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
