely the place from which the inter- 
ment took place. Several other cases which 
1 followed up turned out to have been report- 
ed from places not connected with the origin of 
the disease. 
I present herewith a map of the built-up por- 
tions of the city, with the location of the fatal 
cases marked.* (See p. 5.) 
An examination of the statistics goes to show 
that the district north of Girard avenue, and 
between Ninth street and Frankford avenue, 
presents always the most unfavorable showing. 
It was the district that suffered most from chol- 
era in 1866, from smallpox in 1872-3, and 
1881-2; its death-rate from all diseases, and 
from specially zymotic diseases, is higher than 
in most other sections. 
If we look carefully into the conditions which 
prevail in this section, I think we can discern, 
if not all causes of the excess in mortality, at 
least many of them. 
The section is comparatively newly occupied 
territory. The population is largely composed 
of foreign-born persons, many of them import- 
ed especially for the manufacturing operations 
carried on in the district, and of about the age 
at which the fever appears to be most frequent. 
The condition of the drainage, both natural 
and artificial, is of the most objectionable de- 
scription. The ravines and meadows constitut- 
ing the original water-courses have been filled 
up, for street extension, without proper care, 
and as a large portion of the material which 
is used for filling up is house and mill refuse, 
• At the reading of the paper, the map »hown waa that of the 
case* for 1U4. The map herewith published is for the taller 
half of 1885. 3 
many of the rows of houses have been built 
over garbage. Dr. Wm. R. Cruice, who has 
had a large experience with the diseases of this 
section, has given me a description of the situa- 
tion. 
The question of water-supply must, of course, 
enter largely into our thoughts in investigating 
this subject. There is a large and, I think, in- 
creasing number of sanitarians and physicians 
who regard the disease as strictly a germ dis- 
ease, that is incapable of originating except 
from a previous case. To these the hypothesis 
of water-carriage is entirely acceptable, and 
they would regard the above-mentioned soil, 
climatic and social conditions, as merely pre- 
disposing. The Kensington district has, for a 
long while, been supplied with Delaware water, 
and by general consent, the disproportionate 
amount of diarrhceal disease, has been ascribed 
to this fact. Yet, we cannot overlook the fact 
that the district of Kensington proper, now sub- 
stantially included within the Eighteenth ward, 
does not show a specially high death-rate from 
typhoid. The high death-rate is seen particu- 
larly in the district which has been laid out and 
built up since the war. 
I am inclined to think that if water-carriage 
is an active factor, in this case, in the distribu- 
tion of zymotic disease, it takes place in a man- 
ner different from that usually supposed. The 
consumption of water in mills is an important 
item, and the high taxes imposed by the city for 
water privileges has led to a very extensive 
sinking of shallow wells for general mill supply. 
I have examined a number of samples so ob- 
tained, from different parts of the city, and as 
might be expected, the water generally shows 
evidence of contamination. It is, however, 
frequently quite clear and cool, and the mineral 
matters and gases contained in it give it a pleas- 
ant taste, for which reason the operatives prefer 
it to the river water; and I know that such well 
water is often used even after it has been ex- 
pressly pronounced unsafe. There is reason to 
believe that several slight local epidemics may 
be traced to such a cause. Recently such an 
outbreak occurred at the Glen Echo carpet mills, 
in the lower end of Germantown, and all the 
deaths occurring in the Twenty-second ward 
during November and December, 1885, were 
of persons employed in those mills. Dr. J. 
Howard Taylor, Medical Inspector of the 
Board of Health of this city, and myself, in- 
vestigated the epidemic, and could find no 
other source but the drinking of well-water. 
Dr. E. Frank Garrett writes, in reference to a 
death occurring in Germantown earlier in the 
year, that although no other person had the 
disease in the same house, there were several 
in the same square, and all of them used well- 
water. I think considerable importance ought 
to be attached to the nativity of those affected. 
The foreign-born population of the district that 
suffers most from the disease is not only large 
in proportion, but in many cases of the quite 
recent arrivals. They are the operative class, 
and are, indeed, the actual specimens of the 
‘‘pauper labor” of which so much is said in 
tariff discussion. This class is not certainly in 
the best physical condition, and being new to 
the district, are all the more likely to succumb. I 
find, by examining the figures for six months of 
1884, that the proportion of foreign-born per- 
sons dying of typhoid fever is much larger 
than the proportion dying of all diseases. 
The statistics, in my opinion, entirely nega- 
tive the hypothesis that Schuylkill water is an 
important factor of the disease. This view 
has, indeed, never been tenable. No analy- 
sis of the water has justified the wholesale 
condemnation of it which has been so fre- 
quent of late years. The distribution of the 
mortality from zymotic disease has been several 
times examined, with a view to show such a 
connection, but it has failed. The report of the 
water department for 1883 presents an examina- 
tion of this question, and it fails entirely to 
make out a case against the Fairmount supply. 
It would be impossible to discuss a topic like 
this without saying something about sewer-gas, 
or rather, as it ought to be called, sewer-air. 
When I was a medical student, the sewer theory 
of infectious diseases was a favorite one. My 
preceptor, the late Dr. Rand, laid much stress 
upon this agent as a cause of disease. We 
have recovered from this extreme state of 
alarm, and some of our leading sanitarians now 
teach that it can only act as an exciting cause 
where it carries specific germs. 
As in the case of the Schuylkill water, the 
topographical study of typhoid fever in Phila- 
delphia does not bear out the theory of sewer- 
air as a cause. The districts in which the resi- 
dences are most extensively connected with 
sewers, through the medium, not only of water- 
closets, but of those much more insidious 
routes, the wash-stand and kitchen-sink, are 
just the districts in which the fever is least 
prevalent. An inspection of the map will show 
that in the section from Seventh to Twenty- 4 
second, and from Market to Spruce, scarcely a 
death has occurred. 
There is but one death registered the entire 
length of Chestnut street, from Hroad to the 
river, and this was a young lady who had just 
become a resident. 
Unfortunately for the thoroughness of such 
statistics, the deaths only are accessible in the 
health records. I am of the opinion that, except 
possibly in times of epidemics, there is no dis- 
ease in which it is more important to report the 
cases. In most cities that have efficient sani- 
tary service this is done, and I think Philadel- 
phia is decidedly behind the times in not en- 
forcing such a method. With a view of ascer- 
taining how far the deaths might represent 
infected localities, and also learning the prevail- 
ing opinion among those who had to deal with 
the disease, I addressed notes to about sixty- 
five physicians who had reported deaths, en- 
closing a postal card, bearing these queries: 
Was there any other case of the disease in the 
same house at or near the time of this death ? 
Do you know of any possible source of infec- 
tion ? Was the disease contracted in the city ? 
I have received returns from about fifty-five, 
several answering at length. 
From these answers I learn the following 
points:— 
That the fever is generally solitary, that is, 
only one person is affected in each house. 
That most, but by no means all, of the cases are 
contracted in the city. That, in a certain pro- 
portion, the diagnosis is uncertain or obscure, 
and that occasionally a malarial condition 
seems to precede the true typhoid state. That 
the prevailing idea as to source of infec- 
tion seems to be soil pollution, especially 
by cess-pools. There is but little disposition 
to ascribe it to water supply or to sewer-gas 
proper. 
Just as I was adding the concluding lines to 
this paper, I received the very interesting essay 
on cholera, by Dr. J. M. Cuningham, Sanitary 
Commissioner with the Government of India. 
This work, which represents thirty-three years' 
experience with cholera, has been made the 
subject of extended review, by Pettenkofer, 
in the Archives of Hygiene. I refer to this 
work here, because I regard the sanitary bear- 
ings of typhoid fever as analogous to those of 
cholera; in fact, Mr. Ernest Hart, editor of 
the London Sanitary Record, has stated that, 
where typhoid fever is prevalent, cholera is 
likely to be most serious, which accords with 
our own experience. Now, there is, perhaps, 
a further analogy in these diseases. They may 
be both due to a specific germ, which may be 
carried by water or air; but they are not conta- 
gious in the ordinary sense; and the liability 
to them, both by individuals and by districts, 
is dependent on many accessory conditions. 
Fettenkofer is convinced of the important part 
played by the condition of the soil in the spread 
of typhoid and cholera, and Cuningham's 
facts bear out this view very strongly. We 
have it upon the best authority, that in several 
large European cities, e. g., Dantzig and Mu- 
nich, the diminution of the typhoid death- 
rate was coincident with the improvement in 
drainage, but decidedly not with that of the 
water supply. 
In connection with the work of examination 
of the Health Records, several ideas for im- 
provement in the method of reporting, suggested 
themselves to me. The method of reporting 
by wards is very unsatisfactory. The outlines 
of the wards represent no natural or social divi- 
sions. They are mere expedients. A 
system of classification by sanitary districts of 
uniform size would be much more satisfactory. 
All deaths in Hospitals should, if possible, be 
referred back to the original residence, not cred- 
ited to the Hospital. It would be an advantage 
if the attending physician should be charged 
with the furnishing of the details of statistics, 
in place of the undertakers, who now have the 
duty. 
I have offered this paper almost entirely as an 
opportunity for discussion. The statistical cle- 
ment in it is too slight to constitute a basis for 
sound theory, though it may serve to overturn 
some views and suggest others. I would like 
to hear from the members on the following 
points:— 
What is the probable percentage of fatal cases 
in typhoid, in this city ? 
How far are the conditions of soil pollution, 
or insufficient and defective sewerage, answer- 
able for the disease ? 
Is the prevalence of the disease due in not- 
able proportion to the foreign population settled 
with us ? 
Would it not be advisable for the Hoard of 
Health to require reports of all typhoid cases ?* 
The discussion on the paper is given in a 
somewhat condensed fonn, on account of lack 
of space. 
• The Board ha* recently passed a resolution to this effect. The map represerh distribution of two hundred and eleven 
deaths from typhoid ft ?r, jut of the two hundred and seventy- 
eight occurring in Philat elphia in the last six months of 1885. 
The sixty-seven not entered consist of deaths in West Philadel- 
phia, Frankford, Germantown, Manayunk, or extreme outlying 
districts, also deaths in hospitals, and a few of uncertain location. 
The limits of the map include a pretty closely built-up district, 
about four miles long by two broad, containing a population which 
may be roughly estimated at seven hundred thousand. 
m'k ean street. 6 
DISCUSSION ON TYPHOID FEVER IN 
PHILADELPHIA. 
in Munich, the numlierof case* of typhoid fever Iwars 
a relation to the height of the w ter springs, being 
most prevalent when these are low These Munich 
observers do not believe in the pi pupation of the 
typhoid poison by means of the drii ng water, and 
explain the undoubted coincidence W ■. '-•n the preva- 
lence of typhoid and a low level of the *. *ud water 
by the theory that when the earth is uncovered by the 
recession of the water the air gains access to germs 
previously submerged, and stimulates them to un- 
usual activity. The poison, they say, gaids access to 
the Ixxly through the medium of the atmospheric air. 
Dr. Henry 11. Baker, Secretary of the Michigan 
State Board of Health, has recently verified the state- 
ments of Pettenkofer and Buhl, that the rise and fall 
of the typhoid fever curve are in inverse ratio to the 
rise and fall of the subsoil water, with the following 
notable exception, namely, that in winter, when the 
ground is deeply frozen, a low level of subsoil water does 
not correspond with an increased prevalence of typhoid. 
Dr. CruICE.—I wish simply to say that the cases 
which I have treated during the last summer were 
not among immigrants. The majority of them were 
old residents in the neighborhood, and many of them 
were workers in the mills. A large number of the 
residents along Germantown Road use pump water. 
I have no doubt that much of the trouble has come 
from that source. These cases occurred in newly- 
built districts. A number of the houses were built 
on ground made from the dumping of ashes and 
other debris. I observed the same condition in 1872, 
when I treated a number of cases of smallpox. 
Dr. Richard A. Ci.kf.mann.—I am glad to see 
that the observations of Dr. Ixffmann confirm those 
which I made in the epidemic of 1876. It was at 
that time very unpopular to say that typhoid fever 
was not caused by contamination of sewer gas or 
from the water supply. Careful examination then 
showed that neither the sewers nor the water supply 
could be held responsible for the large majority of 
deaths from typhoid fever in Philadelphia. 
In the absence of any apparent cause, I was dis- 
posed to refer it to emanations from the number of 
open cesspools, which were often in close proximity 
to the houses, and to the constant pollution of the soil 
from them, which became very obnoxious, from the 
subsequent turning up of this soil. 
In regard to the point of Dr. Henry in reference to 
the ground water, no observations have been made 
in Philadelphia. In 1876 we had a condition of 
affairs which, I suggested, might account, to a certain 
extent, for the typhoid fever. There were heavy 
rains, followed by extremely hot weather. I think 
that at that time I established the fact that there is 
no condition more predisposing to a typhoid epidemic, 
other things being equal, than extreme and long-con- 
tinued heat. 
Dr. F. P. Henry, in opening the discussion, by 
request of the chair, said : Dr. Leffmann speaks from 
the standpoint of the health officer rather than that of 
the clinician. The subject of etiology is usually 
divided into predisposing and exciting causes, and 
prophylaxis may deal with the protection of the com- 
munity or of the individual, although both are inti- 
mately allied. I propose first to say a few words upon 
individual predis{x»sition. 
There can be no doubt that certain individuals have 
a tendency to neuroses, congestions, catanhs, in the 
infra-diaphragmatic portion of the trunk, just as others 
have similar tendencies in its supra diaphragmatic 
portion. In such constitutions diarrhoea is produced 
by causes which, in the average individual, would be 
followed by no such effect: such as an unusually 
hearty meal; the partaking of food difficult of diges 
tion or of food that is easily digestible, but of a kind 
to which the individual is unaccustomed; a change in 
the customary drinking water, or, finally, and very 
commonly, atmospheric changes, thermometric and 
hygrometric. Now this susceptibility can be only 
dependent upon an unusually sensitive condition of 
the abdominal sympathetic system. Abnormal flux- 
ions of blood to the abdominal vessels are the result 
of irritants which, in individuals of more stable equili- 
brium, would be considered physiological. Among 
such irritants is possibly the poison, the germ, of 
typhoid fever. We are all acquainted with single 
cases of typhoid in families where all have been ex- 
posed to precisely similar influences. Why is it that, 
in these sporadic forms of the disease, the majority 
of those exposed to the infection escape ? It is be- 
cause the germ finds a favorable soil in one person 
and not in another, and this soil is a catarrhal mucous 
membrane, which very catarrh is produced by the irri- 
tation of the poison, so that in individuals of the type 
above described the germ of typhoid fever flourishes 
because it is able to produce its own culture medium, 
namely, a catarrhal mucous membrane. 
Another cause favoring the development of the 
typhoid germ, and, I believe, through the medium of 
abdominal hypenemia, is change of climate. Dr. I.eff- 
mann has confirmed my observation, made in a general 
way, of the large proportion of foreigners attacked 
with typhoid fever in a certain section of this city, that 
in which the Episcopal Hospital is situated. In a ten 
years' service at that institution. I have yearly observed 
a large proportion, if not a preponderance, of Ger- 
mans and Englishmen—mostly weavers—among the 
cases there treated. 
Several observers, among them Virchow, have 
shown that typhoid fever is more prevalent during 
dry seasons, which is in strict accord with the cele- 
brated observations of Pettenkofer and Buhl, that. 7 
I might say, in regard to cesspools as a cause of 
typhoid, that in Paris much the same condition occurs. 
I was surprised to hear Dr. Leffmann say that the 
deaths in Philadelphia were more numerous than in 
Paris. My memory would contradict him. 
However, the prevalence of typhoid in different 
cities is a good deal a matter of registration. In New 
York, we find many deaths attributed to malaria. I 
have little doubt that in Philadelphia a great many of 
those cases would be classed as typhoid fever. At 
the Health Office here it is customary to register all 
deaths from typho-malarial fever as from typhoid 
fever. 
Abroad, particularly in Germany, I have noticed 
many cases called gastric fever, which here would 
have been called typhoid fever. 
In regard to the death rate, I should say, from my 
own observations of hospital and private cases, the 
death rate is about ten per cent., which is about the 
same as that in London. 
I do not deny that the poison of typhoid fever 
can be communicated through water. On the con- 
trary, I think that it is often carried in that way, but 
that in Philadelphia polluted water is not a promi- 
nent cause. In all the epidemics from poisoned drink- 
ing water, the number attacked, among those who 
drank the water, has been very large, a very much 
larger proportion of the inhabitants than have ever 
been attacked in Philadelphia by typhoid fever. 
Dr. Edward T. Bruen.—I think that the point 
which Dr. Leffmann made, in regard to referring hos- 
pital deaths to the residence of the patient, is very 
important. Taking Blockley Hospital, for example, 
it is rare to have a case of typhoid fever developing 
in the institution; most of the cases are brought from 
the outside. . 
The modern consensus of opinion points to the fact 
that the disease does not arise without the presence of 
the poison. It does not arise de novo. In regard to 
the influence of cesspools, I had an opportunity of 
observing a number of cases of the disease originating 
near Rosemont Station. Most of these cases oc- 
curred from a centre near which a large number of 
houses had recently been built, some twenty or twen- 
ty-five, on an acre of ground. These were occupied 
by the working class. The privy-wells and water- 
wells had been sunk near by. 
Dr. James C. Wilson.—In regard to the death- 
rate of typhoid fever, I am disposed to think that it is 
under estimated in this city. It is possible that some 
of the deaths occurring from the accidents of the 
fever are reported under such heads as peritonitis, 
hemorrhage from the bowels, etc. A recent careful 
study of this subject, in New York, by Dr. Delafield, 
showed that the death-rate varied in different years 
between twenty and thirty per cent. 
The second question of Dr. Leffmann relates to the 
relative frequency of typhoid fever in this community, 
among newly-arrived individuals. Such individuals 
are particularly subject to this disease. This was seen 
three or four years ago, in the Paris epidemics. It was 
observed that those who came in from the country 
were especially liable to contract the disease, and to 
have it in a grave form. This is also the case in our 
own city. I think that this is not only true of locali- 
ties, but also of houses. I have in mind at present 
two houses in which I have seen enteric fever develop 
in a number of individuals, at intervals in the course 
of a series of years. In one of these houses, of three 
cases, two were in individuals who came from a dis- 
tance, and in a few weeks or months developed the 
disease. These cases occurred at intervals of eigh- 
teen months or two years. Local defects of plumbing 
are usually largely concerned in establishing foci of 
infection. 
The more closely we study the etiology of enteric 
fever, the more obvious do the means of its convey- 
ance from one individual to another become, and the 
more manifest becomes the necessity for the immediate 
and effectual disinfecting of the discharges from the 
bowel. It is one of the highest duties of the physi- 
cian to see to it that no case becomes a centre of new 
infection. It seems to me that some of the views 
which have been alluded to to-night do not require 
any special discussion, in view of the experience in 
Plymouth. The causal relations of the epidemic 
there were so clear as not to admit of the slightest 
question as to the manner in which the disease may 
be and usually is conveyed from one locality to 
another, namely, by individuals sick of the fever or 
by the alvine dejections from such individuals. 
The satisfactory solution of the etiological questions 
can, I think, only be arrived at, in a city like this, by 
carrying out the suggestion of Dr. Leffmann, that not 
only the fatal cases, but every case of enteric fever should 
be reported, with full details concerning the local- 
ity in which it took origin. One source of error in 
our statistics is the failure to recognize the fact that 
enteric fever, like other infectious diseases, presents 
different forms. In typhoid fever we have a typical 
form from which there is, however, the widest varia- 
tion. Among the atypical forms may be mentioned 
infantile remittent, the abortive form, mild typhoid 
and typhoid fever of old age. 
I believe that enteric fever is capable, in the course 
of time, of being stamped out. The conveyance of 
the infecting principle from one individual to another 
is so plainly the cause of it, that it is not Utopian to 
hope that the immediate and effectual destruction of 
that principle, by means of the disinfection of the 
stools in every case, would gradually lead to the ex- 
tinction of this disease in the civilized world. 
Dr. S. S. Cohen.—In regard to the causation of 
enteric fever by the water supply, I recall two cases 8 
that I saw last year, in one family living in the Nine- 
teenth ward. These persons had for three weeks 
used water from the well of a factory where the 
father worked, having l>een frightened by the news- 
pajier accounts of the pollution of river water. Two 
sons were taken with mild typhoid, and a daughter 
with non-febrile diarrhira. I could find no source of 
infection other than the drinking water. In regard 
to this district, I may say that we see, at the Jeffer- 
son Medical College clinic, a good many cases of 
“ walking typhoid,” in residents of the northeastern 
part of the city. We also see some few cases in resi- 
dents of the “ Neck ” district. It is from these same 
localities that we get the greatest numltcr of our mala- 
rial cases. 
I)r. William M. Welch. — Some years ago, 
when undertaking to study the statistics of typhoid 
fever in Philadelphia, I asked a physician in the Penn 
sylvania Hospital to look up for me the death rate in 
that institution, and he informed me that it was fifteen 
per cent. There is no doubt Imt that the death-rate 
in hospitals is always much higher than in private 
practice. Dr. Pep|»er stated on this floor, some three 
or four years ago, that of too cases treated by him 
only three died. This, surely, is a remarkably low 
death-rate. 
In seeking for the cause of typhoid fever, we must 
look to the soil and drinking water. Whenever soil, 
especially |M>lluted soil, is u}4urned to any consider* 
able extent there is pretty sure to be typhoid fever. 
I)r. Chari.rs Claxton.— In niy experience, as 
resident of the Episcopal Hospital and in private prac- 
tice in the Nineteenth ward, I have seen many cases 
of typhoid fever. The almost invariable source of 
infection I have found to be defective sewerage, usu- 
ally from ex|iosed privy wells. Such is the condition 
in some of these residences, that during a heavy rain 
the contents of these wells arc flooded into the yards, 
and thence into the cellars, where they would remain 
for long periods. I have now under my care four 
menders of one family, whose sickness is undouU- 
edly due to this wretched state of affairs. The mor- 
tality in typhoid at the Kpisco|>al I loapital, for the last 
ten years, has teen a fraction over 13 |>cr cent. 
Dr. Charles Wi roman.—In 1876, a Russian 
man of-war, with five hundred men on board, anchored 
off ltrown street. In a short time, three cases of 
typhoid fever were brought to the Pennsylvania Hos- 
pital, at which I was a resident, from this ship. Every 
day more were brought, until the numlier reached 
above twenty. Of this number four died. These 
men were drinking Delaware water. They were not 
on shore much, and were not likely to lie where they 
could contract the disease. It is probable that the 
water was contaminated by a sewer which opened at 
this point.