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TYPHOID FEVER
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TYPHOID See also:FEVER . Typhoid or enteric' (Gr. vrepov, the See also:intestine) is a specific infectious fever characterized mainly by its insidious onset, by a See also:peculiar course of the temperature, by marked abdominal symptoms occurring in connexion with a specific See also:lesion of the bowels, by an eruption upon the skin, by its uncertain duration, and by a liability to relapses. This fever has received various names, such as gastric fever, abdominal typhus, infantile remittent fever, slow fever, See also:nervous fever, " pythogenic fever," &c. The name of " typhoid " was given by See also: These relate for the most See also:part to the intestines, in which the morbid processes are highly characteristic, both as to their nature and their locality. The changes (to be presently specified) are evidently the result of the See also:action of the contagium on the See also:system, and they begin to show themselves from the very commencement of the fever, passing through various stages during its continuance. The portion of the bowels in which they occur most abundantly is the See also:lower part of the small intestine (ileum), where the " solitary glands" and " Peyer's patches " on the mucous See also:surface of the See also:canal become affected by diseased action of a definite and progressive See also:character, which stands in distinct relation to the symptoms exhibited by the patient in the course of the fever. (1) These glands, which in See also:health are comparatively indistinct, become in the commencement of the fever enlarged and prominent by infiltration due to inflammatory action in their substance, and consequent See also:cell proliferation. This See also:change usually affects a large extent of the ileum, but is more marked in the lower portion near the ileo-caecal See also:valve. It is generally held that this is the See also:condition of the parts during the first eight or ten days of the fever. (2) These enlarged glands next undergo a See also:process of sloughing, the inflammatory products being See also:cast off either in fragments or en masse. This usually takes place in the second See also:week of the fever. (3) Ulcers are thus formed varying in See also:size according to the gland masses which have sloughed away. They may be few or many in number, and they exhibit certain characteristic appearances. They are frequently, but not always, oblong in shape, with their See also:long See also:axis in that of the bowel, and they have somewhat thin and ragged edges. They may extend through the thickness of the intestine to the peritoneal coat and in their progress See also:erode See also:blood-vessels or perforate the bowel. This See also:stage of ulceration exists from the second week onwards during the remaining period of the fever, and even into the stage of convalescence. (4) In most instances these ulcers heal by cicatrization, leaving, however, no contraction of the calibre of the bowel. This stage of healing occupies a considerable See also:time, since the process does not advance at an equal See also:rate in the See also:case of all the ulcers, some of which have been later in forming than others. Even when convalescence has ' The word " enteric " has been substituted for " typhoid " by the Royal See also:College of Physicians in the nomenclature of diseases authorized by them, and the change was officially adopted by all departments of the See also:British See also:government. Its advantages are doubtful, and it has been generally ignored by those See also:foreign countries which used the word " typhoid." " Enteric " is preferable in that it cannot be confounded with " typhus " and bears some relation to the nature of the See also:affection, the characteristic feature of which is a specific inflammation of the small intestine; but it is not sufficiently distinctive. There are, in truth, several enteric fevers, and the See also:appropriation of a See also:term having a See also:general meaning to one of them is inconvenient. Thus it is found necessary to revert to the discarded " typhoid," which has no real meaning in itself, but is convenient as a distinctive See also:label, when speaking of the cause of the disease or some of its symptoms. We have the " typhoid bacillus," " typhoid stools," " typhoid spots", " typhoid ulcers," &c. The word " enteric " cannot well be applied to these things, because of its general meaning. Consequently both words have to be used, which is awkward and confusing.been apparently completed, some unhealed ulcers may yet remain and prove, particularly in connexion with errors in See also:diet, a cause of relapse of some of the symptoms, and even of still more serious or fatal consequences. The mesenteric glands See also:external to, but in functional relation with, the intestine, become enlarged during the progress of the fever, but usually subside after recovery. Besides these changes, which are well recognized, others more or less important are often See also:present. Among these may be mentioned marked See also:atrophy, thinning and softness of the coats of the intestines, even after the ulcers have healed—a condition which may not improbably be the cause of that long-continued impairment of the See also:function of the bowels so often complained of by persons who have passed through an attack of typhoid fever. Other changes See also:common to most fevers are also to be observed, such as softening of the See also:muscular tissues generally, and particularly of the See also:heart, and evidences of complications affecting See also:chest or other See also:organs, which not infrequently arise. The swelled See also:leg of fever sometimes follows typhoid, as does also periosteal inflammation. The symptoms characterizing the onset of typhoid fever are very much less marked than those of most other fevers. The most marked of the See also:early symptoms are headache, lassitude and discomfort, together with sleeplessness and feverishness, particularly at See also:night; this last symptom is that by which the disease is most readily detected in its early stages. The peculiar course of the temperature is also one of the most important diagnostic evidences of this fever. During the first week it has a See also:morning range of moderate febrile rise, but in the evening there is a marked ascent, with a fall again towards morning, each morning and evening, however, showing respectively a higher point than that of the previous See also:day, until about the eighth day, when in an See also:average case the highest point is attained. This varies according to the severity of the attack; but it is no unusual thing to See also:register 104° or 105° F. in the evening and 103° or 104° in the morning. During the second week the daily range of temperature is comparatively small, a slight morning remission being all that is observed. In the third week the same condition continues more or less; but frequently a slight tendency to lowering may be discerned, particularly in the morning temperature, and the febrile action gradually See also:dies down as a See also:rule between the twenty-first and the twenty-eighth days, although it is liable to recur in the See also:form of a relapse Although the patient may, during the earlier days of the fever, be able to move about, he feels languid and uneasy; and usually before the first week is over he has to take to See also:bed. He is restless, hot and uncomfortable, particularly as the day advances, and his cheeks show a red flush, especially in the evening or after taking See also:food. The aspect, however, is different from the oppressed, stupid look which is present in typhus. The See also:pulse in an ordinary case, although more rapid than normal, is not accelerated to an extent corresponding to the height of the temperature, and is, at least in the earlier stages of the fever, rarely above too. In severe and protracted cases, where there is See also:evidence of extensive intestinal ulceration, the pulse becomes rapid and weak, with a dicrotic character indicative of cardiac feebleness. The See also:tongue has at first a thin, whitish See also:fur and is red at the tip, edges and central See also:line. It tends, however, to become dry, See also: The urine is scanty and high-coloured. About the beginning, or during the course of the second week of,the fever, an eruption frequently makes its appearance on the skin. It consists of isolated spots, See also:oval or See also:round in shape, of a See also:pale See also:pink or See also:rose colour, and of about one to one and a See also:half lines in See also:diameter. They are seen chiefly upon the abdomen, chest and back, and they come out in crops, which continue for four or five days and then fade away. At first they are slightly elevated, and disappear on pressure. In some cases they are very few in number, and their presence is made out with difficulty; but in others they are numerous and sometimes show themselves upon the limbs as well as upon the See also:body. They do not appear to have any relation to the severity of the attack, and in a very considerable proportion of cases (particularly in See also:children) they are entirely absent. Besides this eruption there are not infrequently numerous very faint bluish patches or blotches about half an See also:inch in diameter, chiefly upon the body and thighs. When present the rose-coloured spots continue to come out in crops till nearly the end of the fever, and they may reappear should a :elapse subsequently occur. These various symptoms persist throughout the third week, usually, however, increasing in intensity. The patient becomes prostrate and emaciated; the tongue is dry and brown, the pulse quickened and feeble, and the abdominal symptoms more marked; while nervous disturbance is exhibited in See also:delirium, in tremors and jerkings of the muscles (subsultus tendinum), in drowsiness, and occasionally in " See also:coma See also:vigil." In severe cases the exhaustion reaches an extreme degree, although even in such in-stances the condition is not to be regarded as hopeless In favour-able cases a change for the better may be anticipated between the twenty-first and twenty-eighth days, more usually the latter. It does not, however, take place as in typhus by a well-marked crisis, but rather by what is termed a " lysis " or See also:gradual subsidence of the febrile symptoms, especially noticeable in the daily decline of both morning and evening temperature, the lessening of diarrhoea, and improvement in pulse, tongue, &c. Convalescence proceeds slowly and is See also:apt to be interrupted by relapses. Should such re-lapses repeat themselves, the case may be protracted for two or three months, but this is comparatively rare. See also:Death in typhoid fever usually takes place from one or other of the following causes. (i) Exhaustion, in the second or third See also:weeks, or later. Sometimes sinking is sudden, partaking of some of the characters of a collapse. (2) Haemorrhage from the intestines. The evidence of this is exhibited not only in the evacuations, but in the sudden fall of temperature and rise in pulse-rate, together with See also:great pallor, faintness and rapid sinking. Sometimes haemorrhage, to a dangerous and. even fatal extent, takes place from the See also:nose. (3) Perforation of an intestinal See also:ulcer. This gives rise, as a rule, to sudden and intense abdominal pain, together with vomiting and signs of collapse, viz. a rapid flickering pulse, See also:cold clammy skin, and the marked fall of temperature. Symptoms of See also:peritonitis quickly supervene and add to the patient's See also:distress. Death usually takes place within 24 See also:hours. Occasionally peritonitis, apart from perforation, is the cause of death. (4) Occasionally, but rarely, hyperpyrexia (excessive fever). (5) Complications, such as pulmonary or cerebral inflammation, bedsores, &c. Certain sequelae are sometimes observed, the, most important being the swelled leg, periostitis affecting long bones, general See also:ill-health and See also:anaemia, with See also:digestive difficulties, often lasting for a long time, and sometimes issuing in pulmonary See also:tuberculosis. Occasionally, after severe cases, See also:mental weakness is noticed, but it is usually of comparatively See also:short duration. No disease has been more thoroughly studied in recent years than typhoid fever. The See also:chief points requiring See also:notice are (I) See also:causation and spread, (2) prevalence, (3) treatment, (4) prevention. Causation.—The cause is the bacillus typhosus, discovered by Eberth in 188o (see PARASITIC DISEASES). This organism multiplies in the body of a See also:person suffering from the disease, and is thrown off in the discharges. It enters by being swallowed and is conveyed into the intestine, where sets up the characteristic inflammation. It is found in the See also:spleen, the mesenteric glands, the bile and the See also:liver, not infrequently also in the See also:bone marrow, and sometimes in the heart, lungs and kidneys, as well as in the faeces and the urine. It has also, though more rarely, been found in the blood. The illness is therefore regarded as a general toxaemia with See also:special See also:local lesions. The relation of the bacillus to the other numerous bacteria infesting the intestinal canal, some of which are undoubtedly capable of assuming a pathogenic character, has not been determined; but its natural See also:history, outside the body, has been investigated with more See also:positive results than that of any other micro-organism, though much still remains obscure. Certain conclusions may be stated on See also:good evidence, but it is to be understood that they are all more or less tentative. (I) In crude sewage the bacillus does not multiply, but dies out in a few days. (2) In partly sterilized sewage (i.e. heated to 65° C.) it does not multiply, but dies out with a rapidity which varies directly with the number of other organisms present—the more organisms the quicker it dies. (3) It is said not to be found in See also:sewer See also:air, though Sir See also: These conclusions, which are derived from experiment, are to a considerable extent in agreement with certain observations on the behaviour of the disease on a large See also:scale. The susceptibility of individuals to the typhoid bacillus varies greatly. Some persons appear to be quite immune. The most susceptible See also:age is See also:adolescence and early adult See also:life; the greatest incidence, both among See also:males and See also:females, is between the ages of 15 and 35. The aged rarely See also:contract it. Men suffer considerably more than See also:women, and they carry the period of marked susceptibility to a later age. Predisposing causes are believed to be debility, depression, the inhalation of sewer air by those unaccustomed to it, and anything tending to " lower the vitality," whatever that convenient phrase may mean. According to the latest theories, it probably means in this connexion a chemical change in the blood which diminishes its bactericidal See also:power. The lower animals appear to be See also:free from typhoid in nature; but it has been imparted to rabbits and other laboratory animals. There is no evidence that it is infectious in the sense in which small-pox and See also:scarlet fever are infectious; and persons in attendance on the sick do not often contract it when sufficient care is taken. The recognition of these facts has led to a general tendency to underrate contagion, direct and indirect, from the sick to the healthy as a See also:factor in the dissemination of typhoid fever; but it must be remembered that the sick, from whose persons the germs of the disease are discharged, are always an immediate source of danger to those about them. Such See also:personal infection may become a very important means of dissemination. There is evidence that this is the case with armies in the See also: In Tor cases investigated, See also:Kayser found three still excreting bacilli two years after the illness, and See also:George See also:Deane has recorded a case in which bacilli continued to be excreted 29 years afterwards. Many outbreaks have in recent times been traced to typhoid carriers, one of the first being the See also:Strassburg outbreak. The owner of a bakehouse had had typhoid fever ten years previously, and it was noticed that every fresh employe entering her service See also:developed the disease. She prepared the meals of the men. On her exclusion from the See also:kitchen the cases ceased. In Brentry reformatory, near See also:Bristol, an outbreak numbering 28 cases was traced to a woman employed as See also:cook and dairymaid who had had typhoid fever six years previously. Before entering the reformatory she had been cook to an institution for boarded-out girls, and during her See also:year's See also:residence there 25 cases had occurred. A case is reported by Huggenberger of See also:Zurich (See also:Lancet, See also:October 1908) in which a woman See also:carrier is said to have infected a series of cases lasting over 31 years, including her See also:husband, son, daughter-in-See also:law, and no less than nine different servants. Numerous cases of contamination of See also:milk supplies by a " carrier " have been investigated, and in outbreaks traced to dairies it is See also:wise to submit the blood of all employes to the See also:agglutination test. A persistently high opsonic See also:index to typhoid bacilli is notable among " carriers." Not only do persons who have had tyhpoid' fever See also:harbour bacilli, but also persons who come in contact with cases of the disease and who have no definite history of illness themselves. The other means of dissemination are polluted soil, food and drink, particularly milk and water. The precise mode in which polluted soil acts is not understood. The result of experiments mentioned above shows that the bacillus lives and multiplies in such soil, and epidemiological investigation has repeatedly proved that typhoid persists in localities where the ground is polluted by the leakage of sewage or by the failure to get rid of excrementitious See also:matter. In some instances, no doubt, drinking water thus becomes contaminated and conveys the germs; but there appears to be some other factor at work, for the disease occurs under the conditions mentioned where the drinking water is free from suspicion. Exhalation is not regarded as a channel of communication. The researches of Majors See also:Firth and See also:Horrocks prove that dust,. flies and clothing may convey the germs. Another way in which food becomes the See also:medium of See also:conveyance is by the contamination of oysters and other shellfish with sewage containing typhoid bacilli. This has been abundantly proved by investigations in Great See also:Britain, See also:America and See also:France. Uncooked vegetables, such as lettuces and See also:celery, may convey the disease in a similar way. The most See also:familiar and important medium, however, is water. It may operate directly as drinking water or indirectly by contaminating vessels used for holding other liquids, such as milk cans. Typhoid caused by milk or cream has generally been traced to the use of polluted water for washing out the cans, or possibly adulterating their contents. There is obviously no See also:reason why this See also:chain of causation should not hold good of other articles of food and drink. Outbreaks have been traced to See also:ginger-See also:beer and See also:ice-creams. Water See also:sources become contaminated directly by the inflow of drains or the See also:deposit of excretal matter; indirectly, and more frequently, by the leakage of sewage into See also:wells or by heavy rains which See also:wash sewage matter and night-soil from ditches and the surface of the See also:land into springs and watercourses. Water may further be contaminated in the mains by leakage, in domestic cisterns, and in See also:supply pipes by suction. There is some reason to believe that the bacilli may multiply rapidly in water containing suitable nourishment in the See also:absence of large See also:numbers of their natural foes. Prevalence.—Typhoid fever is more or less endemic and liable to epidemic outbreaks all over the See also:world. It is more prevalent in temperate than in tropical climates. The follow- See also:ing See also:comparative death-rates show its relative prevalence in certain countries in 189o: See also:Italy, 658; See also:Austria, 470; U.S.A. 462; See also:Prussia, 204; England, 179. It has undergone marked and progressive diminution in many countries coincidently with improved sanitation; particularly in regard to drainage and water-supply. Table I. gives See also:annual death-rates in England and \Vales after 1869, when typhoid was registered separately from typhus and " See also:simple " fever. London shows less improvement than Great Britain as a whole, but it started with See also:superior sanitary conditions, and though the reduction has not been maintained in the last recorded quinquennium, the mortality is still much below the mean. The disease is more prevalent in See also:Paris, but the diminution effected has been far greater in the time,, the average annual mortality per million having fallen from 1430 in 1882 and 581 in 1883–1888 to 243 in 1889–1894 and 172 in 1895–1900. Other recorded instances of diminution are See also:Berlin, See also:Hamburg, See also:Munich, See also:Copenhagen, the See also:Netherlands, Buenos Aires (from ro6o per million in 1890 to 140 in 1899). In all these and Persons living—England and See also:Wales. Year. Mortality. Year. Mortality. 1869 390 1889 176 187o 388 1890 179 1871 371 1891 168 1872 377 1892 137 1873 376 1893 229 1874 374 1894 159 1875 371 1895 175 1876 309 1896 166 1877 279 1897 156 1878 306 1898 182 1879 231 1899 199 188o 261 1900 16o 1881 212 1901 173 1882 229 1902 126 1883 228 1903 See also:loo 1884 236 1904 93 1885 175 1905 89 1886 184 1906 92 1887 185 1907 67 1888 172 1908 75 The diminution is more clearly shown if quinquennial periods are taken, as in Table II. 1871-75. 1876-80. 188t-85. 1886-9o. 1891-95. 1896-1900. 1901-05 England and 354 278 218 18o 176 174.8 112.6 Wales. . 256 234 226 150 136 148 — London . other cases the improvement is attributed either to drainage or water-supply, or both. The case of Munich is so instructive that it deserves special mention. For many years typhoid was excessively prevalent in that city. The prevalence was continuous, but aggravated by large epidemic waves, extending over several years. These gradually decreased in magnitude, and ceased towards the end of 1880. Since then the prevalence has still further diminished, the average annual mortality per million having fallen from 2024 in 1851–186o, 1478 in 1861–187o and 1167 in 1871–1880 to 16o in 1881–1890 and 52 in 1891–1900. It has been forcibly argued by Dr Childs (Trans. Epidem. Soc. vol. xvi.) that drinking water had little, if anything, to do with the prevalence of the disease, and that its gradual reduction was due to See also:purification of the soil by improved drainage s/stems and the abolition of slaughter-houses. The epidemic waves were found by von See also:Pettenkofer to be associated with the rise and fall of the subsoil water; when the water See also:fell the fever rose, and See also:vice versa. I-Ie did not, however, consider that the subsoil water exercised any See also:influence itself ; he merely regarded it as an index to certain conditions of moisture which exercised a favourable or unfavourable influence on the development of the disease. His theory, which has been much misunderstood, is to some extent corroborated by some facts observed in Great Britain. One is the seasonal prevalence of typhoid, which in England is an autumnal disease. The minimum occurs in May or See also:June; in See also:August a marked rise begins, which continues throughout the autumn and reaches a maximum in See also:November, after which an abrupt fall sets in. These facts are in keeping with Pettenkofer's theory, for the subsoil water reaches its maximum height at the end of See also:spring and falls throughout the summer and a great part of the autumn. The coincidence is further emphasized by the fact that in dry years, when the subsoil water sinks lower than usual, typhoid is more prevalent, and in wet years the contrary. A glance at the mortality table for England given above will show that the progressive improvement recorded down to 1892 was suddenly interrupted in 1893, when the rate rose abruptly from 137 to 229. That was an extraordinarily dry and hot year, and it was followed by a See also:succession of dry and hot years, culminating in 1899, with two exceptions—1894 and 1897. In both the typhoid rate fell again, but in all the others it rose. One explanation has been suggested by Mr See also:Matthew See also: Perhaps this is sufficient to I ccount for the seasonal prevalence and the annual See also:variations noted. There is, however, a great deal of typhoid which has no connexion with water-supply. Numerous cases of persistent prevalence have been investigated by the medical officers of the local government See also:board, in which drinking water has been exonerated and the See also:mischief attributed to See also:standing pollution of the soil—for instance, See also:Mold, See also:Middlesbrough, Southend, See also:Swinton and Pendlebury, &c. In such places the chronic prevalence is apt to swell at times to more epidemic proportions, as at Munich; and possibly the condition of the ground may be the cause. An examination of the relative incidence of typhoid in the counties of England and Wales (See also:Bulstrode) goes to show that its prevalence, broadly regarded, is not capricious. The areas of maximum and minimum incidence remained practically the same throughout the twenty years 1871–189o, though there was everywhere a large diminution. This fact suggests the reflection that standing conditions are more important factors than those accidental occurrences which attract public See also:attention by causing sudden and explosive outbreaks. When these are on a small scale they may be due to milk; on a large scale they are always water-See also:borne and caused by sudden contamination of a public supply. The classical example is Maidstone. That outbreak began towards the end of August 1897, and within six weeks some 1500 persons were attacked. The See also:total number of cases was 1847, with 132 deaths, in a See also:population of about 34,000. With the exception of 28o cases of secondary infection, which lingered on till the following See also:January, they all occurred before the 18th of October, and the disease subsided almost as rapidly as it arose. A See also:mass of evidence of different kinds See also:left no possibility of doubt that accidental contamination of a water-supply was the cause. Perhaps the most striking point was that Maidstone is supplied with water from three different sources, known as Cossington, Boarley and Farleigh, and out of 1681 cases the respective incidence in these areas was—Cossington 29, Boarley 69, Farleigh 1583. Another great example of water-borne typhoid is furnished by Philadelphia, where 14,082 cases occurred in 1898-1899. Treatment.—Improved knowledge of the nature and causation of typhoid fever has not led to the successful introduction of a specific treatment; nor have means been found to cut short the illness, though its fatality has been reduced. It still goes through the classical stages, which broadly coincide with first, second and third weeks. Attempts have been made to deal directly with the toxins produced by the bacilli, on the hypo-thesis that they are formed in the intestinal canal, by the use of See also:internal See also:disinfectants, such as See also:mercury, See also:iodine, carbolic See also:acid, salol, &c., and these agents are sometimes beneficial; but the treatment remains essentially symptomatic, and follows the principles that were recognized before the See also:discovery of the bacillus typhosus. One of the most important improvements is the See also:regular use of sponging or bathing for the reduction of temperature. It has even been developed into a continuous See also:bath, in which the patient is kept in water throughout the illness. Since the recent development of serum-therapy various serums have been tried in the treatment of typhoid fever, and successful reports are given of the See also:anti-endotoxic serum devised by Dr See also:Allen Macfadyen, while See also:Professor Chantemesse, in the See also:statistics of serum treatment at the See also:Bastion Hospital, Paris, states that from See also:July 1901 to July 1907 he so treated moo cases, 43 proving fatal, a mortality of 4.3%. During the same period, 5621 cases were treated in fourteen other Paris hospitals, with 96o deaths, a mortality of 17%. Chantemesse's serum was employed by Professor Brunon at See also:Rouen in Too cases with three deaths, and Dr Josias of Paris in zoo cases with eight deaths in typhoid fever occurring in See also:young children. The serum is taken from a See also:horse which has received over a long period injections of an emulsion of the bacillus typhosus or a soluble toxin. Sir Almroth See also:Wright has suggested the use of an autogenous vaccine in this as in other parasitic diseases, opsonic See also:control being exercised. - The fatality of typhoid fever varies greatly. Age exercises a marked influence, the fatality rising steadily after the period 5 to Io years. The importance of careful and intelligent See also:nursing is undoubtedly great, but there is a tendency, encouraged by some nurses, on the part of the public to overestimate that factor and to think that nothing more is needed. This is a See also:grave See also:mistake. No disease requires more vigilant attention or greater medical experience. The following table shows quinquennial figures for the London See also:Metropolitan Asylums Board hospitals. Metropolitan Asylums Board Hospitals. See also:County of London. Admissions. Deaths. Ratio per cent. Mean annual of deaths to mortality per admissions. Iwo living. 18-74-1878 1878 379 20 ~ 0.25 1879-1883 2049 381 19 0.23 1884-1888 1937 314 16 0'17 1889-1893 2517 415 16 0.13 ,1894-1898 3328 578 17 0.13 1899-1903 6779 1023 15 0.13 1904-1908 3084 457 _ 15 0x05 Prevention.—If See also:house drainage were always perfectly carried out, sewage satisfactorily disposed of, water-supply efficiently protected or treated, patients segregated, and the typhoid material excreted by them and typhoid carriers " effectually annihilated—if; in short, scientific cleanliness were completely attained, the disease would disappear, or be at least excessively rare. In some communities much has been done in the directions indicated; but in many others the lessons of experience are ignored, and even in the best practice lags behind theory. This is mainly due to apathy and reluctance to spend See also:money, but there are certain real difficulties which stand in the way. To discuss them fully would involve a lengthy See also:consideration of drainage, water-supply and other matters, which would be out of place here; but some points must be noted. The most important is undoubtedly water-supply. The substitution of public water-supplies for shallow wells and small streams liable to pollution is one of the greatest factors in the diminution of typhoid and other water-borne diseases; but it may give rise to danger on a far larger scale, for iwhole community may be poisoned at one See also:blow when such a supply becomes contaminated. Unfortunately, it is extremely difficult to prevent contamination with certainty in a populous See also:country. Theoretically, water may be pure at its source, and may be distributed in that condition. Such is water derived from deep wells and springs, or gathered from uncultivated and uninhabited uplands. In the one case it has undergone natural filtration in the ground; in the other, it escapes all See also:risk of pollution. These See also:waters are generally pure, but the condition cannot be relied on. A See also:tramp or a shepherd may pollute the most remote gathering-ground unless it be fenced in; deep wells may be similarly fouled by workmen, and sewage may find its way into them from the surface or through fissures. In an outbreak of See also:enteritis and typhoid fever at Leavesden See also:Asylum, investigated by Dr A. See also:Shadwell in 1899, the source of mischief was traced to contamination of the well, which was 250 ft. deep in the See also:chalk. The contamination did not take place from the surface, but from some underground source, and there were grounds—corroborated by subsequent observation—for believing that it occurred at irregular intervals, and was probably connected with the level of the deep underground water. At the same time the similar well of a neighbouring poor-law school was found to be dangerously polluted, and it was ascertained that two others in the same locality had been condemned and closed in the past. The deep chalk in that neighbourhood was clearly unsafe, and this was thought to be due to the practice of digging holes called " dumb wells," but in reality See also:cess-pits, as much as 40 ft. deep, in the chalk for the reception of sewage. The same practice is common in all inhabited localities on a chalk forma--tion, as it is an extremely convenient way of disposing of sewage, which percolates away and renders it unnecessary to empty the cess-See also:pit. Several similar cases of deep well pollution have been recorded, notably those of See also:Houghton-le-Spring in 1889 and See also:Worthing in 1893. To secure purity, therefore, and prevent liability to outbreaks of typhoid and .other intestinal diseases, all gathering-grounds should be fenced in, and water, even from deep wells, should be regularly examined, both chemically and bacterioscopically, in See also:order that any change in See also:composition may be detected. In the water-supplies of great populations such examination should be made daily. Further, all supplies which are not above suspicion should be filtered through See also:sand or sterilized by boiling. The latter can be carried out by simple means in the case of individual domestic water, and attempts have been made to apply it by means of See also:mechanical apparatus to supplies on a larger scale. It is not, however, applicable to the water-supply of large towns, because of the liability of such apparatus to get out of order. Sand filtration is at present the best mode, of dealing with these supplies. There is no purer water than that which has been properly treated by subsidence and sand filtration, even when it is taken from an impure source. So far as the prevention of typhoid and other water-borne disease is concerned, it is certainly safer than the unfiltered water which is taken from so-called pure sources. It cannot be a See also:mere coincidence that London, Hamburg, Berlin and other towns using well-filtered but originally impure See also:river water should be generally freer from water-borne disease than many large towns See also:drawing their supply from purer sources but neglecting to See also:filter it, such as Manchester, Glasgow and the American cities. Table III., prepared by Mr Caink, engineer to the city of See also:Worcester, illustrates this fact, which has also been noted by Professor Saltet of See also:Amsterdam as holding good of the Netherlands. type and severity of the illness. Bacteriological See also:science has here come to the assistance of the clinical physician with what is called the Widal or serum reaction, which has a great diagnostic value when carefully performed. Professor Chantemesse has also introduced a cutaneous reaction similar to von Pirquet's reaction in tuberculosis. But obviously these remedies can only be applied to persons in the position of patients; it is of no use in the case of those who do not proclaim themselves ill, but go about their business when suffering from the disease. Such " See also:ambulatory " cases have long been recognized as an important factor in spreading the disease. Many of the most memorable epidemics have probably been caused by them, and it is difficult to see how they can be guarded against. The " typhoid-carrier," however, when discovered should be interdicted from the preparation of food and should undergo a course of treatment with a view to lessening their excretion of typhoid bacilli. The prevention of typhoid among armies in the field is a problem of special difficulty, not in principle but because of the conditions. The water is generally polluted, and soldiers are too thirsty to wait while it is boiled or filtered, even if the means are at hand. The sanitary arrangements are such as to ensure the saturation of the ground with excreta; flies and dust abound; personal cleanliness is impossible, and men feed and See also:sleep together in the closest proximity. No doubt a great deal might be done by efficient sanitary organization, which Source of Water. See also:Town. Annual Typhoid Case-rate per 1oo,000. 1892. 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1900. Deep wells in Red See also:Sandstone } See also:Wolverhampton 109 184 109 146 159 117 124 224 237 t See also:Birkenhead 157 207 185 165 138 126 211 230 145 Deep wells in Chalk See also:Southampton . . 145 159 109 83 78 64 153 171 109 c See also:Liverpool . . . 152 275 267 190 168 16o 129 149 115 Upland surface water . . Manchester . . 120 120 90 96 92 90 118 78 78 See also:Plymouth . . 126 63 47 32 31 49 41 49 120 London 65 84 77 81 71 70 66 98 95 See also:Rivers (filtered) . . . See also:Reading 30 35 28 53 30 67 32 48 41 Worcester 155 145 110 36 43 45 31 50 26 Average of 219 towns . . . . 88 142 103 115 102 100 115 127 116 The amount of typhoid is dependent on other factors besides has hitherto been lacking, and by educating the men. Dr the water-supply, but the close connexion between the two and the See also:Leigh Canney in 1901 suggested a See also:scheme for dealing system- influence of filtration are well attested by the experience of Wor- atically with the water-supply of an See also:army. Extraordinary See also:tester, where the great reduction recorded since 1894 coincided f with new and improved filtration. The weak point about sand filtration is that it is apt to be imperfectly performed when the filters are frozen or newly cleaned, or when the process is too rapid. Filtration through See also:porcelain is an efficient purifier, but it is not applicable to supplies on a large scale, and is liable to break down through clogging of the filters. Other portable filters are regarded as useless or worse. The best emergency treatment for suspected drinking water is boiling. Contamination of water in the mains is due to See also:bad laying, and ought never to occur; that of supply pipes can be prevented by a constant service, and of domestic filters by providing them with covers. Next to water-supply, and hardly less important, is drainage. The drying and cleansing of the soil by good See also:household drainage and See also:sewerage is essential to the prevention of typhoid. Cess-pits, leaking drains and privies, especially when there is only one to several houses, as in many See also:industrial towns, are powerful See also:allies of this disease. The drainage of all old houses is defective and dangerous. The ground about them is commonly honeycombed with cess-pits and saturated with sewage. The only way to discover and remedy such defects is to See also:lay them See also:bare with the pickaxe and See also:shovel. Soil-pipes should always be trapped and ventilated. In short, no disease requires for its prevention more careful attention to house sanitation. The paving of yards and other spaces is also desirable in towns, on account of the liability of the unprotected soil to harbour moisture and filth. Other modes by which the disease is spread—such as shellfish, milk and uncooked vegetables—suggest their own remedy. The dissemination by dust and flies is less easily prevented. All that can be done is to segregate the sick and promptly destroy all dangerous matters proceeding from them. It should be remembered that the urine may be an even greater source of danger than the faeces. The same observation applies to the prevention of infection from person to person. There is no doubt that sufficient care is often wanting, even in hospitals, in handling patients' soiled See also:linen and clothes, and in dealing promptly and effectually with their excreta. For the effectual segregation and treatment of persons suffering from typhoid prompt recognition is necessary; and this, unfortunately, is a matter of much difficulty on account of variation in the results were obtained by the See also:Japanese army medical See also:department in the Russo-Japanese See also:War of 1904-5 in the prevention of typhoid fever, which up to that period was responsible for the largest mortality of any disease affecting armies in the field. Handbooks on the avoidance of See also:cholera, See also:plague and typhoid fever were issued to the troops. Boiled water in quantities was provided for the soldiers, each See also:battalion having its boiling outfit. Even foreign attaches and correspondents were requested to observe the regulations on this point. With this there was a systematic advance testing of wells, the wells being labelled " See also:fit for drinking " or " for washing purposes only." It being impossible to suppress the presence of flies on food,. care was taken to See also:cover all latrines and cover and disinfect excreta, so that infection from flies was reduced to a minimum. Food was transferred from sterilized caldrons into sterilized See also:lacquer boxes and served on sterilized plates. A crematory was attached to See also:base hospitals, where all nightsoil, garbage and See also:waste was burnt daily. Owing to these precautions the incidence of infectious disease, notably typhoid fever, was reduced to a figure unparalleled in any previous war, only 3.51% of the total sickness being due to infectious disease. Taking the number of men at the front in See also:April 1905 to have been 599,617, the entire deaths from infectious and contagious diseases amounted to 1.24% of the entire army in the field. In a table furnished by the Japanese war See also:office at a still later date we See also:note the small percentage of typhoid fever. Percentage of patients in entire Army See also:Corps at a certain date:
Wounds received in action 45.53
Other wounds and injuries 3.71
Typhoid fever 1.61
See also:Dysentery 1.9,5
All other diseases 47.20
In the statistics of General Oku's army, calculated to be at least 75,000 strong, See also:Major-General Mori, chief medical officer, reports the typhoid cases to be 66 only between the See also:dates of October 1904 and April 1905. Of this army 2142 were invalided See also:home or died; 133 only being cases of typhoid fever.
The sickness incidence in the First Army under General See also:Kuroki was as follows during the first six months of the campaign:
Months. Sickness: all Diseases. Typhoid Fever.
See also: The case mortality of the inoculated was 9'5%, of the non-inoculated 13.8%. Several regiments however were not exposed to enteric fever. If these be excluded the incidence in the inoculated is 6.6 per See also:I000 against 39.5 per moo in the non-inoculated. See also:Lord See also:Kitchener, speaking at See also:Middlesex Hospital in October 1910, See also:bore emphatic testimony to the value of inoculation coupled with improved sanitary methods on the health of the army in India, declaring his belief that enteric would before long join cholera in total banishment from the See also:barracks. Additional information and CommentsThere are no comments yet for this article.
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