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Typhoid Bacilli Carriers, William H. Park, M.D.


This case excited so much interest that I decided to have tested a large number of typhoid convalescents. Eight months ago there was a typhoid epidemic at the Trenton (N. J.) State Insane Asylum. Through the courtesy of those in charge we were able during the past two months to examine the stools from 52 persons who had had typhoid at that time: 2 of these were found to pass numerous typical typhoid bacilli. Their stools were examined four times. One case revealed the bacilli only once, in the other they were present every time.

The stools of 16 persons, who had suffered from typhoid fever in the Long Island State Asylum, were sent us by Dr. Agnew. Two of these persons were found to pass abundant typical typhoid bacilli; they had been well for six months. Repeated examinations have shown the constant presence of bacilli. One of these cases was so mild that the patient was only suspected to have typhoid fever because of the other cases of that disease.

We have, therefore, found typhoid bacilli in the stools of 6 per cent of the cases examined. During the autumn we examined the feces from a large number of persons convalescent from typhoid fever just as they left the hospital and found bacilli persisted in the feces of about 5 per cent. It was impossible to trace the cases further.

The bacteriologie tests were carried out by Dr. Goodwin and the Misses Noble and Pratt, bacteriologists in the Research Laboratory.

These examinations indicate that the same conditions exist in the country as in Europe, namely, that fully 2 per cent of persons who have had typhoid fever are typhoid bacilli carriers. A few of these pass infected urine, but most infected feces. Besides these there are numerous typhoid carriers who never had typhoid fever, but through contact with infection became bacilli carriers. Probably at least one in every five hundred adults who have never knowingly had typhoid fever is a typhoid bacilli carrier.

As the majority of typhoid cases occur before the age of 30, the average life of typhoid carriers is fully 25 years, so that we have the somewhat appalling fact that there are at least half as many recovered typhoid cases who are typhoid carriers as there are typhoid cases in any year and that, besides these, there are the typhoid carriers, such as the cook, who have never had typhoid fever.

What can we do under the circumstances? It seems to me that any attempt to isolate and treat on bacteriologic examinations, as Lentz suggests, is impracticable. When we consider that the presence of the bacilli in the feces of these persons is often only occasional, that numerous contact cases having never had typhoid fever would not come under suspicion, and finally, then impracticability of isolating for life so many persons, we are forced to consider isolation utterly impracticable, except as in the case of the cook already described, where conditions increase the danger to such a point that an attempt at some direct prevention becomes an essential.

We must, therefore, as before, turn to the more general methods of preventing infection, such as safeguarding our food and water, not only chiefly when typhoid fever is present, but at all times, for we now know that in every community, whether it be large or small, unsuspected typhoid bacilli carriers may always be present.

DISCUSSION.

Dr. Henry Albert, Iowa City, Iowa: A small epidemic of typhoid fever, traceable to a bacillus carrier, occurred in Cedar Falls, Iowa, last fall. It was an epidemic of thirteen cases of typhoid, occurring at about the same time in three families that lived in the same neighborhood. The water supply was first investigated and it was found that these families were using the ordinary supply of the city, the same as that used by a majority of the people. The water supply as the medium of infection having been ruled out, the milk supply was next investigated and it was found that the families in which the cases of typhoid occurred all obtained their milk from one source, and that no other family in the city was supplied from this source. We then investigated more in detail as to the possibility of the contamination of the milk and found that the owner of the cow, who also did the milking, had had typhoid about fifteen months previously, but had not had a sign or symptom of typhoid since, or for more than a year. A bacteriologie examination of the urine and feces of this man was made and typhoid bacilli found in the urine in considerable number. There was no evidence of an inflammatory condition of the kidneys or bladder. We felt reasonably certain that the epidemic was cause by this bacillus carrier. Hexamethylenamin in the form of urotropin was given and in a few weeks the urine was free from the typhoid bacilli. I feel certain that other epidemics I have observed in the past were caused by individuals of this kind.

Dr. Willam Litterer, Nashville, Tenn.: The subject of typhoid carriers is an exceedingly important one. I have in mind a patient who had typhoid fever one year ago. The patient subsequently developed a post-typhoid necrosis of the rib which was operated on by Dr. W. A. Bryan of Nashville. A sinus appeared and a large amount of pus exuded from this wound, something like for our five ounces a day. This condition existed for three months, the patient growing weaker, rapidly losing flesh, and vague pains developed throughout the body. The surgeon requested that I isolate the organisms in said pus and make a vaccine according to the method of Wright. This I did and much to my surprise I found pure culture of the Bacillus typhosus in enormous numbers. I take this to be unique inasmuch as no other organism, such as the pyogenic cocci or other bacteria could be found in this exuding sinus of over three months' standing. I made a comparative estimate of the number of typhoid bacilli in this pus and found that an ordinary platinum loop full contained nearly a half million of bacilli. This case could be rightfully considered as one of a typical typhoid carrier and an especially dangerous one if the discharges from the sinus were not destroyed. Two months' injection with the antogenous typhoid vaccine produced very gratifying results. The patient is much stronger, gaining steadily in weight and there is an absence of the vague pains throughout body. The sinus has almost healed, only about half a dram of pus exuding in the twenty-four hours. Recently I made another bacteriologie examination and found only a few typhoid bacilli and some specimens of Staphylococcus pyogenes aureus. If the patient ceases to improve I intend to make a staphylococcic vaccine and inject this, with the typhoid vaccine. Dr. Park has called attention to the fact that many of these "carriers" have an infected gall bladder, and it has been suggested by some that, in order to cure this condition, a surgical operation would be necessary. It might be possible to try vaccine therapy in curing these conditions.

Dr. M. J. Rosenau, Washington, D. C.: I can not take Dr. Park's place, but feel sure that if he were here he would say that "typhoid Mary" refuses to submit to surgical interference. She is perhaps justified in this conclusion, because the gall bladder is not the only source of the typhoid bacilli that appear in the feces. Surgical interference therefore may not always correct the condition. Sometimes the feces of these carriers contain such large numbers of typhoid bacilli as almost to displace the colon bacillus; it seems that the typhoid bacillus may take up a natural habitat somewhere in the intestinal tract independent of the gall bladder. We have not been able to find a chronic bacillus carrier of this type in Washington.


 

Consider These Questions

Background

 

1. How can William Park justify both the "impracticability of isolating for life so many persons" and the treatment that Mary Mallon received from the New York City Department of Health?

2. What is the significance of Park's mentioning of "the predominance of women who are carriers over men"?

3. How does Park connect the legal issues and the public health issues of typhoid bacilli carriers?




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