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the middle of the small intestine. Nutrient enemas are, therefore, indicated in disease of the stomach and duodenum, and even in disease of the middle part of the intestinal tract, but are contra-indicated in perityphlitis, typhoid fever, and other affections of the lower part of the gastrointestinal tract.”
As I am now considering only general indications, the details of treatment are omitted, enough having been said to direct any one to the proper understanding and treatment of this class of cases.
By I. B. Gilbert, M. D., Philadelphia, Pa. Considered in the light of its relative frequency in the practice of nearly every physician in country, village, town and city, and, coupled with this, the serious character of the disease, typhoid fever remains a subject for perennial discussion.
And the subject is seemingly inexhaustible through the diversity of views as to the nature and cause of this disease, which is prevalent everywhere and at all times; or, owing to new discoveries in its etiology and pathology; or, the endless suggestions as to its proper care and treatment; or, the novelty and effectiveness of new and rational sanitary means used to curb its spread by destroying the cause.
Assuming, as the initial proposition, that the true cause of typhoid fever has been found and established, I shall not attempt an exposition of the bacteriology of this fever, but shall restrict myself, in a general way, to the consideration of the means by which the specific bacterium may gain entrance and infect the human system, and the possible and probable sources of infection.
The chief factors now generally recognized and conceded as the disseminators of the bacilli of typhoid fever, are milk and its products, and the water supply,-especially that of municipalities. As a matter of course, there are many subordinate causes that play their minor part, some of which I may notice.
Although milk enacts a secondary role, being primarily infected by admixture with water containing typhoid bacilli, or from some other cause; yet, if such a thing were possible, it is a more potent and effective means for propagating and spreading this infection than water itself. For its use is universal, and as a cause for disseminating disease, it is not yet under the ban of suspicion by the public in general, such as is the case with water, owing to the warnings given and the teachings inculcated by Boards of Health and many individual physicians.
Eschewing all controversies, or anything that hinders united action, we should ponder deeply conditions now prevailing, for the history of older times and of older lands is beginning to repeat itself in our own country. Myriads of the inhabitants of the old world are turning to us,-lately in increasing numbers, and, unfortunately, multitudes of those whose condition, habits and customs have not changed for many centuries. Fortunately our country has been large enough to dilute or absorb this stream of emigration, but situations will inevitably develop that will be perilous, unless the current can be turned, or sanitary science is able to cope with this portentous problem.
The remedy is cleanliness, antiseptic, aseptic cleanliness, and adaptation to new conditions. But the physician must learn those now prevailing, owing to our dense population, the aggregate of which consists of all kinds and classes of peoples.
Filth is the most powerful and active ally of infection. It is a center of incubation, and the sustenance of all organisms that are dangerous and prolific in their increase. The feverless Cuban city is simply a clean Havana. A striking object-lesson of cause and effect. A signal exemplification, the “Old” and the “New,” and an exemplary manifestation of present scientific sanitation, and its practical beneficial workings. The virtue of cleanliness has always been known and acknowledged. But modern cleanliness is the effect of the application of the true sanitary science, which is the sequence of a correct knowledge of the cause of infectious diseases and the manner and means of their dissemination.
The mystery of the relentless and insidious spread of typhoid fever will only be revealed and solved when both the profession and the laity become more fully conscious of, and acknowledge and live up to, and in conformity with, our changed and changing conditions.
Roughly and briefly outlined the influences now in force and operating either directly and indirectly, are:
1st– Water. The primary source of infection.
3rd– Increase and closer aggregation of urban population, with a continued drift from country to city.
4th-A large city infected with typhoid will become an immediate center of infection (and a remote one for a much larger area) for smaller towns for a surrounding range of fifty miles by the “trolley" system of communication.
5th-Through increased population sewerage and sanitary methods become inadequate to demands, and the soil itself becomes an
agency of infection. And the smaller towns by the absolute lack of these means of prevention become new points of infection, each dominating a new district of its own.
6th-Foreign emigration, with habits and customs fixed and un-changed for many centuries.
I would not have the temerity to contend that these include all the causes that produce our epidemics, but I am sure they are the chief and fundamental agencies in operation to-day. In regard towater, it must also be borne in mind that relatively as the population increases, so does the pollution of the stream from whence the supply is drawn, and that the remedy is no longer merely a matter of changing to purer sources. All accessible ones are now apparently contaminated, and it has now become a problem of filtration in order that towns and cities be furnished with an abundant, pure and potable supply.
Let me here interpolate an episode, of personal experience, as an example and illustration bearing on the subject of our milk-supply, and also as an evidence that we are now actually in a transition period,-at least in our city with its many improvements, and incidentally, its rapidly progressing filtration plant. It may also be descriptive of other like possible foci of infection; and very happily of its retrogression and disappearance, and the refreshing, aggressive and progressive presence of the “New.”
Standing back about 25 or 30 feet from a dusty street, —now a wide, clean avenue, paved with asphalt and bordered on the opposite side with new, clean and neat dwelling-houses, stood an old frame stable, sheltering about a dozen cows.
In order to reach the homes of some of my patients, I was obliged to pass this building for a number of years previous to its demolition. But thanks to the spirit of progress and improvement, a large, solid, brick factory now covers the greater part of the area then occupied by the stable, the old frame house, the disreputable and slatternlylooking "yard” with its patched and leaning out-buildings and the rickety fence that was attempting to enclose the whole.
With the slope towards the stable (about the only redeeming feature of the place for the inhabitants of the house), the lot was tilted up in the air about 20 feet by the grading of the streets to their proper lines. Now it, too, is leveled down to and sloping in con- . formity with the topography of the streets, and the good, sound laws of scientific sanitary drainage.
The part not covered by the factory building is now a modern, health-invoking lawn; smooth, solid, sodded and surrounded by a
graceful iron fence, each slender rod of which is covered with a glossy black paint, betraying its antiseptic source and character of the healthful phenol odor it still gives forth.
This is a sharp and significant contrast to the old conditions, where sweetness could exhale from nowhere amidst such environments. The odors emanating from the stable were foul and disgusting, and the sense of filth embodied whose sway was not confined to the limits of the palings encompassing the lot.
Contending that filth, consisting of organic matter, is the pabulum of disease germs, and granting that in such surroundings it must inevitably pollute the milk produced, and knowing that a very small quantity of foul and infected milk will contaminate a quantity sufficient to poison a community, need we look further for one great source of typhoid infection?
While not reflecting upon the general cleanliness exercised on the farms scattered over the neighboring territory, from which comes the milk-supply of our towns and cities, we too well know that absolute cleanliness does not prevail in every household, farm and dairy, that adds its individual quota to the whole. The product of one careless slovenly family, or one diseased animal, commingled with and disseminated through the output of the largest, cleanest, healthiest herd, will promptly transform it all into a virulent fountain of disease.
“Creameries," the place in which milk is converted into butter, the supplies of which, too, are collected from a wide scope of country, fall into the same category of possible, or even more likely sources of infection, than when the milk goes directly to the consumer instead of indirectly in the form of butter.
For, may not that which is harmful in the milk be more effectively enmeshed and concentrated in this fatty matter? Can simply washing with cold water remove foreign organic matter from any oleaginous substance?
C. Bruck (Deutsche Med. Woch., Nov. 26th, 1903), a German investigator, has found that butter can be infected through milk stored in vessels rinsed with water containing typhoid bacilli, and has demonstrated that they can exist in it for twenty-seven days without losing their vitality. Dr. Edward Martin, our praiseworthy and efficient Director of the Department of Health, declares his belief that one-third of the cases of typhoid fever existing in our city can be traced to the milk-supply. And I cite as an example of the highly practical manner in which he deals with the problem of prevention, municipal hygiene and sanitation, the fact that he has ordered a list of all milk dealers to be made who deliver milk at the homes of fami-
lies where typhoid fever exists, in order that he may prove this view of infection beyond cavil or doubt.
While writing this, I note in one of the daily newspapers that there is an increase of typhoid fever in one of the sections of the city supplied with filtered water from our new plant. Although this is apparently strongly confirmatory of the milk infection theory, the deduction is strained and doubtful, for the water may become contaminated in its passage through pipes that are not yet free from old deposits.
Nor can this be used as an argument against the purity of filtered water, for the same reason.
It is simply a truism to say that everything that comes in contact with water containing the germs of disease, will become infected by it. The result of it is shown in the many minor and subordinate causes of infection; such as using it for a mouth-wash, and for the ablutions of the face or other parts of the body; for culinary purposes in washing vegetables that are eaten in their raw state. Many other causes might be enumerated but it is not necessary to prolong the list. Heat is the only absolutely sure destructive agent, and all liquids suspected of containing the germ should be thoroughly boiled; and the dejecta of the patient (the seat of the evil) should be subjected to a disinfection that is absolutely destructive to all microorganisms contained in them.
In concluding, I wish to urge one more point with all the emphasis possible, and that is the tenacious vitality of the bacillus of typhoid fever. Neither freezing temperature, nor burying it deeply in the earth will destroy it; and errors in both directions have been the cause of severe and serious epidemics.
If I have succeeded in re-animating and quickening the attention and interest in this all-prevailing disease that sweeps with a blast of death across our whole land with the hopes that some of the ideas contain their grain of truth, this desultory paper has attained its purpose.
THE CLEVELAND HOMEOPATHIC SOCIETY. Remarks by the President-elect, H. H. Baxter, M. D., upon Opening the Session held
February 17th, 1904. A physician in addressing the Washington Homeopathic Society recently, asserted that the study of drug pathogenesy had almost ceased, especially among the younger men of the profession. While this may be stating the case too strongly, I fear the assertion that it is not altogether groundless. I fear that the subject receives too little