Reprinted from 
University Medical Magazine, 
May, 1892. 
REPORT OF AN EPIDEMIC OF TYPHOID FEVER IN 
NORTH CAROLINA, AND ITS INVESTIGATION. 
By Seneca Egbert, M.D., 
Philadelphia. Reprinted front 
University Medicae Magazine, 
May, 1892. 
REPORT OF AN EPIDEMIC OF TYPHOID FEVER IN 
NORTH CAROLINA, AND ITS INVESTIGATION. 
Seneca Egbert, M.D., 
Philadelphia. 
During the month of November last the writer was called upon to inves- 
tigate the nature and cause of a peculiar epidemic that was at that time occur- 
ring in a small manufacturing village in the southern portion of North Carolina, 
and, if possible, to suggest measures for its suppression and for the prevention 
of future outbreaks. 
Inasmuch as some of the characteristics of the epidemic are worthy of note, 
and as the results of my inquiry have seemed to furnish additional evidence to 
that already collated as to the possibility of direct infection by means of the 
drinking-water, I have taken the liberty to make the following report: 
Situated on one of the sand-hills common to that locality, some forty or 
fifty feet above the cotton factory where most of the inhabitants find employ- 
ment, and surrounded by a semi-forest of pine and scrub-oak, the village in 
question covers about nine acres, and consists of sixty-six frame dwellings and 
one store. Everything is owned by and under the control of the company that 
operates the mill, and the people are simply tenants of the houses which they 
occupy. 
The dwellings are in pairs, and with one exception are but a single story 
in height, and for the most part have but two rooms each. In some, where a 
family is large, doors have cut through the dividing partition, and the 
family occupies both houses. Each pair of houses stands in a lot sixty feet 
wide by one hundred and fifty feet long. 
A common pump, not more than ten feet from the back doors, furnished 
the water supply to each pair, and a double privy, or outhouse, was located at 
the extreme end of the lot and at least eighty feet from the pump. The wells 
were driven pipes, having a pointed, perforated "shoe " at the bottom and an 
ordinary iron pump above. The average depth of the wells was about twenty 
feet, with a variation not exceeding three feet, showing that the level of the 
ground water followed closely that of the surface above. EGBERT, AN EPIDEMIC OF TYPHOID FEVER. 
2 
Over the whole area of the village the soil is but a layer of sand, ten feet 
deep. Beneath this is a stratum of so-called clay and then another of sand. 
That the clay stratum is freely permeable was shown by the fact that all the 
wells had to pierce it to obtain water. 
On the surface there was a slight but comparatively uniform slope from the 
northwest to the southeast corner of the settlement, with an especially marked 
hollow, to which I shall again refer, running through the northern part. 
The natural drainage was thus almost directly toward the stream that supplied 
power to the mill, as will be seen by referring to the map. 
There was nothing resembling a cesspool in the village. The outhouses 
were located on the sandy surface, without any preliminary excavation. Up 
to the time when the epidemic became serious, the solid excreta was removed 
at monthly intervals, the liquids, of course, sinking directly into the sand. 
However, as soon as it was observed that the sickness was of an infectious 
character, tight boxes were placed under the outhouses, by the advice of the 
attending physicians, these being removed and emptied twice each week, and 
chlorinated lime and dry earth freely used, daily, by persons appointed for that 
purpose. 
Water-power to the mill or factory was furnished by a large stream, across 
which a dam had been constructed, the resulting pond overflooding a consider- 
able area south of the village and killing a large amount of pine timber. Part 
of this was still standing, and part had fallen and was submerged in three or 
four feet of water. The nearest houses to this pond were from fifty to seventy- 
five yards distant and at least forty feet above it. 
These preliminary details, together with the map, are given, that by means 
of them the discussion of the epidemic may be more readily understood. 
Though the summer and autumn were remarkably dry, following a wet 
spring, until August there was no special sickness in the village, nor had there 
ever been a case of typhoid or like fever from the time the mill and village were 
established, two or more years before. 
About the twenty-first of July a family named Green came to the village 
from a neighboring town, some of the members expecting to find employment 
in the mill. 
They brought with them a sick boy, and went to live in house No. 3 
Main Street. (See plan.) After living there a short time, two other members 
of the family were taken ill, and the family moved into No. 19 on the same 
street, but lower down in the village. After they moved out of No. 3,. another 
family moved in, and of this second family two, and possibly three, members 
were affected with the same malady. 
Other cases then began to appear on both sides of Main Street, though I 
am not sure any special alarm was felt by the people until the death of the 
boy Green,-the one that was sick when he came to the village. This death 
occurred on the twenty-seventh of August. 
From that time on the epidemic increased in gravity, until the earlier part 
of October, when there began to be "a marked decrease in the severity of the 
initiatory symptoms," and on the fifteenth of that month there were only ten 
cases of the disease in bed, and those in charge felt sure that the epidemic was EGBERT, AN EPIDEMIC OF TYPHOID FEVER. 
3 4 
EGBERT, AN EPIDEMIC OF TYPHOID FEVER. 
under control. But it is to be noted that up to this time all the cases had been 
confined to one or the other side of Main Street. After a short respite the dis- 
ease reappeared, but this time among those living on Front Street, and by the 
middle of November there were ten well-established cases on that street. 
The last death directly due to the fever occurred in No. 6 Front Street, on 
November 22d, though there was one death from pneumonia on December 
2 2d in No. 20-the victim being, I believe, one of the two that had the fever 
in that house. Of the nine or ten deaths that did occur, only two were adults, 
and these were both past middle age; all the others were children or young 
persons. 
At the time of my visit, November 24th to 28th, the disease had entirely 
abated on Main Street, and the cases on Front Street had begun to convalesce. 
Since then there has been no recurrence of the malady, and with the exception 
of some cases of grippe the general health of the community this winter has 
been very good. 
That there was possibly at the beginning some doubt as to the nature of 
the epidemic must be admitted, but it soon became evident to the medical 
attendants that it was either ' ' a type of typhoid fever or else malarial fever 
with a typhoid tendency, sometimes called typlro-malarial fever." Two peculi- 
arities noted were the entire absence of the characteristic rose-colored, abdomi- 
nal spots, and the fact that the temperature reached its maximum almost imme- 
diately upon the inception of the disease. As to the first, a physician, who has 
been practising in that locality over twenty years, told me that he very rarely 
found the spots in typhoid cases in that region; and the sudden high tempera- 
ture might be explained by the intensity or concentration of the disease poison 
and by the fact that the habitual diet of the people was of the crudest and coarsest 
kind, viz., pork, sweet potatoes, ground peas, a very coarse species of cabbage, 
hot bread soaked in pork fat, etc. 
That the disease was typhoid fever seems to me to be pretty well established 
by the following facts: The physician who attended the Green family, in the 
town from which they came, writes to me that at the time they left there, in 
July, there was one case of typhoid within twenty yards of their house and 
another just across the street, and that Mrs. Green herself had typhoid after 
the family returned to that town, which they did after the death of their son. 
The physician who attended this son in the village-the very first case to occur 
-told me that he undoubtedly had typhoid; so with other cases treated by 
other physicians. Moreover, the cases I myself saw on Front Street I would 
certainly class as typhoid, though my opportunities for observing them were 
necessarily limited. Lastly, the period of incubation, course and duration 
of the disease, etc., was essentially that of typhoid. 
Owing to the proximity of the mill-pond, south of the village, and the 
presence of so much dead vegetable matter in it, there was a suspicion that the 
trouble might be malarial in character ; but in opposition to this was the state- 
ment from all concerned, both physicians and laity, that it was not at all like 
any malaria they had ever seen ; that the disease had a definite course and 
duration, which was not affected by quinine, and that the earlier cases occurred 
on the street most distant from the pond. To make sure of this point I spent EGBERT, AN EPIDEMIC OF TYPHOID FEVER. 
5 
a whole morning searching for the plasmodium malaria in the blood of those who 
were still sick at the time of' my visit, but without the least success. That 
malaria complicated many cases, however, is more than probable, for a number 
of those I interviewed told me that they had been subject to it for a long time, 
though they were freer from it there than at the places in which they lived 
before coming to the village. 
Taking it for granted that the epidemic was one of typhoid fever, I think 
a study of the map will show that for most of the cases the infectious matter 
was carried by the drinking-water. It will be observed that the lines of 
infection all begin at one or the other of the two houses which the family of 
Greens occupied while in the village,, that these lines of infection coincide 
almost exactly with what should be the lines of natural drainage from these 
houses, and that the sequence of the cases along these lines was unbroken 
from first to last. Beginning back of No. 19 Main Street, the house the 
Greens last occupied, is the hollow of which I have already spoken. This is 
marked, though not deep ; it continues back of three or four other houses in 
the row, then crosses the street abruptly, passes under No. 34 and on toward 
the lower corner of the village, as indicated by the dotted line. It is along 
the line of this hollow, or else along a line drawn directly from the house to 
the creek-according to the slope of the land-that one would expect the sur- 
face drainage from the lot of Nos. 17 and 19 to flow, and it was along just 
these two lines that many of the cases did occur. Almost all the rest were 
along a line from No. 3 Main Street, the house first occupied by the Greens, 
to No. 6 Front Street-almost exactly the line of the surface slope. The only 
other cases that occurred in the village were in the houses Nos. 13 and 41 
Main Street, and these require special mention. In No. 13 there were five 
cases reported, with no deaths ; the family was said to be very lazy and to 
rather welcome sickness as an excuse for not working, though this may not be 
so. I did not learn that any of the five cases had been at all serious, and I 
am not sure that all were genuine. The fact that the family in No. 15, who 
used water from the same pump, had no cases, would seem to indicate that the 
water-supply was not to blame for the cases in No. 13. In No. 41 there were 
four cases with three deaths-the only family in the village where there was 
more than one death. But here again the neighbors in 43, using the same 
pump, had no cases, and, moreover, this house is on a hillock and much higher 
than any of the neighboring ones, thus apparently absolving the water-supply. 
As an xplanation of the extreme mortality I can only give what was practi- 
cally the unanimous report of all the neighbors. One daughter, who had not 
been well during the summer, was stricken with the disease, and then through- 
out her illness and that of the others that followed there were continued dis- 
obedience to the physician's orders, unwillingness to accept neighborly assist- 
ance, inordinate use of stimulants, and, above all, an utter neglect of 
cleanliness and ordinary sanitary precautions. The physician in attendance 
corroborated the above and assured me that there was no excuse for at least 
two of the deaths, or, in fact, for any of the cases except the first. 
To understand how the water-supply became contaminated, one has • only 
to consider the nature of the soil, the location of the outhouses in relation to 6 
EGBERT, AN EPIDEMIC OF TYPHOID FEVER. 
the wells and the depth of the latter, and to remember that in the early days 
of the epidemic, at least, the excreta was received directly upon the soil. If 
wells in ordinary soils drain an area whose radius is equal to four times their 
depth-the exact ratio in this case-how quickly would the liquid portions of 
the excreta deposited in the outhouses reach the wells and be drawn up into 
the pumps of every house in the village ? But worse than that, according to 
common report, the Greens and their neighbors in No. 17, and possibly others, 
made a practice of throwing their liquid and night-slops out on the lot instead 
of carrying them back thirty yards or so to the privy. The poisoning of the 
water could scarcely have been more direct had they poured their filth down 
the pump itself. The unfortunate part of it all is that others than themselves 
had to suffer so grievously. 
The company is to be commended for the promptness and energy with 
which they acted when once the gravity of the situation became apparent. 
Orders were issued to boil all drinking-water; chlorinated lime and other disin- 
fectants were freely used about the outhouses and infected houses, the changes 
already noted as to the disposal of excreta were made, and there was a thorough 
sanitary policing of the whole village. The people were too slow to heed, 
however, and the soil had become too saturated with the poison to prevent the 
cases that occurred on Front Street. I have no doubt that if they had simply 
boiled their drinking-water as directed they would have escaped, but when 
they saw the trouble abating and disappearing in the rest of the village, they 
doubtless became negligent and returned to their old habits. 
Having made the investigation, with the results as detailed above, it 
remained for the writer to suggest how the sanitary condition of the community 
might be improved and the occurrence of any such epidemic prevented in the 
future. 
Undoubtedly, with such a soil and such a population the water from any 
shallow wells in the village could not be considered pure or safe. People will 
be careless or unwilling to exert themselves, and filth and house refuse of all 
kinds will be thrown upon the soil without. Consequently, a new water- 
supply, free from a reasonable possibility of contamination, must be sought for. 
The stream that furnishes power to the mill is of considerable size, comes 
through an almost uninhabited country for sixty miles, is said to be always 
cool and clear, and is apparently free from any possible danger of contamina- 
tion for years to come. I advised, therefore, that the water-supply should be 
pumped from the running stream to a stand-pipe or elevated tank, located in 
the woods west of the village, to be conveyed thence by a system of pipes to a 
hydrant just outside of each house; provided, of course, that the chemical 
analysis of the water proved it to be as pure as it seemed to be physically. 
This analysis, which was made by an eminent chemist of this [city, together 
with others of samples of water from wells in the village, is given 
below, and justifies, at least, the condemnation of the wells in the village. 
The chemist's report is practically as follows: 
' ' The samples of water submitted for examination consisted of 
" (1) From the mill-pond, lying about fifty feet below the average level of 
the houses of the village. EGBERT, AN EPIDEMIC OF TYPHOID FEVER. 
7 
" (2) From a spring on a hillside, divided from the village by the outlet from 
the pond. 
" (3) From a sample obtained by taking a sample of water from each of the 
wells in the village and mixing these samples together. 
" (4) From well at 41 Main Street. 
''(5) From well at 34 Main-Street. 
''(6) From well at 19 Main Street (Green's). 
''(7) From well at 6 Front Street. 
''(8) From well at 5 Main Street. 
' ' The following gives the results of the analysis in parts per million : 
I 
2 
3 
4 
5 
6 
7 
8 
Chlorine 
5-32 
533 
16.96 
14.20 
14 20 
7.10 
6.21 
10 64 
Nitrogen as nitrates .... 
0.252 
None. 
1.40 
1.29 
O.9I 
2.24 
o-35 
0.56 
Free ammonia 
O.O2 
0 01 
Trace. 
0.01 
0.005 
None. 
Trace. 
Albuminoid ammonia . . . 
0.14 
0.07 
0.025 
0.018 
0.025 
0-175 
0.045 
Hardness 
4- 
10. 
5- 
25- 
5- 
None. 
Acidity or alkalinity . . . 
Neutral 
Neutral. 
Slightly 
alkaline. 
Neutral 
Neutral. 
Neutral. 
Total solids (Volatile . . 
Dissolved and< 
suspended (Non-volatile 
(50 
110 < 
( 60 
" The water of the pond has a distinct yellowish-green color and an odor of 
pine. The amount of total solids in this pond water is unduly increased from 
the fact that not only the dissolved but also the suspended matter was reckoned ; 
and the amount of the latter was disproportionately large, from the fact that the 
sample was collected close to the bank and to submerged logs over which the 
water was flowing. 
" The amount of chloride in all the samples is small, and sufficiently indicates 
that the contamination by sewage or urine is so small that it may be neglected. 
On the other hand, the percentage of albuminoid ammonia in the pond water 
would seem to be very much larger than it ought to be. In every other respect 
it appears to be a soft and excellent potable water. A sample should be taken 
in the middle of the pond, away from the banks, and where the water has been 
afforded an opportunity for subsidence. 
' ' The spring water is unexceptionable. 
' 'As to the mixed sample of all wells (No. 3) and the samples from the sepa- 
rate wells, it may be said that while none of them but No. 6 are absolutely 
inadmissible as potable waters, on account of their analyses, yet they show such 
variations in their con tamed matter in solution, that it is evident that they are 
largely affected by superficial drainage, and it is not safe to depend upon them 
to supply drinking-water to the families of the mill." 
In accordance with the suggestion in the above report, a second sample of 
the pond water was obtained, this time at a distance from the shore, and 
analyzed by the same chemist. He reports: ''The agreement between the 
determination of chloride (5.32) in the first and second samples is exact and 
proves there is no contamination from cesspool drainage in the pond.. 8 
EGBERT, AN EPIDEMIC OF TYPHOID FEVER. 
"As I predicted, the percentage of nitrogen as nitrates (0.13), of free am- 
monia (0.01), and of total solids (30), in the second sample, is much less than in 
the first, being one-half in the first two constituents named, to less than one- 
third in the last. But, to my surprise, the albuminoid ammonia (0.178) in the 
second sample is greater than the first, in the proportion of 9 to 7.'' 
That such an excess of the single constituent, albuminoid ammonia, even 
though it approach what is commonly considered the danger line, is not suffi- 
cient to condemn a water in a case like the present, is evidenced by the follow- 
ing quotation from "Parke's Hygiene" :1 
"The presence of a considerable amount of albuminoid ammonia, with 
little free ammonia and chlorides, is generally indicative of vegetable organic 
matter, often peaty. This is the character of the greater part of the water-sup- 
ply of Ireland. The real significance of the albuminoid ammonia has been 
much discussed, but the results obtained are sufficiently uniform to give us a 
convenient measure of purity, provided we are careful not to draw the line too 
close. ' ' 
The above is exactly the condition that obtains in this case. The creek 
comes down from over sixty miles, through pine forests and sandy soil, with 
absolutely no possibility of animal contamination to any appreciable degree, and 
the albuminoid ammonia present must be of vegetable origin. Consequently, 
the writer can see no reason to change his opinion that the stream furnishes an 
abundant, pure and absolutely safe source for a water-supply to the village. I 
might add that the company is now supplying the people with water from the 
spring across the creek, hauling a sufficient supply each day, and that the use 
of all the wells for drinking or cooking purposes has been forbidden and discon- 
tinued. This, however, is only a temporary expedient, until proper arrange- 
ments for obtaining a more abundant supply can be effected. 
It is to be regretted that no bacteriological examination of the water, espe- 
cially of the wells, could be made, though it is doubtful whether the typhoid 
organism could have been thus positively demonstrated, as so long a time had 
elapsed between the inception of even the last cases and that of my visit. I had 
provided myself with a number of gelatine tubes for this purpose, but at almost 
the moment of my departure from the city was informed that the person who 
prepared them'had failed to neutralize the gelatine, and that it would doubtless 
be too acid for satisfactory results. This I tried to remedy on arriving at my 
destination, but my facilities were there so limited that it could only be done 
imperfectly and inaccurately, and the results were correspondingly unsatisfac- 
tory. The impossibility of procuring any ice in that locality also precluded the 
idea of bringing samples of the water to Philadelphia and making cultures from 
them here, as to transport them so far at the ordinary temperature would have 
but favored the growth of certain saprophytic bacteria and the destruction by 
them of all others, including the pathogenic ones we were seeking. 
That the water might be freer from danger, well aerated and cool in sum- 
mer, I also advised that the supply be taken from the running stream rather 
1 Eighth edition, page 709. EGBERT, AN EPIDEMIC OE TYPHOID FEVER. 
9 
than from the pond, and that the stand-pipe or tank be furnished with an auto- 
matic siphon, whereby it would be emptied periodically, say at night, when 
there is least demand for water, and refilled daily with a fresh supply. 
As to the present method of disposing of the sewage (the dry-earth system, 
coupled with frequent removal), under the circumstances, probably no better 
could be devised. In the long run, however, it will probably be more expen- 
sive than a simple system of sewers, but space does not permit such a discussion 
in the present paper. Some system of soil drainage may have to be provided, 
if the sewers are not, to carry off the excess of waste water following the in- 
troduction of the hydrants, but I am inclined to think that this will not be 
necessary, owing to the extreme porosity of the soil, the active oxidizing power 
of that atmosphere and the fact that all refuse is either disposed of in the man- 
ner described or fed to swine outside of the village limits. The company, how- 
ever, will have to take care to prevent excessive waste of water and to provide 
for the proper sanitary policing of the village. 
In conclusion, I regret that certain necessary conditions forbid my being 
more definite as to theexact locality of the village in question, as lam prevented 
not only from acknowledging the courtesies and assistance which were so 
freely extended to me in my work, both by the officials of the company and the 
physicians attending the sick, but also from publicly recording the self-sacrific- 
ing devotion and faithfulness of the latter, which I am confident kept the mor- 
tality lower than it otherwise would have been. As it was, of the three hun- 
dred inhabitants-the approximate population September ist-fifty-three were 
undoubtedly sick with the fever and ten died, practically all of which sickness 
and death might have been prevented, in so far as we can now see, had the well- 
established laws of sanitation and disinfection been properly observed and en- 
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