1911 Encyclopædia Britannica/Typhoid Fever

TYPHOID FEVER. Typhoid or enteric* (Gr. Ev-repov, the intestine) is a specific infectious fever characterized mainly by its insidious onset, by a peculiar course of the temperature, by marked abdominal symptoms occurring in connexion with a specific 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 remit tent fever, slow fever, nervous fever, “ pathogenic fever, ” Src. The name of “ typhoid ” was given by Louis in 1829, as a derivative from typhus. Until a comparatively recent period typhoid was not distinguished from typhus. For, although it had been noticed that the course of the disease and its morbid anatomy were different from those of ordinary cases of typhus, it was believed that they merely represented a variety of that malady. The distinction between the two diseases appears to have been first accurately made in 18 36 by -Messrs Gerhard and Pennock, of Philadelphia, and valuable work was done by other American doctors, particularly Elisha Bartlett (1842). The difference between typhus and typhoid was still more fully demonstrated by Dr A. P. Stewart, of Glasgow (afterwards of London). Finally, all doubt upon the subject was removed by the careful clinical and pathological observations made by Sir William Jenner at the London fever hospital (1849-1851).

The more important phenomena of typhoid fever will be better understood by a brief reference to the principal patholo ical changes which take place during the disease. These relate for the most 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 action of the oontagium on the 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 lower part of the small intestine (ileum), where the “ solitary glands” and “ Peyer's patches " on the mucous surface of the canal become affected by diseased action of a definite and progressive cha-racter, which stands in distinct relation to the symptoms exhibited by the patient in the course of the fever. (I) These glands, which in 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 cell proliferation. This change usually affects a large extent of the ileum, but is more marked in the lower portion near the ileo-caecal valve. It -is generally held that this is the condition of the parts during the first eight or ten days of the fever. (2) These enlarged glands next undergo a process of sloughing, the inflammatory products being cast off either in fragments or en masse. This usually takes place in the second week of the fever. (3) Ulcers are thus formed varying in 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 long 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 erode blood-vessels or perforate the bowel. This 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 time, since the process does not advance at an equal rate in the case of all the ulcers, some of which have been later in forming than others. Even when convalescence has 1 The word “ enteric " has been substituted for “ typhoid” by the Royal College of Physicians in the nomenclature of diseases authorized by them, and the change was officially adopted by all departments of the British government. Its advantages are doubtful, and it has been generally ignored by those 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 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 appropriation of a term having a 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 label, when speaking of the cause of the disease or some of its sym toms. We have the “ typhoid bacillus, " “ typhoid stools, " “ typiioid 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 diet, a cause of relapse of some of the symptoms, and even of still more serious or fatal consequences. The mesenteric glands external to, but in functional relation with, the intestine, become enlarged duringithe progress of the fever, but usually subside after recovery. Besides these changes, which are well recognized, others more or less important are often present. Among these may be mentioned marked 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 function of the bowels so often complained of by persons who have passed through an attack of typhoid fever. Other changes common to most fevers are also to be observed, such as softening of the muscular tissues generally, and particularly of the heart, and evidences of complications affecting chest or other organs, which not infrequently arise. The swelled leg of fever sometimes follows typhoid, as does also periosteal inflammation.

T he symptoms characterizing the onset of typhoid fever are very much less marked than those of most other fevers. The most marked of the early symptoms are headache, lassitude and discomfort, together with sleeplessness and feverishness, particularly at 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 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 day, until about the eighth day, when in an average case the highest point is attained. This varies according to the severity of the attack; but it is no unusual thing to 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 dies down as a rule between the twenty-first and the twenty-eighth days, although it is liable to recur in the 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 bed. He is restless, hot and uncomfortable, particularly as the day advances, and his cheeks show a red Hush, especially in the evening or after taking food. The aspect, however, is different from the oppressed, stupid look which is present in typhus. The 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 IOO. In severe and protracted cases, where there is evidence of extensive intestinal ulceration, the pulse becomes rapid and weak, with a dicrotic character indicative of cardiac feebleness. The tongue has at first a thin, whitish fur and is red at the tip, edges and central line. It tends, however, to become dry, brown or glazed lookin, and fissured transversely, while sordes may be present about time lips and teeth. There is much thirst and in some cases vomiting. Splenic and hepatic enlargement may be made out. From an early period in the disease abdominal symptoms show themselves and are frequently of hi hly diagnostic significance. The abdomen is somewhat distended or tumid, and pain accompanying some gurgling sounds may be elicited on light pressure about the lower part of the right side close to the groin-the region corresponding to that portion of the intestine in which the morbid changes already referred to are progressing. Diarrhoea is a frequent but by no means constant symptom. When present it may be slight in amount, or, on the other hand, extremely profuse, and it corresponds, as a rule, to the severity of the intestinal ulceration. The discharges are highly characteristic, being of light yellow colour resembling pea soup in appearance. Should intestinal hemorrhage occur, as is not infrequently the case during some stage of the fever, they may be dark brown or composed entirely of blood. 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, oval or round in shape, of a pale pink or rose colour, and of about one to one and a half lines in 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 body. They do not appear to have anv relation to the severity of the attack, and in a very considerable proportion of cases (particularly in children) they are entirely absent. Besides this eruption there are not infrequently numerous very faint bluish patches or blotches about halfpan incli 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 relapse 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 delirium, in tremors and jerkings of the muscles (subsullus tendinum). in drowsiness and occasionally in “coma vigil." In severe cases the exhaustion reaches an extreme degree, although even in such instances the condition is not to be regarded as hopeless In favourable 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 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 apt to be interrupted by relapses. Should such relapses repeat themselves, the case may be protracted for two or three months, but this is comparatively rare. Death in typhoid fever usually takes place from one or other of the following causes. (1) Exhaustion, in the second or third weeks, or later. Sometimes sinking is sudden, partaking of some of the characters of a collapse. (2) Hæmorrhage 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 great pallor, faintness and rapid sinking. Sometimes hemorrhage, to a dangerous and even fatal extent, takes place from the nose. (3) Perforation of an intestinal 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, cold clammy skin, and the marked fall of temperature. Symptoms of peritonitis quickly supervene and add to the patient's distress. Death usually takes place within 24 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 ill health and anaemia, with digestive difficulties, often lasting for a long time, and sometimes issuing in pulmonary tuberculosis. Occasionally, after severe cases, mental weakness is noticed, but it is usually of comparatively short duration. No disease has been more thoroughly studied in recent years than typhoid fever. The chief points requiring notice are (1) causation and spread, (2) prevalence, (3) treatment, (4) prevention.

Causation:-The cause is the bacillus typhasus, discovered by Eberth in 1880 (see PARASITIC DISEASES). This organism multiplies in the body of a 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 spleen, the mesenteric glands, the bile and the liver, not infrequently also in the 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 special 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 history, outside the body, has been investigated with more positive results than that of any other micro-organism, though much still remains obscure. Certain conclusions may be stated on good evidence, but it is to be understood that they are all more or less tentative. (1) In crude sewage the bacillus does not multiply, but dies out in a. few days. (2) In partly sterilized sewage (Le. 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 sewer air, though Sir Charles Cameron, from a series of recent experiments, claims to have proved the contrary. (4) In ordinary water containing other organisms it dies in about a fortnight. (5) In sterilized water it lives for about a month. (6) In ordinary soil moistened by rain it has lived for 67 days, in sewage-polluted soil for at least 53 days, in soil completely dried to dust for 25 days, and in sterilized soil for upwards of 400 days. (7) Exposed to direct sunlight it dies in from four to eight hours. (8) It is killed by a temperature of 58 °C., but not by freezing or drying. (9) It multiplies at any temperature between 10° C. and 46° C., but most rapidly between 3 5° C and 42° C. 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 scale.

The susceptibility of individuals to the typhoid bacillus varies greatly. Some persons appear to be quite immune. The most susceptible age is adolescence and early adult life; the greatest incidence, both among males and females, is between the ages of IS and 3 5. The aged rarely contract it. Men suffer considerably more than 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 power. The lower animals appear to be 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 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 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 personal infection may become a very important means of dissemination. There is evidence that this is the case with armies in the field, ag. the conclusions of the commission appointed to inquire into the origin and spread of enteric fever in the military encampments of the United States in the Cuban campaign cf 1898. Out of 1608 cases most thoroughly investigated, more than half were found to be due to direct and indirect infection in and from the tents (Childs: Sanitary Congress, Manchester, 1902). A similar but perhaps, less direct mode of infection was shown to account for a large number of cases under more ordinary conditions of life in the remarkable outbreak at Maidstone in 1897, which was also subjected to very thorough investigation. It was undoubtedly caused in the first instance by contaminated water, but 280 cases occurred after this cause had ceased to operate, and these were attributed to secondary infection, either direct or indirect, from the sick. A good deal of evidence to the same effect by medical officers of health in England has been collected by Dr Goodall, who has also pointed out that the attendants on typhoid patients in hospital are much more frequently attacked than is commonly supposed (Trans. Epidem. Soc. vol. xix.).

Recent discoveries as to the part played in the dissemination of typhoid fever by what are termed “ typhoid carriers ” have thrown light upon the subject of personal infection. The subject was first investigated by German hygienists in 1907, and it was found that a considerable number of persons who have recovered from typhoid fever continue to excrete typhoid bacilli in their faeces and urine (typhoid bacilluria). They found that after six weeks 4% to 5% of typhoid patients were still excreting bacilli; 23% of 65 typhoid patients at Boston City Hospital showed typhoid bacilli in their excretions ten days before their discharge. The liability of a patient to continue this excretion bears a direct relation to the severity of his illness, and it is probable that the bacilli multiply in the gall bladder, from which they are discharged into the intestine with the bile. The condition in a small number of persons may persist indefinitely. In IOI cases investigated, Kayser found three still excreting bacilli two years after the illness, and George Deane has recorded a case in which bacilli continued to be excreted ZQ years afterwards. Many outbreaks have in recent times been traced to typhoid carriers, one of the first being the 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 developed the disease. She prepared the meals of the men. On her exclusion from the kitchen the cases ceased. In Brentry reformatory, near Bristol, an outbreak numbering 28 cases was traced to a woman employed as 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 year's residence there 25 cases had occurred. A case is reported by Huggenberger of Zurich (Lancet, October 1908) in which a woman carrier is said to have infected a series of cases lasting over 31 years, including her husband, son, daughter-in-law, and no less than nine different servants. Numerous cases of contamination of milk supplies by a “ carrier ” have been investigated, and in outbreaks traced to dairies it is wise to submit the blood of all employés to the agglutination test. A persistently high opsonic index to typhoid bacilli is notable among “ carriers.” Not only do persons who have had tyhpoid fever 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 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 Firth and Horrocks prove that dust, fiies and clothing may convey the germs. Another way in which food beoomes the medium of conveyance is by the contamination of oysters and other shellfish with sewage containing typhoid bacilli. This has been abundantly proved by investigations in Great Britain, America and France. Uncooked vegetables, such as lettuces and celery, may convey the disease in a similar way. The most 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 reason why t is chain of causation should not hold good of other articles of food and drink. Outbreaks have been traced to ginger-beer and ice-creams. Water sources become contaminated directly by the inflow of drains or the deposit of excretal matter; indirectly, and more frequently, by the leakage of sewage into wells or by heavy rains which wash sewage matter and night-soil from ditches and the surface of the land into springs and watercourses. Water may further be contaminated in the mains by leakage, in domestic cisterns, and in supply pipes by suction. There is some reason to believe that the bacilli may multiply rapidly in water containing suitable nourishment in the absence of large numbers'of their natural foes.

Prevalence.-Typhoid fever is more or less endemic and liable to epidemic outbreaks all over the world. It is more prevalent in temperate than in tropical climates. The following comparative death-rates show its relative prevalence in certain countries in 1890: Italy, 658; Austria, 470; U.S.A. 462; 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 annual death-rates in England and Wales after 1869, when typhoid was registered separately from typhus and “ simple ” fever.

London shows less improvement than Great Britain as a whole, but it started with 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 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 293 in 1889-1894 and 172 in 1895-1900. Other recorded instances of diminution are Berlin, Hamburg, Munich, Copenhagen, the Netherlands, Buenos Aires (from 1060 per million in 1890 to 140 in 1899). In all these and TABLE I.-Annual Mortality from Entefic Fever per Million Persons living-England and Wales.

Year. Mortality. Year. Mortality.

1869 390 1889 1 76

1870 388 1890 1 79

1871 371 1891 168

1872 377 1892 137

1873 376 1893 229

1374- 374 1894 159

1375 371 1395 175

1876 309 1896 166

1877 279 1897 156

1878 306 1898 182

1379 231 1399 199

1880 261 1900 160

1 88 1 2 12 1901 1 73

1882 229 1902 126

1883 228 1903 100

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 ll.

TABLE II.-Average Annual Mortality per Million in England and Wales, and in London.

1871-75. 1876-80.1881-85. 1886-90. 1891-QS, 1896-1900. 1901-05 England and

Wales. 354 278 218 180 176 174-8 112-6

London . 256 234 226 150 156 1485

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 1851-1860, 1478 in 1861-1870 and 1167 in 1871-1880 to 160 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 purification of the soil by improved drainage syétems and the abolition of slau hter-houses. The epidemic waves were found by von Pettenkoger to be associated with the rise and fall of the subsoil water; when the water fell the fever rose, and vice versa. l-le did not, however, consider that the subsoil water exercised any 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 June; in August a marked rise begins, which continues throughout the autumn and reaches a maximum in November, after which an abrupt fall sets in. These facts are in keeping with Pettenk0fer's theory, for the subsoil water reaches its maximum height at the end of 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 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 l/Ir Matthew Adams of Maidstone. He points out that organic matter deposited on or in the ground asses in normal years gradually through several layers of soil, anti) undergoes a process of destruction or purification before reaching the underground water; but in hot summers the ground becomes baked' and cracked, and there is no such percolation; when rain comes everything is swept suddenly away without any purification, and finds its way into the sources of drinking water. Whether this be so or not, there is no doubt that dangerous material does collect during the summer and is swept into watercourses by the autumnal rains. Perhaps this is sufficient to account for the seasonal prevalence and the annual 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 board, in which drinking water has been exonerated and the mischief attributed to standing pollution of the soil—for instance, Mold, Middlesbrough, Southend, 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 (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 1871–1890, 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 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 waterborne 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 total number of cases was 1847, with 132 deaths, in a population of about 34,000. With the exception of 280 cases of secondary infection, which lingered on till the following January, they all occurred before the 18th of October, and the disease subsided almost as rapidly as it arose. A mass of evidence of different kinds 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 waterborne 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 hypothesis that they are formed in the intestinal canal, by the use of internal disinfectants, such as mercury, iodine, carbolic acid, salol, &c., and these agents are sometimes beneficial; but the treatment remains essentially symptomatic, and follows the principles that were recognized before the discovery of the bacillus typhosus. One of the most important improvements is the regular use of sponging or bathing for the reduction of temperature. It has even been developed into a continuous 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 anti-endotoxic serum devised by Dr Allen Macfadyen, while Professor Chantemesse, in the statistics of serum treatment at the Bastion Hospital, Paris, states that from July 1901 to July 1907 he so treated 1000 cases, 43 proving fatal, a mortality of 4·3%. During the same period, 5621 cases were treated in fourteen other Paris hospitals, with 960 deaths, a mortality of 17%. Chantemesse's serum was employed by Professor Brunon at Rouen in 100 cases with three deaths, and Dr Josias of Paris in 200 cases with eight deaths in typhoid fever occurring in young children. The serum is taken from a horse which has received over a long period injections of an emulsion of the bacillus typhosus or a soluble toxin. Sir Almroth Wright has suggested the use of an autogenous vaccine in this as in other parasitic diseases, opsonic control being exercised.

The fatality of typhoid fever varies greatly. Age exercises a marked influence, the fatality rising steadily after the period 5 to 10 years. The importance of careful and intelligent 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 grave mistake. No disease requires more vigilant attention or greater medical experience. The following table shows quinquennial figures for the London Metropolitan Asylums Board hospitals.

Metropolitan Asylums Board Hospitals.				County of London.
	Admissions.	Deaths.	Ratio per cent. of deaths to admissions.	Mean annual mortality per 1000 living.
1874–1878	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	0·05

Prevention.—If 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 money, but there are certain real difficulties which stand in the way. To discuss them fully would involve a lengthy 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 a whole community may be poisoned at one blow when such a supply becomes contaminated. Unfortunately, it is extremely difficult to prevent contamination with certainty in a populous 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 risk of pollution. These waters are generally pure, but the condition cannot be relied on. A 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 enteritis and typhoid fever at Leavesden Asylum, investigated by Dr A. Shadwell in 1899, the source of mischief was traced to contamination of the well, which was 250 ft. deep in the 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 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 formation, as it is an extremely convenient way of disposing of sewage, which percolates away and renders it unnecessary to empty the cess-pit. Several similar cases of deep well pollution have been recorded, notably those of Houghton-le-Spring in 1889 and 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 order that any change in 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 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 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. S0 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 mere coincidence that London, Hamburg, Berlin and other towns using well-filtered but originally impure river water should be generally freer from water-borne disease than many large towns drawing their supply from purer sources but neglecting to filter it, such as Manchester, Glasgow and the American cities. Table III., prepared by Mr Caink, engineer to the city of Worcester, illustrates this fact, which has also been noted by Professor Saltet of Amsterdam as holding good of the Netherlands.

type and severity of the illness. Bacteriological 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 “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 gf tfpatment with a view to lessening their excretion of typhoid aci 1.

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; liies 'and dust abound; personal cleanliness is impossible, and men feed and sleep together in the closest proximity. N0 doubt 'a great deal might be done by efficient sanitary organization, which TABLE III.-*OCCUVIBWCBS of Typhoid according to Sources of Water-Supply.

Annual T hoid Case-rate r 100, oo0.

Source of Water. Town.

1892. 1893. 1894. 1895. 1896. 1897. 1898. 1899. 1900 Deep wells in Red Sandstone Wolverhampton 109 1 84 109 146 159 1 17 124 224 237 Birkenhead , 157 207 185 165 138 126 211 230 145 Deep wells in Chalk Southampton 145 159 109 83 78 64 153 171 109 Q Liverpool . 152 275 267 190 168 160 129 149 1 I5 Upland surface water Manchester 120 120 90 96 92 90 1 18 78 78 | Plymouth 126 63 47 32 31 49 4I 49 120

- London . 65 84 77 81 71 70 66 98 95

Rivers (filtered) Reading 30 35 28 53 30 67 32 48 41 Worcester 155 145 1 IO 36 43 45 31 50 26

Average of 219 towns ... 4. 88 142 103 II5 102 100 115 127 116 The amount of typhoid is dependent on other factors besides the water-supply, but the close connexion between the two and the influence of filtration are well attested by the experience of Worcester, where the great reduction recorded since 1894 coincided 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 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 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 household drainage and 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 industrial towns, are powerful 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 lay them bare with the pickaxe and 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 frorn 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 linen and clothes, and in dealing promptly and effectually with their excreta. For the effectual segregation and treatment of persons suffering V from typhoid prompt recognition is necessary; and this, unfortunately, is a matter of much difficulty on account of variation in the has hitherto been lacking, and by educating the men. Dr Leigh Canney in 1901 suggested a scheme for dealing systematically with the water-supply of an army. -Extraordinary results were obtained by the japanese army medical department in the Russo-Japanese 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 cholera, plague and typhoid fever were issued to the troops. Boiled water in quantities was provided for the soldiers, each 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 “tit for drinking ” or “for washing purposes only.” It being impossible to suppress the presence of flies on food, care was taken to cover all latrines and cover and disinfect excreta, so that infection from liies was reduced to a minimum. Food was transferred from sterilized caldrons into sterilized lacquer boxes and served on sterilized plates. A crematory was attached to base hospitals, where all night soil, garbage and 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 April 1905 to have been 599,617, the entire deaths from infectious and contagious diseases amounted to I'24% of the entire army in the field. In a table furnished by the japanese war office at a still later date we note the small percentage of typhoid fever. Percentage of patients in entire Army Corps at a certain date:- Wounds received in action ' ..... 45-53

Other wounds and injuries . 3-71

Typhoid fever .... I°6I

Dysentery .... 1-95

All other diseases . . 47'20 In the statistics of General Oku's army, calculated to be at least 75,000 strong, Major-General Mori, chief medical officer, reports the typhoid cases to be 66 only between the dates of October 1904 and April 1905. 'Of this army 2142 were invalided home or died; 133 only being cases of typhoid fever.

The sickness incidence in the First Army under General Kuroki was as follows during the first six months of the campaign:-

Months. Sickness: all Diseases. Typhoid Fever. March 3829 3

April 3545 1

May 3154 9

June 4824 9

July .... 5565 4

August . .. 6006 9

The figures are interesting when we consider that during the South African War of 1899-1902 no fewer than 31,000 men were invalided home to England on account of typhoid fever. One other point requires mention in connexion with prevention, namely, protective inoculation. This is performed with an anti-toxic substance prepared from dead cultures of bacilli, and has been tried on a fairly large scale, particularly on the British army in India and South Africa. Sir W. B. Leishman, writing on the results of anti-typhoid inoculations in the army (/ourn. of R.A M.C., February 1909), gives the total number of men inoculated up to the 1st of June 1908 as 5473, amongst whom 21 cases (3-8 per 1000)with 2 deaths occurred. The number non-inoculated, 6610 men, had an incidence of 187 cases (28-3 per 1000) with 26 deaths. 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 1000 against 39-5 per 1000 in the non-inoculated. Lord Kitchener, speaking at Middlesex Hospital in October 1910, 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 barracks.