COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 49358 RC187.M46 Typhoid fever in 1 RECAP Mchigan. Dept, of health. Typhoid fever in Michigan in 1890 • -<^. RCISl H^6 intlieCttpoflmigork CoUege o( ^ijpgiciansi anb burgeons Hitjrarp Digitized by tine Internet Archive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/typhoidfeverinmiOOmich TYPHOID FEVEK llSr MICHIGhAlSr IN 1890, A SUMMARY FROM REPORTS HEALTH OFFICERS, CLERKS AND PHYSICIANS, COMPILED UNDEE THE DIEECTION OF THE SECRETARY OF THE MICHl&AN STATE BOARD OF HEALTH. [Repeinted feom THE Annital Repoet of the Michigan State Boaed of Health foe THE Yeae 1891.J [Reprint N"o. 383.] SSAL. BY AUTHOEITY. LANSING : ROBERT SMITH & CO., STATE PRINTERS AND BINDERS, 1898. TYPHOID FEVER IN MICHIGAN DURING THE YEAR ENDING DECEMBER 31, 1890, r Reprinted from the Annual Report of the Michigan State Board of Health for the year 1891.] [Repeint No. 382.] There were reported to the office of the Secretary of the Michigan State Board of Health, during the year 1890, 1,924 cases of sickness, and 304 deaths from typhoid fever, in 310 localities. No reports of this disease were received from the following sixteen counties: Alcona, Alger, Arenac, Crawford, Gratiot, Iosco, Iron, Isle Royal, Luce, Mackinac, Manitou, Missaukee, Montmorency, Ogemaw, Presque Isle, Schoolcraft. Table 1 gives, relative to typhoid fever, the number of outbreaks, local- ities, cases, and deaths, average number of cases per outbreak, average number of deaths per outbreak, per cent ratio of deaths to cases, and the number of special final reports received, for the seven years, 1884-90: Table 1. — Typhoid pevee. — Exhibiting the numher of Outbreaks, Localities. Cases and Deaths reported for each of the seven years, 1884-90; also for some of those years the average Cases and Deaths per Outbreak, the per cent ratio of Deaths to Cases, and the number of Special Final reports received. Year. Outbreaks Reported. Localities Reported. Cases Reported. Deaths Reported. Average Cases per Outbreak. Average Deaths per Outbreak. Deaths per 100 Cases. Final Reports Received. 1884 245 200 282 320 296 398 310 969 715 1,194 3,424 1,511 2,530 1,924 290 194 282 411 310 402 304 27 23 18 ■17 21 tl8 16 1885 1886 1887 1888 '_ 1886 1890 218 290 335 316 432 330 3.28 4.15 *7.24 4.78 t5.17 5.83 .89 .75 *1.23 .98 t.98 .92 60 46 60 1 115 135 * The large average number of cases and deaths per outbreak in 1887 is partially accounted for by the fact that in two outbreaks the disease became epidemic, resulting in an aggregate of 535 cases and 7S deaths. t In computing the average numbers of cases and deaths per outbreak, and the per cent ratio of deaths to cases in 1889, the outbreak at Negaunee, in -which 300 cases were reported, is omitted, because the number of deaths which occurred in that outbreak was not reported. As shown in Table 1 there were reported to this office 606 cases and 98 deaths less for the year 1890 than for the preceding year. The average number of cases per outbreak for the year 1890 is slightly more than for 1889. This is explained in part by the fact that, during the year 1889, 27 210 STATE BOARD OF HEALTH.— REPORT OF SECRETARY, 1891. . there occurred an €fj)idemic of this disease, at Negaunee, with 300 cases, which, as stated in the (f ) foot-note to Table 1, were not computed in the average for that year. The reports received at this office show this disease to have been slightly less fatal during the present year than for the preceding year, the number of fatal cases being 2 per cent (of the total number of cases) less in 1890 than in 1889. In 1889 the number of reported cases per 10,000 of population was 12.4, in 1890 it was only 9.2. Notwithstanding the large decrease in the number of reported outbreaks of this disease in 1890, as compared with 1889, there is shown by Table 1, an increase in the number of final reports received at this office relative to those outbreaks. This indicates a gratifying increase of assiduity on the part of local health officials in the discharge of their duties. 8tudy of the regular sickness-statistics in Michigan (conclusions from which are given in Exhibit 1 and Table 8, further on in this article) shows a decrease in the per cent of weekly reports which stated the presence of typhoid fever in 1890, as compared with 1889, which is corroborative of the evidence of the decrease in prevalence of the disease as shown (in Table 1 and the last three preceding paragraphs) by the system of com- municable disease reports on which the first part of this article is based. SOURCE OF CONTAGIUM OF TYPHOID FEVER. Table 2. — Exhibiting the reported " Source of Contagium " of Typhoid Fever in Michigan, during the year 1890. Reported Source of Contaginm. Number of Reports for each Source of Contagium Infected and impure water Supposed to be impure water Unsanitary surroundings... Defective drainage and sewers ._ From a former case From outside jurisdiction whence reported Decaying vegetables in cellar Overwork Digging a ditch Unknown No source stated Sporadic Exposure Bad atmosphere In milk By working on Port Huron tunnel All outbreaks 54 5 13 3 7 47 2 4 1 68 111 7 5 1 1 1 330 TYPHOID FEVER IN MICHIGAN IN 1890. 211 Table 2 shows that relative to 111 of the 330 outbreaks of typhoid fever reported to this office during the year 1890, the source of contagium was not stated, that in regard to 68 outbreaks it was reported as " unknown," and that in 47 instances it was reported as having been brought from out- side the jurisdictions whence the outbreaks were reported. In 52 per cent of the remaining 104 outbreaks the source of contagium was given as " infected and impure water,"' and in 13 per cent as " supposed to be impure water." Below are given extracts from statements found in the reports of local health officers with regard to the source of the contagium of typhoid fever. " Most probably the use of water from a shallow creek t<3 which geese, dogs, cats, cows, horses, men, women and children, both dead and alive, have free access."— G^eo. &. Barnett, M. D., Health Officer of Tilden township, Marquette county. "Investigating the source of this ontbreak of Typhoid Fever, I found the well under the house, dug well, stoned up, about two feet of filthy water containing dead rats, sow bugs and filth from scmbbLng floors. Hog yard, hen park and privy all within fifty to seventy-five feet of the well."— iT. C. Maynard. Health Officer of the Village of Hartford, Van Buren county. " From fiJth of cistern and reservoir, under the dwelling house, large enough to contain water for the use of 500 cattle in time of a drouth."— ^tejcander C. Kidd, Health Officer, Albee tmcnship, Saginaw county. " This patient contracted the disease while engaged as a sailor. The vessel on which he was working lay in Detroit at the outlet of a sewer. He drank of the water."— H'. K. Moore, Health Officer, Algonac, St. Clair county. " This fever has prevailed here every year during the summer and autumn for the past six years, and very little, if anything has been done to prevent the ravages of the disease. Much of the land in and around about the town is low and swampy and the drainage and natural water courses are blocked up with slabs and saw dust along the whole front of the town. Water is obtained from two sources, water pipes in L'.-inse Bay, and surface wells. The water pipes draw water from the bottom of a shallow bay, only a short distance from the shore, directly in front of two saw mills, and only a few feet from large docks built of mill waste. In summer the water always has a bad odor. As to the wells, water can be obtained anywhere by digging a few feet. After a heavy rain wells and shallow privy vaults are running over so that pollution of the well water is very general; and this is increased by lack of drainage."— ^. J. Braden, Health Officer, Baraga tcAunship, Baraga county. The following diagram, on page 212, drawn from sketches and informa- tion furnished by Mr. Braden, illustrates the conditions under which the water-supply of Baraga is obtained; which conditions seem to fully warrant "the opinion that the source of the disease in Baraga was polluted drinking water. TYPHOID FEVEK AT SAULT STE. MAEIE. The following correspondence between the Secretary of this Board and Dr. A. J. Campbell, health officer of Sault Ste. Marie, bears on the source of contagium, and history, of an outbreak of typhoid fever which prevailed at that place from August to October, 1890, and which resulted in 300 cases of sickness and 20 deaths. It also illustrates some of the difficulties with which health officers have to contend in their efforts to restrict and stamp out dangerous communicable diseases which appear in their jurisdictions. August 28, 1890, Dr. Campbell wrote to the :8ecretary as follows: " I forward you a notice of an outbreak of typhoid fever. I will send you a fuller report soon. The physicians will not report. The prosecuting attorney will not prosecute for want of evidence. I can go and diagnose typhoid fever; the physician in attendance says no. I'll get three to say yes ; he will get six to say no. The prosecuting attorney says, no evidence. Your health officer is ignominiously defeated. No remedy. My salary is U9.3i per month. Who can attend to his duty under such circumstances. I wish I had the power to get others to do their duty, and I would not mind it so much. I would like to hear from you in regard to the matter. I have the law; but 1 cannot get the prosecuting attorney to act. ********** " Bend a few of ' The Prevention of Typhoid Fever.' " 212 STATE BOARD OF HEALTH.— REPORT OF SECRETARY, 1891. Plai of CL ^oiftioft of the i/iUct.^e cf Ba-raga.,M,ickigayv. ^hou/ing unsaiisf actor i/ iocctfion af ura&er intake^. /, 5, 3, S'f % lOy //, IZ, f^, /S, /(>, /7, /r, = Bu/e Hi Tigs . y, ssBoarding-house^u/^ere f or /O eases of ^JbhoidSeirer' occurred. X,= fShalUra/ .^rivi/-\/aults . o,!=7faier- CIoariej^iohisran^u//iere an outbreaA of tt/^hoid Jeuer occurred. Pfaierfordonjestic ^ury^oses was us&d from the eanul uihen ol iargenu^rt- ocr of vssseis me^e detained ft if e or six days u/ith canal closed uihiie the locks u/ere heina TC^aired. J)urin^ that ii?ne garbage and faecocly^atcer u/Cre aontiTtualli/ thrown into the canal franr t/'iese iresse/s. 214 STATE BOARD OF HEAL.TH.-REPORT OF SECRETARY, 1891. In reply to the last preceding letter, Dr. Campbell wrote: " In compliance to yonr request regarding the history of the typhoid fever outbreak in the city of Sault Ste. Marie last summer: The fever made its appearance immediately after the canal locks were repaired. In my monthly report to our city council I called attention to the impurities of the water used for domes- tic purposes during the time the canal was closed, and when between three and four hundred vessels were- detained during the space of five or six days. We sent samples of water to Dr. Yaughan, Michigan Uni- versity, for analyses. He discovered disease germs— typhoid fever germ, and having collected the poison from the specimen sent, injected, hypodermically, the same into the abdomen of a rat, result, death. One month after the fever began to abate, I sent specimens from the cataract pump house, and from a tap in the most distant point from the pump house, meirking them Nos. 1, 2 and 3, — result, pure, no disease germ, no poison. ■■ I enclose you a diagram of the water works, or pump house, cataract and canal. There were about three hundred cases of typhoid and typho-malarial fevers ; probably 20 deaths. The fever began about two weeks after the canal was opened. First case reported to me in August, the last on the 20th October. " I trust the State Board of Health will urge, with effect, the propriety of every town and city having a board of health. The council too often are under political obligations that bind them hand and foot." ' ' The water in the bay where the pump house is situated is almost dead water. The intake pipe runs through the south pier of the canal into the canal. You will observe the indication of the course of the water. The current runs into the rapids past the canal; but a small current runs into the canal and turns back if the upper gate is closed, and catches the current running into the rapids, x x x x show where the vessels were standing for five days dumping out diseased garbage and faecal discharges while the locks were being repaired. The water thus saturated was taken by the intake pipe and thus supplying the city byway of S. 8. I recommended carrying the intake pipe (to be carried from a pump house erected at (+ ) ) to the center of the rapids, and be no longer at the mercy of an accident on the canal locks." In thanking Dr. Campbell for his report, as given above, the Secretary wrote : " In reference to the intake of the water-supply of your city, how would it do to place it beyond the light house, in the river, just above where it could receive any water from the canal.^ If below the bridge it would still take in some water which came from the canal," Following are a diagram (drawn in this office from the one referred to in the above letter) and explanations thereof, given by Dr. Campbell, which graphically portray the conditions under which the water supply of Sault Ste. Marie, believed to have been the cause of the outbreak of typhoid fever there, was obtained: TYPHOID FEVEE IN HAETFORD, VAX BUEEN COUNTY. Relative to an outbreak of typhoid fever in the village of Hartford, of which the source of contagium was believed to be impure drinking water, Dr. H. C. Maynard, health officer of the village, wrote to this office as follows : "The case of typhoid fever reported, is a young man that has been boarding at the principal hotel of this village all summer. I procured and tested the water furnished the guests of the house and find it a mass of organic matter. " I send you diagram of the water supply." Following is a diagram made in this office, from the one referred to in Dr. Maynard's letter. TYPHOID FEVER IN MICHIGAN IN 1890. 215 K^myfyure source of waier used hy yfoeyson u/ho eontracted fy^?ioidfei;er, in /{cLytJorcl, ^ic/v . htl^i OTL St. JiT W. Z s am u/ell . Hotel Qyi'ell Barn "^v k^'" ,iL^ 5^ b/ LJ Cess-^ool / slxftsq/uar*e and e i^^tft dee^. Si ^ INFECTED MILK THE SUPPOSED CAUSE OF TYPHOID FEVER IN WYANDOTTE. Sept. 28, 1890, Dr. E. P. Christian, of Wyandotte, Wayne county, wrote to the Secretary of this Board relative to typhoid fever in that city as follows: — " Typhoid fever has been with us this fall unusaally prevalent and of more than common severity. This is rather severe on the doctors of onr city who advocated getting in water works as a sanitary measure in this respect. We had the river water introduced a year ago this fall, and to have had such an increase in number and severity of cases since its introduction has led to the surmise that we had been intro- ducing to our houses the diluted sewage of Detroit. Perhaps this is so to some extent, for the solid parts no doubt settle to the bottom all along down, and when a heavy wind prevails the water from the penstocks is at times decidedly roily Eind ofif color. " However, the fact is that the disease has prevailed as to numbers, about equally among users of well water and of river water — giving rise to the suggestion that we must look elsewhere for the cause of tha disease than in the drinking water. " This I have suspected for a long time and have had a suspicion that this cause was in the milk. " I have had an experience within the past two months which has strengthened that suspicion. " In the family of Mr. A. two cases of enteric fever, and all the family ailing — in the family of T. three (3) cases and others ailing, one deceased. In the family of Mrs. F., one severe case— all these in imme- diate neighborhood — all it is true using river water, but all getting milk from one cow, a neighbor's — also in Dr. C.'s practice in family of Mr. T., one case getting milk from same cow, but also using river water. This animal is stall-fed, kept up in barn. To be sure there have been many other cases of fever in those using well water and milk from other sources. But is it not singular that so many cases have occurred in one small neighborhood and all getting milk from the same animal? " It would be worth while for the Boeird of Health to purchase this animal and investigate her." 216 STATE BOARD OF HEALTH.— REPORT OP SECRETARY, 1891. Sept. 30, 1890, the Secretary sent to each member of this Board a copy of Dr. Christian's letter accompanied by the following from himself: — " Dear Sir: — I shall be glad to receive any suggestions which you will make on the subject of the above letter from Dr. Christian." Samples of the milk, of the river water, and of the well water were sent to Prof. Yaughan, Director of the Laboratory of Hygiene, Ann Arbor; and at the meeting of this Board Oct. 14, 1890, he made a verbal preliminary report that bacteriological examination revealed the fact that both of the samples of water and the milk contained micro-organisms which, by their life processes, in nutritive solutions, form poisons. At the same meeting Drs. Vaughan and Kellogg were appointed a com- mittee to further investigate this subject; and later, Dr. Vaughan reported as follows relative to analyses of waters and milk sent to him from Wyandotte : MICHIGAN UNIVERSITY — LABOEATORY OF HYGIENE. ^Report of the Sanitary Condition of Water sent by E. P. Christian, M. D., Wyandotte, Michigan: Source of water, with remarks on the sanitary surroundings. No. I.— From H. Millspaugli' s ivell. No. II.— From Water Works. PHYSICAL PROPEETIES. No. I. No. II. Color Sedimentary Clear. Odor None None. Reaction... Neutral Neutral. Hardness 13 _. 7 (Clark's Scale.) Chemical Analysis {Parts per Million.) (1) Total residue obtained by evaporation at 110 C. (2) Residue after ignition, or inorganic matter in residue <3) Organic residue, or loss on ignition (4) Amount of earthy bases, calculated as oxides,. (5) Amount of chlorine, calculated as sodium chloride (6) Amount of sulphates calculated as 8O3 Strongtrace (7) Parts of potassium permanganate reduced by the organic matter in the water 1(8) Amount of free ammonia.. (9) Amount of albuminoid ammonia XIO) Amount of nitrates, calculated as N2 O5 ..- {11) Amount of nitrites, calculated as No Os Microscopical Examination. — Description of deposit, magnified 100 diameters. No. I. Crystals. Yellow amorphous matter. White amor- phous matter. No. II. Crystals. Algse. Yellow amorphous matter. White amorphous matter. Same magnified 500 diameters. No. I. Sodium chloride crystals. Algse. Yellow amorphous matter. White amorphous matter. No. II. Sodium chloride crystals. Silica. Fibres. Algse. Vorticellse. Yellow amorphous matter. White amorphous matter. 1090. 221. 850. 191. 240. 30. 20.798 10.976 266.4 49.5 jng trace None. 41.08 32.548 0.46 0.08 0.56 0.52 13.06 0.653 0.247 0.0082 TYPHOID FEVER IN MICHIGAN IN 1890. 217 Bacteriological Examination. — Number of germs developed on a gelatin plate inoculated with one drop of water: No. I. No. II. Milk. (1) After 24 hours -- 2480 1770 3460 (2) After 48 hours 2580 1890 3460 (3) After 72 hours 1 2580 1890 8460 Remarks on the Kinds of Germs Observed. — In No. I. are two kinds of germs: (a) the green bacillus of water, and (b) a non-liquifying toxicogenic germ. In No. II. are two kinds of germs: (a) the green bacillus of water, and (b) a liquifying toxicogenic germ. In the milk there are three or four kinds of germs, among which there is the same non-liquifying toxicogenic germ found in the well water. Inoculation Experiments. — Kind of animal inoculated with the germs: Rats. Method of inoculation: By injection into the peritonial cavity. Kind, amount, and age of culture used: Twenty drops of a beef-tea cul- ture 24 hours old. Results of the inoculation: Death with all the samples. Post-mortem appearances: These were practically the same with all samples, and consisted of engorgement of the spleen, the mesen- teric glands, liver and kidney. Description of the germs, if any, found in the organs: The toxicogenic germs found in the waters and in the milk were also found in the organs of the animals. In what organs were the germs, if any, found growing? Spleen, liver and kidney. Explanation. — One drop of the water is added to one drachm of some culture medium, such as beef-tea, and this, after it has been kept at the temperature of the body for 24 hours or longer, is used for inoculating animals. Conclusions. — I regard both the waters and the milk unsafe. Of the two waters, that from the well is the worse both chemically and bacteriologically. The milk was examined only bacteriologically. The poison-producing germ in the well water is identical with that in the milk. I am inclined to the opinion that if the typhoid fever was due to one of the waters, the well water is the one more likely to be the cause. E berth's germ (the so-called typhoid germ) was not found in any of the samples. This, how- ever, does not mean, in my opinion, that the waters would not cause the typhoid fever. I have never yet found Eberth's germ in drinking water (with one possible exception). The river water probably has changed in its character since the sample was taken, but the well water certainly should not be used. V. 0. VAUGHAN, Director of the Michigan State Laboratory of Hygiene. Ann Arbor, Nov. 12, 1890. 218 STATE BOAKD OF HEALTH,— REPORT OF SECRETARY, 1891. TABLE 3. — Exhibiting the Localities from which Typhoid Fever was spread {accord- ing to the official reports), with the number of Cases and Deaths, if reported; the Secondary Localities into which the Disease was said to have been Introduced from the First {with number of Cases and Deaths.) Compiled from Reports by Health Officers who were able to trace the source of Contagium to other Localities. First Localities from which Typhoid Fever Spread. In "First" Locahtles. Secondary Localities infected from " First." In 'Secondary" Localities. Antrim county: Torch Lake township. Baraga county: Peqnaming, L'Anse township , Berrien connty: Berrien Springs village Calhoun connty: Battle Creek city. Cass county: Dowagic city. Emmet county: Petoskey village. Gogebic county: Bessemer city Hillsdale connty: North Adams township. Houghton county: Calumet village Ingham connty: Stockbridge village. Kent connty: Grand Rapids city . Leelanaw county: Empire township . Lenawee county: Adrian city Lenawee connty: Roliin township Mecosta county: Big Rapids city. Oscoda county. Presque Isle county. St. Clair connty: St. Clair city 193 29 5 Antrim county: ( Central Lake township . 5 Houghton connty: ( Lake Linden village 5 Berrien county: ( Berrien township . f Calhoun county: I Beford township.. I BEirry county : L Barry township. 5 Van Buren county: i Keeler township ( Lenawee county: ( Morenci village.. 5 Ontonagon county: I Rockland township. ( Jackson county: I Liberty township 5 Ontonagon county: ( Rockland township. ( Ingham county: ■J Dansville village.. ( Ingham township . r Allegan county: I Allegan township. I Kent county : I Cannon township . L Cascade township. Leelanaw county: Glen Arbor township.. Lenawee county : Dover township ( Lenawee county: ( Rome township. 5 Muskegon county: 1 Muskegon city.. Sanilac county: Marion township . ( Cheboygan county: ( Tuscarora township 5 St. Clair connty: ( Columbus township * This outbreak was not reported to this office by the Health Officer of the " first " locality at the time it occurred. This shows neglect in the locality from which the disease spread. TYPHOID FEVER IN MICHIGAN IN 1890. 219 TABIiE 3. — CoNciAJDTET).— Exhibiting the Localities from which Typhoid Fever was spread. Fii'St Localities from which Typhoid Fever Spread. St. Clair connty: Port Hnron city. Wayne connty: Detroit city.. Adjoining township. (Outside the State.) Canada . Chicago . Colorado Illinois Bardick, Indiana Grarrett, Indiana .. Montana In "First" Localities. 39 10 Secondax'y Localities infected from " First." ( Huron connty: ( Verona township. f Lenawee connty: Morenci village. . Macomb county: Richmond village. Romeo villsige Oakland county: Rose township. Wayne county: ^ Hamtramck township. 5 Saginaw county: / Albee township Tuscola county: Gilford township fKalamazoo county: I Schoolcraft township. I Macomb connty: l_ Richmond village Shiawassee county: Perry township.. Hillsdale county: Ransom township. Lenawee county: Clayton village. Lenawee county: Morenci village . 5 Livingston county : ( Deerfield township. In 'Secondary'' Localities. * This outbreak was not reported to this office by the Health Officer of the " first " locality at the time it occurred. This shows neglect in the locality from which the disease spread. In the following instance the contagium was reported to have been carried to a third locality: — From Pequaming, L'Anse township, Baraga county to Lake Linden village,- Houghton county, thence to Torch Lake township, Antrim county. EFFORTS FOR THE PREVENTION AND RESTRICTION OF TYPHOID FEVER. It is gratifying to note that the increased interest on the part of local health officers in carrying out the preventive and restrictive measures recommended by the State Board of Health in outbreaks of typhoid fever mentioned in the Annual Keport of this Board for 1890, is again apparent this year, and that many of those officials have been very zealous in efforts to induce physicians to report cases of that disease occurring in 220 STATE BOARD OF HEALTH.— REPORT OF SECRETARY, 1891. their practice, to obtain amelioration of the water-supply in localities where typhoid fever has occurred, and in advocating the introduction of measures calculated to improve the sanitary conditions in their jurisdictions. The following extracts from letters and reports received at this office illustrate the nature of the efforts made by those officials and show that those efforts are not always made under the most encouraging or favorable circumstances. " I am doing all that I can in. the way of disinfection of all bowel discharges, cleanliness, etc. and whenever I can prevail upon them to do so, I have all drinking water boiled. The popnlation is largely foreign. There is very little public sentiment in favor of improvement, and only a small minority that will givH any encouragement or cooperation in that direction."— 4. J. Braden, Health Officer, Baraga toivnship, Baraga county. " Inclosed please find final report of those cases reported. They are all well and I have been able to make the owner of the house in which those cases were, understand that it was his duty to tear the house down. The house is old and is built on saw dust which has been there for years and which would surely canse some other troubles before long. I have found out that years ago, about four or five years, people living in the same house, died of a disease not recognized then, but which seems to me to be the same as the one reported as typho-malarial."— JfeZi'iHe E. deLaval, M. D., Health Officer, Schoolcraft township, Houghton county. " Drains opened, cleaned and disinfected. Privy vaults cleaned. Cellars drained." — A. J. Braden, Health Officer, Baraga toivnship, Baraga county. " Your enclosed circular and other documents duly received. In reply would say that we have had •eleven cases of fever in this location this year. The last case of which is now ready to be returned to his home. Our fever is cared for here in our hospital by experienced nurses, in a ward devoted exclusively to their use, where they are protected from officious friends. Their diet intelligently administered, the soiled clothing placed in disinfecting fluid on the same floor, the sputa received in sanitary cups and burned, the excreta received in disinfecting fluid and placed in barrels at remote points in disinfecting fluid, and, next month when frozen, removed beyond possible chance of communication. As the season seemed to be prolific with fever, we had in readiness a large hall, capable of holding fifty beds, should our hospital be overtaxed. " Our reason for caring for our people in this manner is due to the fact, that since 1883 we have had no case of fever originate in our location. Previous to and including that date, fever was a common and •constant visitor, in the latter year reaching eighty cases. Our mining officers with myself, drafted sanitary rules, the cleaning of wells, ordering garbage and slops placed in pits remote from the welle, the filling and disinfecting of vaults, the cleaning of cellars under the rigid daily inspection of a proper officer, as a means of purifying the ground surface and the protection of our water supply which is from the surface entirely. Every year from the interchange of employes coming from infected districts, we are the victims of transplantation of fever and for the avoidance of seed sowing, such cases are, as soon ■as discovered, removed where the details of restriction can be carefully carried out, and, from the fact that so far, in the time named, we can trace the neighboring point from which the patient came ; and that we have yet to record a case as being infected from any extension of the disease, speaks plainly the result of the attention given it. " We have no municipal organization here, all measures being under the control of the mining com- pany, whose representatives are the township officers, and I cannot too highly compliment the manager and officers of the mining company for the intelligent and cheerful accord by which is made possible such sanitary and life-saving methods."—/. Freund, 21. D., Health Officer, Champion township, Marquette county. DIFFICULTIES EXPERIENCED BY LOCAL HEALTH OFFICERS IN RESTRICTING TYPHOID FEVER. Some of the difficulties which local health officers experience in the performance of the duties required of them by law, are shown by the following extracts from correspondence of this office with those health officers in regard to typhoid fever: TYPHOID FEVER IN MICHIGAN IN 1890. 22 J Alvinza C. Merrill, M. D., Health Officer of Harbor Springs, Emmet county, reports, relative to an outbreak of typhoid fever, as follows: — " The attending physiciEin did not inform me, nor did he report the cases to me as he shonld have done." In reply to the question "What exceptions were there to the complete accomplishment of the disinfection of excreta, boiling of water, etc.," in an outbreak of typhoid fever, N. D. Lee, M. D., Health Officer of Saginaw, West side, wrote: — " None, when it was reported by a physician; bat they do not report more than half the cases. 1 get more than half of the cases through newspapers, after they are dead or well." F. M. Kerry, Health Officer of Benton Harbor, Berrien county, reported in regard to an outbreak of the disease: — " Three families were reported by well founded rumor. In two of these deaths occurred. The physi- cians did not report cases. My attention would be called to the fact by rumor or funeral notice. Physi- cians claimed disease was typho-malarial or bilious remittent fever. " Have not had a case of typhoid reported to me by a physician." N. B. Sherman, M. D., Health Officer, Waterloo township, Jackson county, reporting in regard to typhoid fever, wrote: — " I have learned in a casual way of the death of Jas. Kowe, Mrs. Hall, and Henry Arty. The attending physicians were Dr. Rowe, of Stockbridge; Dr. Condon, Munith; Dr. Raymond, Grass Lake. These cases have not been reported to me. * * * * Possibly these Drs. before mentioned do not understand their duty." In studying the effects of efforts of health officers for the restriction and prevention of typhoid fever, and of the difficulties experienced by some of them in carrying out the methods recommended by the State Board of Health to that end; it is interesting to note the difference in the reported numbers of cases of sickness and of deaths, from this disease, in outbreaks where local health officers were enabled to enforce isolation and disinfec- tion, and in those outbreaks in which, for any reason, those restrictive measures were neglected. The diagram on page 222 graphically illustrates this difference, and shows that in outbreaks relative to which the reports state that isolation and disinfection were enforced, there occurred 1.97 cases and 0.32 of one death per outbreak; whereas in those outbreaks where isolation and disin- fection were neglected, there were 6.58 cases of sickness and 0.96 of one death per outbreak; or about three times as many cases and deaths in out- breaks in which isolation and disinfection were neglected, as there were in outbreaks where those restrictive " measures were enforced. It therefore seems probable that if proper restrictive measures had been adopted in all the 330 outbreaks of this disease which were reported to this office during the year, with results similar to those obtained in the above-mentioned outbreaks where isolation and disinfection were enforced (1.97 cases and 0.32 of one death per outbreak), there would have occurred only 650 c^-ses of sickness and 106 deaths from this disease in the State during the year, instead of the 1,924 cases and 304 deaths which actually occurred in those outbreaks which were reported; and a saving to the State of 1,274 cases of sickness and 198 lives would have been effected. This showing seems to present a forcible argument in favor of the adop- tion of the preventive measures above referred to, and a strong plea for the cooperation of all the people, in the efforts of health officers to stamp out this preventable disease. 222 STATE BOARD OF HEALTH.— REPORT OF SECRETARY, 1891. ISOLATION AND DISINFECTION RESTRICT TYPHOID FEVEE. ^y^hoid^euer'mtMichigran in /S90:-Sxhibitiv^ the a^er-^ age numbers of cases and deaths yf:>er outbreak:- in all out- breaks in uuhlch isolation and disinfeciion u/ere both negr- leefed'f and in all oatbyeakj in whick both ujere enforced. (CoYn^iled IK the office of the Secyetary of the Jtate Board of Health, from reports made lu local health officers- ) — _| _ . — 1 ^ . . 1 . ^J^ _ isolation and disinfection e nf o rceoL. ^?7cluding the disinfeeiion of iJhe bowel discharges of the foaticnis , TYPHOID FEVER IN MICHIGAN IN 1890. 223 AYEEAGE DUKATION OF TYPHOID FEVEE. - FATAL AND NON-FATAL CASES. Table 4. — Exhibiting by Sex of patient, the Average Duration {in days) of Fatal cases of sickness from Tyi^hoid Fever, in Michigan, during the four years, and dur- ing each of the four years 1881-90. {Compiled from those reports which stated the length of time the patient was sick.) 00 Fatal cases of Typhoid Fever. S.2 = -5.2 d.S5 Duration of Sickness:— Per cent of Deaths in each | Period of Days. <° Co o i i o o O i s o 1 1§§ Males ... 81 32 100 100 10 31 7 19 15 19 21 16 16 6 11 3 12 2 4 6 1 Females . .. X 00 Males 40 33 100 100 20 24 13 21 18 '1 10 9 8 6 3 5 3 3 9 Females ... 15 12 00 00 Males 42 51 100 loe 17 18 14 24 19 14 7 16 14 10 5 2 7 6 2 2 7 2 7 8 Females. .. . © 00 1-1 Males . 57 26 100 100 19 19 9 23 21 8 23 8 5 19 5 12 7 8 4 2 4 Females 6 Males 220 142 100 100 17 23 11 22 18 14 19 IS 11 11 7 6 5 2 2 3 5 2 2 2 3 3 Females... From Table 4 it may be seen that of the 220 males who were reported to have died from typhoid fever -within the four years 1887-90, and of which the interval between the day of being taken sick and day of death was given, the largest per cent died in the two periods from the 15th to the 20th and from the 20th to the 25th day of sickness, and that 54 per cent were sick twenty or more days before they died; while of the 142 females reported as having died in the same time, 23 per cent died before the tenth day, and that only 42 per cent were sick longer than nineteen days. The average duration for the fatal cases, was in males 22.4 days, and in females 20 days. In Table 5 it may be noticed that the duration of sickness in non-fatal cases of typhoid fever for the four years, 1887-90, was about the sanae for both sexes; 62 per cent of the males and 64 per cent of the females recovered before the thirty-fifth day of sickness. The average duration was: — males 32.8 days, females 31.5 days. The average duration of all cases, fatal and non-fatal, was: —males, 27.6 days, females, 25.8 days; and for all cases of both sexes, 26.87 days. 224 STATE BOAKD OF HEALTH.-REPORT OF SECRETARY, 1891. TABLE 5. — Exhibiting by Sex of patient, by per cent of cases which recovered in specified periods of time, the average duration {in days) of non-fatal cases of sick- ness from Typhoid fever, in Michigan, during the four years and during each of the four years 1887-90. {Compiled from those reports which stated the length of time the patient was sick.) u Non-Fatal Cases of Typhoid Fever. 11 OT3-5 0-35 Daration of Sickness: — Per Cent of Cases in Period of Days. each n CM S o s 1 d s o d 1 s o II s 2 Males 203 158 100 100 5 9 4 2 6 9 13 7 12 19 9 11 16 12 13 15 18 17 15 15 15 11 9 19 9 6 10 4 6 4 9 8 3 3 9 10 8 9 7 8 X X- X Males. _ 164 111 100 100 1 Females.. . .... 05 X X Males -. ... 166 165 100 100 2 6 7 8 13 9 14 14 16 19 14 12 12 11 9 8 6 4 2 2 5 7 Females .. .... © S5 X Males Females .. 226 110 100 100 1 1 4 4 7 14 15 16 18 17 19 13 12 14 10 9 5 2 2 5 8 6 o •«ijx X Males .. 759 544 100 100 1 2 5 6 10 10 13 16 16 16 17 14 12 14 io 7 7 5 4 5 7 8 Females TABLE 6. — Exhibiting, by Sex of patient, the Age of persons reported sick from Typhoid Fever, in Michigan, duriny each of the four years, 1887-90, and the aver- ages for the four years. Also the Average Age, and the Number of cases, in which the age was stated, reported in each of the four years. {Compiled from reports of those cases in which the Age was stated.) (B Sickness from Typhoid Fever. 6 o a-d Age, —In periods of Years. Per Cent of Cases in each Period of Age. i < o o s § s IS m 8 5" S s g 3 in si g* 1^ X X Males . . - 24 22 316 245 100 100 10 17 10 10 14 20 20 15 17 10 9 10 8 5 4 4 2 3 4 5 Females QO X X Males . 24 23 310 199 100 100 12 12 13 22 15 20 20 14 11 8 11 5 5 4 4 6 3 3 6 7 S5 X X Males ... .. 24 23 362 310 100 100 13 16 11 17 17 20 25 12 10 8 8 7 6 7 3 4 2 4 6 5 © as X- Males — . 22 20 325 199 100 100 14 16 12 16 16 24 25 17 16 11 7 6 4 5 3 1 2 2 3 4 Females.. . © ■^x X Males 24 22 1,313 953 100 100 12 15 12 16 16 21 23 15 14 9 9 7 6 5 4 4 2 3 5 5 Females TYPHOID FEVER IN MICHIGAN IN 1890. 225 AGE OF OCCUREENCE OF TYPHOID FEVER. In studying table 6 relative to age of persons who have typhoid fever, it should be borne in mind that there are more persons living at the earlier ages than at the more advanced ages. After the publication of the census of 1890, it will be possible to compare this table with one exhibiting the per cent of persons living in each period of age, and thus complete the study here provided for by this statement of facts relative to nearly two thousand three hundred cases of typhoid fever. TWO LINES OF EVIDENCE OF THE PREVALENCE OF TYPHOID FEVER. In studying the prevalence of typhoid fever in 1890, from the facts pre- sented in the preceding and following pages, it must be borne in mind that those facts are derived from two distinct sources of information : 1. — The numbers of outbreaks, of cases of sickness, and of deaths from typhoid fever are taken from special reports from health officers and other township, city and village officers, during the course of an outbreak, at its close, or in spe^^ial reports at the close of the year. If all the people and officers reported as the laws provide, the facts presented would represent the actual numbers of outbreaks, cases of sickness, and deaths from typhoid fever which occurred in the State during the year; but all do not so report. It is just, however, to state that, as the people generally are becoming better instructed in the measures recommended by the State Board of Health for the saving of life and health, better and more com- plete reports are made year by year. So, each year, we believe that an increasing proportion of the cases of sickness and deaths from the danger- ous communicable diseases are reported to this office. This tends towards an apparent increase in the prevalence of the disease each year, modified, of course, by the real fluctuation in prevalence. While waiting for perfect reports, the facts derived from those now received are valuable for purposes of study. 2. — The prevalence of typhoid fever, or of any given disease, as indicated by the " per cent of reports " is taken from the weekly postal-card reports from regular correspondents of the State Board, health officers of cities and villages, and others. The " per cent of reports " is the per cent of the whole number of reports received which stated the presence of the disease named; it gives the relative prevalence of the disease, under the observa- tion of the physicians who report. It may represent the relative area of prevalence of the disease, combined with the relative number of weeks the disease continued where it did occur, hut not the actual number of cases. 29 226 STATE BOARD OF HEALTH.— REPORT OF SECRETARY, 1891. 60 .Ti , — , Inche d out Comp fated ^ 8 i CO 1 fO W a ?>l iS « ^ S 2'^ o 555 ^ 5..-0 .2 "K '^^ » 1 u « § H.A hq ;. 2! ri£ 1 A t-^ J -Si'*: M t«> ^ -« H :25 5i < •<;» § l'^ No. of cases and out- breaks included in this table. m t; to 03 OS 10 00 cq o> CO IM 1 ° gs CD to S % ] ih" '^ Q -* lO ■* t. CO Q OS ^ cq ^ CD CD JO Ol 03 (Ta i ^ ^ l:~ M OS -* ^ CO ^ ta ^ 00 eq CO o ai Oi OS -H OS (jq (Ta >1 CO o O 50 ^ -* oa iH c- CO in 00 -* OS Q c^ ifi 05 •rH OS cq 1-H ■^ «i OS 03 ft c_ W »-( •* oa 00 CD «5 00 ^ 00 CO oo OS l a « r^ j3 tj ja ts .d •a JS tT X] 1 ao o 5 88 00 i i 8 5 S p ft d t>l ft a ^ ft d (-1 ft d g ft d > fa fa § fa fa 9 ^ fa fa 3 « Ul 1 1 .s i ^ 1^ 5 1 I* .2 .a 0) > t t3 ■§ t T3 1 -e -d 1 T3 .d 1 2 •g •3 <0 5 1 1 +3 1 !d 1 ft 1 1 1 1 ft 1 t-i S) t^ CO gj _&. (!) k> GO 9 ►> (C 0} ^ (C an k ■*3 ^ > +3 M > **-* Jd (► ■*^ ^ k ■*^ ^ a o *« CS •s tM *« *!::! s .a ?> .fl A3 (D .0 9 .a '•§ e8 .0 ^ i M C8 S .0 ca 1 .a 03 S J !? ^ s ja ■H 43 4J Xi ■tj X] u a CO d d ^ CS d d ta c3 o 1 u p c3 u e3 •M 1 \ \ \ 1 1 1 / i \ \ 1 / 1 \ \ 1 ( \ \ \ 1 J -\ \ 7 / 1 / Its - / / N^ \ / / \ \ / / s / / l$i Jittnenjnm Tupkcid Fever _., Ground Water Hndicetin^ uhaiperetnl^all refioris receii^ed Hated the /bresenee of Jut hold Jhuer then under the cttser^'a. Uon q the finyjtetans rthcrling ^ -yi im Uii dtayrdm . i^kn Uert rrt Hi mtrt '/nc/kti 230 STATE BOARD OF HEALTH.— REPORT OF SECRETARY, 1891. Comprehensive study of this subject was made by the Secretary of this- Board in a paper read before the American Public Health Association, at St. Louis, Mo., Oct. 16, 1884, which was printed in the Annual Report of this Board for the year 1884, pp. 89-114, and the study was continued subsequently, in the Annual Reports of this Board for the years 1888, pp. Iv-lvii; 1889, pp. 254-262; 1890, pp. 247-251. The evidence is conclusive that there is a necessary relation between the low water in wells and the sickness from typhoid fever. TABLE 10.— Exhibiting, for Michigan, by Months, during the Twelve Years, 1878, 1880-1890,* the Relation of Low Water in Wells to Sickness from Typhoid Fever; also, the Reported Number of Deaths from Typhoid Fever. Month. Av, inches of ground above the water in wellsf - - Flnctnation from Max. Depth of water in wells.. Sickness from Typhoid fever:{ At. number of reported deaths from Typhoid feveril Jan. reb. Mar. April. May. June. July. Aug. Sept. Oct. NOY^ Dec. 200 195 191 188 183 186 202 209 215 220 215 212 17 12 8 3 19 26 32 37 32 29 10 8 6 5 5 5 7 13 19 21 18 13 24 21 24 25 24 22 27 58 92 101 72 54 * The data relating to the sickness and the deaths from typhoid fever in the years 1878, 1880-90, were used in order to coincide with the same period for which the measurements of ground above the water in wells were already obtained. t The year 1879 could not be included as, for that year, there was no station from which reports were received for the whole year. The stations used in the compilation of this line, and the years for which reports were received and compiled from each are as follows: Elsie, 1878; Thornville, 1880-1 and 1885-7 ; Hillsdale, 1880, 1884, 1887-90; Mendon and Union City, 1880; Linden and Dearborn, 1881; Brockway Center, 1882 and 1883 : Otisville and Woodland, 1882; Saginaw City, 1883; Kalamazoo, 1884, 1888 and 1889 ; Lansing, 8. B. of H., 1885-90; Ann Arbor and River Raisin, 1886-90; Alpena, 1887-88; Otsego, 1887; Traverse City, 1888-90; Battle Creek, 1888, t Per cent of weekly reports, from observers in different parts of the State, which stated the presence of typhoid fever. II The data used in the compilation of this line were taken from the Registration Reports of Michigan. — Vital Statistics. From January to May the fluctuations in the sickness from typhoid fever and the depth of the water in wells are nearly coincident. In June the increase in the sickness follows the decrease of the water with an inter- val of about a month. Thence during the rest of the year, the agreement of the two is very close. The maximum of sickness and the minimum of water are coincident in October. The stations at which the measurements of water in wells are taken and the number of years which are available from each station are stated in the dagger (f) footnote at the bottom of Table 10, this page. The Office has been unai3le thus far to get accurate measurements of the height of water in wells for a long period of years from any stations in Michigan. This absence of extensive data is especially deplored when a comparison of one year with a series of years is desired, but in the averages for a series of years by months, the evidence is accurate and valuable. It is believed that all the wells from which measurements of water are made for this office, except the well at Lansing, are used. The well at Lansing is in the capitol grounds, far enough from other wells so as not to TYPHOID FEVER IN MICHIGAN IX 1890. 231 be liable to be affected by tbe rise and fall of the water in other wells from daily use, and so would more nearly represent the gradual rise and fall of the ground water than would measurements in wells from which water is drawn. But it has been found, by long-continued observations and investi- gations, that the rise and fall of the typhoid fever is in much closer rela- tion to the fall and rise of the water in wells in actual use than to the fluctuations in the well at Lansing. TABLE 11. — Ground Water. — Inches of Earth above the Water— by Months for the six years, 1885-90, and for the Ittst four months of the year 1884, and for each of the six years, 1885-90, at Lansing-, Mich., — Well in the Capitol Ch'ounds. Period of time. Year, Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec. 1885-90 292 293 294 292 289 289 288 290 291 293 290 282 287 291 293 305 300 295 291 285 286 294 297 308 300 295 293 281 291 297 294 311 298 297 292 280 294 294 300 312 300 1884 1885 284 281 290 294 304 300 288 276 296 292 298 309 289 278 287 298 304 307 292 274 280 294 304 305 280 272 282 293 302 302 281 273 285 293 304 296 279 277 288 293 299 292 282 282 290 293 299 293 283 287 291 290 302 295 1886 1887 . 1888 — 1889 1890 Table 11 exhibits the height of ground above the water in the well at Lansing, by months and year for the six years, 1885-90. In table 13 the first line of table 11 is used, with the average line in the following table (12), together with the average sickness from typhoid fever during the same years. TABLE 12. — Temperature of the Water in the Well at the State Capitol in Lansing, Mich., by Months for the Six Years, 1885-90, and the last four months of the year 1884. Year and period of years. Year. Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec. At. Six Y're, 1885-90. 49 50 47 46 46 48 48 48 50 51 51 52 50 1884 50 50 52 50 51 50 51 51 50 52 51 51 51 51 51 51 51 52 52 51 52 49 45 50 51 51 51 51 1885 47 48 48 49 50 50 49 49 50 50 50 50 47 47 41 49 49 49 43 46 42 48 49 49 42 45 46 47 48 48 46 46 47 48 49 49 48 46 48 48 49 49 47 47 49 47 50 49 48 50 51 50 50 50 1886 1887 1888 1889. 1890. 232 STATE BOARD OF HEALTH.— REPORT OF SECRETARY, 1891. TABLE 13. — Sickness from Typhoid Fever in Michigan {as indicated by the Weekly Card Reports by all Observers) and the depth of Earth {in inches) above the Water in the Well, and the temperature of the water in the Well, at Lansing, Michigan, by Year and Months for the Six Years, 1885-90. Year. Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec. Sickness from Tyhoid rever * 9 8 6 4 3 4 5 6 12 17 17 15 10 Inches of Earth above Water In Well 292 293 294 292 289 289 288 290 291 293 295 295 297 Temperature of water In WeU.. 49 50 47 46 46 48 48 48 50 51 51 52 50 * Per cent of all reports received (from observers in different parts of the State) which stated th& presence of typhoid fever. ♦ From table 13 it may be seen tliat the relation of sickness from typhoid fever to the ground water, as represented by the depth of water in the well at Lansing, is not so close as that which is shown to exist between sickness from typhoid fever and low water in wells in Table 10, on page 230 of this report. It is still possible, however, that if we could obtain measurements of water in unused wells in the different localities whence the reports of typhoid fever are derived, or could we have a full and correct report of all cases of the disease which occurred in Lansing during the same period for which we have measurements of the well there, and before there was a general water supply in Lansing, comparison of those data might show the existence of as close affinity between low Ground-water and typoid fever, as exists between typhoid and low water in wells. TABLE 14. — Exhibiting the Average Total Annual Rainfall at Stations in Michigan, the same for Lansing, the inches of Earth above the Ground Water at Lansing, the Inches of Water in an undisturbed Well at Lansing, and the Reported Sickness from Typhoid Fever in Michigan, as indicated by the per cent of all the weekly card-reports which stated the presence of Typhoid Fever. Year, and period of years. Av. Total Annual Kainfallat Stations in Michigan, in inches. d.a KM .5 53-3 Inches of Earth above the Ground Water at Lansing. .a IS ^: u SI . OgM -a S Ground Water, higher (+) or lower (— ) than the six years' Average in inches. Av. Per Cent of all Weekly Card-Re- ports Stating the presence of Typhoid Fever. More (+) or less (— ) Sickness from Typhoid Fever than the six years' aver- age. Av. 6 Y'rs, 1885-90.- 30.96 29.15 291 32 = 9 = 1885 35.82 32.16 29.82 29.55 28.18 30.20 34.51 29.52 30.08 25.76 23.28 31.73 284 281 290 294 304 292 40 42 34 29 10 28 + 7 +10 + 1 - s -13 + 1 8 8 10 10 10 8 —1 —1 +1 +1 +1 -1 1886 1887 1888 1889 1890 TYPHOID FEVER IN MICHIGAN IN 1890. 233 Table 14 is a summary of the facts presented in tables 8 and 9, with the addition of the facts relative to the height of water in the well at Lansing. From the evidence given in this table (14) it appears that, notwith- standing increased population and more numerous and better reports from local health officials, the reported prevalence of typhoid fever in Michigan was less in 1890 than in either of the previous three years; and also than the average for the six years 1885-90. The rainfall, both throughout the State and at Lansing, was greater in 1890 than for either of the previous three years; and at Lansing was more than the average for the six years 1885-90. In this connection, it is proper to hold in mind the fact that the efforts of the State Board of Health, the issuing of leaflets, diagrams and other literature bearing upon the restriction and prevention of typhoid fever, have continued for a number of years, and there is reason to believe that the influence of that work is increasing; possibly, if it were not for that work, the typhoid sickness during 1890 might have been as much or more, than in the preceding years, notwithstanding increased rainfall and water in wells. 30 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special arrange- ment with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE 1 1 j C28(iI4i)m100 RC187 M46 ^'i'^'isan. ne,t. of health. ^mm