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Causation

The cause is the bacillus lyphosus, discovered by Eberth in


1880 (see Parasitic Diseases). This organism multiplies in
the body of a person suffering from the disease, and is
thrown off in the discharges. It enters by being swallowed
and is conveyed into the intestine, where sets up the
characteristic inflammation. It is found in the spleen, the
mesenteric glands, the bile and the liver, not infrequently
also in the bone marrow, and sometimes in the heart, lungs
and kidneys, as well as in the faeces and the urine. It has
also, though more rarely, been found in the blood. The
illness is therefore regarded as a general toxaemia with
special local lesions. The relation of the bacillus to the
other numerous baeteria infesting the intestinal canal, some
of which are undoubtedly capable of assuming a pathogenic
character, has not been determined; but its natural history,
outside the body, has been investigated with more positive
results than that of any other micro-organism, though much
still remains obscure. Certain conclusions may be stated on
good evidence, but it is to be understood that they are all
more or less tentative. (I) In crude sewage the bacillus does
not multiply, but dies out in a few days. (2) In partly
sterilized sewage (i.e. heated to 65° C.) it does not multiply,
but dies out with a rapidity which varies directly with the
number of other organisms present - the more organisms
the quicker it dies. (3) It is said not to be found in sewer air,
though Sir Charles Cameron, from a series of recent
experiments, claims to have proved the contrary. (4) In
ordinary water containing other organisms it dies in about a
fortnight. (5) In sterilized water it lives for about a month.
(6) In ordinary soil moistened by rain it has lived for 67
days, in sewage-polluted soil for at least 53 days, in soil
completely dried to dust for 25 days, and in (sterilized soil
for upwards of 400 days. (7) Exposed to direct sunlight it
dies in from four to eight hours. (8) It is killed by a
temperature of 58 °C., but not by freezing or drying. (9) It
multiplies at any temperature between io° C. and 46° C.,
but most rapidly between 35° C and 42° C. These
conclusions, which are derived from experiment, are to a
considerable extent in agreement with certain observations
on the behaviour of the disease on a large scale.
The susceptibility of individuals to the typhoid bacillus
varies greatly, Some persons appear to be quite immune.
The most susceptible age is adolescence and early adult
life; the greatest_ incidence, both among males and
females, is between the ages of 15 and 35. The aged rarely
contract it. Men suffer considerably more than women, and
they carry the period of marked susceptibility to a later age.
Predisposing causes are believed to be debility, depression,
the inhalation of sewer air by those unaccustomed to it, and
anything tending to "lower the vitality," whatever that
convenient phrase may mean. According to the latest
theories, it probably means in this connexion a chemical
change in the blood which diminishes its bactericidal
power. The lower animals appear to be free from typhoid in
nature; but it has been imparted to rabbits and other
laboratory animals. There is no evidence that it is infectious
in the sense in which small-pox and scarlet fever are
infectious; and persons in attendance on the sick do not
often contract it when sufficient care is taken. The
recognition of these facts has led to a general tendency to
underrate contagion, direct and indirect, from the sick to
the healthy as a factor in the dissemination of typhoid
fever; but it must be remembered that the sick, from whose
persons the germs of the disease are discharged, are always
an immediate source of danger to those about them. Such
personal infection may become a very important means of
dissemination. There is evidence that this is the case with
armies in the field, e.g. the conclusions of the commission
appointed to inquire into the origin and spread of enteric
fever in the military encampments of the United States in
the Cuban campaign of 1898. Out of 1608 cases most
thoroughly investigated, more than half were found to be
due to direct and indirect infection in and from the tents
(Childs: Sanitary Congress, Manchester, 1902). '' A similar
but perhaps less direct mode of infection was shown to
account for a large number of cases under more ordinary
conditions of life in the remarkable outbreak at Maidstone
in 1897, which was also subjected to very thorough
investigation. It was undoubtedly caused in the first
instance by contaminated water, but 280 cases occurred
after this cause had ceased to operate, and these were
attributed to secondary infection, either direct or indirect,
from the sick. A good deal of evidence to the same effect
by medical officers of health in England has been collected
by Dr Goodall, who has also pointed out that the attendants
on typhoid patients in hospital are much more frequently
attacked than is commonly supposed (Trans. Epidem. Soc.
vol. xix.). Recent discoveries as to the part played in the
dissemination of typhoid fever by what are termed "typhoid
carriers" have thrown light upon the subject of personal
infection. The subject was first investigated by German
hygienists in 1907, and it was found that a considerable
number of persons who have recovered from typhoid fever
continue to excrete typhoid bacilli in their faeces and urine
(typhoid bacilluria). They found that after six weeks 4% to
5% of typhoid patients were still excreting bacilli; 23% of
65 typhoid patients at Boston City Hospital showed typhoid
bacilli in their excretions ten days before their discharge.
The liability of a patient to continue this excretion bears a
direct relation to the severity of his illness, and it is
probable that the bacilli multiply in the gall bladder, from
which they are discharged into the intestine with the bile.
The condition in a small number of persons may persist
indefinitely. In ioi cases investigated, Kayser found three
still excreting bacilli two years after the illness, and George
Deane has recorded a case in which bacilli continued to be
excreted 29 years afterwards.
Many outbreaks have in recent times been traced to typhoid
carriers, one of the first being the Strassburg outbreak. The
owner of a bakehouse had had typhoid fever ten years
previously, and it was noticed that every fresh employe
entering her service developed the disease. She prepared
the meals of the men. On her exclusion from the kitchen the
cases ceased. In Brentry reformatory, near Bristol, an
outbreak numbering 28 cases was traced to a woman
employed as cook and dairymaid who had had typhoid
fever six years previously. Before entering the reformatory
she had been cook to an institution for boarded-out girls,
and during her year's residence there 25 cases had occurred.
A case is reported by Huggenberger of Zurich (Lancet,
October 1908) in which a woman carrier is said to have
infected a series of cases lasting over 31 years, including
her husband, son, daughter-in-law, and no less than nine
different servants. Numerous cases of contamination of
milk supplies by a "carrier" have been investigated, and in
outbreaks traced to dairies it is wise to submit the blood of
all employes to the agglutination test. A persistently high
opsonic index to typhoid bacilli is notable among
"carriers." Not only do persons who have had tyhpoid fever
harbour bacilli, but also persons who come in contact with
cases of the disease and who have no definite history of
illness themselves.
The other means of dissemination are polluted soil, food
and drink, particularly milk and water. The precise mode in
which polluted soil acts is not understood. The result of
experiments mentioned above shows that the bacillus lives
and multiplies in such soil, and epidemiological
investigation has repeatedly proved that typhoid persists in
localities where the ground is polluted by the leakage of
sewage or by the failure to get rid of excrementitious
matter. In some instances, no doubt, drinking water thus
becomes contaminated and conveys the germs, but there
appears to be some other factor at work, for the disease
occurs under the conditions mentioned where the drinking
water is free from suspicion. Exhalation is not regarded as a
channel of communication. The researches of Majors Firth
and Horrocks prove that dust, flies and clothing may
convey the germs. Another way in which food becomes the
medium of conveyance is by the contamination of oysters
and other shellfish with sewage containing typhoid bacilli.
This has been abundantly proved by investigations in Great
Britain, America and France. Uncooked vegetables, such as
lettuces and celery, may convey the disease in a similar
way. The most familiar and important medium, however, is
water. It may operate directly as drinking water or
indirectly by contaminating vessels used for holding other
liquids, such as milk cans. Typhoid caused by milk or
cream has generally been traced to the use of polluted water
for washing out the cans, or possibly adulterating their
contents. There is obviously no reason why this chain of
causation should not hold good of other articles of food and
drink. Outbreaks have been traced to ginger-beer and ice-
creams. Water sources become contaminated directly by the
inflow of drains or the deposit of excretal matter; indirectly,
and more frequently, by the leakage of sewage into wells or
by heavy rains which wash sewage matter and night-soil
from ditches and the surface of the land into springs and
watercourses. Water may further be contaminated in the
mains by leakage, in domestic cisterns, and in supply pipes
by suction. There is some reason to believe that the bacilli
may multiply rapidly in water containing suitable
nourishment in the absence of large numbers of their
natural foes.
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