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.
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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
