THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
HENRY B. BAKER, M. D., Lansing, Mioh. 
[ Reprinted from the Annual report of the Michigan State Board of Health for the year 1896.] 
[ Rbpeint No. 486.] THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
HENRY B. BAKER, M. D., Lansing, Mich. 
[Reprinted from the Annual Report of the Michigan State Board of Health for the year 1896.] 
[Reprint No. 4.86.] THE ETIOLOGY AND PATHOLOGY 
OF 
TYPHOID PEYEE.* 
HENRY B. BAKER, At. 13. 
ETIOLOGY. 
The fact that, by request of a committee, this paper has been prepared 
to “open a discussion” on the etiology and pathology of typhoid fever, 
implies that neither of these two branches of the subject is settled. In 
connection with both branches, there are, however, very many facts which 
are more or less well established; so it must be one function of this paper 
to recall to our minds some of these facts, and, if possible, to do this in 
such order as shall suggest harmonious interpretations of the facts, to aid 
us in arriving at conclusions concerning the etiology and pathology of this 
important disease. 
1. Filth as a Factor in the Causation of Typhoid Fever. 
It seems to me that it is established that typhoid fever is a “filth disease,” 
that is, that what we know as “filth” has had much to do in the causation 
of typhoid fever. 
♦ A paper read at the meeting of the Michigan State Medical Society, June 4,1896. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
The eminent Sanitarian, Dr. Joseph von Foder, compiled the facts rela- 
tive to the surroundings of fatal cases of typhoid fever in Buda Pesth, 
Hungary, during fifteen years—lB6B-77, with results as follows;—* 
Deaths from typhoid fever per hundred houses when the interior of the 
dwelling was:— 
1. Yery clean 165 
2. Clean 177 
3. Dirty 182 
4. Yery dirty 356 
There was gradual increase from “very clean” to “dirty,” and a very 
great increase from “dirty” to “very dirty.” Compared with the “very 
©lean,” there were more than twice the proportion of deaths in the “very 
dirty” dwellings. 
With the yards surrounding the houses, the result was as follows:— 
Typhoid fever deaths per one hundred houses when the yard was:— 
1. Very clean 159 
2. Clean 186 
3. Dirty 208 
4. Yery dirty 282 
The evidence was conclusive that want of cleanliness outside the dwell- 
ing had great influence in the causation of typhoid fever, but not nearly 
as great as had want of cleanliness inside the dwelling. 
Other evidence that filth is a factor in the causation of typhoid fever, is 
the experience in Munich before and since the filth of the city has been 
promptly carried out of the city by means of sewerage: Thus, in 1852-9 
when the drinking water was from wells, and the human excreta was stored 
in overlying vaults, the mortality from typhoid fever was 24.2 per 10,000 
inhabitants. In 1860 the vaults were required to be cemented; in 1860-7 
the typhoid mortality was reduced to 16.6 per 10,000. In 1866-78 a system 
of sewers was commenced, involving the commencement of the use of a 
general water-supply; in 1868-75 the typhoid mortality fell to 12.7. The 
sewers were continued in 1874-80, in 1877-79 the typhoid mortality was 
reduced to 7.8. In 1881-4 the sewers were further continued, and a good 
spring water was added to the general water-supply; the typhoid mortality 
decreased, until in 1884 it was only 1.4 per 10,000 inhabitants.! The 
death rate from typhoid was then only about one-seventeenth what it had 
been when Munich drank water into which human filth percolated. 
This indicates the nature of the filth which seems to have causal rela- 
tion to typhoid fever,—the excretions of human bodies. This evidence of 
the etiology is in harmony with some of the evidence of the pathology of 
the disease,—one approved name of the disease is “enteric fever”; an 
important effect of the disease is in the intestine; it is reasonable to sup- 
pose that the cause of the disease may be given off from that part of the 
body in which the pathological change occurs. Apparently this is true; 
the disease appears to be spread by a cause which goes from the intestine,| 
and is capable of producing the disease when it reaches the intestine of 
another person. 
* Archiv fur Hygiene Zweiter Band, 18s4. Zeite 269, 272. 
tThis is graphically exhibited in the diagram, p. cxliv. 
$ Recent investigations make it probable that the urinary excreta also convey the germs of typhoid 
fever. Experiments by Wright and Semple, London Lancet July 27, 1895, page 196. STATE BOARDJ'OF HEALTH.—REPORT OF SECRETARY, 1896. 
TYPHOID FEVER^SEWERS, 
AV.3I3CITI.ES WITHOUT 
1854-59, 
NEGL'CT 
1860-65, 
CEMENT VAULTS 
1866-73.PART S W’RS 
1874-80.SE WERS CON'T'D 
1881-84, SEWERS CONTINUED. 
AVERAGE,39 CITIES WITH 
MUNICH. 
[PLATE NO. 651.] THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEYER, 
Typhoid Fever Among Plumbers. 
In a report of the Board of Health of Montclair, New Jersey, mention 
was made of a plumber being attacked by typhoid fever in consequence of 
having made repairs in one or more of the houses in which the fever had 
occurred.* A similar case occurred under my observation 
Michigan, a few years ago. 
Is the Cause a Chemical Poison, or is it Specific. 
Many classes of facts seem to demonstrate that the cause1 of typhoid 
fever cannot be simply a non-living chemical poison not capable of repro- 
duction, and that it must be an organized body capable of reproduction and 
continuous multiplication./ For instance, as an illustration, from a house 
in Philadelphia in which there was typhoid fever, a man went to Plymouth, 
Pa., was taken sick with typhoid fever, his discharges were thrown out on 
the snow which melted and was washed into a small mountain stream which 
served as the source of a public water-supply. In a short time about a 
thousand persons who drank that water contracted typhoid fever, while 
many other persons in the same village who drank water from wells, the 
water from which when analyzed at the laboratory of the Michigan State 
Agricultural College was found to be very much more badly contaminated 
with leachings from human excreta, did not then contract typhoid fever; 
although, afterwards, when there had been opportunity for the privies to 
have been “infected” with typhoid discharges, the disease appeared, in 
some instances, to have been contracted from water in the underlying wells. 
In the mountain stream the dilution was such as to make it impossible that 
so many cases of fever could have been caused by any chemical poison; 
there must have been reproduction of the “infection” in the intestines of 
the patients. And the contaminated well water did not cause typhoid 
fever until after it became infected. 
At Cumberland, Md., in 1889-90, the evidence is that typhoid fever was 
not present until the discharges from a typhoid patient living on one of 
the little streams which empties into the Potomac about 200 feet above the 
pumping station, found their way into the city water supply, f Dr. Kober, 
who has made a special study of the subject, says: “Such instances can be 
recited by the hundreds.”! lam myself familiar with many such instances. 
In a great many instances, notably the outbreak at Plymouth, Pa., the 
tendency of such evidence is to prove that typhoid fever is not caused by 
non-infected human excreta; but by excreta of typhoid fever patients. 
This is equivalent to saying that typhoid fever is caused by a specific 
organism, or organisms. 
The Practical Restriction of Typhoid Fever Proves its Communicability. 
The lessening of typhoid fever by sewerage and improved water-supplies, 
shown in diagrams and charts I and 11, submitted herewith, J is evidence 
that typhoid fever is communicable, and that it may be restricted by the 
measures mentioned. 
♦Jour. Am. Med. Assoc., Vol. 23, page 691. 
t Report of Dr. George M. Kober, in Annual Report Comm. Dist. of Columbia, 1895, page 259. 
Pages cxlvi-cxlvii. STATE BOARD OF HEALTR.—REPORT OF SECRETARY, 1896. 
CHART L- MATHS fro*, TYPHOID FEVER 10 tad, /0,000 M- 
>an3 since the INTROUUCTION of 'AG / THE ETIOLOGY AND PATHOLOGY OF TYPHOID"FEYER 
CHART 11.-MATHS from TYPHOID FEVER /0,0o0 INHABITANTS 
i* SEWERED jJIMEWEREM CITIES.Jlv-.f S~yrS., /BS'O~ ft'*/,- unless otherwise, 
B.Cities without sewers, crvery 
I'm'perftctly Sew era.#. 
A.Cities wit)i s&wers anR 
a g&'nera'l hraier-S u'p-p/y, 
2. . . . f-i—-i-i—~n—i—-n—m—r 
[PLATE 644.] STATE BOARD OF HEALTH—REPORT OF SECRETARY, 1896, 
LIVES ..SAVED BY PUBLIC-HEALTH WORK. 
COMPARISON OF DEATH-RATES IN MICHIGAN 
FROM SCARLET FEVER AND SMALL-POX BE- 
FORE AND SINCE THE STATE BOARD OF 
HEALTH WAS ESTABLISHED AND FROM TY- 
PHOID FEVER BEFORE AND SINCE ITS RE- 
STRICTION WAS UNDERTAKEN BY THE STATE 
BOARD. COMPILED FROM STATE DEPART- 
MENT’S “VITAL STATISTICS* OF MICHIGAN. 
REPORTED DEATHS PER 10,000 INHABITANTS. 
MVE« §AVED FROM: FEVER (17 YEARS) 1268; SNAIL-POX 07 YEARS) L»a> Tt. WOID FEVER (|2 YEARS) 1671. f 
< iWy 
PLATE NO. 517, THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER 
Isolation and Disinfection Restrict Typhoid Fever. 
STyfhoid Sever in xMiehigan in IZfl.- 6xhibiting the Sljk. 
erage numbers of eases and deaths fer outbreak:-in alt 
outbreaks in which isolation and Disinfect ion, were both, ~ 
neglected} and in alt outbreaks in which both were 
(tom filed in the office of the Secretary of the State Board/ : 
of Health, from reports made by local health officers.) 
isolation and Disinfection, 
Tie fleeted/ . 
Jhr e 7* a g e>. 
isolation and Dis inject tort 
en fo 'rcecL • 
J}i/eTCLqes. 
■** including the disinfection of the iousel discharges of 
the . STATE BOARD OF HEALTH.—REPORT OF SECRETARY, 1896. 
A similar line of evidence is that in the diagram, entitled “Lives Saved 
by Public-Health Work,”* wherein it is shown that during those years in 
which the State Board of Health has been laboring for the restriction of 
typhoid fever the mortality has been less than it was before. That diagram 
relates to the entire State; if we confine the inquiry to local outbreaks, 
and separate them into two classes, as is done in the construction of the 
diagrams “Isolation and Disinfection Restrict Typhoid Fever,”f it is plain 
that isolation and disinfection restrict typhoid fever, which implies that it 
is a communicable disease. The disinfection includes that of the bowel dis- 
charges from the patient; and it should, by all means, have included that 
of everything in any way soiled by their urine which, in some instances, 
has been found to be almost a pure culture of the typhoid bacillus.J 
In the outbreaks studied, probably the urine, dried on linen, has been 
entirely overlooked as a cause of typhoid fever. But the evidence seems 
to be conclusive that in townships, villages, and small cities typhoid fever 
may be restricted so that only about two cases, and an average of one-fourth 
of one death shall occur to each outbreak. In the year 1891 a few epidemics 
greatly increased the average in localities where isolation and disinfection 
were neglected, but the results of isolation and disinfection were about the 
same as in the other years. 
It seems to me to be established that typhoid fever is a specific communi- 
cable disease. How is it communicated? 
The facts relative to the lessening of typhoid fever in Munich, and facts 
of similar import in cities throughout the world, seem to demonstrate that 
the prompt removal of excreta by sewers, associated as that usually is with 
an uncontaminated water supply, decreases the spread of typhoid fever. 
“The example of Dantzig, however, shows that an abundant water-supply 
alone does not diminish the death-rate. This city was supplied with water 
in 1869, and sewered in 1872. No marked diminution in the death-rate of 
typhoid fever occurred until after the introduction of the sewers. Wash- 
ington, with a daily individual supply of 177 gallons, has an average annual 
mortality of 6.2, while New York, with 74 gallons per capita, has 8.1 deaths 
yearly to 10,000 population. Abundance of water alone, as might well be 
supposed, does not limit the spread of typhoid fever.Ӥ 
In such cities as have sewerage but still have a contaminated water 
supply, typhoid fever still remains. Philadelphia is an example. Chicago 
has been a noted example. Cities like New Orleans where there have been 
imperfect sewerage, but a water supply from rain-water cisterns not much 
contaminated by human excreta, do not suffer much from typhoid fever. 
Logically it seems to follow that the large part of the typhoid fever must 
be caused by the typhoid excreta in the drinking water. . / 
There are on record specific instances too numerous to mention where 
typhoid fever epidemics and local outbreaks have been traced to the use of 
water infected with excreta of a typhoid fever patient. 
Typhoid Fever is a Communicable Disease Sometimes Waterborne. 
* Page cxlviii, 
[ f Pages cxlix, cli and clii. 
± Experiments made by Wright and Semple, London Lancet July 27,1895, Vol. 11, No. 4, page 196. 
§ Report of Medical Society Dist. of Columbia, in Journal Am. Med. Assoc., Vol. 23, 1894, p. 82. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
Isolation and Disinfection Restrict Typhoid Fever. 
Jyfhoid clever in Michigan in 6xhibiiing the average 
numbers of cases and deaths gbef outbreak :-in all outbreaks 
in which, isolation and Disinfection u/ere both neglected- 
and in all outbreaks in which both were enforeed.^fComfiled 
in the office of the Secretary of the State Board of Health jrent 
reports made hy local health officers.) 
isolation and Disinfection 
neglec te d . 
isolation and Disinfection 
e nfo rceoL. 
* dnclading the disinfection, of the howet discharges of 
the foaiients. STATE BOARD OF. HEALTH.—REPORT OF SECRETARY, 1896. 
Isolation and Disinfection Restrict Typhoid Fever. 
«Typhoid Sever in Michigan in JF93:- Sx-hihi tiny the average 
nuMosrs of eases and deaths doer outbreak'.- in all outbreaks 
in which, isolation and disinfection, were both Neglected; 
and in all outbreaks in which, hath were On foreectM'fCom- 
filed in the office of the Secretary of the State Board.of Healthy 
from reports made lay local Health, Officers.) 
isolation and Disinfection 
neglected . 
Per Outhre ak, 
Cases . I Pea th.s. 
isolation and Disirife&tioro 
e nfo re e ci • 
Pex 0 utl r* e afc 
Cases . Deaths. 
* 9n.clu.ding the of the houuel discharges qf 
the patients. 
7^(7.] THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
fjfiouj Water m Wells, and Sickness from Typhoid fever in Michigan. 
! By months, for a period of fdyears, mtand, lifO~9Z, the re- 
\latio7i of Sickness from SypholdJever to the rise and fall qf water 
iin wells. \nMichigan,. (The depth qf the water in wells,andthe depth of 
earth above theufater was reportedly observers at,from /to f Stations.) . 
> Sickness from Jyphoid ?>»*>*•-. .qround 
* Sndicating what per cent of all reports received stated the 
presence of Typhoid fever then under the observation, of the physicians reporting 
' The danger from typhoid fever is greatest in October, when the water in. 
mils is lowest, and. least in^pril, when the water in wells is highest. 
[PLATE NO, 1681.] STATE BOARD OF HEALTH-REPORT OF SECRETARY, 1896. 
Low Water in Wells and Typhoid Fever. 
The foregoing leads naturally to an interpretation of the facts concerning 
the very close relation of low water in wells to typhoid fever in localities 
dependent upon wells for the water-supply. Many years ago Dr. George 
E. Ranney, then Secretary, and later President of this Society, called 
attention to an increase in typhoid fever at a time of low water in wells. 
Dr. Poster Pratt, also an Ex-President of this Society, spoke, in June, 
1874, of a similar circumstance under his observation. With a view of 
studying the subject systematically, about 20 years ago, I induced regular 
observations and records of the depth of water in wells in Michigan; five 
or six years later I tabulated the results, and found a very striking relation. 
Herewith is a diagram (Plate No. 681)* exhibiting the facts for 14 years, 
1878 and 1880-92. It is plain that the relation is very nearly quantitative. 
The lower the water the more typhoid fever. 
Prof. Max von Pettenkofer was the first to make a systematic study of 
this subject, and he established the fact of a very close relation of typhoid 
fever and ground water in Munich.f His interpretation of the fact, how- 
ever, was not that the disease was caused by drinking in the germs with 
the infected water, as was my belief; but that it was caused by breathing 
typhoid germ-laden air forced out of the ground by fluctuations of atmos- 
pheric pressure. This cannot be the true explanation of the facts in 
Michigan, because my tables and diagrams show that the average daily range 
of atmospheric pressure does not sustain such relations to typhoid fever as 
to make this possible; the range of pressure is at its minimum in July and 
its maximum in January, while typhoid fever has its minimum in April 
and May, and its maximum in October; and a curve representing its increase 
and decrease shows no influence of the atmospheric pressure. 
On the other hand, the drinking-water interpretation takes account of 
the fact that in times of low ground water a well in use drains a wider area,, 
and is therefore more liable than in times of high ground water to be 
infected by leachings from more privies at a distance. Again, it takes 
account of the fact that any infection which may reach the well will be 
much more diluted when the groundwater is high than when it is low; the 
chances of contracting typhoid fever are, therefore, greater when the water 
is low. 
There is another interpretation which may be true under some circum- 
stances, not, however, so universal as the drinking-water explanation, but 
which may contribute toward the same result. When the ground water 
is low the surface of the earth will generally be dry. Human excreta on 
the surface of the earth or in shallow receptacles will, more generally than 
when the ground water is high, be in a condition to permit the wind to 
detach any typhoid germs which may be on its surface or which may be 
trampled into dust, and to float them off, to infect air, food or drink, or to 
be washed from roofs of buildings into the rain-water cistern. 
Typhoid Fever Spread hy Milk. 
Mr. Ernest Hart has collected and tabulated facts relative to 50 outbreaks 
of typhoid fever spread by milk. 
* Page cliii. 
f “ Boden and Grundwasser,” etc., by Pettenkofer, Munich, 1869 THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
In the report of the health officer of the District of Columbia for 1895.* 
Mr. Hart’s tabulation is included with 88 other outbreaks collected by Drs. 
Busey and Kober; altogether there are tabulated the details of date, place, 
number of cases, deaths, circumstances of outbreak, reporter, and reference 
to publication, relative to one hundred and thirty-eight outbreaks of 
typhoid fever in different patts of the world, believed to have been caused 
by infected milk. (The table, with additions collected by myself, is sub- 
mitted as an appendix to this paper.) 
Many of the outbreaks caused by infected milk were traced further back 
to infected water, used, in 51 instances for washing the cans and utensils. 
In 14 instances the intentional dilution of the milk with polluted water is 
admitted. In six instances the infection is attributed to the cows drinking 
or wading in sewage-polluted water thus infecting the udder, and finally the 
milk. In three instances the infection was spread in ice cream prepared 
in infected premises. In 21 instances the dairy employees also acted as 
nurses.f In outbreak No. 1 reported by Dr. Taylor, in Edinburg Med. 
Jour., May, 1858, “the outbreak, which affected 7 families, was traced to a 
supply derived from a milk-man in whose cottage were cases of typhoid 
fever. The milk was kept in the kitchen, where the children lay, and the 
mother, who was the nurse, also milked the cows.”* 
In a few instances water seemed to have no part in the spread of the 
disease. 
Typhoid Fever Spread by Oysters. 
Uncooked oysters “fattened” in typhoid-infected waters are now known 
to be a means of spreading typhoid fever. An outbreak due to this cause, 
at Wesleyan University, Middletown, Conn., in October, 1894, was 
thoroughly investigated, and the results published in the report of the 
Connecticut State Board of Health for 1894. J Two cases of typhoid 
fever, the discharges from which went through a private sewer into the 
Quinnipiac River near where the oysters were placed in fresh water to 
“fatten,”—absorb fresh water—just before they were to be used, were the 
source and cause of the outbreak. Twenty-three students and six other 
persons who attended the banquet, contracted the disease. 
The general subject of typhoid bacteriology and oysters in salt and fresh 
waters, at ordinary temperatures, was afterwards investigated by Charles 
J. Foote, Demonstrator of Bacteriology in Yale University.§ “Many 
bacilli were found in the oyster juice and in the stomach of the oyster a 
month after infection, from which it appears that typhoid bacilli may live 
even longer in the oyster than in the water which surrounds it, from which 
they usually disappear within three weeks when new infection does not 
occur.”^[ 
Typhoid Fever Spread by Infected Clothing. 
Dr. Kober in the report of the health officer of the District of Colum- 
bia, for 1895, page 259, summarizes a report by Gelau as follows: “A Ger- 
man artillery regiment, with an average mean strength of 358 men, between 
the years 1873 and 1884 furnished not less than 146 cases of typhoid fever. 
* Pages 346-364. 
t Page 330. 
+ Report by H. W. Conn. Professor of Biology, Wesleyan University, pp. 243-264. 
§ Med. News, Mar. 23,1895. 
T Modern Medicine, Feb., 18P6, p. 40. STATE BOARD OF HEALTH—REPORT OF SECRETARY, 1896. 
The water-supply was above suspicion, disinfection of the quarters and 
even abandonment of the barracks failed to check the disease. This fin- 
ally led to the suspicion that the clothing might be the source of infection, 
especially as the garments were promiscuously worn. Examination revealed 
the presence of fecal spots in a number of pantaloons. The clothing was 
now disinfected, after which only three mild cases appeared, and these were 
confined to the men engaged in disinfection.” 
In several instances brought to my notice but not published, typhoid 
fever has, apparently, been contracted by taking the specific cause into the 
mouth with the air inhaled. In two such instances the nurses who con- 
tracted the disease slept in the same room with their patients. Bearing in 
mind the frequency with which a sleeping person breathes through the 
mouth, and the fact that then the normal protection of the nose with its 
moist hairs, disinfecting saline mucus, constantly flowing downward to be 
evaporated and imprison incoming dust and germs, one may realize the 
greater liability of a sleeping person to contract typhoid fever. In the 
Southern States it has many times been observed that yellow fever is much 
more often contracted by sleeping in an infected locality than by visiting 
it in the daytime. 
While investigating an outbreak of typhoid fever in the State Prison at 
Jackson, I contracted typhoid fever notwithstanding I took no food or 
water while there. The outbreak occurred soon after a new prisoner had 
come into the prison, and the disease was apparently spread in more ways 
than one, but not through the drinking water. A wooden bucket in each 
cell every night was emptied every morning, and an attempt made to dis- 
infect it by rinsing it with a disinfecting solution; but inspection led me 
to think that the disinfection was not complete, so it is possible that some 
of the cases were caused by emanations from an infected bucket, because 
no effort was made to have the same bucket go to the same cell every night. 
Among the first persons about the prison to contract typhoid fever, was 
the guard who was stationed on top of the wall immediately over the place 
where the buckets were each morning emptied into the sewer, then rinsed 
and placed in rows to be dried and aired during the day. The typhoid 
patients were put in the hospital on the fourth floor of the central build- 
ing, and their dejecta went into a Soil-pipe in which there Was a break, or 
from which air could pass through a “dead-end” to a sewer under the 
lowest floor. 
In cells along a line between this source of sewer air and a very large 
ventilator at the other end of the room, prisoners contracted typhoid fever, 
so there was reason to believe that the disease was spread through the air 
from the soil-pipe, on its way to the ventilator. To answer the question 
whether this was possible, because it was known that micro-organisms 
are not given off to the air from moist surfaces, a bottle was sterilized, filled 
with sterilized water, the bottle held in the “dead-end” to the sewer, the 
water allowed to run out, and the bottle to fill with air from the sewer. 
While this was being done, the soil-pipe from the hospital on the fourth 
floor was flushed, foul air rushed out but no .fluid or solid came near the 
bottle. Meantime, with other members of the State Board of Health, I 
was standing near in conversation with the Warden of the Prison, The bottle 
was taken by Prof. Vaughan to the laboratory at the University, and I 
Typhoid Fever Spread Through the Air. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEYER. 
understand that Prof. Yaughan found the bacillus of Eberth or at least 
a pathogenic bacillus in its interior. Soon after my return home, I was 
mildly sick for nearly three weeks, with unmistakable typhoid fever, 
contracted apparently through the atmosphere. 
A few years ago, there was typhoid fever in Iron Mountain, Michigan, 
and it was especially noticeable to Dr. Anderson, then in that city, that 
there were most fever cases in houses the rear ends of which were on the 
three sides of a sort of court in which were numerous foul privies which in 
wet times drained into a foul pond near the center of the court, but which 
in a dry time permitted their overflowed contents to be trampled by those 
who passed through into dust to be blown about by the winds. One windy 
day, I inspected the locality, and it was easy to understand that if the 
specific cause of typhoid fever had been deposited in any one of the privies, 
its dissemination by the wind would be almost certain, because the germ is 
not rapidly destroyed by drying. 
What is the Specific Cause of Typhoid Fever? 
Dr. George M, Kober, of Washington, D. C., in a recent report on the 
subject, after giving different views of the specific cause, has said; “All 
scientific physicians agree, however, upon one point, viz., that typhoid 
fever is caused by an organized germ capable of reproducing itself within 
and without the body.”* 
Just here, however, is where we arrive at a point in the etiology where 
differences of opinion exist; for, while a majority of the prominent bac- 
teriologists conclude that the Bacillus typhosus demonstrated in typhoid 
cadavers by Eberth in 1880, and obtained in pure cultures by Gaffky in 
1884, is the sole and only cause of typhoid fever, there are those who regard 
this as, to say the least, “not proven.” Thus, the last edition of “Ptomains 
and Leucomains” by Vaughan and Novy, says: “In this belief Yaughan 
refuses to concur, and claims that the Eberth bacillus as found in the 
spleen after death is an involution-form of any one of a number of germs 
which are found in certain waters. Yaughan claims that the typhoid 
bacilli can be detected in drinking-water by the following characteristics: 
(1) They grow at 37°, while many of the non-pathogenic germs of water 
grow only at lower temperatures. (2) They are pathogenic to rats, guinea- 
pigs, mice, and rabbits. (3) They do not coagulate milk. (4) When grown 
in milk or gelatin colored blue with litmus, the color is not altered.”! 
A recent writer has stated that the pathology of typhoid fever has long 
been known, but the etiology has only recently been discovered. In this 
paper I shall endeavor to omit so much of the pathology as has very long 
been known, and devote all the time I am permitted to use to the considera- 
tion of a few points in pathology which are comparatively new. And, to 
my mind, there are a number of important facts in pathology which have 
not very long been known; facts which could not be fully appreciated until 
considerable progress had been made in the etiology of the disease, Eor 
instance, the significance of abscesses, in various parts of the body, could 
not be appreciated until the bacteriologists had investigated the pus in 
THE PATHOLOGY OF TYPHOID FEVER. 
* Report of Health Officer of the District of Columbia, 1893, p. 257. 
+ Edition 1896, page 208. STATE BOARD OF HEALTH—REPORT OF SECRETARY, 1896. 
those abscesses, and found there the apparent specific cause of typhoid 
fever. A new light is thrown on the pathology of typhoid fever by the 
knowledge that the specific germ has been found in the blood, and in nearly 
every organ and tissue of the body. This supports the view that typhoid 
fever is a disease of general blood infection. New light is supplied by the 
knowledge that the life-processes of the germs produce a poison, the effects 
of which, in various parts of the body, are important. Thus “Sanarelli’s 
prolonged studies upon experimental typhoid fever lead him to maintain 
that the intestinal disturbances in this disease are due to the toxin, and 
not to the local action of the typhoid bacteria.”* 
“Agro (Annales de Micrographie, vi., 1894) has discovered the very 
interesting fact that the mixture of the cultures of bacilli coli and bacillus 
typhi abdominalis has greater toxic power than a similar quantity of either 
in pure culture/’f 
“In 1889 Vaughan isolated from mixed cultures from typhoid stools a base, 
forming crystalline salts and capable of inducing in cats and dogs a marked 
elevation of temperature accompanied by severe purging.”* 
“In 1890 Vaughan reported the isolation, from water supposed to cause 
typhoid fever, of a number of toxicogenic germs. The chemic products of 
two of these have been studied. They belong to the proteids, and an 
analysis of one of them by Freer shows it to belong to the nucleins 
In a paper read at the meeting of the American Medical Association at 
Baltimore, in 1895, William B. Noyes, M. D., of New York, after stating 
the proportions of children in each of numerous epidemics in Europe 
and in this country, says: “In conclusion, we would once more emphasize 
that typhoid in early infancy in a typical form is rare in this country, 
though not uncommon abroad. It is in a mild or abortive form that we 
much look for it here, if we wish to separate it from other intestinal or 
meningeal diseases that may appear.” 
Dr. Noyes says;— 
“ The pathologic changes in the infantile cases, while distinct, are much less severe than in adults. 
It is a very interesting fact that in a series of animal inoculations with typhoid bacilli by Santerelli 
(Annals de L'lnstitute Pasteur, 1892-1594) the changes in the intestine and other viscera were almost 
identical with those we have just described in children. These experiments consisted of a series of 
inoculations of rabbits, guinea pigs, white mice and monkeys with pure cultures of the Eberth bacil- 
lus, and were followed by a second series of experiments of inoculations with sterilized filtered pro- 
ducts of the Eberth bacillus. The results were similar in the two cases. Swollen hyperemic spleen, 
congested intestine, diarrheal intestinal contents, infiltrated and congested Peyer’s patches, red and 
hypertrophied solitary follicles. Hardened microscopic sections of the intestine showed a change in 
the epithelial lining, especially, and detachment of masses of epithelial cells together, such as 
occurs in a poisoning by arsenic or other corrosive drugs. Enormous infiltration of Peyer's patches 
occurred, abundant accumulation of lymphoid cells in and around the follicles and invading the sub- 
mucous spaces. This change was not a simple hypertrophy of lymphatic plaques, but a condition just 
short of a beginning purulent infiltration. No typhoid bacilli could be found in these Peyer’s patches 
in the animal, but enormous numbers were seen in the adjacent lymphatic glands and in the connective 
tissue of the mesentery. From these experiments, Santerelli comes to the conclusion that typhoid 
fever produced in animals is by preference an infection of the lymphatic system, and the toxin pro- 
duced by the Eberth bacillus causes the anatomic lesions. These changes occur in all mucous surfaces 
and we should expect to find in both animals and in man, lesions in the mucous membrane of the mouth, 
larynx, bronchi and stomach with resulting symptoms which occur very frequently. Typhoid fever can 
no more truly be called a disease of the intestine than small-pox of the skin, though both have their 
characteristic lesions in those places.”-—Jour. Amer. Med. Assoc. Vol. 25, Sept. 2S, 1895, pp. 530-31, 
* Jour. Amer. Med. Assoc , Vol. 23, Oec 22, 1891, p. 933. 
f Jour. Amer. Med. Assoc., Vol. 23, Dec. 22, 1891, p. 931-935. 
I Ptomains and Leucomains, 1896, p. 209. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
“Stern {Volkmann's Sammlung klinischer Vortrage, No. 138) has published another suggestive paper 
on typhoid.” * * * “ The question as to the presence of typhoid bacilli in the blood was tested in six 
cases, with positive results in three ; twice in blood from roseohe and once in blood from a vein. In the 
negative cases the blood was examined only once in two of the three cases. In the third case, confirmed 
by autopsy, three examinations were negative. In the cases with positive results the number of colonies 
was always small, as has been found by other investigators. The bacilli were found between the ninth 
and twenty-fifth days of the disease. The question whether the blood from the spots or that from the 
veins is most favorable requires further investigation.’’* 
Otitis in Typhoid Fever. 
The hearing is often affected in typhoid fever, “Botkin states as the 
results of observation in twenty-six cases, that he found in all but five an 
acute and bilateral inflammation of the outer ear.”f 
“Peri-articular Abscess due to the Typhoid Bacillus. 
“Swiezynsky (Centralblatt fur Bakteriologie und Parasitenkunde, Band 
xvi., No. 19, p. 775) has reported the case of a man, 18 years old, with the 
following sequence of an attack of typhoid fever of considerable severity: 
swelling and pain appeared in the right arm, followed by redness, tender- 
ness, and fluctuation about the shoulder-joint, although this itself was not 
involved. In the course of a little while an abscess formed beneath the 
right deltoid, and an incision evacuated a quantity of pus mixed with 
blood.” * * * “Bacteriologic investigation of the pus evacuated from 
the abscess about the joint disclosed the presence of typhoid bacilli 
exclusively.’’J 
Pylephlebitis and Abscess of the Liver Following Typhoid Fever. 
“Lannois has recently described pylephlebitis and abscess of the liver 
following typhoid, in which the bacillus of was present in the pus 
from the abscess, though not in pure culture.Ӥ 
Intrauterine Infection with Typhoid. 
“Freund and Levy (Berliner klinische Wochenschrift, 1895, No. 25) 
report the case of a multigravida who was admitted to the hospital in the 
eighth day of typhoid, being five months pregnant. She progressed fav- 
orably until the fourth week, the temperature being but slightly elevated. 
Without apparent cause she expelled a living foetus, which soon perished. 
Her temperature rose during labor, but fell immediately afterwards. The 
foetus and placenta were received in sterile glass vessels, and an examina- 
tion made of the spleen, blood of the heart, and placenta twenty minutes 
after birth. No gross lesions were found. Typhoid bacilli developed, 
however, after incubation.” * * * 
“The case is a remarkable demonstration of the direct passage of infec- 
tion from mother to child, without anatomical lesions.”)] 
Suppurative Parotitis Caused by the Typhoid Bacillus. 
“To the list of suppurative processes complicating typhoid fever, in 
which the typhoid bacillus alone has been found as the cause of the abscess 
* Amer. Jour. Med. Sci., Vol. 111, March, 1896, pp. 349-350, 
t Jour. Amer. Med. Assoc., April 5, 1896, p, 694. 
i Amer. Jour. Med. Sci., Vol 109,1895, p. 328. 
S Amer. Jour. Med. Sci., Vol. 111, March, 1896, p. 347. 
(I Amer. Jour. Medical Sci , Vol. 110, Oat., 1895, pp, 488-489, STATE BOARD OF HEALTH.—REPORT OF SECRETARY, 1896. 
formation, Janowski,* has recently (in 1895) added a case of suppurative 
parotitis. ”t 
“The patient, a young man, had been sick in the hospital seven weeks, 
during which time he had greatly emaciated; had had more or less fever, 
and toward the last had developed hemorrhagic nephritis and a tender 
enlargement of the right parotid gland. The diagnosis of typhoid fever was 
first made on the autopsy-table, Beyer’s patches showing distinct appear- 
ances of recently-healed ulceration. The right parotid gland was found to 
be infiltrated with pus, which was in places collected in small abscesses. 
Cultures from this pus developed only the typhoid bacillus, whose idenity 
was carefully proved with comparison of known cultures of the typhoid 
bacillus and of the bacillus coli communisJ 
In a paper read at the meeting of the American Medical Association in 
1889, Professor Yaughan, in speaking of the Eberth bacillus, said:—“Gaffky 
and others found it always present in the mesenteric glands and spleen, 
often in the liver, and not so frequently in the kidney. In the intestine it 
has been found in the early stages in the swollen follicles and plaques and in 
the deeper layers, before there is any necrosis; but with the advent of ulcera- 
tion there is found secondary invasion. But in addition to these organs, the 
Eberth germ has been reported by Chantemesse and Yidal in the lungs of 
typhoid patients with bronchitis, broncho-pneumonia, and pneumonia. The 
same observers report the germ in the brain, Curschmann in the spinal cord, 
Zenker and Hoffmann in the voluntary muscles and in the marrow of the 
bones, and Rehtr, Neuhauss and Chantemesse and Yidal in the placenta 
of typhoid patients. In twenty samples of blood taken from the finger, 
during life, of typhoid patients, Meisels reports the finding of this germ in 
nineteen. Neuhauss examined the blood taken from the eruptive spots in 
typhoid fever with success. Maraglinao and others examine the blood 
taken from the spleen during life as a means of diagnosis.” * * * 
“Granting that these observers have not been mistaken in the nature of the 
germ which they have found, we must admit that the Eberth germ is widely 
distributed.Ӥ 
In the same paper Dr. Yaughan says; “To sum up the evidence which 
we have found on this point we may say: (1) The Eberth germ is found 
invariably in the bodies of those dead from typhoid fever. (2) It has been 
isolated and grown in pure cultures. (8) All attempts to induce typhoid 
fever in the lower animals by inoculation with this germ have so far been 
without success. (4) Experiments show not only that the germs fail to 
multiply in the lower animals, but that when introduced by inoculation it 
soon died. * * * But the bacteriologist stops here and says; ‘The lower 
animals do not have typhoid fever, and we must not conclude from the 
failure to induce this disease in them with Eberth’s germ that this bacillus 
is not the true cause of typhoid fever.’ ‘lf we could experiment upon 
man,’ says he, T have no doubt that we could be successful.’ 
Because the chemical products of the Eberth bacillus had not been 
demonstrated to be capable of producing the characteristic symptoms and 
lesions of typhoid fever, Dr. Vaughan then said; “We certainly cannot say 
that the Eberth germ has been demonstrated to be the true and sufficient 
cause of typhoid fever.” j) 
♦ Cenralblatt f. Bakt. u Parasitenknnde, 1895, XVII., No. 22,875. 
JAm. Jour. Med Sciences, October, 1893, page 501. 
Am. Jour. Med. Sciences, October, 1895, page 501. 
Jour. Amer. Med. Assoc., Vol 13, 1889, pp. 831-32. 
Jour. Amer Med. Assoc , Vol. 13, 1889. page* 832-33. 
i| Jour. Amer. Med Assoc., Dec. 14, 1889, page 833. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
But in that same address Dr. Vaughan gave details of the inoculation of 
several dogs with a pure culture of germs resembling the Eberth bacillus, 
and in several instances the pathological results resembled those of typhoid 
fever in man. Dr. Vaughan said: “Notwithstanding the marked resemblance 
of our cultures to those of the Eberth germ, I must conclude from the 
effects obtained that we either had a wholly different organism or an impure 
culture.”* Other investigators believe that typhoid fever is due to a mixed 
infection. 
Typhoid Bacilli in the Urine; Typhoid Fever a General Blood Infection, 
One of the most important ideas, however, is the view set forth by Drs. 
Wright and Semple, professor and assistant professor of pathology in the 
British Army Medical School at Netley, based partly upon their experi- 
ments on the infectivity of the urine in typhoid fever, which had been 
previously pointed out by Sanarelli working under the auspices of Metsch- 
nikoff, but on which fact Drs. Wright and Semple build up still further 
Sanarelli’s new theory on the pathology of typhoid fever. Drs. Wright 
and Semple found the typhoid bacillus in the urine of six out of seven 
cases of typhoid fever. “In some cases the urine, even before incubation, 
is absolutely turbid with typhoid bacilli.”f 
They say:J 
“ The theory of typhoid fever, which is currently held and currently acted upon, is the theory that 
typhoid fever is an ' intoxication process’ much in the same way as cholera is an ‘ intoxication process. 
In other words it is assumed that the typhoid bacillus vegetates in the intestine, that it effects a lodg-. 
ment in the intestinal walls and that the poisons which are elaborated by the bacelli are absorbed into 
the system from the intestine. The systemic disturbance which characterizes typhoid fever is 
attributed to this absorption. This theory of typhoid fever is brought into harmony with notorious 
bacteriological facts by the assumption that there is a certain leakage of typhoid bacilli from the 
intestine into the system. This leakage theory is supposed to dispose of the fact that typhoid bacilli 
are invariably found in the spleen and mesenteric glands of patients suffering with typhoid fever. Now, 
this ‘intoxication’ theory of typhoid fever was originally based upon the fact that a bacillus which is 
morphologically indistinguishable from the typhoid bacillus is found in large quantities in the stools 
in every case of typhoid fever. Subsequent investigation, however, showed that this bacillus which 
predominates in the intestinal floor in cases of typhoid fever can be distinguished from the true typhoid 
fever bacillus by a series of chemical differences. The bacillus which is found in large quantities in the 
stools of patients suffering from typhoid fever is therefore not the true typhoid bacillus. It is the 
bacillus which is known by the name of ‘ Bacillus coli communis.’ Recent research has therefore been 
directed to the question as to whether, in addition to the bacillus coli communis, the true typhoid 
bacillus is not also to be found in the stools of patients suffering from typhoid fever. The following 
are the results of careful examination of this question: The true type of typhoid bacillus was detected 
in the stools of only four of the twelve cases of typhoid fever which were studied by Wathelet. In 
the case of these four patients the typhoid bacillus was detected only four times in a total of twenty- 
four examinations and even on these four occasions the true typhoid bacillus was outnumbered by the 
bacillus coli communis in the proportion of about three to one. In the case of the other eight cases of 
typhoid fever the bacillus appeared to be absent from the stools throughout the whole course of the 
disease. Wathelet has further shown that if the bacillus typhosus and the bacillus coli communis are 
implanted into one and the same tube of nutrient broth the bacillus coli communis will outgrow and 
kill off the typhoid fever bacillus even when at the outset an enormous numerical preponderance is 
given to the typhoid bacillus over the bacillus coli communis. Again, Wathelet has shown that 
whereas the bacillus coli communis will flourish in a nutrient medium containing the toxins elaborated 
by the typhoid fever bacillus, the typhoid fever bacillus will not grow in a nutrient medium containing 
the toxins elaborated by the bacillus coli communis. If this holds true in every case, and it has seemed 
* Journal Amer. Med. Assoc., Dec. 14, 1889. page 834. 
+ London Lancet, July-Dee., 1895, page 199. 
i London Lancet, July-Dee., 1895, pages 196-9. STATE BOARD OF HEALTH—REPORT OF SECRETARY, 1896, 
to hold true in the few test experiments we have performed, we are evidently in a position to infer on 
a priori grounds that typhoid fever bacilli will be absent from the intestine whenever, as in the case of 
typhoid fever, we have to deal with the multiplication of the bacillus coli communis in the intestine. 
Both a priori reasons and actual observations therefore point to the absence of typhoid fever bacilli 
fxom the intestinal tract, and therefore the symptoms of typhoid fever cannot be interpreted as a result 
of the absorption of typhoid toxins from the intestine. They seem to ignore the poison of the bacillus 
coli communis. We are therefore compelled to seek for a new theory for typhoid fever, and if typhoid 
fever is not the result of an intestinal intoxication process we must evidently seek to explain it as a 
result of blood infection. This is, if we understand it aright, the theory of typhoid fever which has 
recently been put forward by Sanarelli, under the auspices of Metchnikoff. We have to see whether 
typhoid fever can be explained upon the basis of this theory. And evidently the first thing to be 
explained in the case of typhoid fever is the turgidity of the spleen and the presence of the typhoid 
bacilli in the splenic tissue. Now, this turgidity of spleen and this presence of micro-organisms in the 
splenic tissue is an invariable accompaniment of every septicsemic process. We find it in the case of 
such blood infections as anthrax in cattle and spirillum fever and malaria in man. And we have the 
explanation of this phenomenon in the experiments of Werigo which show that the introduction of any 
foreign particulate matter into the blood invariably results in a deposition of that particulate matter 
in the spleen (and other internal organs), and in an aggregation of polynuclear white blood corpuscles 
around the foreign particulate matter, and finally in a process of phagocytosis. Every body who has a 
rabbit and a little carmine, or any bacterial culture at his disposal, can readily verify these facts for 
himself. The enlarged spleen and the presence of bacteria there are thus quite in harmony with the 
theory of a blood infection in typhoid fever. The fact that the white blood corpuscles are diminished* 
in the circulating blood in typhoid fever is also in harmony with this explanation. We have further in 
connection with typhoid fever to account for the eruption of pink spots on the skin. These were inex- 
plicable on the intoxication theory of typhoid fever. They are, however, of the easiest explanation 
if we make the assumption that typhoid fever is characterized by a blood infection, for here, as in other 
cases, we may instance the skin eruption in the case of human glanders; the spots evidently correspond 
to lodgments of the bacteria in the capillaries of the skin. This interpretation of the skin eruption has 
been borne out in the case of typhoid fever jnst as it has in the case of glanders by the fact that the 
specific bacteria have been cultivated from the spots. We have been able to confirm this observation 
in one of the cases of typhoid fever reported below. 
“ The intestinal symptons of typhoid fever are of somewhat uncertain explanation. Possibly they 
are to be explained as Sanerelli explains them, as a specific effect of the typhoid fever toxin on the 
adenoid tissue of the intestine, and of the subsequent invasion of that tissue by the bacillus coli com- 
munis” * * * “ The occasional presence of typhoid bacilli in the intestine is easily accounted for by 
assuming that a certain number of the typhoid fever bacilli escape through the intestinal wall into the 
intestinal contents. 
“ In addition to the points which have just been touched upon, we may refer to other points which, 
although they have been comparatively neglected, throw an important light upon the pathological 
processes which are associated with typhoid fever. The phenomena in point are the presence of 
so-called 1 miliary lymphomata1 in the kidney and the presence of the typhoid bacilli in the urine. We 
have no recent opportunity of studying the miliary lymphomata which are describ d as occurring in 
typhoid fever, but they are probably quite comparable to the miliary lymphomata which are described 
as occurring in the spleen in cases of spirillum fever, and to the miliary lymphomata which are pro- 
duced by the injection of fairly resistant bacteria, such as tubercle bacteria into the blood. Such 
lymphomata correspond to aggregations of the white blood corpuscles around bacteria which have 
lodged in the capillaries. They are a repetition in small of the aggregations of phagocytic white blood 
corpuscles which are seen on a far larger scale in the spleen. Lastly, in regard to the presence of 
typhoid fever bacilli in the urine. Even if typhoid fever bacilli were found in the urine only in 
occasional cases their presence there would be a strong argument in favor of the theory of a blood infec- 
tion and against the intestinal intoxication theory. But the argument in favor of the septicaemic 
theory of typhoid fever becomes irresistible if it can be shown that the typhoid fever bacilli are almost 
always found in the urine in cases of typhoid fever. With a view of ascertaining this point we have 
examined the urine in the following typical cases of typhoid fever.” 
*“ It may be pointed out incidentally here that the paucity of white blood corpuscles in the blood pro- 
bably stands in some connection with the fact that epistaxis is of frequent occurrence in typhoid fever. 
This epistaxis, if we may judge from a great many observations which one of us has made of the con- 
dition of the blood-coagulability, is almost certainly an indication of a diminished blood-coagulability 
such as can be obtained by the injection of particulate matter into the blood. In an experiment made 
by one of us the coagulation time of a dog’s blood in the standard capillary tube was reduced from 
three minutes to fifteen minutes by an injection of carmine particles. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEYER. 
The Journal of the American Medical Association summarizes the con- 
clusions of Drs. Wright and Semple as follows:* 
“1. It is true that the typhoid bacilli are present in the urine of patients 
suffering from typhoid fever, and if, as we shall see, typhoid bacilli are 
generally absent from the feces, it will be evident that it is the urine, and 
not the feces of patients suffering from typhoid fever which is responsible 
for the spread of typhoid infection. 
“2. If typhoid bacilli are constantly present in the urine of typhoid 
patients it may be possible to diagnose the presence or absence of typhoid 
fever by undertaking a bacteriologic examination of the urine. 
“8. If it is true that typhoid bacilli are constantly present in the urine 
in cases of typhoid fever while they are generally absent from the feces, 
it will be evident that the conception of typhoid fever upon which the 
ordinary clinician proceeds is an entirely erroneous one. 
“4. The working hypothesis regarding this fever in the minds of medi- 
cal men generally, favoring as it does the notion that this fever is an 
intestinal intoxication process, should be revised, and substituted for it one 
that will have regard to the wide range of pathologic appearances, some of 
which at least fit in well with a hypothesis of blood infection, such as 
malarial fever in man and anthrax in cattle.” 
While most of the views expressed by Drs. Wright and Semple seem 
to me to accord with the facts, a few important discrepancies are noticeable, 
(1.) From several lines of evidence it is apparent that the infection of 
the body by typhoid fever is primarily by way of the alimentary canal: 
therefore, the “assumption that there is a certain leakage of typhoid bacilli 
from the intestine into the system” appears to be true in fact. This, 
however, does not negative their assumption that later there may be a 
“leakage” from the general circulation and the tissues into the intestine. 
(2.) Inasmuch as the common bacillus of the colon is increased in typhoid 
fever, and in its life processes produces a poison which when mixed with 
the product of the typhoid bacillus has increased toxic power,f intestinal 
antiseptics in typhoid fever may yet be important, notwithstanding the 
contrary suggestion of Drs. Wright and Semple, so that, although we may 
come to rely upon the poison of the bacillus coli communis to destroy the 
typhoid germs, instead of substituting for the intestinal intoxication 
theory, there may be added to that doctrine the idea of general blood and 
systemic infection, which seems to be well established by the independent 
observations of a very great number of investigators. 
* Jour. Amer. Med. Assoc., Oct. 5, 1895, p. 589. % 
t Agro, Annales de Micrographie, vi, 1894: Jour. Amer. Med. Assoc , Vol. 23, pp. 934-935, Dec. 22,1894. STATE BOARD OF HEALTH—REPORT OF SECRETARY, 1896. 
No. 
Date. 
Place- 
No. of cases. 
1 No. of deaths. 
No. of cases among 
milk consumers. 
| Per cent. 
Circumstances of the outbreak. 
Reporter and reference. 
1 
Penrith 
The outbreak, which affected 7 families, was traced 
to a supply derived from a milkman in whose cot- 
tage were cases of typhoid fever. The milk was 
kept in the kitchen, where the children lay, and the 
mother, who was the nurse, also milked the cows. 
Dr. M. W. Taylor, Edin. Med. 
Jour., May, 1858; Brit. Med. 
Jour., Vol. II, 1870, p. 623. 
2 
July and Aug , 1870 
Islington (part of)... 
175 
30 
175 
100 
No evidence of typhoid fever at the premises; there 
was an underground water tank at the milk shop, 
communicating by means of rat burrows with two 
old drains, possible overflow of sewage from these 
into the tank, from which the water was used to 
wash the milk cans. 
Dr. E. Ballard, M. O. H., Brit. 
Med. Jour., Yol. 11, 1870, p. 589. 
Med, Times and Gazette, Vol. 
II, 1870, p. 611. 
3 
Armley, near Leeds.- 
107 
11 
Traced to a milk farm where typhoid occurred in 
Dr. E. Ballard, M. O. H., Reports 
May, dejecta suspected tohave been thrown on dung 
pit; in the latter part of the patient’s illness copious 
rains fell and probably washed the germs from the 
pit or polluted soil into the well, as about this time 
the cause of the fever began to operate among con- 
sumers of milk. 
Medical Officer of privy council 
and local government board, 
Vol. II, 1874, p. 79. 
4 
Leeds 
93 
14 
80 
86 
Typhoid f-ver at milk farm since September. Water 
Dr. M. K. Robinson, M. O. H., 
supply pure, sick room communicated with kitchen 
and dairy, and the air of these premises common. 
Kitchen drain communicated with manure heap, 
and the privy, which received typhoid excreta, was 
overflowing. 
Brit. Med. Jour., Vol. I, 1873, 
p. 68. 
Note.—In this appendix, 171 outbreaks of typhoid fever believed to be due to contaminated milk are grouped. The first 49, collected by Ernest Hart, and the 
succeeding 89, collected by Drs. Busey and Kober, are taken from the appendix of the Report of the Health Officer of the District' of Columbia for 1895. The 
succeeding 9 were collected by Henry B. Baker, M. D., Secretary of the Mich. State Board of Health. The remaining 24 were collected by Dr. Rowland Godfrey 
Freeman, and published in his pamphlet, “ Milk as an Agency in the Conveyance of Disease.” In his pamphlet, however, Dr. Freeman cites 53 outbreaks, 29 of 
which are previously mentioned in this appendix as collected by Drs. Busey and Kober. 
Epidemics of Milk-Typhoid. (Hart.) 
APPENDIX. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEYER 
5 
Nov. and Dec., 1872 
Moseley and Balsall 
Heath. 
96 
10 
A'case of what was no doubt typhoid fever occurred 
in a house located between two milk sellers; dejecta 
thrown into the privy from which the virus must 
have found access to the water of the milk sellers’ 
wells. One of them polluted the milk, the other 
made no profession of selling it pure. 
Dr. E. Ballard, M. O. H., Report 
Medical Officer local govern- 
ment board, No. II, 1874, p. 92. 
Brit. Med. Jour., Vol. I, 1873, 
p. 68. 
6 
Jan., 1873 
Parkhead, Glasgow.. 
39 
6 
46 
86 
Typhoid fever at dairy among the children in Decern- 
Dr. J. B. Russell, M, 0. H,, Glas- 
ber. Milkers also nursed the affected children. 
gow Med. Jour. 
. 7 
April, 1873__. 
Chester 
15 
15 
100 
Cases of fever at the milk shop in the latter part of 
Dr. E. Waters. 
1872. A grocery and provision shop used also as a 
milk house. 
8 
July and Aug., 1873 
Marylebone and ad- 
joining districts. 
244 
26 
218 
89 
Occupant of milk farm died June 8 of ambulant ty- 
phoid fever; dejecta buried in an ash heap, the 
soakings from which must have found access to the 
well used for dairy purposes. 
Dr. J. N. Radcliffe and W. H 
Power, Report Medical Officer 
local govt, board, No. II, 1874, 
pp. 103-136; Brit. Med. Jour., 
Yol. II, 1873, pp. 206, 207, 296. 
9 
July, 1873, to Nov., 1877. 
Ascot 
69 
58 
84 
No case of typhoid occurred at the milk farm till 
Dr. E. Ballard, Brit. Med. Jour., 
August, 1876, when the epidemic had lasted for 
three years. Contagion originally reached farm 
probably through the water entering the well in 
the yard, carrying the germ from elsewhere, after 
which the water used for washing milk utensils had 
an opportunity of specific pollution at the farm. 
Yol. 1,1880, p. 83; Report Med. 
Officer local government board 
for 1877, p. 39. 
10 
August, 1873 
Brighouse, Yorkshire 
68 
8 
65 
95 
No typhoid fever at milk farm or dairy ; cows healthy, 
but drank from a cess pool. Complaints of milk 
smelling badly and becoming offensive after stand- 
ing awhile. 
Dr. T. Britton, M. O. H., Brit. 
Med. Jour., Vol. II, 1873, pp, 
267 and 334. 
11 
August, 1873.. 
63 
14 
Two children of dairyman sick with typhoid fever in 
Dr. J. H. Love, M.O. H., Brit. Med. 
August. Well within a few inches of an old flat- 
bottomed brick sewer. Epidemic stayed by cutting 
off the supply of pump water by this milkman. 
Jour., Yol. 11, 1873, pp. 267, 290, 
334, 447. 
12 
May and June, 1874 
Brierly Lane. .. 
65 
4 
50 
76 
First person attacked was the dairyman. Wife 
Dr. R. T. Thorne, Brit. Medical 
nursed him and milked the cows. The dairy well 
upon analysis was found ‘little better than filtered 
sewage.’ No evidence, however, of specific pollu- 
tion. 
Jour., Yol. II, 1874, p.391; Sani- 
tary Record, Vol. I, 1874, p. 214. 
13 
June, 1874 .. 
Taunton 
5 
5 
100 
No evidence of typhoid fever at the source of milk 
Dr. H. J. Alvord, M. O. H. 
supply. Well water of the dairy subject to “ fear- 
ful contamination with the sewage.” 
14 
August, 1874 
Queensbury 
36 
1 
34 
94 
Farmer’s wife sickened of typhoid during outbreak. 
Ann. Report of Med. Officer of 
Well close to house; drain roughly made of stone. 
Earth between drain and well saturated with 
sewage. 
Health for 1874. STATE BOARD OF HEALTH.—REPORT OF SECRETARY, 1896. 
No. 
Date. 
Place. 
No. of cases. 
j No of deaths. 
No. of cases among 
milk consumers. 
1 Per cent. 
Circumstances of the outbreak. 
Reporter and reference. 
15 
Oct. and v. 1874 
Dundee 
19 
4 
19 
100 
Typhoid fever cases at farm; 4 patients occupied a 
bedroom adjoining the milk store. Well water re- 
ported to be contaminated with the products of 
decomposing organic matter of the nature of 
sewage. 
Dr. G. C. Pirie, M. O, H., Brit. 
Med. Jour., Vol. 1, 1875, p. 225, 
16 
Feb. and Mar,, 1875 
Crossbill, Renfrew- 
153 
Drs. H. D. Littlejohnand E. Dun- 
can, Brit. Med. Jour., Vol. I, 
1875, p. 391. Sanitary Record, 
Vol. II, 1875, p. 61. 
shire. 
ease; dejecta thrown either in the manure heap or 
into the ditch. Nurses also connected with the 
collection and disposal of the milk. Well water 
quite impure. 
17 
August, 1875 
34 
2 
31 
91 
Six of the farmer’s family, including himself, found 
ill with typhoid. Direct communication between 
dairy and sick room. Dairy also used as a wash 
house. The daughter acted as nurse and milkmaid. 
Dr, John Spear, M. O. H., Brit. 
Med. Jour., Vol. II, 1875, p. 372. 
Sanitary Record, Vol. Ill, 1875, 
p. 195. 
18 
September, 1875 
2 59 
3 
58 
98 
Two cases of typhoid at farm. Washing for patients 
done on August 3,10, and 27, in a wash house closely 
situated near pump well. Water quite impure. 
Dr. J. B. Russell, M. O. H., Brit. 
Med. Jour., Vol. II, 1875, p. 535. 
19 
September, 1875 
Glasgow3 
121 
3 
98 
81 
Do. 
20 
Jan. and Feb , 1876 
a Eagley and Bolton 
105 
13 
No typhoid fever cases at farm, which, however, de- 
pended for its water supply upon a brook which 
had been fouled with the excrement of men engaged 
in building a mill 200 yards off. There was evidence 
that some individual who had used the stream had 
suffered from diarrhea. 
Dr. W. H. Power to local govern- 
ment board. J. Robinson, M. 
O. H., Brit. Med. Jour., 1876, 
pp. 201, 233, 273, 293, 491. 
21 
Autumn, 1876... 
Cburwell and Morley 
(*) 
9 
A case of fever at the farm; well water unfit for 
drinking purposes, but farmer denied having used 
it for dairy purposes. 
Dr. J. G. Clark, M. 0. H. 
29 
February, 1876 
144 
8 
Greenock 
20 
A farmer allowed a case to be brought into his house 
and after awhile 3 servants and several members of 
his family wore taken sick with enteric fever, and 
communicated the disease to over 200 consumers 
of milk. 
Brit. Med. Jour., Vol. 1,1876, p. 
425. Sanitary Record, Vol. IV, 
p. 234. 
Epidemics of Milk-Typhoid. {Hart.)—Continued. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
22 
Nov., 1876 „ 
Great Coggeshall 
28 
28 
100 
Imported case of typhoid fever at dairy, dejecta 
thrown into a drain emptying into a brook which 
was used for dairy purposes. 
Dr. R. T. Thorne, Official Report. 
23 
Dec , 1876 
13 
13 
100 
Sixteen cases of typhoid at the farm within twenty 
years. Well close to a privy cesspool, and a yard 
or so off was a sink for dirty water. 
Rep. of Med. Off. of Health 
for Salford, 1875-76. 
24 
Dec. and Jan., 1876-77 . 
Barrowford, Lanca- 
shire. 
57 
7 
57 
100 
Recent cases of typhoid at farm. Milk tins washed 
with the same dish cloth as used among fever pa- 
tients ; farmer nursed children and milked cows. 
Dr. T. Doan, M. O. H., Medical 
Times and Gazette, Vol. 1,1877, 
p. 72. 
25 
1877... 
The Gurnos Ystaly- 
fera. 
7 
7 
100 
Miik dealer’s son sick with typhoid fever. Milk 
Dr. H. L. Parsons, Rep. on Sani- 
stored in a pantry leading out of the living room 
of a small, overcrowded house. 
tary Conditions of Ponkar- 
darve rural sanitary district, 
1880. 
26 
Jan., 1877 
Greenock 
20 
2 
16 
80 
No details 
Dr. J. Wallace, M, O. H., Brit. 
Med. Jour,, Vol I, p. 108. 
27 
Feb., 1877 
St. Pancras, part of 
35 
2 
30 
85 
Sudden and explosive outbreak traced to a milk sup- 
Dr. T. Stevenson, M. O. H., Brit. 
the northeast dis- 
trict of parish. 
ply, with no evidence of enteric fever at milk shops 
or farms. Water supply contaminated with tilth. 
Med. Jour., Vol. I, 1877, pp. 275 
and 329. 
28 
Aug., 1877 .. 
Edinburgh, Colt- 
(5) 
A case of typhoid fever at dairy communicated the 
Brit. Med. Jour., Vol. II, etc., 
bridge. 
disease to over twenty families. 
1877, p. 392. 
29 
Oct. and Nov., 1877 
Tunbridgewells 
68 
— 
... 
Milk supplied from various sources ; no typhoid fever 
at the farms, but at one of them the sewage of the 
town flowed through the cowyard; in the village 
there had been cases of typhoid fever. 
Dr. W. H. Rix, M. O. H. 
* 
30 
Dec. and Jan., 1877-78.. 
Glasgow and Hill- 
head. 
166 
16 
Typhoid fever at lof the supplying milk farms; nurs- 
ing performed also by dairy hands, dejecta thrown 
into a channel running on each side of the central 
passage provided in byres for cattle droppings 
From the middle of the byre the washing home 
was entered, and through this the milk-house. 
Dr. J. B. Russell, M. O. H., Brit. 
Mod. Jour., Vol. 1,1878, pp. 101, 
165, 270. 
31 
Jan, to Mar , 1878 
Morsside near Man- 
chester. 
32 
3 
29 
90 
Two deaths from typhoid at farm in February. Well 
in close contiguity to ash pits, and water found to 
be sewage polluted. 
Dr E. Sutcliffe, M. 0. H., Med. 
Times and Gazette, Vol. 1,1878, 
p. 517. 
32 
July and Aug., 1878 
131 
12 
131 
100 
A young lady visited the farm in June, just conval- 
escing of typhoid fever. One of the farm servants ill 
Aug. 1. Cesspool overflowing and its contents were 
traced by a recurrent course to well, which was 
used for dairy purposes. 
Dr. D. Davies, M. O. H., Brit. 
Med. Jour., Vol. II, 1878, p. 226. 
Sanitary Record, Vol. II, 1878, 
pp. 100-166, 
33 
Croydon. 
48 
37 
77 
A sudden and explosive outbreak traced to a milk 
Dr. C. W. Philpot, M. O. H., Ann. 
Report, 1878. Brit. Med. Jour., 
Vol. II, 1879, p. 675. . 
supply, but no evidence of enteric fever at the 
source of supply. 
1 Washington street epidemic. 2 And 30 suspicious cases. 3 Pollock Shaw’s road and Kingston epidemics. * A great number, 5 Several deaths. 
® There was also a supposed outbreak of milk typhoid at Bristol, 8 cases in 5 houses in spring of 1880. Their common milk supply was the only connection. STATE BOARD OF HEALTH.—REPORT OF SECRETARY, 1896. 
No. 
Date. 
Place. 
No. of cases. 
No. of deaths. 
No. of cases among 
milk consumers. 
j Per cent. 
Circumstances of the outbreak. 
Reporter and reference. 
34 
Sept,, 1878 ... 
153 
78 
64 
Farmer’s children had typhoid fever and no doubt 
Dr. G. Turner, Brit. Med. Jour., 
poisoned the well, for two children who were out 
walking and drank water from this well were sub- 
sequently attacked. Milk supplemented from 
another farm where well was within a few feet of 
cesspool of a common privy. 
Yol. II, 1879, p. 675. 
35 
Sept., 1878 
Colston near Glas- 
40 
40 
100 
Infected clothing brought to a dairy farm to be 
Dr. J. Christie, Sanitary Record, 
1 
gow. 
washed. On the 14th and 15th days later, symp- 
toms of enteric fever appeared in persons receiving 
milk from this farm; also a convalescing child 
brought to farm. Water supply on premises de- 
ficient; shallow dip well, but not used for drinking 
purposes. 
Yol. IV, p. 342. 
• 
36 
Oct,, 1878 
(») 
All the families in which the disease appeared had 
Brit. Med. Jour., Yol. II, 1878, p. 
their milk from one dairy. 
645. 
37 
Dec. (Christmas), 1878. 
67 
100 
A probable case of typhoid at dairy in November 
Dr. C. A. Cameron, M. O. H., 
and middle of December. “ A strong wind blow- 
ing into the yard would certainly waft particles 
of coal ash, etc., from the dung heap; to these 
minute portions of human excreta might have ad- 
hered.” Nurses also connected with dairy. 
Dublin Jour, of Med. Sci., July, 
1879, Pt. I. 
38 
Nov., 1878 
Huncoat 
12 
12 
100 
Children of farmer sick with typhoid fever. Father 
Dr. T. Dean, M. O. H., Sanitary 
would nurse the children and also attend to the 
cattle. 
Records, Yol. IY, p. 362. 
39 
Feb., 1879 
50 
6 
Milking hovel near a stream which received large 
Dr. Hubert Airy, Brit. Med. Jour., 
quantities of filth. Milkmen washed udders of 
cows with water from the stream, which probably 
at the time contained the specific poison. Privy 
pit only 8 yards from well, but no history of any 
recent typhoid at the farm. 
Yol. II, 1879, p. 475. 
40 
Oct., 1879 
(*) 
Milk traced to a suspected farm where there was no 
Dr. Davies, M. O. H., Brit. Med. 
enteric fever, but water from pump in a dairy ab- 
solutely stunk when pumped, and was described 
as “ simply poisonous.” 
Jour., Yol, II, 1879, p. 625. 
Epidemics of Milk-Typhoid. (Hart.) —Continued. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
41 
Jan., 1880.. 
■ Penzance 
26 
4 
26 
100 
Three cases of typhoid at the farm. The same per- 
son who milked the cows and attended to washing 
of dairy utensils, also nursed the patients. 
Dr. G. B. Millett, M. 0. H., Brit. 
Med. Jour., Vol. II, 1880,p. 37. 
42 
April, 1880 
Glasgow 
508 
69 
373 
73 
Dairymen of the farm sickened with enteric fever in 
March. Subsequently some of the children took 
sick and lay in bedroom next the kitchen; also 
dairymaid was taken sick and occupied a room 
above milk and wash house. Soiled discharges 
from sick bed washed at dip well, probably also 
used for other domestic purposes. 
Dr. J. B. Russell, M O. H., Brit. 
Med. Jour., Vol. 1,1880, p. 985. 
43 
April, 1880 
Possilpark, Glasgow. 
92 
.... 
90 
97 
(See above, No. 42.) Dairyman supplied milk shops 
in Possilpark also. 
Dr. J. Christie, Brit. Med. Jour., 
Vol. 1,1880, p. 864. 
44 
July to Sept., 1880 
Millbrook, Cornwall. 
• 
19 
19 
100 
Six cases of typhoid within three weeks at milk sell- 
er’s house; milk kept in a filthy apartment near a 
badly trapped and very offensive drain inlet, which 
drain communicated with another which had 
received infected excreta. 
Dr. E. Ballard, Brit. Med. Jour , 
Vol. 1,1881, p. 20. 
45 
Sept, 1880. 
Rochdale 
35 
9 
26 
74 
In a cottage between the farmhouse and shippen(2) a 
woman had been suffering from typhoid fever, her 
excreta were thrown over the wall opposite the 
door into a cesspool, from which the dip of the soil 
inclines toward farm well. Cattle also waded 
about this cesspool. Milk probably diluted. 
Dr. Joseph Henry, M. 0. H., Brit. 
Med. Jour., Vol. II, 1880, p.597. 
46 
Sept, and Oct,, 1880 
Portsmouth, Cam- 
bridge Barracks. 
7 
7 
100 
Milkman’s son had fever with typhoid symptoms in 
a room upstairs, and dejecta had to be carried 
through the back kitchen, also used as a dairy. 
Infection being caused by absorption or by the act 
of milking being performed by attendants on the 
sick boy. 
Surg. Maj. Jameson, Brit. Med. 
Jour., Vol. 1,1881, p. 61. 
47 
Oct, 1880.. 
Bridlington 
48 
8 
48 
100 
Convalescent from typhoid fever visited the dairy- 
man’s house, probably in September. The outbreak 
occurred in the early part of October. Dairy well 
close to manure pile; privies only 13 yards distant, 
water evidently largely contaminated by sewage. 
Dr. J. Allison, M. O. H. 
48 
Oct, 1880... 
Marylebone, Clifton 
Hill, etc. 
9 
97 
1? 
100 
Nil. All cases occurred about the same date. In- 
vaded houses not on the same side of the street, 
nor adjacent. Five out of six households invaded 
had their milk from one dealer. 
Dr. A. W. Blyth, M. O. H., Brit. 
Med. Jour., Vol. 1,1881, p. 61. 
49 
Oct., 1880 
Southport 
32 
2 
32 
100 
No typhoid fever at a dairy, but well in close proxim- 
ity and exposed to excremental pollution; water 
declared to be nothing but liquid sewage. 
Dr. H. H. Vernon, M. O. H., Brit. 
Med. Jour., Vol. II, 1880, pp. 
820-934. 
2 Cowhouse. 
i Several cases. STATE BOARD OF HEALTH -REPORT OF SECRETARY, 1896. 
slo. 
Date. 
Place. 
No. of cases. 
[ No. of deaths. 
No. of cases among 
milk consumers. 
Per cent. 
Circumstances of the outbreak. 
Reporter and reference. 
50 
Oct. and Nov . 1880 
44 
8 
44 
100 
A case of enteric fever in the house; excreta thrown 
into a defective drain, which was near the well 
used for dairy purposes; distinct evidence of soak- 
age from the drain into well. 
Dr. C. Kelly, M. O. H., Brit. 
Med. Jour., Vol. 11,1880, p. 934. 
51 
1868 
Investigation convinced reporter that the milk was 
the vehicle of the poison and that it became in- 
fected by absorption and not through contaminted 
water. 
Congress for Hygiene and 
Demogr., 7th session, 1891, sec. 
3, p. 170. 
52 
Aug. 28 to Sept 3,1872 . 
0)8 
All 
too 
Dr. Holmloe, Nork Mag. f. Lae- 
gerk, 1873, p. 654; Hirsch Hand- 
buch, Yol. I, p. 683. 
tributed the milk. Explosive outbreak. All cases 
taken sick between Aug. 28 to Sept. 3. 
53 
(*) 
Enteric fever at milk farm. Well highly polluted 
with refuse. Water used for cleaning milk uten- 
sils. No new cases after Sept. 5, when customers 
stopped purchasing milk, except in one family, 
who continued to buy the milk. 
Dr. Lube, Allegem, Zeitschft f. 
Epidem., 1876, Vol. II, p. 218. 
54 
Nov, 1878 ... 
0) 
Piggery close to milk room ; bad drain passed under 
the pump, whence the water for household was 
procured. 
F. A. McEuen, London Practit,, 
1881, XXVI, 161-164. 
55 
Jan., 1879 
Do. 
15 
Do. 
level of the dung hill, and open to any sewage that 
might percolate in that direction. 
56 
Jan., 1881 
(2) 
Dr. W. N. Thursfield, Sanitary 
Record, London, 1880-81, n, s. 
II, 243. 
liable to contamination either directly through 
persons suffering from the disease or indirectly 
through sewer emanations of water charged with 
the specific infective element of the disease for 
which the milk may also have acted as a cultiva- 
tion fluid.” 
57 
March/1882 
Leicester Infirmary.. 
12 
2 
12 
100 
A fatal case of typhoid fever at dairy. Polluted 
well. All patients had used unboiled milk. 
W. Elgar Buck. Mid. Med. Misc., 
Leicester, 1883,11, p. 73. 
Epidemics of Milk-Typhoid. {Hart.)—Continued. 
Outbreak No 50 and the succeeding 88 were collected by Drs. Busey and Kober, THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER 
58 
May and June, 1882 
Glasgow 
59 
6 
50 
85 
Nearly all cases occurred within one week in May. 
None since June 1, “and its area has been most 
distinctly marked out in relation to the milk sup- 
ply.” 
Med. Jour., Vol. II, 1882, July 8. 
59 
June, 1882 
Allegheny City, Pa... 
40 
4 
Typhoid fever at dairy. Well only 50 ft. from privy 
vault; the latter was full and higher upon the hill 
than the well. 
Dr, D. N. Rankin, Pittsburg, 
Med. Jour., 1883, III, 289-292. 
60 
June, 1882 
20 
19 
95 
All cases taken sick within 24 hours; all supplied 
with one exception, with milk from same dairy; 
health officer unable to explain milk infection. 
Brit. Med. Jour., 1882, Vol. II, p. 
216. 
61 
July, 1882 
Halifax Stone Chair. 
11 
1 
11 
100 
Two cases of probable typhoid at farm. Father of 
farmer’s wife arrived July 11, taken sick July 21; 
no medical attendant. His wife came to nurse 
him Aug. 14; taken sick Aug. 21; died Sept. 6. Un- 
sanitary condition of farm; untrappod drain in 
room where milk was stored; polluted water. 
Dr. Britton, Brit. Med. Jour., 
1882, Vol. II, p. 749, 
62 
Nov., 1882 
Newton Heath 
60 
Henry Tomkins and James Ni- 
ven, London Lancet, 1883, Vol. 
I, pp. 360, 641. 
same dairy; 2 obtained their milk from shops and 
2 from still other sources; no details, doubtful 
connection. 
63 
4 
4 
100 
Typhoid fever at milk farm and unsanitary condi- 
tions. 
Dr. E. Almquist, Vrtljschr f. 
Gesundhtspfl., 1889, XXI, 327. 
64 
Jan , 1883.. 
270 
The cases were distributed in 54 households, all sit- 
uated in the best part of the city. Typhoid among 
servants at milk farm; polluted water used in 
cleaning utensils. 
Dr. B. Auerbach, Deutsche Med. 
Wochenschft., Berlin, 1884, X, 
709. 
65 
Feb., 1883 
Gateshead 
44 
6 
44 
100 
All in 30 households supplied with milk from a farm 
where enteric fever prevailed among the children; 
the mother nursed and also assisted in milking and 
dairy work. Utensils kept in a dirty scullery. 
Chas. Green, London Lancet, 
1883, Vol. 11, 986. 
66 
July to October, 1883... 
St. Pancras 
431 
62 
368 
Epidemic invaded 276 families, all using milk from a 
particular dairy farm where enteric fever started 
in a boy who arrived July 6, and sickened July 16. 
Shirley F. Murphy, London Lan- 
cet, '83, Vol. II, p. 652. 
67 
Oct,, 1883 
102 
36 
Disseminated by the sale of milk from a dairy kept 
by a man of whose family several members were 
sick with typhoid fever. 
Brit. Med. Jour., 1883, Vol. II„ 
p. 839. 
68 
Oct, and Nov., 1883 
Englewood, N. J 
10 
.... 
10 
100 
Typhoid fever case at dairy; a woman who assisted 
in nursing also helped to wash milk utensils. 
D. A. Baldwin, Med. Record, N. 
Y., 1883, XXIV., p. 585, 
69 
Oct, and Nov., 1883 
Port Jarvis, N. Y 
159 
17 
(3)2t 
80 
Three cases of typhoid at milk farm in August and 
September. The bulk of epidemic cases occurred 
between October 24 and Nov. 15, the sale of milk 
having been stopped Nov. 4. 
Dr. A. P. MacDonald, N. Y. Med. 
Times, 1883-84, XI., p. 328. 
Families. 2 Several cases. 3 Either this number or the per cent in next column is probably wrong. H. B. B STATE BOARD OF HEALTH.—REPORT OF SECRETARY, 1896. 
No. 
Date. 
Place. 
03 
© 
03 
J3 
C0 
tie 
§2 
a s 
<« a 
m 2 
© H 
c3 o 
Circumstances of the outbreak. 
Reporter and reference. 
O 
«4H 
O 
6 
55 
O 
6 
55 
6 3 
55 
j Per cen 
70 
Dec., 1883 
25 
2 
25 
100 
Daughter of the owner of the milk farm reported to 
have been ill with diarrhea; water froin an open 
ditch polluted with sewage and the dejecta of a 
previous case of typhoid fever, located above the 
farm, had been used for dairy purposes. Milk sup- 
ply diluted. 
Dr. Simpson, M. O. H., London 
Lancet, Vol. 1,1884, p. 487. 
71 
Jan. and Feb,, 1884 
Upsala,Lakare ForSn 
42 
.... 
42 
100 
Typhoid at milk farm and bad, unsanitary condi- 
tions. 
Ernst Almquist, Vrtljschr, f. Ge- 
' sundhtspfh, 1889, XXI., 327. 
72 
May and June, 1884 
St. Albans.. 
131 
23 
Of 396 houses supplied with the suspected milk, 86, 
or 21.7 per cent, were infected. Some of the milk 
sent to London affected consumers there. Milk 
obtained from a farm where cases of typhoid had 
occurred. 
S. F. Murphy, Rep. Med. Off. local 
govt, board, 1884, Brit. Med. 
Jour., 1884, Vol. I., 1162, Vol, II., 
p. 1086. 
73 
October, 1884 
Tweedmouth.... 
23 
23 
100 
All due to milk sold while there was typhoid fever at 
cow keeper’s house, for which he was fined 3 
guineas. 
Sanitary Record, London, n. s., 
1884-85, p. 204. 
74 
August and Sept., 1884. 
Belvidere, Royal, and 
Western infirma- 
ries, Glasgow. 
143 
32 
Traced to a particular milk farm where dairy maid 
took sick at the same time as the outbreak in Glas- 
gow. Prior to this cattle had suffered from febrile 
disease, attributed to drinking sewage water; 
enteric fever epidemic in adjacent villages; diffi- 
cult to say whether infection originated with the 
cows or had been conveyed from another focus. 
Dr. J. B. Russell, M. O. H., Brit. 
Med. Jour., 1884, II, 626, 724, 
Sanitary Jour., Glasgow, 1884- 
85, n. s., VIII, pp. 225-239. 
75 
October, 1884... 
Derby 
40 
40 
100 
Sudden outbreak among customers of a particular 
dairy, where 4 cases of typhoid fever had previously 
occurred. Well liable to gross pollution, being 
situated on the brink of a ditch which rec’d the 
drainage from the farm house. 
Brit, Med. Jour., 1884, Vol. II, p. 
786. 
76 
Nov., 1884; Mar., 1885... 
Groningen 
58 
46 
79 
Infected well at dairy ... 
Dr. Ali-Cohen. Nederl. Tijdschr. 
v Geneesk,, Amster,, 1887, 
XXIII., 2d, pp. 78,84. 
77 
Dec ,1884 
Aberdeen 
65 
7 
43 
66 
Dr. Simpson, Brit. Med. Jour., 
Vol. I., 1885, p, 193. 
farm; well polluted. 
Epidemics of Milk-Typhoid. (Busey and Softer.)— Continued. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEYER. 
78 
Feb., 1886 
Leichhardt, Australia.. 
38 
5 
Sewerage polluted well at dairy 
J. Ashburton Thompson, Austr. 
Med. Gazette, Sidney, 1885-6, 
Vol. V., p. 265. 
79 
July, 1886 . 
Swanage Dorset 
This epidemic of typhoid fever at its commencement 
was associated with the use of milk from a dairy, 
situated near a polluted brook, and no other water 
supply was on the premises. 
Outbreak originally traced to cream derived from a 
certain dairy, where no other evidence could be 
found than a liability of the well to pollution. 
Mr. W. Harvey, Rep. Med. Off. 
80 
July, 1886 | 
Lancing College, 
Shoreham. 
14 
80-100 
!2 
14 
100 
local govt, board, 1886, No. 16, 
p. 294. 
Dr. C. Kelly, London Practit., 
1886, XXXVII , pp. 223-231. 
81 
30 
24 
)(') 
1 59 
Traced to a dairy where typhoid cases had existed, 
preceded by a febrile disorder among the cows; 
water supply and sanitation being quite good. 
William Brown, Sanitary Record, 
London, 1887-88, n. s. IX, pp. 
10-15. Practit., London, 1888, 
XV., pp. 382-392. 
82 
Nov. and Dec,, 1886 
Cambridge, Mass 
73 
The epidemic invaded 36 families, and was traced to 
a certain milk farm where a child was ill with 
typhoid fever; the father had entire charge of the 
nursing, emptied the excreta, and also prepared 
the milk for the market. 
Chas. Harrington, Boston Med. 
and Surg. Jour., 1888, CXIX, pp. 
49-52. 
83 
Feb., 1887 
GOteborg 
43 
43 
100 
Affected 34 families, all supplied with a particular 
milk. Typhoid fever at milk farm, and suspicious 
sanitary conditions. 
Dr. Ernst Almquist, Vrtljschr. f. 
Gesundhtspflg., 1889, XXI., pp. 
327-338. 
84 
Aug., 1887 
Do 
5 
5 
100 
In 3 families, typhoid fever at farm. 
Dr. Lehmann of Copenhagen, before the Interna- 
tional Congress of Hygiene and Demographie, held 
at Wien, 1887, described 2 epidemics of typhoid 
fever traced to a certain creamery, and pointed out 
the difficulty of tracing infection when milk is re- 
ceived from a number of farms and mixed. 
85 
1887,.... 
Denmark 
Deutsche Med. Wochenschrft, 
1889, Vol. 15, p. 17. 
86 
Mar., 1888 
Gdteborg... 
4 
Typhoid fever at milk farm, and bad unsanitary sur- 
roundings. 
Dr. Ernst Almquist, Vrtljschr. f. 
Gesundhtspflg , 1889, XXI., 327- 
338. 
87 
1888 
Wash. Heights, N. Y.. 
Dr. Edson is quoted as having reported this epidemic 
of a disease resembling typhoid fever, confined to 
the customers of a certain milkman. On careful 
inspection of the cows 1 of them was found to be 
suffering from a loathsome abscess of the udder. 
The cow was being milked into the common pail. 
No other cause could be found, and the sickness 
speedily stopped when this cow was quarantined. 
Brooklyn Med. Jour., 1888, Vol. 1, 
p. 182. 
88 
July to Dec., 1888 
Spennymoor, Dur- 
ham. 
25 
5 
Outbreak occurred in 19 families, 11 of which were 
supplied with milk from a dairy where typhoid 
fever and evidence of polluted water were found, 
Dr. David Page, Public Health, 
June, 1889; Lancet, London, 
1888, Vol. II, p. 941. 
1 Appears to be wrong. Should be 80? H. B. B. STATE BOARD OF HEALTH —REPORT OF SECRETARY, 1896, 
No. 
Date. 
Place. 
09 
<D 
s 
| No. of deaths. 
be 
O m 
2 n 
a> g 
S3 
cS o 
Circumstances of the outbreak. 
Reporter and reference. 
«4H 
O 
6 
£5 
o S 
j Per cen 
89 
1888 
Evesham 
6 
1 
5 
83 
Typhoid at dairy; milk adulterated with polluted 
water. 
Dr. Fosbroke, Public Health, 
Feb., 1889. 
90 
1889 
Country town in New 
York. 
200 
Investigation showed that only the customers of a 
certain milkman were affected. His well was con- 
taminated by the drain of a neighbor’s house in 
which typhoid had recently occurred. Water used 
to wash milk cans, and possibly also for adultera- 
tion. 
Dr. William M. Smith,quoted by 
Dr. Cyrus Edson, Med. Record, 
N. Y., XXXV, 1889, p. 10. 
(>) 
91 
1889 
St. George, Hanover 
Parish. 
Dr. Barry, medical inspector, reports to the local 
government board on this sudden and localized 
outbreak of enteric fever, which he attributed to 
temporary admixture of infected milk with the 
usual supply, and also refers to nuisance from 
sewer ventilators, etc. 
Report Med. Off. local govern- 
ment board, 1889, p. 47. 
92 
Dundee 
23 
23 
100 
All cases occurred among the customers of a particu- 
lar dairy, and the most searching inquiries failed 
to find any trace of disease among the persons 
handling the milk or in the household, but one of 
the milch cows was suffering from a peculiar teat 
eruption, and as the disease declined upon stoppa ge 
of the milk, April 15, Dr. Anderson feels justified 
to regard the cow as an etiological factor. Other 
sanitary improvements were made in connection 
with sewer. 
London, 1889, II, p. 463. 
93 
February, 1889 
Stirling 
40 
4 
40 
100 
Typhoid fever at milk farm; polluted water; air of 
the milk house liable to contamination. The epi- 
demic affected especially families supplied with 
milk which had been kept overnight in the milk 
house. 
Dr. McFadyan, Brit. Med. Jour., 
Loudon, 1889, Vol. I., p. 1250. 
91 
Strand District, Lon- 
10 
10 
ICO 
Dr. Conway Evans, the medical officer of that dis- 
trict, reports that he had traced 10 cases of typhoid 
fever to the milk supply and was ordered to visit 
the farm and take necessary steps. 
Brit. Med. Jour., 1889, Vol. I., p. 
725. 
don. 
Epidemics of Milk-Typhoid. (Busey and Kober.)—Continued. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
95 
Svarteberg, Sweden.. 
104 
11 
Typhoid-fever cases at milk farm; contaminated 
water used for dairy purposes, also for adulteration 
of milk. 
Ernst Almquist, Zeitschft. fttr 
Hygiene, Leipsic, 1890, Vol. 
VIII, 137-140. 
96 
July, 1889 
Belgard 
11 
11 
100 
All the 11 typhoid fever cases had obtained their milk 
of the owner of a single milch cow, a poor woman, 
whose child was ill with typhoid fever, the milk 
being kept in a safe in the sick room, it being the 
only room at their disposal. 
E. Roth. Deutche, Vrtljschr. 
f. Offentl. Gesundhtspfl,, 1890, 
XXII, pp. 238-245. 
97 
July, 1889 
Leeds 
m 
(3) 
No details as to the condition of the dairy farms 
given. Cases occurred in the best residential part 
and were traced to a particular milk supply. 
Dr. Goldie, M. O. H.. Brit. Med. 
Jour,, 1889, Vol. II, p. 110. 
98 
November, 1889 
York 
120 
Three cases of typhoid fever had occurred at the milk 
farm. Inspection revealed a probably infected 
well close to the privy; milk vessels kept close to 
privy and milk adulterated with 10 % of polluted 
water. 
tioner, London, 1889, XLIIL, 
393-400. 
99 
63 
The epidemic was traced to a particular dairy where 
the most unsanitary conditions were found. Men 
were seen spitting in their hands while polishing 
milk cans. There was also evidence of reckless 
watering of the milk with polluted water. 
Dr. Vincet, Epid6mie typh. pro- 
pag6e par le lait, Geneve, 1890, 
p. 15. 
100 
May, 1890... 
36 
Three cases of typhoid fever at the dairy farm 
whence milk was supplied to 28 families. Milk 
exposed to the contamination of an infected drain. 
Dr. Murray, M, O. H., Sanitary 
Jour., Glasgow. 1890-91; n. s., 
XIV., p. 113, 
101 
May, 1890.... 
7 
7 
100 
Nephew of milkman sick with walking typhoid 
fever; continued at work. Milk supply stopped 
June 20. After June 26 no fresh cases occurred. 
Dr. Phillip Boobytr, M. O. H., 
Annual Report, 1890, Public 
Health, London, 1891, 92, IV., 
p. 110. 
102 
June, 1890 
Waterbury, Conn. 
50 
41 
82 
Typhoid fever cases at the milk farm from which at 
least 41 of the cases had consumed milk. One of 
the farm hands continued to work in the care of 
cans and at milking for a week before giving up; 
he also defecated in the cow stables throwing the 
stools into the barn yard and thus infecting mate- 
rial everywhere. 
Dr. Herbert E. Smith, Sanitarian, 
N. Y., 1890, XXV., pp. 298-308. 
103 
Stittenseen, Hanover 
103 
This epidemic affected only persons who had drunk 
water from a specifically infected well or skimmed 
milk from a certain creamery supplied by 70 or 80 
milk producers, and the evidence appears to indi- 
cate that this milk supply was contaminated by 
the owner of the suspected well adulterating the 
milk ; 8 cases occurred in the house with the sus- 
pected well and 78 cases among contributors of 
milk to the creamery, and who, of course, were 
the largest consumers of their skimmed milk. 
Dr. Schroder, Zeitschft. f Med. 
Beamte, Berlin, 1891, IV, pp. 
227-262. 
I Nearly. 2 Or more. 3 Several deaths. STATE BOARD OF HEALTH.—REPORT OF SECRETARY, 1896. 
Mo. 
Date. 
Place. 
| No. of cases. 
| No. of deaths. 
No. of cases among 
milk consumers. 
| Per cent. 
Circumstances of the outbreak. 
Reporter and reference. 
104 
Wyandotte, Mich 
11 
2 
11 
100 
All supplied with milk from a stall-fed cow which 
drank water from a well polluted with animal mat- 
ter. Cases continued to occur as long as this milk 
was used, and disappeared upon its stoppage, ex- 
cept in 1 family, who returned to the milk, and 
this was followed by 2 more virulent cases in the 
family. Professor Vaughan examined the milk 
and water bacteriologically, and while failing to 
discover Eberth’s germ, he found similar patho- 
genic germs in both media, in larger proportion in 
the cow’s milk. 
Dr. E. P. Christian, Am. Lancet, 
Detroit, 1891, n. s., XV, pp. 121- 
128. Phys. and Surg., Detroit, 
1892, XIV, pp. 337-343. 
105 
74 
9 
The first and greatest number of cases occurred at a 
watering resort, which was supplied both with 
water and milk from a farm where typhoid cases 
had occurred. 
Dr. Penkert, Zeitschft. ftir Med. 
Beamte, Berlin, 1891, IV, p. 50. 
106 
Waversley, Rand- 
wick, Sidney. 
89 
These cases occurred in 89 households, and “the out- 
break was clearly proved to be caused by con- 
taminated milk.” [We have been unable to refer 
to Dr. Thompson’s original report.] 
London Lancet, 1891, Vol. I, p. 
223. 
107 
Toorak, Australia 
A number of cases occurred, all pointing to a partic- 
ular milk supply derived from a farm which was 
watered by a creek to which the cows had free ac- 
cess; an orchard on which infected night soil had 
been deposited drained into the creek higher up. 
No evidence given whether the milk had been 
adulterated with this polluted water, where the 
cans were washed, or whether udders were infected 
while cattle waded in the stream. 
Austrl. Med, Jour., 1890, n, s.,XH, 
p. 422. 
108 
Sept, and Oct., 1890 
63 
3 
The outbreak occurred in 41 families who derived 
Dr. Harvey Littlejohn, Edin- 
burgh, Med. Jour., 1880-91, 
XXXVI, Part 11, pp. 801-814. 
Brit. Med. Jour., 1890, Vol. II, 
p. 1,318. 
their milk from a farm whore a case of typhoid 
was found, and 2 others subsequently occurred 
there Sanitary conditions bad; milk cans filled in 
a tainted atmosphere; water-supply found to be 
contaminated by sewage and liable to gross pollu- 
tion. Milk supply was stopped until a better 
water-supply had been provided, after which no 
more cases occurred, 
Epidemics of Milk-Typhoid. (Busey and Kober.)—Continued. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
109 
1891 
U. S 
2 
Dr. Brady describes 2 cases of typhoid fever which 
he attributed to infected milk, and considers it 
perfectly conceivable when we recall the sanitary 
condition of the average milk farm, and the dairy 
boy with bespattered boots, dirty hands and shirt, 
etc. 
Dr. E. J. Brady, Cincinnati Lan- 
cet and Clinic, 1892, n. s., 28, p. 
20. 
no 
1891 
5 
5 
100 
Typhoid fever at dairy conveyed by digital infection, 
as dairy hands also assisted in nursing the typhoid 
patients. 
Dr. E. J. Brown, Trans. 111. Med. 
Society, Chicago, 1891, XLI, pp. 
145 148. 
in 
Feb., 1891 
Avondale 
12 
12 
100 
Two cases of typhoid fever at a dairy. Milkers and 
dairy hands also assisted in nursing. Water prob- 
ably contaminated and owner in the habit of dilut- 
ing the milk. 
Dr. E. W. Mitchell, Cincinnati 
Lancet and Clinic, 1892, n. s., 
28, p. 647. 
112 
8 
1 
8 
i00 
All these cases received the milk from one cow which 
had no access to pure water, but drank from a 
nearly dried up swamp on the island. (No bacteri- 
ological examination of the water.) 
Dr. B. P. Christian, Phys. and 
Surg., Detroit and Ann Arbor, 
1892, XIY, 337-343. 
113 
Shawland, Glasgow 
42 
4 
37 
89 
Mild case of typhoid at the farm in August. Dung- 
pit located near byre received the typhoid'excreta 
the water supply contaminated from this dung- 
pit ; other unsanitary surroundings. 
Dr. A. M. Campbell, Public 
Health, 1891-92, Yol. IV, p. 275. 
114 
Borough of Nanti- 
coke, Pa. 
42 
31 
74 
A case of typhoid fever at the dairy farm, attributed 
to a contaminated well which received drainage 
from a cemetery. 
.Dr. L. H. Taylor, Annales, Hy- 
giene, Philadelphia, 1892, Yol. 
VII, pp. 393-403. 
115 
12 
1 
12 
LOO 
A fatal case of typhoid occurred at the milk farm 
twenty days before the present outbreak. The 
parents continued their dairy work while nursing 
their sick child. 
Dr. F. M. Williams, M. O. H., 
Brit. Med. Jour., 1892, Yol, I, 
p. 1,157. 
116 
August, 1892 
Springfield, Mass.... 
150 
25 
101 
67 
After a painstaking investigation, traced to a partic- 
ular milk farm, where cases of typhoid had oc- 
curred ever since last spring. Well liable to infec- 
tion from dejecta of patients. Milk contaminated 
by placing cans in the well for the avowed purpose 
of keeping the milk cool. 
Drs. Sedgwick and Chapin, Bos- 
ton Med. and Surg. Jour., 
CXXIX, 20, p. 485, 1893. 
117 
Aug. 20-Sept. 10, 1892... 
Somerville, Mass 
35 
30 
86 
Epidemic traced to a particular milk supply. The 
son of this milkman handled and delivered the 
milk while suffering from a mild attack of typhoid 
fever, which had remained unrecognized until the 
investigation disclosed exact facts. 
Dr. W. T. Chapin, Boston Med. 
and Surg. Jour,, CXXIX, 20, 
1893,p. 485. 
118 
Sept. 14-Oct. 15, ’92 
Greenwich', Eother- 
hithe. 
61 
56 
91 
This epidemic was limited to consumers of ice cream 
manufactured by Italian vender. Investigation 
revealed the existence of several cases of enteric 
fever in two ice cream shops, and much reason for 
believing that ice cream was prepared in dangerous 
proximity to the patients. 
Dr. Geo. Turner, Practit., Lon- 
don, 1892, XLIX., p. 141, 160. STATE BOARD OF HEALTH—REPORT OF SECRETARY, 1896. 
No. 
Date, 
Place. 
j No. of cases. 
No. of deaths. 
No. of cases among 
milk consumers. 
Per cent. 
Circumstances of the outbreak. 
Eeporter and reference. 
119 
1893..., 
Altenmuhr 
(') 
A house epidemic existed at a certain farm. A young 
gentleman took sick with enteric fever, while visit- 
ing a neighboring chateau. He had been supplied 
with milt from this farm, and his female servants 
who carried the milk were taken sick likewise. 
Dr. Franz Spaet, Arch, fur Hy- 
giene, Milnchen and Leipzig, 
1893, XVII., p. 306. 
120 
1893. 
(!) 
In this instance Dr. Wepley traced the infection to a 
creamery which collected milk from a number of 
farms, at one of which a few cases of enteric fever 
occurred, infection originally carried from Cork. 
The milk at these creameries is separated, the 
cream made into butter, and the skimmed milk 
returned to farmer, thus causing intimate relation- 
ship, and the disease may easily become widespread 
among the users of milk. 
Dr. Wepley, Brit, Med. Jour., 1893, 
Vol. II., p. 698; London Lancet, 
1894, Vol. II., p. 1085. 
121 
Feb , 1893... 
Univ. of Virginia 
14 
14 
100 
These cases of a typical typhoid fever occurred among 
the students of the university, all boarding at the 
same hotel and consuming a particular milk sup- 
ply from a dairy which is located on the banks of 
the creek, which receives the sewage from one of 
the main university sewers. An ignorant negro, 
who lives 1 mile above the dairy, had typhoid fever 
during the preceding fall, and his dejecta was 
thrown on the ground without disinfection. The 
milkman used creek water to wash the udders of 
the cows. 
Dr. Wm. C. Dabney, Med. News, 
Philadelphia, 1893, LXIll, 630- 
632. 
122 
May, 1893 
362 
228 
70 
These cases occurred within one month, and as 70 
per cent were consumers of milk from one particular 
dairy, a sanitary inspection was made and revealed 
the following facts. A typhoid fever house in close 
proximity ; dejecta thrown on the ground close to 
a small dam in the creek, from which a pipe sup- 
plied a large tank 75 feet below with water for 
dairy purposes; moreover this polluted water 
flowed through the cow pasture. 
Dr. S M. Mouser, Occident Med, 
Times, Sacramento, 1893, VII., 
pp. 503-504. 
Epidemics of Milk—Typhoid. (Busey and Kober.)—Continued. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
123 
July, 1893 
Paisley, Renfrewshire 
86 
86 
100 
This epidemic was traced to the consumption of ice- 
Dr. Campbell Munro. Brit. Med. 
cream made at the premises of a vender where an 
unreported case of typhoid fever was found, and 
this patient had remained in contact with the 
business during most of her illness. 
Jour , 1894, Yol. II., p. 829. 
124 
Aug,, 1893. ... 
(') 
All traced to milk from a suburban dairy found in 
the most unsanitary condition; no privy, but a 
highly polluted w'ell, which was used for washing 
the utensils and very likely also for adulteration. 
Dr. Lefenberg, city physician, 
quoted by Dr. Dornbliith, Jahr- 
buch f. Kinder Krankheiten, 
1893, XXXVI., p. 181. 
125 
July, 1893 
Vicinity of Bethsada, 
15 
1 
15 
too 
This limited epidemic was intimately connected with 
Unpublished memoranda fur- 
Montgomery Co, 
Md. 
a certain milk farm, the owner of which was obliged 
to use a neighbor’s well, in whose family typhoid 
fever had occurred during the summer of 1892 
Three weeks after using this well the first case oc- 
curred at the milk farm, and shortly after the 
owner of this well was also taken sick. This re- 
sulted in a cleaning of the well, which was found 
to be contaminated with a very foul sediment, a 
dead chicken, and other organic refuse. The season 
being unusually dry, and the ground water being 
low, had resulted in concentration of the impuri- 
ties, and as this well had been used for dairy pur- 
poses, it was doubtless the source of infection. 
nished by our friend, Dr. 
George Lloyd M a grader of 
Washington, D. C., and Dr. W. 
F, Elgin, of Montgomery Co., 
Ala. * 
126 
Shildon, Durham Co. 
In a very extensive epidemic of enteric fever a large 
share in spreading the fever was due to a particular 
dairy, where cases of typhoid fever existed and the 
wife, who managed the milk business, also nursed 
the sick children. There was, moreover, a direct 
connection between the sewer and the room in 
which the milk and utensils were kept. 
Dr. Bruce R. Low, Rep. to the 
local government board on an 
outbreak of enteric fever at 
Shildon, London, April 23,1894. 
127 
1894 ... 
Castle Island, Ireland 
A serious outbreak was traced to a creamery receiv- 
ing among others the milk from a farm where 
enteric fever had occurred, and which was handled 
by a person who also assisted in nursing those suf- 
fering from the disease. The cream had been sep- 
erated and the skim distributed in due proportions 
among the different farms. 
Brit. Med. Jour,, 1894, Vol. I., p. 
815. 
128 
Jan. and Feb., 1894 
Richmond Hill, Sur- 
rey Co. 
55 
52 
94 
Traced to a common milk supply; no evidence of 
typhoid fever at the milk farm, although the disease 
had prevailed In the vicinity; very unsanitary con- 
titions, such as liquid and semi-liquid filth sur- 
rounding 36 cows. The epidemic speedily subsided 
after stoppage of the milk supply from this dairy. 
Drs. Rowland and Seaton, Brit. 
Med. Jour., 1894, Vol. 1, p. 1325. 
129 
Mar. and April, io„* .. 
59 
10 
55 
93 
Traced to a particular milk depot, affording no other 
evidence except unclean methods and a water 
supply subject to pollution from a yard drain. The 
water tank, on being emptied, contained a deposit 
of 4 inches of offensive matter; no bacteriological 
examination. 
Brit. Med. Jour., 1894, Yol. I, p. 
1148. 
1 Several cases, STATE BOARD OF HEALTH.—REPORT OF SECRETARY, 1896. 
No. 
Date 
Place. 
m 
CD 
c3 
-4-3 
c8 
<D 
tD 
fl 
2 2 
a © 
CO a 
cC P 
Circumstances of the outbreak. 
Reporter and reference. 
T 
o 
6 
Z 
o 
6 
0:3 
6 a 
z 
| Per cen 
130 
Mar., 1894 
Montclair, N. J. 
107 
14 
Of 44 families supplied with milk from a particular 
dairy, typhoid fever occurred in 28, or 63.6 per cent. 
Of 20 cases reported from Bloomfield and Glenridge, 
18 were traced to the same dairy, where a case of 
typhoid occurred Feb. 11, but the sale of milk was 
not stopped until Mar. 29, and epidemic checked 
promptly after that date. Unsanitary condition at 
dairy and polluted well water. 
Dr. R. C. Newton, Med. Record, 
N. Y., 1894, XLV., pp. 713-715. 
131 
60 
10 
This epidemic was traced to a milk farm where the 
cows were partially fed on fresh grass cut from the 
fields of a sewage farm. It was also shown that 
water from a brook running through the same land, 
and presumably contaminated, had been used to 
adulterate milk. 
Dr. Verdon, M. O. H, Brit. Med. 
Jour., 1894, Yol. I, p. 1112. 
132 
Aug., 1894 
19 
1 
Fourteen of these cases were found in close proxim- 
ity to a bakery where ice cream was sold and made 
in a very filthy place. A case of typhoid had oc- 
curred at this bakery, and persons who made the 
ice cream also assisted in nursing. Of 10 cases, 8 
had used ice cream or milk from this bakery, and 
the disease was promptly checked upon closing 
the bakery. 
Dr. Thomas Horton, Med, Rec., 
N. Y., 1894, XLYI, p. 651. 
133 
July, 1894 
15 
15 
100 
Dr. W. H. Katzenbach, N. Y. 
Med. Record, 1895, Yol, 47, p. 
165. 
a milk dealer who derived his supply from three 
dairies, at one of which a young man was taken 
sick July 1, with what proved to be a case of ty- 
phoid fever, and continued to milk his cows daily 
until July 11. The first case of typhoid fever 
among consumers of the milk occurred July 14, and 
the last case 19 days after this patient stopped 
milking. How the infection could be conveyed 
may “ be left to the imagination of those who are 
familiar with the personal habits of Some who 
work on dairy farms.” 
Epidemics of Milk-Typhoid. {Busey and Kober.)—Continued. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
134 
Dec., 1894 
Arbroath, Scotland,. 
44 
This epidemic was traced to an unrecognized case at 
a dairy. The patient there was a woman 64 years 
old who had been waited on by two other women, 
who* also milked the cows, washed the milk ves- 
sels, and attended generally to the sale of milk. 
Many of the later cases of the outbreak were not 
directly attributable to the milk sale, secondary 
centers of infection having, as is quite common, 
been established. 
London Lancet, Yol. 11,1894, p, 
1517. 
135 
Great Harewood 
80 
5 
100 
Dr. Edw. Sargeant, London Lan- 
cet, Yol 1, 1895, p. 1328; Brit. 
Med Jour., Yol. 1,1895, p. 1110. 
lently and with greater certainty than those per- 
sons who took the milk in coffee and tea. The chief 
symptoms were headache, often diarrhea, some- 
times nausea, characteristic temperature, and fre- 
quently abdominal rose spots. Traced to a milk 
farm, where a young woman who assisted in milk- 
ing the cows and looking after the cans had been 
sick since and prior to the outbreak with what she 
thought to be a cold. Upon examination she was 
found with a coated tongue, a pulse 108, tempera- 
ture 100, and a few days after rose colored spots 
appeared on her body, in fact, a typical case of 
ambulatory typhoid fever. The decline of the out- 
break, allowance being made for the period of in- 
cubation, coincided with her withdrawal from the 
dairy operations. 
136 
307 
Traced to the premises of a milkman whose barns 
were in the rear of his lot, surrounded on all sides 
by dwellings and outhouses ; his tank for cooling 
milk was fed from a well 12% feet deep and filled 
with water to within 114 ft. of the surface. West 
of the pumps were two outhouses, one 20 feet and 
the other 15 feet each above the level of the bot- 
tom of the well, and the drainage of those led di- 
rectly toward the pump. It is believed the typhoid 
germs were brought to this neighborhood by Ital- 
ians who had been at work in the vicinity of the 
dairy and the disease was traced almost directly 
to their camp. The well water was examined by 
Dr. T. M. Prudden, and found to be swarming with 
bacteria. 
Med. Record, N. Y,, Yol. 47, pp. 
562, 627. 
137 
New Milford, Conn... 
23 
The daily papers contained accounts of an epidemic 
of typhoid fever which is prevailing in New Mil- 
ford. The disease is said to have been distributed 
by milk obtained from a certain farm in the neigh- 
borhood. Up to May 9, 23 cases had been reported. 
(Details wanting.) 
Med. Record, N. Y., Yol. 47, p. 
627. 
138 
Woolwich 
19 
In 10 of these cases the milk was supplied from the 
same dairy and others from various sources. In 4 
cases the milk supplied was from the Plumstead 
dairy, where the epidemic first broke out. This 
dairy has been closed by the authorities. 
Brit. Med. Jour., Yol. 1,1895, p. 
1423. STATE BOARD OF HEALTH.-REPORT OF SECRETARY, 1896. 
No. 
Date. 
Place. 
| No. of cases. 
No. of deaths. 
No, of cases among 
milk consumers. 
j Per cent. 
Circumstances of the outbreak. 
Reporter and reference. 
139 
Providence, R I 
31 
3 
31 
100 
A milkman kept no cows, but obtained his milk from 
two farmers in the same town. On one farm no 
trace of disease could be found; on the other it was 
learned that there had been two cases of typhoid. 
The nurse taking care of the milk as well as the 
sick. When this fact was learned the milk from 
this farm was not sold and the epidemic stopped. 
Report of Supt. Health Dept., 
Ohas V. Chapin, M. D., Provi- 
dence, R, I., in report of Dec., 
’95. 
140 
May, 1894 
Montlignon, near 
Paris. 
First case, origin unknown, recovered. The clothes 
of the person having been sick, were washed in a 
brook which flowed past a milkman’s place. This 
milkman had been in the habit of washing his 
pails in this brook. Dr. Hourlier is convinced that 
the milkman carried disease to Ms customers in 
the milk served them. Dr. Hourlier traced another 
case to another dairyman, who, being out of milk, 
borrowed from the first and became sick. 
Dr. Hourlier, in the Progrbs Med- 
ical. 
141 
Marlborough, Mass.. 
49 
49 
100 
Apparently due to infected skimmed milk. A man 
was engaged in peddling milk from a creamery, lo- 
cated in the midst of the infected district. He was 
taken sick with typhoid about the time the epi- 
demic was raging its highest, but facts in his ill- 
ness went to show that he might have been the 
unconscious cause of the whole epidemic. He 
continued at his work for 10 or 12 days before tak- 
ing to his bed, during which time he had typhoid 
symptoms. 
Report of W. T. Sedgwick, in 
Mass. Am. Report, year 1894, 
p.765. 
142 
Winter of 1S72-73 
Near Birmingham, 
Eng. 
50 
(') 
47 
94 
Defective sanitary conditions on the dairy farm. 
Dejecta contaminating the water in the well. The 
dairyman used the water in the well to dilute his 
milk. 
Ernest Hart, D. C. L., Brit. Med. 
Jour., July 13, ’95, p. 89. 
143 
1875 
Renfrewshire, Eng... 
153 
153 
100 
“ Unmistakably to a particular milk service ” 
Do. 
Epidemics of Milk-Typhoid. {Baker.)—Continued. 
(Outbreak No. 139 and the eight succeeding ones were collected by Henry B. Baker, M. D.) THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER 
144 
1876 
A case of typhoid existed on a farm. The cow, 
whose milk was used only for domestic supply, 
refused to graze. She was sent away and conval- 
escence of the patient set in. The fact developed 
that in her first pasture, her water supply was con- 
taminated by the drain of a sewer. 
145 
May and June 
Plumstead, Eng 
177 
33 
159 
90 
Actual source of disease could not be definitely lo- 
cated, but was distinctly traceable to a particular 
milk fupply. On the dairy farm, the drains were 
very defective, the cow sheds dirty, and businets 
conducted in a slovenly manner. 
Dr. Sydney Davies, Brit. Med. 
Jour., Dec. 21,1895, p 1561. 
146 
April, 1893 
386 
22 
376 
97 
Tim epidemic was caused by infected milk. Origin 
of the infection not satisfactorily determined. The 
probable supposition is that the milk became in- 
fected from contaminated well water used in wash- 
ing the cans. Privy 25 ft. from well and natural 
surface drainage toward the well, Privy had a 
shallow vault and was leaking at the top. Water 
in well 1 Vi ft. from land surface. Sanitary condi- 
tions of the dairy building poor. One low frame 
building in which were the cow stables, and also, 
at one end of which was the sink used for washing 
the cans. 
Dr. Herbert E. Smith, Report on 
the Stamford typhoid fever 
epidemic, Connecticut. Li- 
brary No. 9603. 
% 
147 
June, 1890 
50 
44 
88 
Three cases of typhoid appeared on the dairy farm. 
One case of ambulant typhoid fever—one week. 
Dairy work not done with sufficient caution 
Milk set to cool in a tank near to the manure heap 
Tops of cans opened slightly and subject to infec- 
tion from particles floating in the air. Deficient 
sanitary conditions about tQe farm, and particu- 
larly in the dairy room. 
Dr. Herbert Smith, Report State 
Board of Health, Conn., 1890, 
p, 243, also Pamp. Library No. 
7516. 
Households. STATE BOARD OF HEALTH.—REPORT OF SECRETARY, 1896. 
No. 
Date. 
Place. 
No. of cases. 
No. of deaths. 
No. of cases among 
milk consumers. 
Per cent. 
Circumstances of the outbreak. 
Reporter and reference. 
148 
Hawick 
Nearly every case received milk from a farm where 
typhoid prevailed. Mils supply stopped. 
Br. Md. Jr., ’81, ii., 273. 
149 
1881. ... 
Christ Church, New 
All houses infected (including a lunatic asylum) were 
supplied by same dairy. Dairy premises in a filthy 
condition. 
Br. Md. Jr , ’81, ii, 570. 
Zealand. 
150 
1882 
Cases were consumers of milk from a dairy where 
Br. Md. Jr.,’82, ii, 590. 
typhoid had recently existed. 
151 
Grangemont 
Cases supplied with milk from a house where there 
Br. Md. Jr., ’82, ii., 911. 
was a case of typhoid. Milk was ordered destroyed 
until the typhoid patient was removed. 
152 
Cologne 
280 
61 
Several cases of typhoid at a dairy. One case nursed 
Auerbach, Schmidt’s Jahrb , ’83, 
near cow stables. 
ccvii, 72. 
153 
1883 
12 
1 
12 
100 
Milk dealer died from typhoid and his son contracted 
Br. Med. Jr., ’83, i., 1,136. 
it from him. Milkman’s water supply polluted. 
154 
1883 
37 
Followed typhoid in milkman’s family 
Almquist, Ztschr, fur Hyg., Vol. 
890, p. 137. 
r 
155 
148 
128 
Typhoid at dairy in August and September, three 
cases. These were nursed by the same person who 
attended to the dairy work. 
Curtis, Rep, N. Y. Bd. of Health, 
’81,185. 
156 
All the cases had milk from one dairy. In one family 
Janssen, Rouvier, Le Lait, p 208. 
all who drank the milk raw, contracted typhoid, 
while, those who drank it cooked escaped. Water 
supply hear privy. Case of typhoid previously in 
farmer’s family. Epidemic stopped with the with- 
drawal of milk. 
157 
96 
86 
96 
Three cases of typhoid at dairy. One a few weeks 
preceding epidemic. 
Swartz. (Reference not pub- 
lished.) 
158 
1888 
Durham.. 
12 
12 
100 
O’Hanlon, London Lancet, ’88, 
ii., 941. 
Epidemics of Milk-Typhoid. {R. G. Freeman, M. D.)—Concluded. 
Outbreak No. 148 and the ten succeeding ones were collected by R. Gr. Freeman, M. D. THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER. 
159 
Nov., 1888 
Cambridge, Mass 
73 
58 
Traced to one milk route. Typhoid fever found at 
one of the farms supplying this milk route. 
Harrington, Bep. Mass. Bd. of 
Health, ’88, p.25. 
160 
Mar , 1889 
43 
43 
Originated in a case in the family of the milk dealer 
Allen, Intercol. Med Congress, 
Melbourne, ’89. 
161 
1890 
Geneva, Switzerland. 
Traced to the milk of one dairy. It was shown that 
the dairyman washed his pails in a stream in which 
the linen of a typhoid patient was washed, Milk- 
man sued dairyman for damages and got 1500 
francs. 
Vincent, Lancet, ’90, ii., 730; Br. 
Med. Jr., ’92, 1., 1279. 
162 
1891 
Cases occurred among drinkers of milk from a dairy 
where a child sick from typhoid was allowed to 
handle dairy utensils. Milk dealer fined. 
Br. Md. Jr., ’91, ii , 1179. 
163 
Feb. to Apr,, 1891 
Sutton, Coldfield 
40 
5 
40 
100 
All cases had conta minated milk. Epidemic stopped 
by stopping milk supply. 
Hill, Br. Md. Jr., ’91, p 136. 
164 
Aug. and Sept.. 1892 
82 
6 
43 
Typhoid at dairy in August. Milk supply stopped 
August 28th. 
Anderson, Br. Md. Jr , ’92, ii., 902. 
165 
June, 1892 
7 
Dairy assistant worked for three weeks while suffer- 
ing from fever, vomiting and diarrhoea. Dairy 
supplied twenty-six families. 
Boobyer, Public Health, ’92, iv., 
110. 
166 
Dec., 1891, to Jan , 1892. 
Clermont, Ferrand... 
23 
6 
18 
Originated in dairy where the proprietor and his 
daughter had typhoid. 
Gayon, etc., Rev. de H., ’92, 993. 
167 
1892 . 
Every case except one supplied by milk which had 
been mixed with contaminated water. 
Ballard-Arnley, Stevenson and 
Murphy, Hygiene, i , 334. 
168 
Aug., 1893 
23 
23 
Creamery case. Typhoid on one of the farms con- 
tributing to the creamery. N ineteen cases infected 
from the creamery milk. 
Welpey, Lancet, ’94, i , 992. 
169 
1893 
E., near Strasburg... 
All the cases had milk from one milkman. Seventeen 
per cent of those who drank the milk had typhoid, 
while among three hundred others there was no 
case. Epidemic stopped on withdrawal of milk. 
Schmidt, Hyg, Eundsch., 94, p 
694. 
170 
Oct., 1895 
Shettleston.. 
35 
2 
15 
Case of typhoid at dairy in September. Dairy sup- 
plied sixteen families and seven of these, or over 
forty per cent, suffered. 
Wilson, Br, Md. Jr., '95, ii., 1204. 
171 
A farmer nursed his son sick with typhoid; twenty- 
one days later typhoid became epidemic in two 
institutions supplied by him with milk, as well as 
in most of the families he supplied. 
Tripe. Eouvier de Lait, p. 209. 
•