Typhoid Fever

Various Factors.

The amount of typhoid is dependent on dangerous matters proceeding from them. It should be remem bered that the urine may be an even greater source of danger than the faeces. The same observation applies to the prevention of in fection from person to person. There is no doubt that sufficient care is often wanting, even in some 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 from typhoid prompt recognition is necessary; and this, unfortunately, is a matter of much difficulty on account of variation in the type and severity of the illness. Bacteriological science has here come to the assistance of the clinical physician with blood cultures and the Widal reaction, which are of great diagnostic value when carefully performed. 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 impor tant factor in spreading the disease.

Typhoid Among Armies.

Before the introduction of anti typhoid vaccination the prevention of typhoid among armies in the field was a problem of special difficulty, not in principle but because of the conditions. During the South African War of 1899-19o2, 31,00o men were invalided home to England on ac count of typhoid fever. Extraordinary results were obtained by the Japanese army medical department in the Russo-Japanese War of 1904-05 in the prevention of typhoid fever, which up to that period was responsible for the largest mortality of any disease other factors besides the water-supply, but the close connection be tween the two and the influence of filtration are well attested by the experience of Worcester, where the great reduction recorded after 1894 coincided with new and improved filtration. The weak point about sand filtration is that it is apt to be imperfectly per formed when the filters are frozen or newly cleaned, or when the process is too rapid. Filtration through porcelain is an efficient puri fier, but it is not applicable to supplies on a large scale, and almost invariably breaks down through clogging of the filters. Other port able filters are useless or worse. The best emergency treatment for suspected drinking water is boiling, and the next best is chlorination.

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. Cesspits, 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 dan gerous. The ground about them is commonly honeycombed with cesspits 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 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 correspond ents were requested to observe the regulations on this point. With

this there was a systematic advance testing of wells, the wells be ing labelled "fit 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 flies 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 nightsoil, 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 in fectious 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 1.24% of the entire army in the field. In the World War care in disposal of sewage, chlorination of water and anti-typhoid vaccination of the troops reduced the typhoid incidence and case mortality to a still lower point notably in the British armies in France (see THERAPEUTICS).

Anti-typhoid Inoculation.

This consists in a hypodermic injection of the dead organism of the disease into the person who is to be protected. Protection is acquired in about 10 days and lasts 18 months to 2 years. The method was initiated by Sir Almroth Wright in 1896, who first used broth cultures sterilized at 6o° C. The method now in use is to grow the organisms on a solid medium and to suspend them in a saline. Sterilization is carried out at a temperature of 53° C and 0.4% Lysol is added afterwards. The vaccine is standardised to contain i,000 million typhoid organisms and 75o million rf each of the two paratyphoid bacilli per cubic centimetre. Table I. shows the details in con nection with the disease in various wars during modern times, and of these the European war was the only one in which anti typhoid inoculation was extensively used.

The opponents of antityphoid inoculation attribute the enor mous reduction of enteric fever in the last war to improved sani tary measures. These have undoubtedly played their part, but that prophylactic inoculation must have had a large share in this reduction is supported by the lower incidence of the disease amongst inoculated as compared with uninoculated persons when both were living under the same conditions. Table II. contains a few comparisons between these two sets of persons in different parts of the world.

There is besides abundant proof that though an inoculated man may contract the disease it is less likely to prove fatal than in the case of an uninoculated man. Good reports have been re ceived from the Continent of oral administration of the typhoid vaccine, but this method must be considered to have only reached the experimental stage at present. (N. T. W.) BIBLIOGRAPHY.-(Typhoid and Paratyphoid fevers). H. Vincent and L. Muratet, Typhoid fever and paratyphoid fevers (Eng. trans. from and French ed. London, '917) ; A. E. Webb-Johnson, Surgical Aspects of typhoid and paratyphoid fevers (London, 'gig) ; F. Rathery and others, Les fievres paratyphoides B. (Paris, 1916) ; F. A. F. Barnardo, "Difficulties in early diagnosis of typhoid group of fevers" (Indian Med. Gaz., 1927, lxii. 393) ; Schwabe, "Der gegenwartige Stand des Paratyphusprobleme und Seine Auswerbung in der Seuchenbe kampfung" (Ztschr. f. Med.-Beamte, 1927 xl., 352) ; J. A. Arkwright, "Value of different kinds of antigens in prophylactic 'enteric' vac cines" (Jn. Path. and Bact., 1927 xxx., 345, bibl.) ; Uhlenhuth and W. Seiffert, "Der gegenwartige Stand des Paratyphusprobleme (unter besonderer Beriicksichtigung eigener Untersuchungen)" (Dent. med. Wchnschr., 1926, lii., 649, 689, 737).