Epidemic

by David DeKok

  Chapter 8

  Typhoid, and How the

  Epidemic Began

  There were few godlike figures in the world of medicine in 1902, but Dr. Robert Koch was one. He was known far beyond his native Germany and was arguably the most famous healer in the world. Short, bearded, and bespectacled, he did not resemble a deity, but his pioneering achievements as a bacteriological and epidemiological researcher put him squarely atop the medical Mount Olympus.

  Koch achieved his fame by taking on the big diseases, the ones that killed significant numbers of people. In 1882, he discovered the microbe that caused tuberculosis, the leading cause of death in nineteenth-century Europe and North America, killing one of every seven people. The German government created the Institute for the Investigation of Infectious Diseases for him in Berlin ten years later. It remained under Koch’s direction until his death in 1910, after which it was renamed after him.1 “Personally, Koch is a most approachable man, kindly in his relations with his associates and assistants, and a most industrious and enthusiastic worker,” wrote Dr. Hermann M. Biggs, the New York City health commissioner in 1901. “He has the power, to a remarkable degree, of inspiring his pupils with his own scientific spirit and enthusiasm.”2

  Koch studied anthrax, tuberculosis, cholera, and malaria and learned how they lived and died. He used that knowledge not to cure those dread diseases, which would await the coming of antibiotics after World War II, but rather to contain their spread, to stop them from infecting new human hosts. In so doing Koch stopped epidemics, saved countless lives, and gave the public hope. Biggs and the Health Department used his rigorous methods to contain a cholera outbreak in New York in 1892 after infected ships arrived from Hamburg, Germany, where an epidemic was raging, and spawned new cases in the densely populated tenement districts of the Lower East Side.3 Now it was the turn of typhoid fever, the world’s third-leading killer disease, to be subjected to rigorous research and analysis by Koch and his associates. Finally, he was ready to report his findings and scheduled a speech to military doctors at the Kaiser Wilhelm Institute in Berlin. To say his speech was much anticipated in the European medical world was an understatement. No one, rich or poor, could be smug about typhoid.4

  Typhoid, also known as “the fever,” was commonly spread by polluted water, and because everyone drank water, everyone was vulnerable. Water filtration was far more common in Europe than the United States in 1902, but it was done mainly in the large cities. Neither continent had yet embraced the use of chlorine to kill typhoid bacilli in drinking water. That would not happen in America until 1909. Some of the better-known typhoid victims in history included former first lady Abigail Adams in 1818; Prince Albert, husband of Britain’s Queen Victoria, in 1861; President Lincoln’s son Willy in 1862; Mark Hanna, President William McKinley’s chief political strategist, in 1904; and Wilbur Wright of airplane fame in 1912. There were countless others, real and fictional.

  Among the latter were Hanno Buddenbrook, the fifteen-year-old musical prodigy in German author Thomas Mann’s 1901 novel and family saga, Buddenbrooks, and Molly Malone, a young Irish lass who sold shellfish from a wheelbarrow on the streets of Dublin. In the mournful Irish folk song that memorializes her, Molly’s ghost still roams the streets crying, “Cockles and mussels, alive, alive-o.” Live cockles, which are similar to scallops, were supposedly safe to eat, but as Molly herself learned, an unwitting diner could end up dead if that cockle, mussel, or oyster came out of typhoid-contaminated waters. Any number of nineteenth-century typhoid outbreaks in Europe and America were linked to shellfish harvested too close to a sewage discharge pipe, although most cases still resulted from drinking contaminated water. It was a dirty age.

  In the fall of 1894, for example, twenty-five students at Wesleyan University in Middletown, Connecticut, contracted typhoid, and four of them died. Each had attended one of three fraternity dinners for new members the night of October 12. Raw oysters were the appetizer. They had been harvested in the deep waters of Long Island Sound but then were placed in a pen in the freshwater Quinnipiac River near New Haven, Connecticut, for several days of fattening. This was a common practice at the time. The pen, probably unbeknown to anyone, was three hundred feet downstream from a private sewage discharge pipe leading from a house where a woman lay dying of typhoid. An investigation by Dr. Charles J. Foote of Yale University Medical School found that typhoid bacilli between the shells of oysters taken from the river were still virulent after forty-eight hours. Later research found that the virulent period could be as long as five to nine days.5

  The 1890 United States census found the worst typhoid fever death rates in Birmingham, Alabama, with 264 deaths per 100,000, and Denver, Colorado, with 217 deaths per 100,000. The 1900 United States census reported 35,379 total deaths from typhoid that year, which meant that roughly 350,000 Americans had contracted the disease. Dr. Edwin O. Jordan, a prominent bacteriologist from Chicago, considered those numbers to be “considerably below” the true figures.6

  Koch’s interest in conquering typhoid derived from all this human suffering but also from the military needs of Germany. For every great power of the early twentieth century, typhoid was a pressing national security issue, capable of turning modern armies into tents of feverish, moaning invalids and killing off 10 percent or more of the soldiers who became infected. As Koch noted at the beginning of his speech in Berlin, some seventy-three thousand German troops contracted typhoid during the Franco-Prussian War in 1870 and nine thousand of them died. Nearly fifty-eight thousand British troops contracted typhoid during the Boer War in South Africa between 1899 and 1902, and more than eight thousand died.7 The United States lost more troops to typhoid than to Spanish bullets and artillery during the Spanish-American War of 1898.

  Even though German Army deaths from typhoid had declined by 25 percent since the 1880s, thanks to cleaner drinking water and better sewer systems in its garrison cities, the smaller towns and vast rural areas of Germany, including the western border region with France, had not benefited from this new attention to public health. There remained hotbeds of typhoid almost guaranteed to infect the troops if they had to mobilize for another war with their historic foe. By framing typhoid as a national security issue, Koch was more easily able to get funding and facilities from the German government to do the research that needed to be done.8

  The irony, of course, is that his speech occurred at the very time work on the Six Mile Creek dam was ending for the season and the countdown to the Ithaca epidemic had begun. As momentous as it was for the future of typhoid treatment, the speech had no impact on Ithaca because important medical findings at the beginning of the twentieth century could take months, if not years to cross the Atlantic from Europe. Instead, Koch is our oracle, voicing warnings that were an accurate road map to the Ithaca catastrophe.

  “We know that typhoid fever is an illness which spreads mainly, I would like to say, really depends nearly completely, on how one handles sewage,” Koch said that night. “Feces is the vehicle by which the typhoid bacilli are spread from the human body to the outside world.”9

  His method of fighting cholera and malaria, which he now adapted to typhoid, had been to find the patients—not always an easy task—then isolate them and disinfect their environment so they could not spread the disease to new hosts. Because cholera and malaria microbes could not live, or at least not for very long, outside of a host organism, a properly contained epidemic expired on its own. Koch believed the same would work with typhoid.

  The problem with typhoid was that it was difficult with existing diagnostic methods to quickly confirm a case, leaving a large window of opportunity for ignorance to spread the disease. For example, the test known as the Widal Reaction, based on discoveries by French medical researcher Georges Fernand Isidor Widal in 1896, only gave results beginning around the second week of a typical three-week course of typhoid, by which time the patient could have infecte
d his caregivers and anyone else in the vicinity. If given too early, the Widal test might yield a false negative. Diagnosis by examination of bacterial cultures under a microscope was only a little better, requiring several days to grow the culture to a point in which the typhoid bacilli could possibly be distinguished from their E. coli neighbors, which produced somewhat similar symptoms. “If one must wait several days for the diagnosis, then it is not useful for our purposes,” Koch told his audience in Berlin.

  Aided by his associates, Wilhelm von Drigalski and Hermann Conradi, Koch adapted a method that had provided quick diagnoses of cholera. Nutrients were added to the culture to speed up the growth of typhoid bacilli, while other substances were added to retard the growth of E. coli bacilli. Then, taking advantage of the acidic nature of E. coli and the alkaline nature of typhoid, they added litmus solution to the culture, turning the typhoid blue and the E. coli red. One further step, agglutination, or clumping together, made certain the bacilli were typhoid and not dysentery. The whole process took twenty to twenty-four hours.10

  Once satisfied that their new diagnostic procedure worked, Koch and his associates examined several typhoid cases in Berlin, looking at the patients and the people around them, just as they would in a cholera outbreak. In some cases, they found typhoid fever bacilli “in humans who had no clinical symptoms,” again replicating findings in cholera outbreaks. Such a person was a “carrier,” or in German, a Typhusbazillentrager, meaning he or she harbored and could spread the disease but displayed no symptoms and appeared to be outwardly healthy. From Berlin, Koch and his assistants moved on to Trier in the German state of Rhineland-Palatinate and then to a group of four villages about twenty-five miles from the Luxembourg border.11 This region, known as the Hochwald, was in the forward deployment zone of the German Army and was a hotbed of typhoid.

  They learned many things in the Hochwald, notably that young people were the most likely victims of typhoid because they “come new to the infection,” not yet having had an opportunity to pick up immunity. They found that local physicians knew little about stopping a typhoid outbreak, and even in rules-conscious Germany, could not be counted upon to report all typhoid cases they treated to public health authorities. Typhoid sufferers often did not seek treatment out of fear of the cost but came readily to Koch’s clinic once assured there would be no charge. There was a catch, though. Patients were kept “from diagnosis to dismissal,” often several weeks, and were not allowed to go home until three bacteriological examinations proved them to be free of the typhoid bacilli.

  The new methods worked. Typhoid was exterminated from the four villages after three months and did not return, even though other villages in the Hochwald had their usual annual outbreaks, typically in August or September. He had broken the chain of transmission from one new patient to another, and finally, with nowhere to go, the typhoid had simply expired.

  Koch found validation in the Hochwald, too, for his belief that infectious diseases did not spring to life from the miasma. Miasma believers, who in 1902 included surprising numbers of physicians and sanitarians, argued that diseases such as typhoid sprang to life from dirt, filth (i.e., horse manure in the streets—a common problem before the ascendancy of the automobile), and foul gases arising from putrid matter. Even the Encyclopedia Britannica wrote in its ninth edition in 1894 that the connection of typhoid “with specific emanations given off from decomposing organic or faeculant matter . . . is now almost universally admitted.”12 But not in Berlin. At the core of the miasma belief was a certain moral smugness, a justification for the well-to-do to blame the poor and their living conditions for diseases that afflicted them. Koch dismissed miasma in his Berlin speech, stating that the results of the Hochwald clinic showed that people and people alone were the sources of typhoid. “If, for instance, the infection could attack humans in some other way, such as from the soil, then despite our efforts we would have had new cases of typhoid fever,” he said. Case closed.

  But the biggest news that night was of typhoid carriers, Koch’s groundbreaking finding that seemingly healthy individuals could harbor the typhoid bacilli and spread it to others for years after apparently recovering from the disease. It didn’t happen often, but often enough. “The so-called carriers are the most dangerous,” he said during the question-and-answer period that followed. “They are not lying ill in bed, where everything can be disinfected, but they travel around, sometimes make long journeys and carry the bacilli everywhere.”13 Carriers were the answer to why typhoid outbreaks sometimes seemed to occur for no reason, when there was no evident Patient Zero.

  Koch was not the only physician to study typhoid. Many had gone before him, back well into the nineteenth century. One famous predecessor was Dr. William Budd of Great Britain. Budd published a pair of articles in the British medical journal Lancet in November and December of 1856 outlining his findings on typhoid, nearly all based on observation rather than laboratory work. He was the first to assert that typhoid was transmitted through the excretions of a typhoid patient, usually after they found their way to the local water supply.14

  Over the years, medical researchers spent considerable time studying how long the typhoid bacilli could live outside a human body. While the estimates varied widely depending upon whether the bacilli were in water, excrement, or ice, the consensus was that at most, typhoid could survive no more than five months in a frozen state, including frozen excrement, and just a few days to a couple of weeks if not frozen. Modern research mentioned in an Indian medical journal in 2001 slightly reduced the survival time of the typhoid bacilli to forty-eight hours to seven days in water, up to a month in ice, and up to seventy days in soil irrigated with sewage.15

  The outbreak every typhoid researcher remembered before Ithaca occurred in the winter of 1885 in Plymouth, Pennsylvania, a town of eight thousand across the Susquehanna River from Wilkes-Barre. A man who was exposed to typhoid in a distant city arrived in town and fell ill in a house that happened to be on a hillside. We know little about him other than he was nursed by the occupants of the house for several weeks and gradually recovered. The weather was bitterly cold, as cold as twenty-two degrees below zero. His caregivers threw his contaminated excrement out into the snow on the hillside behind the house, where it quickly froze. The hill sloped toward a stream that was Plymouth’s water supply. When the spring thaw came on March 26, the melting snow carried the excrement into the stream. The still-live typhoid bacilli caused an explosive outbreak in Plymouth, sickening 1,104 residents and killing 114 of them. The death rate was a whopping 1,368 per 100,000. It was the worst typhoid epidemic in America in percentage terms up to that time, but the victims were mainly miners and their families, and so their deaths were mainly of academic interest, if at all, to the rest of America.16

  The Ithaca typhoid epidemic was caused by a fatal combination of human recklessness and bad luck with the weather. The “what-ifs” are many. If William T. Morris, the new owner of Ithaca Water Works, had agreed to Professor Gardner S. Williams’s recommendation that he first build a filtration plant, there very likely would have been no typhoid epidemic. It would not have mattered if one or more of the workers was a typhoid carrier or if there was a live case further up the watershed. Similarly, if Morris, his contractors Tucker & Vinton, the engineer Williams, or his assistant, Shirley Clarke Hulse, had enforced sanitary conditions in the camp, as the contract required, we would not be writing this story either. Instead, the typhoid bacilli, aided by the unusual weather, moved remorselessly toward Cornell University and the city of Ithaca.

  How do we know one (or more) of the workers at the dam site was a typhoid carrier? Let us examine the evidence. We have already read observations of the grossly unsanitary conditions tolerated at the work camp for those who built the dam. Five witnesses saw significant amounts of human excrement along the banks of Six Mile Creek during the fall of 1902. There was but a single outhouse for the camp, and the workers, bein
g no different from any other workers around the world in 1902, did their business wherever it was convenient. No apparent effort was made to rein in the men and force them to observe the sanitary regulations that were written into the contract.17

  Why do we suspect one (or more) of the workers was a typhoid carrier? It is not because they were immigrants, but rather where they were immigrants from. Most had emerged from the river of humanity flowing out of Italy at the beginning of the twentieth century, most often from southern Italy, a hotbed of typhoid. Even today, typhoid has not been fully eradicated there.18 Italy in 1902 had the highest typhoid rate in Europe, 35.2 deaths per 100,000, and in southern Italy, where many peasants still lived in backward, feudal conditions, the rate was doubtless much higher, with the national rate held down by the relatively cleaner northern regions. One need not look long in nineteenth-century travel and medical literature to find references to the southern Italian typhoid problem. John Murray wrote in 1883 about the effort in Naples to enclose stinking open sewers that ran along city streets, saying, “They are tending to remove the bad name which Naples had not undeservedly acquired for typhoid fever.” Dr. J. Burney Yeo wrote in 1889 that “the cities of southern Italy and some even of the more northern ones have laid many a British visitor low by their fever-laden atmosphere.”19 He was referring to typhoid, though also to cholera and malaria.

  What this meant is that southern Italian workers were far more likely to have been exposed to typhoid during their lifetime than workers who had grown up in Ithaca, and thus were more likely to be typhoid carriers. Ithaca had been relatively free of typhoid until 1903, with just a handful of deaths each year and no large epidemics. Ithaca City Hospital records show that only twenty-three people were treated for typhoid in all of 1902, with one death. Thirty-six patients were treated in 1901, the year Common Council became concerned about water purity, and six died. On average, about sixteen people annually contracted the disease.20 Ithaca was not like southern Italy. Had Morris hired Driscoll Brothers of Ithaca (the second-lowest bidder) to build the dam, the likelihood of there being a typhoid carrier among the local workers employed by Driscoll would have dropped dramatically.