UC-NRLF $B n? bD2 MILROY LECTURES 1902 THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA PRESENTED BY PROF. CHARLES A. KOFOID AND MRS. PRUDENCE W. KOFOID 4 THE ETIOLOGY OF TYPHOID FEVER AND ITS PREVENTION Digitized by the Internet Archive in 2007 with funding from IVIicrosoft Corporation http://www.archive.org/details/etiologyoftyphoiOOcorfrich THE ETIOLOGY OF TYPHOID FEVER AND ITS PREVENTION BEING THE MILROY LECTURES DELIVERED AT THE ROYAL COLLEGE OF PHYSICIANS IN 1902 BY W. H. CORFIELD, M.A., M.D. (Oxon.), F.R.C.P., ^ Hon. A.R.I.B.A. OONSULTINa SANITARY ADVISER TO H.M. OFFICE OF WORKS, AND HONORARY SANITARY ADVISER TO UNIVERSITY COLLEGE AND HOSPITAL. PROFESSOB OF HYGIENE AND PUBLIC HEALTH AT UNIVERSITY COLLEGE, LONDON; PRESIDENT OF THE EPIDEMIOLOGICAL SOCIETY OF LONDON; PAST-PRESIDENT OF THE SOCIETY OF MEDICAL OFFICERS OF HEALTH; VICE-PRESIDENT OF THE SANITARY INSTITUTE; SOMETIME MEDICAL FELLOW OF PEMBROKE COLLEGE, OXFORD ; "MBMBRE D'HONNEUR" & MEDALLIST OF THE ROYAL SOCIETY OF PUBLIC HEALTH OF BELGIUM HONORARY MEMBER OF THE SOCIETY OF HYGIENE OF FRANCE AND OF THE HUNGARIAN SOCIETY OF PUBLIC HEALTH; HONORARY CORRESPONDING MEMBER OF THE ROYAL ACADEMY OF MEDICINE OF BELGIUM, OF THE IMPERIAL SOCIETY OF MEDICINE OF CONSTANTINOPLE, AND OF THE ROYAL SOCIETY OF HYGIENE OF ITALY FELLOW OF THE MEDICAL SOCIETY OF SWEDEN. LONDON H. K LEWIS. 136 GOWER STREET, W.C 1902 K* TABLE OF CONTENTS. LECTURE I. \c- Preliminary Typhoid v. Enteric Historical, Murchison Christopher Mayr's Work on Typhode Fevers Msijr's Con^ect7is Fehrium (Taible I.) Mayr's Five Species of Typhus (Table II.) Phthisis classed by Mayr among fevers Description of Mayr's five species of typhus Causes of these diseases Mayr's view of contagion Hildenbrand on typhus fever Hildenbrand on overcrowding Louis' Work on Typhoid Fever Typhus and typhoid fevers distinct from one another Gendron on typhoid epidemics in small places ... Contagiousness of typhoid fever Chomel's work on typhoid fever Various names of typhoid fever Impossibility of tracing contagion in large cities Gaultier de Claubry's memoir on the differences between typhus and typhoid fevers 14,16 Typhoid rash simulating typhus rash 14 Montault's memoir on the differences between typhus and typhoid fevers 15, 16 Bouillaud's definition of typhoid fever 16 Lombard's investigations 17 Gerhard and Pennock's ditto 17 Rochoux's views 17 Trousseau's ditto 17,18 Barlow's paper on The Distinction between TyphajeL/^ PAGE 1 ,. 2 2 .. 2 ,. 3 ,. 3 .. 4 ..4, 5 ..5, 6 .. 6 ..6,7 .. 8 .8-11 .. 10 .. 11 ,. 11 11-14 ,. 12 ,. 13 Fever and Dothienenterie Stewart on same subject Forget on follicular enteritis 18, 19 19,20 20, 21 'r^^-»•-%^a ^^ m VI William (afterwards Sir William) Jenner on the Identity or Non-identity of Typhoid and Typhus Fevers 22-25 William Jenner on the different causes of these diseases 25 Typhoid fever contagious 25 Murchison on the etiology of continued fevers . . . 26-28 Murchison on the cause of typhoid fever 28 Murchison on the incubation period of typhoid fever ... 29 William Budd on typhoid fever 29 Sir Thomas Watson's vievi^s ... ... ... ... ... 29 Budd on the contagiousness of typhoid fever 30 Tyndall's view on the contagiousness of typhoid fever ... 30 The Author's paper ' ' On the Alleged Spontaneous Pro- duction of the Poison of Enteric Fever " 31-33 The poison is particulate 31 Contagious or non-contagious ? 31,32 Difficulty of tracing typhoid fever 32, 33 Not self -generating 33 vu LECTUKE II. PAex Predisposing causes ... 34 Outbreaks connected with general insomitary conditions 35-38 Whitehaven, Grantham, and Debenham, by Dr. Bristowe 35, 36 Bridport, by Dr. Buchanan 36 Dr. (afterwards Sir George) Buchanan's observations on the reduction of typhoid by public improvements 36, 37 Winterton, Lincolnshire, by Dr. Thorne Thorne 37 Mr. (afterwards Sir John) Simon's summary of reports during 1870-73 37 Selborne, Hants, by Dr. Blaxall 37, 38 Slaughter-houses 38 Outbreaks at Runcorn, by Mr. Spear; Hatfield, Broad Oak, by Dr. Richmond ; and Widnes, by Dr. Bruce Low ... 38 Polluted Water as a cause of typhoid 38-86 Festiniog, by Dr. Buchanan ; Harpenden, by Dr. Hunter 38, 39 Guildford, by Dr Buchanan 40 Sir John Simon's observations on ditto ... 40, 41 Dr. Buchanan's observations on the period of incubation 41 Sir John Simon on polluted water 41 Outbreak at Wicken Bonant, by Dr. Buchanan ... 41, 42 Outbreaks caused by water from shallowwells ... 43-53 Market- Weighton, Yorks, by the Author; Stone, Staffs ; by Dr. Ballard 43 Norwood, by Mr. Power 43-46 Hitchin, by Mr. Power 46-50 Dr. Buchanan's remarks on ditto 46,47 Beverley, Yorks (deep well), by Dr. Page 50 Balranald, New South Wales, by Dr. Ashburton Thompson 61 Pierrefonds, France, by Professor Brouardel 51-63 Dt. BroMBidel on typhoidette ... 53 Vlll FAOE Outbreaks caused by water from '^ « ® fl «|i * 9 f4 '^^ a a o o e( "|& 58 a serious outbreak of the same disease which took place in that town from June to October, 1897, and was traced to the ' pollution of the town supply by excremental matters from the mines which filtered through the soil into the wells of the public water-supply after a heavy flood which swamped the mines and washed the faecal matters out of the pails in the mines before they could be removed.'' My friend Professor Kuborn, M,D., of Seraing, Liege, the President of the Koyal Society of Public Health of Belgium, has kindly forwarded me a number of reports to the Minister of Agriculture by the provincial medical commissions of that country, from which I find that the spread of typhoid fever there is due (Report for 1891) "for many places to the pollution of the water-supplies, for some to importation and to direct contagion ; in these the relations of cause and effect are precise. Lastly, in a more vague sort of manner overcrowding, moisture, and want of cleanliness are alleged causes. " That it is due to polluted well-water is not to be surprised at considering that the following is given as a description of the wells supplying the working classes in one of the great towns : • ' A well surrounded with privies, heaps of manure, and goat- stables furnishes water to all the inhabit- ants. These come there to obtain the water with vessels which have served for all sorts of purposes. Most of the inhabitants are workpeople employed in the city — a fact which explains the rapid spread of the disease." In another report we are informed that while the water is at fault in gome places in others "it is the houses which are at fault, whether by overcrowding or by filth." In Luxembourg I find from the report of works carried out during 1892 an account of an outbreak at Marcour, ' ' which has for the last 15 years had a public water-supply and which during that time has not been visited by typhoid fever, but the water-supply to the inhabitants was com- pletely spoilt on account of the drought which had laid dry the open end of one of the main pipes drawing water from a stream ; various animals having found their way into this pipe died there and the decomposition of their bodies polluted the whole of the water-supply. As soon as this cause of pollution was withdrawn a stop was put to the epidemic. And in another place called Bastogne, where there had not been a single case of fever since 1887, when the public water-supply was established, "the drought having diminished the quantity of water available, the communal authority allowed resort to be made to old wells, recommending the people by placards not to use the water for drinking. But a certain number of the inhabitants took no notice of this warning ; 20 days after the reopening of the wells there were 30 cases of typhoid fever ; a month later 100 cases, of whom 10 died." ^ Again, in the report for 1893 we are told that "in the a Deutsche Vierteljahrschrift, 1898 59 great majority of cases it has been possible to trace the origin of the disease and the causes of the same, which were found almost always indicated. The most frequent by far consists in the pollution of the drinking water due to the defective construction of wells, the filtration of organic matters through their walls, the mixture of spring or river waters with waste waters in a state of putrefaction, of manure deposited on the fields or in the proximity of houses, especially after heavy rains have washed the country, cleansed the streets, and made the cesspits and the water- courses overflow. Next to this came the importation of the disease by individuals, most frequently workmen coming home from an infected locality ; direct contagion operating habitually between persons of the same family or living together in small apartments ; emanations from foul sewers ; and the want of disinfection of the stools of typhoid patients. " In the report for 1900 I find it stated that ' ' sometimes typhoid fever is also spread by means of the bad habit which farmers have of throwing typhoid excreta on the dung-heaps. It has resulted that in the spring while spreading the manure on the fields the workmen who had carted the winter manure were infected by the bacilli which had been deposited in the autumn. The manure in preserving its temperature, its humidity, and also certain salts and albuminoids, supplies them with an excellent cultivating medium." Water-supplies have sometimes been shown to be polluted at or near their springs by infiltration into them of excre- mental matter, and outbreaks of typhoid fever have taken place when such matter is specifically polluted. Among these are the following. Bricksworth (Northamptonshire). — Dr. Thorne in 1874 reported that this fever was habitually prevalent and that the water was liable to surface and excremental pollu- tion. Dr. Hubert Airy reported on an outbreak of enteric fever at Blackburn in Lancashire in 1881 as follows : ' ' This water- supply of Blackburn runs the risk of pollution at its several sources. There is risk at the gathering ground above Pickup Bank ; there is risk at the White Birk colliery of some acci- dent similar to that which befell the Caterham well ; and there is risk at the well on Eevidge, for houses are pretty numerous round about and the soil is a porous sandstone rock. Moreover, as regards the water from Pickup Bank there is risk at veiy many points along the route by which it is conveyed to the town. The stone culvert is of rough construction, built of the ragstone of the district in rude wedge-shaped lumps, fitted together without mortar or cement, but well bedded in thick puddle ; and remem- bering that this culvert has lain for more than 30 years, only three or four feet deep, on the slope of the hillside, with a constant tendency to increase of pressure on the upper side, and lessening of pressure on the lower side, it can hardly be 60 supposed that the structure is still sound throughout. Indeed, on one or two occasions at different points the crown of the arch has fallen in, and probably at a hundred points it has yielded more or less, so as to admit a leakage of sub-surface water on the upper side. " After pointing out that there is danger from the manuring of the ground over the culvert he goes on to say : ' ' There is also the sewage and ordure of Belthorn, the village on the crest of the hill, above the line of the culvert, to be taken into account. At the time of construction of the waterworks Belthorn had no sewer or cesspool, but disposed of its slops and excreta close around the dwellings. Of late years the house- slops have been received in a roadside sewer delivering into a watercourse which formerly was impounded in a little ' lodge ' close above the culvert and used to supplement the supply from Pickup Bank. Even to the time of my visit the conduit remained open at this point, but the lodge had long before been emptied by a pipe carried under the culvert. Still, it has occasionally happened that this pipe has been choked with rubbish or with snow and the water has half- filled the lodge before it has been possible to clear the pipe again. The water bailiffs, however, declare that the water in the lodge under these circumstances never reached the open conduit. Again, there are one or two other points where sewage from Belthorn has to pass over or under the culvert and where the accident of a defective joint might admit impure water to the latter. The drainage from one row of houses goes into a cesspool on the hill slope. The cesspool sometimes overflows and the liquid runs down a lane and enters a drain which passes under the culvert. Even in the last 20 yards of its course before it dischargee into the Guide reservoir the culvert is in manifest danger of receiving soakage from the neighbourhood of a row of cottages (Shorrock's-row) in the village of Guide. " After describing how he found a place where water was leaking into the culvert he continues ; "On opening the ground at a corresponding point in the pasture above the men struck upon an old stone land drain which was then traced some distance back and appeared to run obliquely across the meadow from the upper side. Approaching the culvert it ran within nine yards of the last of a row of privy pits which lay outside the bounding wall of the back yards of Shorrock's-row, accessible from the meadow, for the convenience of the farmer who took the manure. The farmer assured me that he spread this manure only on the land below the culvert, never above, but there were signs of the overflow from the privy pits having been conducted on to the pasture above the culvert. The impression left upon my mind, though I could not positively prove the fact, was that there was a probability of soakage from these privy pits and from the slop gutter in front of Shorrock's-row affecting the purity of the water in the culvert. I have dwelt somewhat at length on these dangerous condi- 61 tions along the line of the conduit because I shall have to show that the chief outbreak of enteric fever in Blackburn followed close upon, and possibly was caused by, the occurrence of enteric fever at Belthorn and Shorrock's-row. The water on leaving the culvert, just within the wall of the reservoir enclosure, runs in an open enclosure for 20 or 30 yards before discharging into the reservoir. An empty can or two lying in this channel showed that it was exposed to casual addi- tions and I noticed just within the gate of the enclosure and immediately over the mouth of the culvert the remains of human ordure. In the side of the open channel is a gate- sluice which, when desired, can be set open so as to divert the stream, or part of it, into an open by- channel which runs down between the Guide embankment and the public road and is finally turned into the lower (Fishmoor) reservoir. In its course it receives the contents of a ditch which, when traced back, is found to take origin at the back of some dwellings in the upper part of Guide village, whence it comes along a cartway trodden and befouled by cattle, past a farm- yard, and through a field, exposed in its whole length to the risk of pollution. I heard tales also of mischievous fellows throwing ' nast ' (filth) into the reservoirs themselves. The six-foot enclosure wall is easily climbed. " Dr. Airy then shows how one of the privies had been shortly before the outbreak infected by the stools of a man, Aspden, who had typhoid fever and goes on to say : ' ' This case was not visited by the medical officer of health nor by the inspector of nuisances ; the danger to the public health attending the preseTice of a case of enteric ^ever so near the main artery of the tvater-swpply was overlooked. An unskilled labourer who works under the nuisance inspector was sent to the house with some carbolic acid powder. Aspden states that this disinfect- ant was used to discharges which were then thrown into the privy, one of the row of privies that have their pits opening to the meadow through which the water-culvert passes. Slops and rinsings of vessels undisinfected were thrown down a sink in the backyard or thrown into the roadside gutter in front of the house. Either channel would carry them, as already described, immediately over the water-culvert, at points where it was evident on internal examination that fluid was in the habit of oozing into the culvert. Any such admixture, supposing it to occur, would be infinitesimal in comparison with the quantity of water flowing in the culvert, and that again, in comparison with the whole body of water in the reservoir which received it, would be but as a river flowing into the sea. It certainly taxes the imagination to suppose that so minute a portion of infected matter would suffice to give a poisonous taint to so largt a body of water, unless it possessed the property of self-multiplica- tion." (Eleventh report of the medical officer of the Local Government Board, 1881.) The second report, for which I have to thank Dr. 62 Brouardel, was on an outbreak which took place at Clermont- Ferrand, prevailed from September to December, 1886, and was investigated by himself and Dr. Chantemesse. This outbreak was "more severe and more generally spread in the southern portion of the town which includes the best quarters. " There were two separate outbreaks, not only at Clermont-Ferrand but at Mont-Ferrand, towns two kilometres apart. These outbreaks "had the same course in the two towns and their maximum height was almost on the same days." On the other hand, the outbreak did not attack Royat and Chamali^res, two little towns equally near to Clermont-Ferrand, yet the explanation was found in the fact that Clermont-Ferrand and Mont-Ferrand are supplied with the same water, while Royat and Chamalieres have each a separate and independent source of supply. It was observed that the persons in the two infected towns who drank only boiled water or mineral water were not attacked, and that in a convent at Clermont-Ferrand supplied by a special fountain in its park there was only one case of typhoid fever and that occurred in the case of a person who had visited her parents and had drunk of the town water-supply. The first outbreak appears to have been caused as follows. In August a woman suffering from typhoid fever lodged in a villa at 35 metres from the water conduit ; the cesspool of the house was not watertight and there was a washhouse which discharged its water into a stream passing over the water conduit, but the landlord stated that the visitors' washing was done in the public laundry at Royat, close to which was a water conduit for Clermont-Ferrand, the pipes of which were "made of earthenware in such bad condition that eight days after our inspection at the end of December the municipality of Clermont has thoroughly replaced the earthenware pipes by iron ones." 20 days afterwards typhoid fever broke out in the town, appearing in nearly all quarters at once. The second outbreak, on the other hand, appears to have been caused by the excretal matters of two typhoid fever patients having been thrown out in the street in the month of October "on this soil of lava cracked with fissures of 20 to 25 metres in depth either at the point where the mater of Clervwnt is obtained or close to it." The second outbreak took place at Clermont-Ferrand and at Mont-Ferrand at the beginning of November and especially towards the middle of the month. The typhoid bacillus was found in the water in the cistern of a house where there had been typhoid fever during the second outbreak. This cistern had not been cleaned for two years and a young girl who drank water from it had an attack of typhoid fever. The third report, kindly forwarded me by Dr. Brouardel, was on an investigation made" by himself and Dr. Chantemesse in 1887 into some outbreaks of the disease in the barracks of the Marines at Lorient. They reported that although the fever raged among the troops the civil 68 population remained almost intact, while during the cholera epidemic in 1866 the population was attacked and the soldiers almost all escaped. It appears that the inhabitants of Lorient and the troops drank water coming from two different places. The causes of the outbreak were stated to be as follows : ' ' The principal cause is the intermittent infection of the drinking-water ; the secondary- cause is defective installation of the latrines in the barracks. It appears that the excremental matters of the town are collected in moveable pails in which they are carried outside the town and spread upon the fields as manure twice a year, in the beginning of February and during August. This is regularly done by the farmer of the fields, under the surface of which the waters which supply the arsenal collect. The springs under these fields are produced by the rain-water which falls on the neighbouring hills and in the valley above the fields. Sometimes the level of the underground water which forms the spring is only separated from the surface of the soil by a bed of pebbles of a few centimetres in thick- ness. These waters, which at their point of collection are already polluted, arrive at the arsenal in old pipes which are not watertight. The principal conduit traverses the sub- soil of heavily manured meadows and of the garden of the hospital on which the excreta of all the patients are con- stantly being thrown. In the passage of this conduit across that garden the condibbns are such that it is not possible that the drinking-water should not be sometimes polluted. The secondary cause of propagation of the fever is the infection of the air due to the installation of latrines which are mere wooden tubs placed immediately under the windows of the barrack-rooms. As soon as these latrines are infected by typhoid excreta they can spread around the germs of the disease. On the first and second floor of the barracks one window is more particularly situated immediately above the tubs ; the three beds placed by the side of this window on the first and second floors have been occupied by soldiers who have all been attacked with typhoid fever. Around them in the same messes of the barracks the victims of the disease were much more widely separated. Thus twice a year human excrement is thrown upon the meadows where the source of water which supplies the barracks of the arsenal springs and twice a year an epidemic of typhoid fever bursts forth. The manuring takes place first in January and February and then in August ; the epidemics appear in March and in October or November. The rain is the bond which closely unites these two facts, the manuring of the land and the explosion of typhoid fever." Further proof, if any were necessary, is to be found in the fact that ' ' for some time past in order that the recruits may avoid the dangers of living in the barracks of the arsenal they have been made to encamp on their arrival at the ' Polygene de Lorient ' supplied by the town water. While typhoid fever has raged in the arsenal at its ordinary periods there has no tbeen a single case of it among the recruits. " 64 At Rotherham (Yorkshire) and two adjoining districts typhoid fever and ' ' fever of a less definite sort " was again prevalent in 1891-92, and Dr. Theodore Thomson reported that it was ' • not due to sewerage or drainage, nor to excre- ment disposal, nor to milk-supply, but to a public water- supply common to the invaded parts of each district " and to the high-level section of it, which section was shown to have been similarly related to fever prevalence in previous years. In a subsequent report Dr. Thomson shows that this water was contaminated by being collected from gathering grounds which "contained a great deal of cultivated ground which is manured not only with farmyard but also with privy midden refuse, and sewage from villages as well as from detached houses finds its way into the water-supply, more especially on the high-level gathering grounds. " In 1896 Dr. Bruce Low reported on an outbreak of fever at Penrhynside (Carnarvon). The nature of this disease was ' ' at first obscure ; some cases resembled typhus, others cerebro-spinal fever, and a few influenza ; ultimately malady regarded as true enteric fever ; infection imported. The water-supply was from an extension of the Llandudno water- mains. At the time of the outbreak the pipes were encrusted and partially blocked. There was no evidence of pollution of this public water-supply. The service was scanty and intermittent, "causing the villagers to seek temporary supplies from springs and spouts on slopes of hillside below village. Some of these temporary supplies were most probably polluted by washing of surface filth from village down the slopes by heavy rainfall ; hence the spread of the disease. " In 1897 Dr. Bruce Low reported on an outbreak of typhoid fever in the Horsforth Urban District (Yorks.). He found that the gathering ground for the water company was high-lying pasture land dressed freely with stable manure and night-soil and that the sewage from farmhouses and also road washings reached the feeders of supply. ' ' Sand filtration was provided, but in summer months as well as at other times it has been customary to turn on unfiltered compensation water to the town mains to augment supply. Following use in September, 1896, of this unfiltered water there occurred a sudden outbreak of enteric fever in October, attributed by the medical officer of health to polluted water of company's service. " In 1898 he also reported on a sudden outbreak of typhoid fever in December, 1899, in the town of Camborne (Cornwall) and an adjoining parish and village. The only condition common to these three places was their water- supply. * ' One of the two sources of this supply was from some springs at Boswyn, to augment which section of the supply a pipe had been laid from the brook to the service tank. The brook was fed freely ly surface rvater from a hillside on which, in a cottage, four cases of enteric fever occurred in October and November, 1897. The bowel dis- 65 charges of these cases reached a pond close to the house which had no privy. In wet weather the pond overflowed and the water from it ran down a channel to the brook, entering at about 100 yards above the intake pipe of the Camborne Company. In mid-November the rainfall was excessive and the flood-water washed out the pond and carried the pollution to the brook and thence to the service reservoir. After the removal of the pipe connecting the brook with the reservoir, and after cleansing the service tank and flushing the mains, the epidemic abruptly ceased." In 1897 Mr. J. S. Davy, Dr. Theodore Thomson, and Mr. G. W. Willcocks were appointed by the Local Government Board to inquire into an epidemic of typhoid fever at Maidstone which Mr. M. A. Adams, the medical officer of health, believed to have been caused by the pollution of some of the springs supplying the water company's water by the excremental matters from a colony of hop-pickers. The arguments used by Professor Sims Woodhead and myself against this view were that there were cases of typhoid fever in Maidstone before the hop-pickers came at all, that many of the public sewers and house-drains and other sanitary appliances were in an extremely defective condition, so that contaminated air from them gained access to the houses, and that after the suspected water was cut off and a further period of 16 days allowed for incubation of any subsequent cases 357 more cases, which could not have been caused by the water, occurred in the town — a contention which the inspectors said was in their judgment "in the main a just one" — and that there- fore the causes which operated to produce them might have produced the whole epidemic, a contention which the inspectors said "is probably in some degree admissible." Nevertheless, they came to the conclusion that the epidemic was caused ' ' by the pollution of the water supplied by the Maidstone Company from their Farleigh sources, " I now come to instances of outbreaks of typhoid fever which have been traced to the pollution of streams and rivers supplying drinking-water. Early in the ' ' seventies " I traced a severe outbreak of about 180 cases of typhoid fever which occurred in the fishing village of Mevagissey (Cornwall) to the contamination of the stream running through the village by the excreta of a typhoid fever patient who had come there during an early stage of the disease. In 1882 Dr. F. W. Barry reported on an extensive outbreak of typhoid fever at Bangor and its neighbourhood. He showed that this outbreak was due to an '■'■ extremely well-marked case of enteric fever of a severe type which occurred at a place called Llwynrhandir. The medical officer of health directed the inmates to bury all excreta, &c. , and this they promised to do. From information, however, obtained from credible witnesses," says Dr. Barry, " I am convinced that nothing of the kind was done until a considerably later period, when no doubt the discharges from this particular patient were buried F 66 in the garden. The slops and washing water from this house ure thrown into a sink at the hack and pass by means of a covered rubble drain along the back of it and the house adjoin ing, where it discharges into a small rapid stream, which in its turn is conveyed as far as the boundary wall of the garden in a similar covered drain, and is thence conducted by means of an open ditch direct to the river Gaseg, into which it dis- charges at a point about 350 yards above the intake of the Bangor water-supply, the whole distance from the house to the intake being about 700 yards. Upon removing some of the stone covers from a portion of the stream near the house a most offensive smell was perceived. The stream has an exceedingly rapid flow, so much so, indeed, that some white- wash which I poured into the sink behind the infected house could be traced for a considerable distance towards the Gaseg. It will thus be seen that there is a direct com- munication between the infected drain at Llwynrhandir and the small stream from which the Bangor water-supply is drawn and in this manner no doubt infected matter found its way into the filtering reservoir. The privy at Llwynrhandir is of the ordinary cesspool type ; the pit is, however, below the level of the drain already referred to. As to the capability of the filtering material in the filtering beds at the water- works for destroying or preventing the passage of infective matter we know little, and here the question need not be con- sidered, because I found that from the presence of old defec- tive plugs in the filters themselves fully a third of the water was passing direct into the watermain without any filtration whatever. The filtering sand has not been renewed for a great number of years, although I understand that it under- goes a certain amount of cleansing from time to time. I was further informed by the clerk to the urban sanitary authority, who is also the waterworks manager, that from the peaty character of the water the filters frequently become clogged, and at such time the water cannot be filtered rapidly enough to meet the demand, hence the water is passed into the mains without any attempt whatever at filtration. Here, then, we have established a direct means of communication between the consumers of water and the specifically poisoned contents of a drain at Llwynrhandir ; further, we have cases occurring simultaneously miles apart from one another which, with the exception of the water-supply, had no circum- stances in common, there being also an entire absence of cases in houses not so supplied. I have, therefore, now no hesitation in attributing the primary spread of the disease to the water-supply. " After describing the course of the outbreak he concludes as follows : ' ' Taking all the facts of the case into considera- tion, it is my opinion that the water-supply became specifically infected to a slight degree on or about May 22nd, and that this pollution continued imtil the end of June. That this continuous slight pollution accounts for the dropping nature of the cases up to July 7th. That the special outbreak in 67 the second and third weeks of that month was dne to the communication of infected matter in a concentrated form owing to the disturbance in the reservoir and filter-beds, resulting from the accident to the main on June 30th. Finally, that a certain number of the cases which have occurred from the end of the first period to the present time are due to the direct introduction of infected air from the sewers into which the discharges from cases of enteric fever had been received." (Twelfth report of the medical oflBcer to the Local Government Board for 1882.) An outbreak at Mytholmroyd (Yorkshire) in 1888 was attributed by Dr. Page to pollution of the river Calder by the sewage of towns higher up its course. In 1891 Dr. Hubert Airy prepared a most important and comprehensive report on the Outbreaks of Enteric Fever in the Valley of the River Tees in 1890-91, in which he showed that these outbreaks were especially amongst the users of water from the river for domestic purposes ; thus ' ' it was found that the rate of attack from enteric fever per 10,000 living during the first six weeks' epidemic had been 33 amongst persons supplied by the Tees water, and three amongst persons supplied with other water ; whereas in the second six weeks' epidemic the rates were 28 and one respectively. Indeed, during the two periods together for every single person who contracted enteric fever amongst the population not using the Tees water 15 contracted it amongst those who were supplied from the river." This river was liable both habitually and still more during floods to fouling by human excreta and other filth from the town of Barnard Castle and some 20 villages and hamlets. Commenting on this the late Sir R. Thome remarked: "Over a wide area covering 706,020 acres, or 1103 square miles, and containing 503,616 inhabitants, enteric fever has for years past been unduly prevalent. Within this area, where the infective material is thus constantly ready to hand, there occur in 10 sanitary districts, covering 117,404 acres, and containing a population of 217,363, two marked and sudden outbursts of enteric fever, each of large amount, the remaining area meanwhile exhibit- ing, as regards its constituent sanitary districts, com- paratively insignificant 'fever' rates. One of the out- bursts is at a time of year when, apart from some exceptional and unusual factor, enteric fever is not apt to prevail in epidemic form in this country. Within the sanitary districts invaded by the two epidemic prevalences some localities suffer heavily whilst others escape excep- tional incidence to the disease. One factor alone is found to be common to the places thus suffering exceptionally from enteric fever and this is the use of water pumped from the river Tees. This river is found to be at all times subject to conditions of the grossest fouling by reason of the fact that human excreta and other filth are knowingly and deliberately conveyed to it. Opportunities for the access of the specific 68 material of enteric fever to the river had been constantly recurring. And immediately antecedent to the epidemic outbursts sudden floods washed vast masses of the filth which had been accumulating on the banks of the river down the stream up to and past the points of intake from which the water was being pumped and, after filtration through sand and gravel, delivered to certain populations. These populations it was who suffered from the two exceptional prevalences of enteric fever. Seldom, if ever, has a case of the fouling of water intended for human consumption, so gross or so persistently maintained, come within the cognisance of the medical department, and seldom, if ever, has the proof of the relation of the use of water so befouled to wholesale occurrence of enteric fever been more obvious and patent." (Report of the medical oflficer of the Local Government Board for 1892-93.) In 1891 Mr. E. L. Jacob traced an outbreak of 25 cases at Catteshall Paper Mills, near Godalming, to the temporary use of the water of the river Wey for drinking. ' ' At one of the houses in the borough of Godalming which drained into the river Wey above the mills there were some cases of typhoid fever in April and May ; the specific poison of the fever, therefore, was probably passing into the river from that house at the time when it was distributed to the cisterns in the clay-room at the mills." {Pullio Health, vol. iv., p. 188.) An outbreak of typhoid fever at King's Lynn and Gaywood (Norfolk) was reported on in 1892 by Dr. Bruce Low. This outbreak was particularly interesting because it was ushered in by a " sudden outbreak of diarrhoea attacking all classes and all parts of the town during the last few days in February, followed by development of numerous typhoid cases about a fortnight later. " This outbreak was due to the fact that the water-supply of the town was derived from Gaywood river which flows through cultivated fields and gardens. The intake of the water is within the borough boundary and the filtration adopted is very insufficient. The contents of privy pits in the town into which the discharges of some typhoid fever cases have been thrown were spread before the time of the outbreak on part of a market garden abutting on the river and about a mile above the intake of the water-supply and the "excreta from a house outside Gaywood wherein eight persons were attacked one after the other with typhoid fever between November and March had been placed in a pit in the garden, from which it was washed into the river above the intake by the melted snow and heavy rainfall that occurred in the third week in February." Dr. Bruce Low reported in 1893 on an outbreak at the villages of Nunnington and Ness-in-Ryedale (Yorks). The water-supply of these villages is derived from the river Rye which is largely polluted by the sewage of Helmsley and by the washings from land on which local privy "muck "and Leeds town manure are spread from time to time. The chief interest in this outbreak is that it was cut short by all 09 the water used for all domestic purposes being boiled. In 1895 Dr. Bruce Low reported on an outbreak of typhoid fever in September in certain riverside villages below Helmsley, just after the outbreak at that town caused by infected milk (see page 94). This outbreak was ' ' con- fined to those persons who drank raw river water taken from the Rye at points below that at which it is polluted by the sewage of Helmsley. " Dr. Maclean Wilson reported in 1893 on a sudden outbreak of typhoid fever at Chester-le-Street (Durham) which was followed after a short interval by another equally sudden. The sufferers in both cases were almost entirely persons using one public water-supply which had before the com- mencement of both outbreaks been contaminated by enteric fever discharges from some cases in a group of cottages about three miles above the intake of the water company. The sewage from these cottages ran by means of a covered drain into a small stream, a tributary of the Stanley burn which supplies the filter-beds of the company, but these filter-beds were quite ineflScient for the purpose of preventing any germs of enteric fever contained in that water from gaining access to the street mains of the company. In 1897 Dr. F. St.G. Mivart reported on a sudden outbreak of typhoid fever at King's Lynn borough and Gay wood parish (Norfolk) early in October. The fever was distributed indifferently throughout both places. The water-supply was derived from the river Gay wood ' ' which is exposed freely to pollution of all kinds throughout its course." The river water was delivered without filtration, an abundance of con- taminating matters having been washed into the river by the excessive rainfall on Sept. 29th. In 1899 Dr. S. W. Wheaton reported on an outbreak in the borough of Ilkeston (Derbyshire) as follows : ' ' Fever pre- Talence in all probability due to pollution of the general water-supply of the town, which is derived from the Nut brook and imperfectly filtered. The water of the Nut brook is grossly polluted by liquid refuse from dwellings at Henor, effluent from the Henor sewage farm, and numerous other sources of contamination. " In the twenty-second annual report of the State Board of Massachussets for 1890 is a report on typhoid fever in its rela- tion to water-supply by Mr. Hiram F. Mills, in which it is stated : ' ' Twenty-five years ago the average number of deaths by typhoid fever in 1Q,000 inhabitants in the places which are now cities in this State was 7 "8, the number now dying yearly from this disease in the same places is 4-6 in 10,000 inhabitants. In fact, the actual number of deaths from this disease 25 years ago in these places, when their population was only six-tenths as much as at present was as great as it is now, and if measures for its prevention had not been taken and the death-rate had continued as it was 25 years ago we should now have 1000 deaths yearly, when the actual number in the cities is about 600. By carefully plot- 70 ting upon maps of the cities the residence of all cases re- ported to the local Board of Health, together with the deaths, the distribution, though not even over the whole city nor strictly proportioned to the density of population, was so general that it could not be attributed to possible cases of typhoid fever at two or three of the large number of farms that supplied milk to the 100 or 200 milkmen who distributed milk through the territory where the cases of disease were found. On the other hand, the cases found in Lawrence were all within the territory supplied with water from the city waterworks, and several of the cases were in the thinly settled and apparently very healthy portions of the city, near the outer limits of the water-pipes. In Lowell the cases were very generally distributed through- out the territory, the numbers following nearly the density of the population. These conditions and the discovery of a probable cause of the contamination of the Lowell water- supply by faeces of typhoid patients discharged into Stony Brook, only three miles up stream from the intake of the Lowell waterworks, followed in a few weeks by the very rapid increase in the number of deaths from typhoid fever in Lowell, and these deaths followed in about six weeks by an alarming increase in the number of deaths in Lawrence, whose water-supply is drawn from the Merrimack river nine miles down stream from where the Lowell sewage enters the river, and the further discovery in December of typhoid fever germs in water from the service-pipes of the city of Lawrence, induced the board to send to the Mayor of Lawrence" a letter "warning the citizens not to use the city water for drinking until after it has been boiled for at least 15 minutes ; and that when boiled it should not be cooled by putting into it ice obtained from the river this winter. This precaution should be continued as long as typhoid fever prevails in Lowell." And he sums up the results of his investigation as follows : ' ' We have found this relation existing between typhoid fever and water-supply — viz. , that in general in the cities of the State the death-rate by typhoid fever has been greatly reduced by the introduction of a pure public water-supply ; that in the one city, where there has not been such a reduction, a portion of the people use for drinking water from canals or from wells subjected to serious pollution by sewage ; and that the deaths from this disease are much more frequent among that portion of the community than among others. The only two remaining cities which have not decreased death-rates by typhoid fever after the intro- duction of public water-supplies receive their supplies from a river polluted by sewage ; and the seasons in which this disease prevails in these cities are later than those of other cities, and in the lower city on the river later than in the upper city, at a season when other cities are nearly free from the disease and at the time when it would follow if produced by the sewage from the upper city ; further, that when the 71 water of the river which passed the upper city and received its sewage during the greatest prevalence of the disease there had reached the service-pipes of the lower city, and there was the greatest prevalence of the disease in the lower city, typhoid fever germs were found in water from these service-pipes." In the twenty -fourth volume of the reports and papers of the American Public Health Association for 1898 an account is given by Dr. John Leal, health oflQcer, Paterson, New Jersey, of an outbreak of which he says : "No possible common means of infection could be found except the public water-supply, upon which all of those affected, with the possible exception of two or three, were dependent for at least a portion of the 24 hours. It also appeared that the only section of the city which did not contain a single case of the disease was also the only section not furnished with the public water-supply." It appears that "a resident of Little Falls (a place on the river above Madison) returned from a summer resort ill with typhoid fever on August 28th. The fever subsided about Oct. 1st but a relapse followed, lasting from about Oct. 8th to the end of the month, when finally convalescence began. The water-closet receiving the discharges of the patient was connected with a series of cesspools, connected with each other by overflow-pipes, and the last cesspool of the series discharged through a hidden pipe into the river. These cesspools, having thus become infected about Sept. Ist, continued to receive fresh infection until about Nov. 1st, when the patient was actually convalescent." Bacterio- logical examination of the water above Little Falls gave a negative result both as to bacillus coli and bacillus typhosus, but "below Little Falls the chemical evidence of harmful pollution was found, the average number of bacilli per cubic centimetre was 600, and in 90 per cent, of the specimens examined colonies of the common colon bacillus appeared. " On a specimen taken at the intake on Sept. 23rd Dr. Connolly reported as follows : "Tests for typhoid bacilli revealed the presence of a non-liquefying active-motile bacillus which did not produce gas in the presence of culture media con- taining sugar, nor did it produce indol, and in other respects was identical with the typical bacillus of typhoid fever." On Nov. 24th the discharge pipe from the last cesspool into the river "was discovered and further infection from that source prevented. Not more than 28 cases were infected after this date and of the 28 cases 18 were infected within the first week and seven within the second week after it. Thus it appears that within two weeks of the shutting off of fresh infection the typhoid bacilli already in the river had practically disappeared owing to surrounding conditions not being so favourable as in the cesspools and to the effect of the downward flow of the current. It seems reasonable to believe, however, that the infection of the river and its attendant results might have continued indefinitely, owing to the conditions favourable to 72 bacterial life existing in the cesspools, had not those sources of infection been discovered and cut off." In the twenty-fifth volume of the reports and papers of the American Public Health Association for 1899 Dr. Leal reported on an outbreak at Paterson which he showed was caused by the public water-supply derived from the river Passaic ' ' which at least 98 per cent, of those infected were known to use for at least a portion of the 24 hours." In the course of his report he says : ' ' The suspicion thus cast upon the public water-supply as being the only factor common to the case was confirmed by the following facts : First. The only section of the city in which the disease did not appear is the only section not having the public water-supply. Second. The city of Passaic, supplied from the same source, was found to be suffering from an outbreak of typhoid fever at the same time. Third. The course of the epidemic was marked by sudden rises and falls. Fourth. These rises and falls were preceded by heavy rains and, consequently, rising waters." He found that the outbreak was caused by the excreta from a case of typhoid fever which developed during the early part of August, 1898. "The drainage from the premises of said patient was through a pipe into a small tributary of the Passaic river about 8000 feet above the intake. The local board of health, learning of the case on August 23rd, at once cut off drainage from said tributary, so that infection directly from said case ceased on that date." The water from the tributary had to run through a swamp before joining the river and refuse from a glue and gelatin factory also contaminated the waters of the tributary. The theory evolved by Dr. Leal from these facts is as follows : ' ' That the said tributary was infected from said case of typhoid while high from the heavy rain of August 10th ; that the infected water of tributary spread over said swamp and, falling, left numerous pools, puddles, &c. , cut off from the natural channel. That in these pools, puddles, &c. , existed the conditions favourable to the vitality and multiplication of the specific bacilli, these conditions being the low dilution, the unusual amount of organic matter on account of the glue and gelatin factory, the close and rank vegetation, &c. That a certain number of these bacilli were washed down the river by the rising water following each rain, with a certain amount of damage as a result — the greater the rainfall the greater the amount of damage done. That the infection of new cases ceased after the first week in February is explained by the fact that the general thaw following the heavy rain of Jan. 24th changed said swamp into a raging torrent, thoroughly washing it out and keeping its entire area under three to 10 feet of water for two or three weeks. " An interesting report by Dr. H. C. H. Herold, the president of the Board of Health, on an outbreak at Newark, New Jersey, is contained in the same volume. It appears that Newark was formerly supplied by the [Passaic river, the 78 water of which was contaminated, but that in April, 1892, that supply was abandoned and a supply known as the Pequannock water system was adopted. After this there was a steady decrease in the number of cases of typhoid fever until 1898 when there was a marked increase, especially in August and September. This was found to be due to ' ' shortages " in the daily Pequannock supply having been met by turning in contaminated water from the Passaic river. My friend Dr. Pistor of Berlin has kindly forwarded me a copy of a report by Dr. Rauber of Remscheid (Rhine Province) on a serious outbreak in that town in 1900. There had been a few cases yearly since 1890 and a small outbreak in 1899, but in 1900 the number of the cases rapidly increased until there were no less than 118 cases between July 9th and 21st. The cause was found to be from the water of one of the streams contributing to the water-supply having become polluted {Zeitscliriftfilr Medizinalheamte, Heft 19, 1901), and also one by Dr. Mewius of Cosel (Silesia) on an outbreak at Leukan and two other villages on the course of the same ditch which supplied them with water and which was contaminated by the excreta of two typhoid fever patients in a cottage higher up {ZeiUchrift fiir Medizinalheamte, Heft 17, 1900). Whereas the seasonal prevalence of typhoid fever is normally in the autumn months this disease is more pre- valent and fatal in London during the winter months. Since 1890 I have pointed this out for St. George's, Hanover- square, for which I was formerly medical officer of health, and the following table from my report for 1900 shows that during every year except 1897, the monthly average for November and December was higher than that for August, September, and October. Cases of Typhoid Fever. VaoK August, September, and October. November and December. Number of cases. Average per month. Number of cases. Average per month. 1891 .. 1892 .. 1893 .. 1894 .. 1895 .. 1896 .. 1897 .. 1898 .. 1899 .. 1900 .. 6 15 16 14 11 15 16 7 14 13 2-0 5-0 5-3 4-6 3-7 5-0 5-3 2-3 4-7 4-3 12 15 18 29 10 15 6 18 11 10 6-0 7-5 9-0 14-5 5-0 7-5 3-0 9-0 5-5 5-0 Average 12-7 4-2 14-4 7-2 74 This rise in the number of cases of typhoid fever reported in the months of November and December "is coincident with the increase of organic matter in the drinking water due to the flooded state of the river. " On account of my condemnation of the water supplied during the month of December, 1898, in my report for that month, in which I stated that the samples of water supplied by both the com- panies (Grand Junction and Chelsea) were, according to Mr. Cassal's analysis, of "decidedly inferior quality, " both of the companies wrote letters on the subject, forwarding with them reports by Professor Sir Edward Frankland and by Sir William Crookes and Professor Dewar, on which I prepared the following report : — "With regard to the letters from the water companies, on which you have asked me to report to you, I find that the reports sent with them confirm my opinion of the inferior quality of the samples of water supplied in December as deduced from the results of the analyses made by your public analyst, Mr. Cassal. " Thus Professor Sir Edward Frankland, in his report, referring to the Thames companies, says, that 'owing to heavy floods and insufficient storage the water sent out by all the companies, except the West Middlesex, contained an excess of organic matter which was, however, almost entirely of vegetable origin ' (the italics are mine). It is true that he says it * was in every case efficiently filtered before delivery,' but this means that it contained no notable quantity of sus- pended matters and neither did Mr. Cassal's analyses show any excess of such matters. " Sir William Crookes and Professor Dewar, in their report, make no remark on the amount of organic matter beyond stating that ' the purity of the water in respect to organic matter has been determined by the oxygen and combustion processes.' From the results of their analyses, as shown in their tables, I find that the ' oxygen required to oxidise the organic matter' averaged for the Grand Junction Company 0"071 of a grain per gallon, and for the Chelsea Company 0*063 of a grain per gallon, whereas in the month of September last it averaged only 0"025 for each company ; in other words, the amount of ' oxygen required to oxidise the organic matter' was for the Grand Junction Company nearly three times as much, and for the Chelsea Company two-and-a-half times as much as that required in September. " I may remind you that this impurity of the waters supplied during the winter months is no new thing. I have reported on it year after year since 1873, and you may remember that you have addressed com- plaints to, and received similar answers from, the water companies many times before. " i may also remind you that I have pointed out that for several years (with the exception of 1897) there have been more cases of enteric (typhoid) fever in the parish per month during November and December than during the preceding three months, and also that this disease has been unusually prevalent and fatal in London during the last three months. Now November, December, and January are not the months for the ' seasonal prevalence ' of this disease, and, therefore, some other cause for the excess of it must be sought for, and it may be something more than a coincidence that in those very months London is supplied with water which, according to Sir Edward Frankland's report, contains ' an excess of organic matter.' " (Feb. 14th, 1899.) In answer to this the following letter signed by Sir William Crookes for himself and Professor Dewar was sent to the vestry clerk by the directors of the Grand Junction Water Company : — " Our attention has been! drawn to a special report on the water- supply by Professor W. H. Corfield, medical officer of health to the 75 Parish of St. George, Hanover-square, fr m which it appears he con- firms the opinion of Mr. Cassal that the water delivered by the Grand Junction Company during December last was of inferior quality. This is diametrically opposed to the opinion we have arrived at from our extensive experience of the conditions of the water-supply from day to day. "Dr. Corfield draws attention to the fact that both our report and that of Sir Edward Frankland on the character of the water-supply to the metropolis during December last show that the majority of the Thames-derived supplies contained an amount of organic matter in excess of the average amount. This observation is simply an expression of the fact that all river-derived supplies have a period of maximum and minimum amount of organic mattei during the course of the year. The maximum generally occurs in Thames water during the winter months and the minimum during the summer; and, as Sir Edward Frankland stated in his report for December, the over-charge of organic matter was 'almost entirely of vegetable origin.' "The same remark applies to the amount of oxygen required to oxidise the organic matter. It is nothing unusual for river supplies to require three times as much oxygen during some period of the winter as compared with the summer supply. With regard, then, to the Thames supply during the month of December last, there was nothing exceptional in the oxygen absorption. " Dr. Corfield, having pointed out these admitted facts, nevertheless puts an erroneous construction on what Sir Edward Frankland and ourselves intend to convey by our statement that the water before delivery had been efficiently filtered. Dr. Corfield seems to think that this is intended to express that the supply contained ' no notable quantity of suspended matters,' whereas our intention, and no doubt that of Sir Edward Frankland, was to convey that the water had not only been freed from matter in suspension, but had been bacterio- logically purified to the extent of over 99 per cent, from its natural con- dition ; thus removing the suspicion of the possibility of its conveying any water-borne disease. "Dr. Corfield proceeds to point out that enteric fever has been more Srevalent in the parish of St. George, Hanover-square, during fovember and December than during the three preceding months and that the same remark applies to London generally. From this occurrence, combined with the fact to which we have above referred, relating to the organic matter, he suggests that the coincidence may be attributed to the cyclical excess of organic matter which occurs during the winter months. "All the facts are against any such hypothesis. Our recorded analyses of the Thames-derived waters since 1881, together with the Registrar-General's statistics of enteric fever, enable us to state that there is no causal relation between the two. Indeed, this must inevitably be the case, for it is cemmon knowledge that if any such disease as enteric fever originates through a contaminated water- supply, it is not the amount of organic matter but its nature that is the dangerous factor and this must be the presence of the specific living germ characteristic of the disease. " No one has alleged that Thames water which has undergone storage and filtration similar to that of the London supply contains any such pathogenic organisms. It is true that Dr. Corfield seems to entertain a different view of the origin of typhoid epidemics, for during the course of the Maidstone inquiry, when it was proved beyond all doubt that one of the sources of supply had been grossly contaminated with faecal matter and had been distributed to Maidstone without proper and systematic, or indeed any, filtration. Dr. Corfield, while admitting there had been pollution, said ' it was some vegetable pollution that had got in.' "There is no comparison between the conditions of the polluted spring water-supply which originated the Maidstone epidemic and any polluting conditions which can arise in the Thames valley, where strict supervision of all sources of contamination is so efficiently maintained— a supervision which we know has materially improved the condition of the raw river water over what it was 10 years ago. " We say dehberately that after mature investigation we know of no example of a water-borne disease having originated from a river supply 76 where proper precautions are taken for adequate storage and effective filtration, such as exist in the case of the London water-supply." (31«t March, 1899.^ This was referred to me by the committee of works, and I prepared the following answer to it, which was issued as a ' ' Further Special Eeport on the Water-supply " : — " In accordance with your instructions I have considered the report forwarded to you by the Grand Junction Waterworks Company, and signed by Sir William Crookes on behalf of himself and Professor Dewar, the company's analysts, and beg to report thereon as follows : — "The report in question admits the fact that there is an excess of organic matter in the filtered river water supplied to London in winter, and explains it by the statement ' that all river-derived supplies have a period of minimum and maximum amount of organic matter during the course of the year. The maximum generally occurs in Thames water during the winter months and the minimum during the summer.' This is another way of stating what I have pointed out for many years past, that the water supplied by the Thames water companies during the winter frequently, and indeed usually, contains an excess of organic matter, due to the fact that the river water in winter is dirty from the washing of polluting matter from variovis sources into the river. To say that there is nothing exceptional in the occurrence of an excess of organic matter in the water in winter is merely to admit that the water in winter is generally polluted. " The report next accuses me of putting an erroneous construction on what Sir Edward Frankland and the writers intend to convey bj- the statement that the water before delivery had been ' efl&cientlj' filtered,' in saying that this was intended to express that it contained ' no notable quantity of suspended matters,' whereas their intention ' was to convey that the water had not only been freed from the matter in suspension, but had been bacteriologically purified to the extent of over 99 per cent, from its natural condition.' This would seem to imply that bacteria are not suspended in the water, but as that cannot be intended I need only reply that I included them among the suspended matters, that my statement was strictly correct, and that apparently eificient filtration is not to be considered to include the removal of foul organic matter in solution in the water. " The non-removal of such organic matter is, then, admitted by the company's analysts, and I may remind you that Sir Edward Frank- land in his report for December, referring to the Thames companies, says that 'owing to heavy floods and insufficient storage the water sent out by all the companies, except the West Middlesex, contained an excess of organic matter which was, however, almost entirely of vegetable origin,' but the writers of the report in question go on to traverse my very temperate statement that ' it may be somethmg more than a coincidence' that the exceptional prevalence of enteric fever in London during November, December, and January, which are not the months for the seasonal prevalence of this disease, occurs in the very months in which London is supplied with water which contains ' an excess of organic matter.' They say ' it is common knowledge that if any such disease as enteric fever originates through a contaminated water-supply it is not the amount of organic matter but its nature that is the dangerous factor, and this must be the presence of the specific living germ characteristic of the disease. No one has alleged that Thames water which has undergone storage and filtration similar to that of the London supply contains any such pathogenic organisms.' " In answer to this I may, in the first place, point out that Sir Edward Frankland and others have over and over again found organisms in the filtered Thames water supplied to London, consider- ably in excess of the number taken as the standard— viz., 100 microbes per cubic centimetre. " In a report recently issued by the Joint Public Health and Water Committees of the London County Council, I find that 'in the years 1896 and 1897 Sir Edward Frankland made 199 examinations of filtered water for the purpose of ascertaining the number of bacteria, and found 77 that they varied from 16,000 per cubic centimetre down to nothing. The average, taking the whole of the 199 examinations, gave 232 per cubic centimetre, the standard admitted by Sir B. Frankland being that they should not exceed 100 per cubic centimetre. Out of the 199 days' examination by Sir E. Frankland there were 55 days in which the bacteria exceeded the standard, and for the whole 55 days they averaged 763 microbes per cubic centimetre; so that 28 per cent, of the results of Sir Edward Frankland's examination tend to show that the filters are not an effectual barrier against the passage of bacteria.' " In the twenty-sixth annual report of the Local Government Board Sir E. Frankland states that ' in June, 1896, nearly the whole of the filter beds of all the companies became infected with bacteria.' Further on the same report states that ' the engineer of the Southwark and Vauxhall Water Company in the evidence recently given by him before the Roval Commission on London Water Supply admitted that in December,"'l896, 16,000 bacteria per cubic centimetre were found in water that had passed one of their company's filters and that nothing was discovered to explain the fact. " Drs. Parkes and Rideal have recently submitted a valuable joint report to the Chelsea Vestry on their examination of the water supplied by the Chelsea Waterworks Company from November, 1897, to November, 1898. In this report they clearly show that organisms of various kinds and in varying numbers passed through the filter-beds, some of these organisms being of the kind of which the bacillus coli communis, which is found in enormous numbers in sewage, is a type ; and being found in 19 per cent, of the total number of specimens tested for them. Of this test they remark : ' The test, also, when it gives an affirmative result, not only tends to indicate the tainted sources of supply of the Thames, but also tends to show that the methods of sand filtration pursued by the company are ineffectual in eliminating from the filtered water microbes of which the common resting place is sewage and animal excrement.' The conclusions they arrived at are ' that even in a year exceptionally favourable to the purifying opera- tions undertaken by the water companies, the element of danger necessarily attaching to the supply of a water taken from sources inevitably exposed to contamination is not by any means invariably eliminated by the methods of purification at present relied upon. A system of filtration which does not invariably keep out or destroy the common accompaniments of sewage and animal pollutions may, on the occasion of epidemic prevalences in communities on the river banks above the companies' intakes, also allow the passage of the infective disease organisms in numbers sufficient, as the case may be, to cause epidemics amongst the water consumers, or mere sporadic outbreaks, or isolated occurrences amongst the more susceptible of the population. We are, therefore, of opinion that considerations of public safety require that reliance should not be placed upon sand filtration as at present conducted, as the sole means of defence, when the water to be operated upon is derived from a tainted source. The question of the presence of "blood-heat" organisms in the water, their relations to season and to water temperature, and to the occurrence of diarrhoeal complaints in the late summer, to which some reference has been made above, appear to be deserving of more prolonged and detailed investiga- tion.' (The italics are mine.) " As to the fact that ' pathogenic organisms' have not been found in the water supplied by the Thames companies I need merely say that the bacillus of enteric fever has rarely, if ever, been found in any water- supply. It was not found, for instance, in any sample of water supplied to Maidstone, and on this point Dr. Washbourn said in his report that ' no importance can he attached to the failure to discover the typhoid bacillus in water suspected of being the cause of an epidemic of typhoid fever.' If this is so, it is still less likely that the typhoid bacillus would be found in water which is merely suspected of pro- ducing tj-phoid fever in those persons of the community who are peculiarly susceptible to it. In fact, the test which shows whether a water contains typhoid poison is not the discovery in it of the bacillus of the disease, but the fact of its producing or not producing that fever among the peonle who drink it. " Sir Wm. Crookes and Professor Dewar ailude to the Maidstone inquiry and say that ' it was proved beyond all doubt that one of the 78 sources of supply had been grossly contaminated with jsecal matter. ' The Local Government Board inspectors who conducted the inquiry came to no such conclusion ; they merely say that the Avater sources ' were all exposed to the risk oj pollution ' and they add ' there is no conclusive evidence to show either how the specific pollution of tjrphoid fever was introduced into the supply, or which of the springs was thus polluted.' (The italics are mine.) "As to the chemical evidence of pollution of the Maidstone water I have before me the table of analyses of the water referred to, and find that out of 22 samples examined five showed signs of organic con- tamination. In one sample this contamination was rather greater than in the samples of water supplied to St. George's, Hanover-square, last December, but not greater than in samples that have been supplied on other occasions, but in the other four it was less, and in all of them the results of analysis tend to show that the organic matter was ' chiefly of vegetable origin ' " The organisms found by Drs. Sims Woodhead and Washboum in the Maidstone water were of similar kinds to those found by Drs. Parkes and Rideal in the waters supplied to Chelsea, and, as already stated, the typhoid organism was not found in any sample. "The company's analysts go on to say 'there is no comparisou between the conditions of the polluted spring water-supply which originated the Maidstone epidemic and any polluting conditions which can arise in the Thames Valley, where strict supervision of all sources of contamination is so efficiently maintained,' a conclusion diametrically opposite to that arrived at by the Public Health and Water Committees of the London County Council, who say in their report : ' We consider that in respect of physical conditions the causes which led to the typhoid epidemic in Maidstone have a parallel in the conditions of the London water-supply. The epidemic was caused by water drawn from polluted sources. It is admitted, and the facts above quoted con- clusively show, that the water supplied to London is also derived from sources liable to become polluted. As Sir Alexander Binnie points out : ' This is but another instance among many which teaches the general lesson that for many years a population may be supplied with water from various sources without any apparent harm to the con- sumers and that the water so taken has been repeatedly pronounced after chemical examination to be pure and wholesome, but that if the water is derived from a source liable to pollution sooner or later the time generally arrives when an epidemic breaks out owing to circum- stances connected with the pollution of the supply.' "In this connexion the following remarks of Dr. Clowes, the council's chemist, are worthy of attention : ' While there are grounds for believing that the comparative immunity from typhoid fever which is enjoyed by the consumers of London water depends largely on the ^ective working of the filters, it must be understood that a breakdown in the filtering arrangements might possibly, at any time, produce a serious epidemic. And although the ordinary process may remove 90 per cent, of the bacteria which are at present in the river water, it is reasonable to suppose that the remaining 10 per cent, of the bacteria may occasionally number in their midst the bacillus of typhoid fever.' "As Sir William Crookes and Professor Dewar refer to their 'extensive experience,' I may be permitted to remind you that I have reported on the water supplied to St. George's, Hanover- square, for the last 25 years, and with regard to their remark that I seem to entertain a different view of the origin of typhoid epidemics from that generally held, I may mention that I have seen some hundreds of cases of typhoid fever and investigated some thousands in this and other countries during the past 30 years ; that 25 years ago I combated the then prevailing opinion, advanced by Dr. Murchison, that the poison of the disease was produced by the decomposition of fsecal matter, that, in fact, it originated de novo ; and that I have for a long time past come to the conclusion, which many others share with me, that typhoid fever spreads in other ways than by the pollution of drinking-water. " I am, nevertheless, of opinion that such other ways are not competent to account for the increase of typhoid fever in London during the winter months, when it ought to diminish, and that there is in all probability some connexion between this increase and the fact 79 that the greater part of Loudon is then supplied with water which contains * an excess of organic matter.' *• I will also add that it is at any rate a remarkable coincidence that I am able this month to report to you that the number of cases of typhoid fever in London has very considerably diminished and the death-rate from it gone down to its normal amount now that the water- supply has ceased to show the signs of contamination to which I have drawn attention." (April 11th, lb99.) To this no further answer was received from the advisers of the water companies. Mr. Shirley Murphy, in his annual report for 1894 as medical officer of health of the London County Council, drew attention to the fact that the distribution of cases of typhoid fever in London ' ' was characterised by the increase of prevalence in the forty-ninth, fiftieth, and fifty-first weeks," and that this late outbreak was exceptional and "was observable in the population supplied by all the London water companies except the East London and the Kent Companies. Also that the water supplied from the Thames and Lea was polluted owing to the fact that severe floods had occurred in November." He also states that : " Inquiry as to the behaviour of enteric fever in populations in the vicinity of the county gives indication of some differ- ence of behaviour of this disease in the population supplied by water from the Thames and Lea and in the population otherwise supplied, the population supplied from these rivers experiencing an increase of disease in the forty-ninth, fiftieth, and fiity-first week, corresponding with that experi- enced in London. The hypothesis of water-borne contagion appears better able than any other to afford explanation of the increase of disease in the weeks in question." I have no doubt from the above facts that the unseasonable prevalence of typhoid fever in November and December in London is due to the distribution of inefficiently filtered river water containing the poison of the disease, in sufficient amount, however, only to attack the most susceptible persons among the population. Dr. S. Davies, the medical officer of health of Plumstead, reported in 1893 that the cases of enteric fever among the men employed in the Arsenal were caused by their habit of drinking water used for an engine and drawn from the Arsenal canal. This water is liable to be polluted with the excreta of labourers and is very liable to contain the infection of enteric fever. This reminds me of the account given by Dr. de Kenzy of the prevalence of typhoid fever at Millbank Prison when it was supplied with water drawn direct from the Thames. On supplying the prison by means of an artesian well the disease became as rare there as it was frequent before. There are very few instances in which sewage irrigation on land has been shown to be the cause of typhoid fever. It is indeed a remarkable fact that typhoid fever does not occur among the employes on sewage farms, even when they drink the water of wells on the farm, which is frequently the 80 case. In some few instances, however, owing to mismanage- ment of some kind or other, outbreaks of typhoid fever have occurred in connexion with sewage irrigation. One was the outbreak at Beverley in 1884 already referred to. In not a few instances — and some of them very important ones — the water-supply has become polluted while in the mains, whether on constant or intermittent service, by the specific poison of typhoid fever and serious outbreaks have been caused by this. Thus Dr. Alfred Carpenter com- municated a paper to "Public Health" in July, 1873, entitled ' ' The Danger of an Intermittent Water Supply when delivered by house services designed for use under constant pressure." He had noticed that cases of sickness, diarrhoea and typhoid fever broke out in houses in Croydon after the constant water service had been temporarily replaced by an intermittent service, and that the tap-water was com- plained of as not being good ; he found that water from the soil was sucked into the water-mains through defective joints, and also that foul matters were sucked into them through direct connexions with the basins of rcater -closets. At Lewes (Sussex) Dr. Thorne reported in 1874 that there was a " large epidemic of enteric fever due in the first instance to pollution of the town water-supply from water drawn from the Ouse, which receives the town sewage, and mainly spread by suction of polluting matter into the water-pipes of an intermittent water service " (Eeport of the medical officer of the Privy Council and Local Government Board, New Series, No. IV. , for 1874). He also reported as follows on an outbreak at Wolverton : ' ' Water- supply exposed to risk of pollution by suction of foreign matters from closet-pans into mains of an intermittent service " (Report of the medical officer of the Privy Council and Local Government Board, New Series, No. VII., for 1875). And on another at Tideswell, Derbyshire: "Spread of disease favoured by conditions in an intermitting water surface allowing of suction of foul air into water-pipes" (Sixth Report of the medical officer of the Local Government Board for 1876). Dr. Thorne also reported on an outbreak in the Dewsbury registration district as follows : ' ' Water- supply for some districts liable to pollution at its sources and periodically fouled in delivery mains during intermissions in the service." And again in the Dewsbury Urban Sanitary District : "Water-supply subject to pollution at, and probably on its course from, the gathering ground. Supply inter- mittent and liable to be fouled by suction of filth into mains (Eighth Report of the medical officer of the Local Government Board for 1878). In 1874 Dr. F. R. Blaxall reported on an outbreak at Sherborne (Dorset) as follows : ' ' The influence of milk in the distribution could be excluded, but respecting the circum- stances of the water-supply the following facts were ascer- tained. During December, 1872, and January, 1873, the water 81 was frequently shut off from the town at a point near to the reservoir and the same thing was done every night in February. It is known that when the water was shut off there were certain delivery pipes up which there was a rush of air immediately the tap was unscrewed. Now many of the openings to the pipes are situated in the pans of the water-closets. At night, after the closet had been used, the tap would be turned on for the admission of water ; none flowing, the tap, in many instances, would not be turned off again ; thus, a direct passage into the water mains would be left open, but the accidental circumstance of leaving the tap open was not required as many taps were broken and admitted a continuous flow of water during the day but at night, no water being present, were uninterruptedly open to sewer air. Through these openings during the night air commonly passed from the closet-pan to the water-pipe ; in other words, the system of pipes for the water-supply became the means of ventilating the closet-pans ; if a trap happened to be broken or out of order it became a means of ventilating the sewers, and if a pan happened to be full of excrement, that excrement would be sucked into the water-pipe. In January and February, when there were at least 27 cases of enteric fever in the town, closet-pans thus circum- stanced were doubtless in some instances tainted with the specific contagium of enteric fever ; some may even have been filled with excrement from the bowels of fever patients. The sewer air which entered the pipes at night, when the water was turned off, would in the morning, when the water was turned on again, be driven forward, washing the pipe surfaces on which foul air had for hours been resting, and could hardly (even supposing no actual excrement to have got into the pipes) have failed to contain fever contagium ; and this water went on, not only to cleanse closet-pans, but to be drunk by the people in the town. I think it probable that the recent outbreak of enteric fever was caused by persons drinking of this con- taminated water and I base this opinion on the following considerations : first, the sudden appearance of so many cases in the first week in March — i. e. , after the water had been shut off every night in February ; secondly, by the gradual diminution of cases after the first week in March, during which month the water was not turned off at nights ; thirdly, by the manner in which the cases were scattered about the town ; lastly and mainly, by the fact that the pro- portion of cases occurring amongst persons who derived their water from the board of health supply was much greater than amongst persons who had their water from other sources " (Report of the medical officer of the Privy Council and the Local Government Board, New Series, No. II,, for 1873). In 1882 the same inspector reported on another outbreak of typhoid fever at Sherborne produced in exactly the same way. In the same volume is a remarkable report by Dr. Buchanan G on an outbreak which occurred in 1873 at Caius College, Cambridge, from which I extract the following: "All the more usual ways of enteric fever spread have now been con- sidered and none of them have appeared adequate to account for the intensity of incidence of fever upon Caius College or for its remarkable incidence on Tree Court. Holding always in view the special character of these occurrences let us observe that the water-supply to the college is taken from a surrounding five-inch main at six different places, and that one of them, at the Gate of Humility, is for Tree Court and for no part but Tree Court, What if there should be something wrong with this one local supply? 'Ew en. prima facie there is something to be said for this view. The suddenness of the outbreak in the college was such as at once to suggest to Dr. Paget and Dr. Brad- bury, and equally to myself, the thought 'that it might be due to the contamination of the water or milk. ' The area of the particular water distribution is exactly the area of the fever, at lea&t of 12 out of 15 cases, one or more of the remaining cases requiring probably no explanation beyond every-day circumstances. The good character of the com- pany's general water-supply would not avail as an argument against a local contamination in a local service. And at an early period of my investigation I was struck with the cir- cumstance that while every water-closet in the old part of the building was provided with a cistern proper to itself, the closets in the Tree Court buildings were supplied with water direct from the high-pressure constant-service pipes. Complete intermission of supply was found to have actually occurred on two occasions at least during the last term. The earlier occasion can be defined as the evening of the second day of an October frost, and thus far might have been either on Oct. 25th or on Oct. 30th, but other associations suggest Oct. 25th as being the more probable of the two days ; on this occasion only the particular service through the Gate of Humility was stopped. The latter occasion was when the water company's servants, having, for the purposes of pipe repair, cut off the water-supply of some half of Cambridge, there was hurrying to restore the supply in order to gain water-power to blow the organ of King's College Chapel for a musical service. This fixes the date of the second known intermission at about 10. 30 A. m. on All Saints' day, Nov. 1st. Now a fortnight is about the incubation time of enteric fever. A fortnight after Oct. 25th is the date of the first attack in Tree Court. A fortnight after Nov. 1st is the date of the second, third, and fourth attacks. And though it was known that other cases of fever kept dropping in till the end of November the coincidence of the early fever with these ascertained intermissions was not the less suggestive as indicating the direction that further inquiry should take." Dr. Buchanan then showed that the water in that main was contaminated by suction into it, during the periods of intermission of the supply, of foul air from a soil-pipe (aud so from a sewer) through a "weeping pipe " which supplied the trap on the waste-pipe of the safe- tray of a water-closet, which trap was liable to siphonage. (Report of the medical officer of the Privy Council and the Local Government Board, New Series, No. II., for 1873.) In the annual report of the medical officer of the Local Government Board for 1887 is an important report on an epidemic of typhoid fever in the Mountain Ash Urban Sani- tary District, Glamorganshire, by Mr. John Spear, in which, after discussing the evidence, Mr. Spear continues : ' ' The facts all tend to bring into more and more prominent relief the point of initial contamination of the water, and, in view of the now clearly established premises of my argument, the exact condition of the Oxford-street main and its relation to immediate surroundings become matters of exceeding interest and importance. I have shown that the water, as it passed into the main and for the first 160 yards of its- course there, produced no ill-effects in its consumers ; and I have identified that point just at the Henry-street bifurcation as the one point indicated by the facts of fever prevalence where specific contamination of the water main had in all likelihood habitually occurred. For the purpose of this inquiry the two pipes were laid bare a little above and for some distance below the point indicated. The Henry-street pipe was laid some 25 years ago and has been found to be much corroded. That of Oxford-street was relaid, as I have said, in 1885. IJiere is no douht that the relaying was very carelessly, not to say recklessly, done. Owing to the exigencies of water-supply it was done mostly at night, and the work being in private hands was subject to no supervision on the part of any official or authority having concern with the public health. Accordingly, the main was carried, without any special precaution, immediately above, alongside, and even through the old rubble drains : and when in the course of trenching pipe-drains were cut through no trouble appears to have been taken to replace them. I find the inspector of nuisances reporting in September, 1885, a third case of injury and stoppage of a drain from this cause. Although the old stone culverts to which I have referred are not ostensibly sewage-carriers now they formed the sole sewage system some 20 years ago ; and even now refuse matters are often poured, as I saw myself, into the roadside gullies that are connected with them. One of the culverts through which the Oxford-street main was carried (a 'collar' or junction between two pipes being in the interior, was found to contain a quantity of exces- sively foul sewage deposit, a slaughter-house apparently, amongst other places, draining into it. It may be said that, as one result of the careless laying of the main, the latter was at different points from time to time bathed in refuse matters and habitually at certain points in sewage-con- taminated air." 84 Leakages were found in the mains and also direct con- nexions with the water-closet pans. "Of course, during intermission of water pressure, the flaws in the pipes represented by the 'leaks' would afford means for the entrance into the pipes of air from the soil, or from the neighbouring drains as the case might be, and doubtless of liquid also. I had myself opportunities of observing how considerable was the suction of air into the pipes at certain points after intermission of supply and on its renewal how much air coming with much noise and force had to be expelled. No special valves being provided for the purpose this air must have entered by accidental openings. At any time of intermission it is plain that the leaky water-pipes were at liberty to discharge their contents through any opening at a lower level and that they would convey not only such water as remained in them but those matters also which entered at the points of leakage. In short, the leaky pipes would act as so many means of draining the ground in which they were placed. Passing through or alongside old rubble culverts they would take up foul air and liquid from these culverts and from the soil around and would deliver these matters at lower levels (if not during inter- mission, on the first renewal of supply) for consumption as ' drinking-water. ' Intermission of water-current, however, is not by any means essential to the introduction of foreign matters into water-pipes. Under various physical conditions very powerful insuction of external matters into a full- flowing water-pipe can take place. Some of these conditions were considered in a departmental report on Croydon in 1875. It results from the foregoing observations that during intermissions of the service large contamination of the water of the Oxford-street and Henry-street mains must have occurred and that contamination, although on a com- paratively minute scale, during continuance of supply is probable. Chemical analysis of the water, and still more microscopical examination, afford important confirmatory results. Dr. Dupr6, to whom samples were sent for analysis, reports that water taken from a house tap in Henry-street before the nightly intermission of service was pure, while that from the same tap after intermission gives evidence of animal contamination and of the appearance of low forms of life. Water from a tap in Victoria- street (Miskin) shows similar deterioration both in the night and morning supplies. " An interesting case at Buckingham in 1888 was reported upon by Dr. Franklin Parsons. There was a sudden outbreak of typhoid fever in that town in January and February, 1888, confined at first to a poor suburb of the town, and especially affecting persons drinking water from a particular "spout." ' ' The water conduit to this spout was exposed to pollution from a leaky drain which had received specifically infected excreta from a previous case of enteric fever. " An outbreak of typhoid fever at Fareham (Hants) was 85 reported by Mr. Spear in 1888 to have been traced by the medical officer of health ' ' to pollution of an intermittent water-supply through numerous direct connexions between the water mains and the pans of water-closets. After this was remedied and a constant supply of water afforded enteric fever became less prevalent in the town." Mr, Spear also reported in the same year that an outbreak had taken place in Flint, where the water-supply was intermittent and where in the specially infected locality there was an ' ' allega- tion of discolouration of the water when turned on in the morning. " In 1889 Mr. Spear reported that at Strood and Rochester, where typhoid fever had been prevalent, he "found water-closets supplied direct from the mains — i.e., without the intervention of any cistern or tank. The danger of insuction of air and even of solid matter into the water-pipes from closet-pans during any temporary disconnexion of water-pressure is well known to attend this objectionable arrangement. " Dr. Wheaton reported in 1893 on an outbreak which was almost entirely confined to a limited area in the town of Atherstone (Warwick). The "outbreak was not due to excrement disposal, sewerage, drainage, or milk-supply ; but to the introduGtion nightly into the town mater viains for a period of eight roeeks of an extraneous water-supply which was subject to pollution. The localisation of the fever outbreak was explained by the peculiar distribution of the water mains owing to which the suspected water was almost entirely con- sumed within the area to which the fever in question was almost entirely confined. The prevalence of the disease was in part due to infection from the privy-middens, also to con- tamination of water-supply by a residue of suspected water remaining in the mains and continued consumption of the same water, which was obtained from a public tap." In 1899 Dr. G. S. Buchanan reported with regard to a serious outbreak at Falmouth (Cornwall) that there were "reasons for inferring that insuction of infectious matter into Falmouth water mains during periods of intermission of supply had concern with the epidemic." The water-pipe, in which there was a roughly made and leaky joint, was laid underneath the stones of a yard where the soil was ' ' every- where black and impregnated with foul organic matter." This was caused by the leaky drain and a water-closet down which typhoid excreta had been thrown, and Dr. Buchanan proved by a test that suction into this main actually did take place under certain circumstances. Drinking water may also, after it has been delivered inta the house, be contaminated with the poison of typhoid fever. In illustration of this point I may be allowed to quote again from my paper " On the alleged spontaneous production of the poison of enteric fever," read before the Epidemiological Society of London in March, 1874. "In large towns the enteric fever poison spreads chiefly through the medium of 86 sewer air, in which it is doubtless suspended, and in London I find that this fever especially prevails in houses where the waste-pipe of the drinking-water cistern communicates directly with the house-drain, a sanitary defect which is very common indeed in many parts of London, especially in old houses in the best neighbourhoods ; to quote from my report on the sanitary condition of the Parish of St. George, Han- over-square, for the year 1873: — 'Out of 39 houses in which there were cases of enteric fever, 22 had the sanitary defect in question ; while there were 11 other houses with the same defect, in which cases of low fever, or some other ill-defined disease, were found. It may be mentioned that diarrhoea frequently breaks out in such houses.' The waste- pipe being a ventilator, and often the only one to the drain, the foul air, which may contain, suspended in it, some of the poison of the disease, rises up this pipe into the space between the water in the cistern and the cover, and the suspended particles fall into the water which is drunk, and which may, and often does, give rise to enteric fever in the persons drinking it." There can be no doubt that the remarkable diminution in the number of cases of typhoid fever in London during recent years is very largely, if not chiefly, due to the disconnection of the waste-pipes of drinking-water cisterns from the drains. We now come to the distribution of the disease by means of infected milk. In 1862 an investigation was made by Professor John Gamgee on Cattle Disease in Relation to the Supply of Meat and Milk, and his report was published in the fifth report of the medical ofl&cer of the Privy Council. He came to the conclusion ' ' that the cause at present operating most actively to deteriorate the milk of cows in this country is the prevalence of epizootic aphtha. This disease attacks the human subject and many cases of communication from cattle to man have been observed either from the virus pene- trating a wound or passing into the system with the milk. " Sir John Simon adds to this : ' ' Experiment seems to have established as certain that, at least under some circumstances, the human affection may be caused by the consumption of milk drawn from a diseased animal. " And it is stated in a foot- note that ' ' more than 20 years ago Professor Hertwig published particulars of such experiments performed by him on himself and two friends with the result of producing a very definite eruptive fever. " Dr. Edward Ballard, when medical oflnlcer of health of Isling- ton, first traced an outbreak of typhoid fever to a particular milk- supply in 1870. This investigation is so important that I insert the following lengthy quotations from his report : ' ' The general result of an inquiry into the milk-supply of the families, within the quarter-mile radius into which I ascer- tained that typhoid fever had entered was this — viz. : That it occurred in the house of the milk vendor where the business, was carried on. He died and seven other persons, members of his family or boys employed and living on the 87 premises, had typhoid fever and one of the latter died. That it occurred in the family of a person who dwelt in a small cottage in the cowyard distant about 100 yards from the last-mentioned house and dairy, three persons having fever here. The first case here was in a girl, who, a fortnight before she actually fell ill, had left a situation at a public-house supplied with milk from this dairy and since then had been residing at home. This family, the mother of the girl told me, rarely took milk, except on Sundays, being poor, but when the girl was ill milk was given to them from the dairy. The mother herself, and subsequently a little boy, had typhoid fever when the girl was convalescent. That, in addition to the two boys who had lived in the house for a longer or shorter time, two men engaged in the business who did not live in the house had typhoid fever. One of these was the cowman engaged after the master was taken ill ; the other was a young man who worked at the cowyard and carried out milk and who took all his meals at a cofEee-shop supplied from the dairy and where two families also supplied from the dairy had fever. That a fifth man employed at the cowyard and residing at home had fever. He also occasionally had his meals at the above-mentioned coffee-shop and his tea at his mother's who was supplied from the dairy. His family being poor he bought no milk for them anywhere and he was the only member of it attacked. That another single man residing within the radius in a wholesome house and engaged as a coachman outside the radius, who habitually took his meals at this same coffee- house, had an attack of typhoid fever. That (omitting the girl who came ill from the country) out of 62 other families within the district which are known to have suffered from typhoid fever, 54, or fully 87 per cent., were constantly supplied from the dairy with the milk they required, two were occasional customers, and five only stated that they did not deal there at all. I am not quite sure that complete reliance can be placed on this last statement ; certainly, I doubt it in one case of the five. All five resided close to the dairy and it is very probable obtained there, as the most convenient place, any extra milk their families required. In another instance a girl was attacked in a family not supplied by the dairy, but it appeared that on two consecutive days in the beginning of July she had taken tea with a school- fellow who, with her mother, had typhoid fever a few days later, this family being supplied from the dairy. No one else in this girl's family had fever." On inquiring into the fatal cases happening in families residing in the quarter-mile radius from the dairy he found, ' ' That the members of 142 families were supplied with milk from the dairy in question. The district within the quarter- mile radius alone must contain over 2000 families. So, after all, no very considerable proportion got their supply from this source. Out of these 142 families (which include the 88 dairyman's household) I have ascertained that 70 were invaded by typhoid fever within the 10 weeks during which the outbreak extended — that is to say, half of them were invaded. This includes all the families which had deaths from typhoid fever." On searching for the cause of the con- tamination Dr. Ballard found that it came from an under- ground wooden tank constructed 16 years before which had become rotten and was found to communicate with two old drains by means of rat-burrows in such a manner that not only foul air from the drains but also an oviarflow of sewage itself could obtain access to the tank. The water from this tank was used for washing the milk-cans. An outbreak at Balsall and Moseley Heath, near Birming- ham, was investigated in 1873 by Dr. Ballard who thus sums up its etiology: — " 1. Two wells upon adjoining premises occupied by milk-sellers became infected early in November with the infectious matter or virus of enteric fever through the soakage from a privy into them of excremental matters containing that matter of infection. 2. Through the medium of water drawn from these wells the milk supplied by these milk-sellers became infected and many of their regular customers who drank the milk suffered from the disease. 3. The same infected milk having been sold to two other milk purveyors, some of the persons using the milk supplied by these milkmen also suffered in a similar manner. 4. There is no evidence that the disease spread in these districts in any other way than through the consutinption of these infected milks " (Report of the medical officers of the Privy Council and the Local Government Board, New Series, 1874). A serious outbreak of typhoid fever in Marylebone was investigated in 1873 by Mr. J. Netten Radcliffe and Mr. W. H. Power, the former making the country inspections and the latter the inquiries in London. Mr. Kadcliffe was also accompanied in his inspections by Dr. Whitmore, the medical officer of health of Marylebone, Colonel W. Hope, V.C, and Mr. Chalmers Morton, representing the company supplying the milk, and myself as medical officer of health of St. George's, Hanover-square, and also for that occasion sanitary adviser to the company. ' ' Early in the outbreak Dr. Murchison, whose family suffered very severely from it, satisfied himself that the only probable mode of introduction of the disease into his house was by the milk-supply. The suspicion having been aroused, he quickly ascertained that almost the whole of the families which were then affected with enteric fever within his knowledge and that of his pro- fessional friends, obtained their milk from the same dairy which supplied his household. The preliminary inquiry had made it certain that the milk of six out of the seven farms supplying the dairy was, at the time of the outbreak, free from any suspicion of infection with enteric fever material. But with regard to the milk from the seventh farm the result was very different. Here a condition of things was found which rendered it highly probable that milk from this farm had been charged with enteric fever material and not improbably with the excremental discharges of a patient suffering from enteric fever, shortly before and during the earlier period of the outbreak in Marylebone, From this farm was obtained all the milk specially siq>plied by the implicated dairy for nursery use, the consumption of which milk, as has already been shown, furnishes the strongest evidence of the infection of the milk. On June 8th the occupier of the farm died suddenly in the fourth week of an attack of ambulant enteric fever (typhus ambulatorius). For some time pre- vious to the seizure it had been suspected that he suffered from some disease of the heart. The suddenness of the death at a time when it was believed by his medical attendant that recovery from the enteric fever had commenced led to the death being ascribed to the presumed heart disease and to its having been cer- tified as occasioned by this cause, no mention being made in the certificate of the disease from which he was considered to be recovering at the time of death. The history of this case, indeed, is that of well-marked ambulant enteric fever. Previously to the haemorrhage there had been no disturbed action of the bowels. After the hEemorrhage Mr, Humphreys (the medical attendant) gave directions that all discharges from the bowels and bladder should be kept out of the common privy of the farmhouse and buried somewhere outside the premises. This direction was carefully carried out, and from the first haemorrhagic stool to the last chamber slops all the discharges were removed to an ash-heap beyond the precincts of the farm buildings (as will presently be more fully described) and there the evacuations from the bowels were buried and the slops cast. No disinfectant was mixed with either the one or the other before being got rid of ; for, on the one hand, it did not seem to be necessary from the place of burial or casting away, and, on the other, it was not advisable to retain upon the premises the great bulk of the evacuations passed within a brief period until a disinfectant had been procured. On August 12th, a son of the above patient, aged 13 years, was seized with enteric fever, and he passed through a slight but well-marked attack. ' ' A series of carefully executed excavations were carried out under the supervision of Colonel Hope, V.C, one of ourselves and the manager of the implicated dairy being also present, to determine whether soakage from the privy and from the drains of the farmhouse could find its way into the dairy well. A previous examination of the interior of the well, the water having been pumped out for the purpose as low as practicable, disclosed a well-marked line of soakage through the interstices of the brick steining on the south side of the well, three feet six inches above the inlet of the drain from the feeding well and nine feet from the surface. Other more doubtful points of soakage existed, which need not be described. These 90 excavations proved conclusively (1) that no soakage was possible from the privy into the dairy well ; (2) that no soakage had taken place either from the surface yard drain or from the dairy drain into the well ; and (3) that no soakage from the farmyard drain or the farmyard or elsewhere had passed along the upper part of the trench in which the conduit from the well in the meadow to the dairy well was laid. These questions having been carefully put aside a trench was run up to the yard wall from the garden plot on the south side, a little to the east of the position of the well, and on digging beneath the foundation of this wall unquestionable signs of soakage of some foul matter were found. On this being discovered an excavation was made between the well and the yard wall and a line of soakage disclosed along the foundation of the wall through the made earth intervening between the wall and the well to the point where soakage had been discovered in the well. The reason of the growing foulness of the water from this well, which had caused its disuse some time before for drinking and cooking, now became at once obvious. The soakage could only come from one direction — that of the pigsty. The yard wall and the southern wall of the pigsty were continuous. The drainage of the pigsty flowed to the south side of the wall and there accumulated. The surface drainage from the yard was also occasionally dammed up against the wall, as one of us at the time of the first inspection of the premises had occasion to see. Now there can be no reasonable doubt, from the result of the excavations, that the drainage of the pigsties and of the yard had in the progress of time made its way along the foundation of the wall, a distance of about 26 feet, to the vicinity of the well and then soaked through the intervening soil into the well. The latter process from the nature of the soil would be a slow one, but it had been accomplished so effectually that the clay which constituted the bulk of the made ground between the wall and the well was, along the line of soakage, reduced to the consistence of very soft paste. Against the wall along the foundation of which this soakage takes place and close to the pool formed by the drainage from the pigsty is the ash-heap of the farm. In this ash-heap were buried all the evacuations from the bowels of the sick occupier of the farm on June 1st, 2nd, and 3rd, and upon it were cast all the chamber slops of the sick man's room from June 1st to 8th. In other words, hy an unhappy and altogether unforeseen change and in carrying ont precautions to obviate any possibility of mischief the matters from which mischief was most apt to arise were deposited in perhaps the only spot on the farm premises where tliey would certainly find their way into the water used for dairy purposes. ' ' For the ultimate purpose of this inquiry it is suflBcient to have shown a probability, amounting for practical purposes to a certainty, that (1) the outbreak of enteric fever which 91 forms the subject of inquiry was caused by milk infected with enteric fever material ; (2) that this milk came from a particular farm ; and (3) that the water used for dairy purposes on this iarm contained excremental matters from a patient suffering from enteric fever immediately before and at the time of the outbreak " (Report of the medical officer of the Privy Council and the Local Government Board, New Series, No. II., 1874). In the seventh annual report of the medical officer of the Local Government Board, 1877, is a report on an unusual prevalence of enteric fever at Ascot during a period of four years and a half by Dr. E. Ballard, from which I quote the following: "In the middle of 1873, at the very time that the outbreak in Marylebone which was traced to the milk- supply of a particular dairy was in progress, three cases of enteric fever occurred almost simultaneously on the top of the ridge of hill on which the village of Ascot stands • ' The three cases occurred in persons who had recently been in London, arid two of whom had certainly when there used the inilh of the particular dairy. I failed to get evidence of the third case having partaken of that milk." Dr. Ballard makes the following interesting observation ; — ♦' What is to he gathered from coincidences i* — In an inquiry into an epidemic such as this, where the cases of the disease are distributed about a district having certain common features, there are four sources which are ordinarily looked to as those whence the contagium of the disease is most lilcely to have proceeded and by the medium of which it may have been distributed, viz. : (1) a common source of water- supply, such as some particular well or stream or the mains of a system of public supply, in which case infection of the water, either at its source or in its progress for distribution, may result in the distribution with it of an infective material ; (2) a common system of drainage, in which case a sewer becoming infected may be the means of distributing, through the medium of the sewer air, infective matter to the houses in relation with such sewer ; (3) where there is no common water-supply and no common system of drainage to account for a wide distribution of fever, the cause of the spread may be found in the progressive infection of independent privies, &c., and by soakage from them into independent wells or other supplies of drinking-water ; or (4) the cause of the spread may be found in the distribution over the district of some particular article of food, such as milk, which has become infected. " Dr. Ballard then shows that the first three sources were not operating in this case, but that the fourth was, almost all the families infected being supplied with milk from a farm known as the Brick-kiln farm, and he comes to the following conclusion : "The facts which I have detailed can leave, I think, no doubt upon the mind that the use of milk distributed from Brick-kiln farm was in some way directly 92 associated, as cause with effect, with the distribution of enteric fever through the Ascot and Sunninghill districts during the long period of four and a half years. * It is no valid objection to this inference to say that many families to which this milk was distributed have hitherto escaped invasion, and that a few families which used milk from other sources suffered similarly from fever. The obvious reply to the first of these objections is that in no milk epidemic hitherto investigated has more than a fraction (although usually a large fraction) of the families using the infected milk been invaded ; and to the second objection that the operation of one predominating cause of an epidemic of fever by no means precludes the operation of other causes con- currently existent." After describing the premises he adds : •'The above account of the condition in which I found the farm and dairy premises, and of the slovenly arrange- ments under which the business was conducted, indicates more than one way in which the milk might have become befouled. It is obvious that the cans in which the milk was sent out were liable every day or any day to befoulment even during the process of cleansing. The water used for rinsing the cans was a dangerous water to use for the reasons just assigned, being doubly liable to befoulment — namely, first, from the soakage of foul matters into the well from privies and the manure heap, and, secondly, from the absorption of the foul emanations from the drains which communicated with the pump case. After rinsing they were again liable to befoulment from drain emanations rising through the sink pipe over which they were sometimes inverted to drain. And, finally, the milk itself might at any time have become befouled by standing in the room into which the sink pipe opened. In addition to all which the brush used in cleansing the cans and the rags used for the same purpose, or for plugging the pump spouts, might, from their constant vicinity to the sink pipe, have become fouled by the drain emanations and thus have become a medium by which these filthy emanations might have been conveyed to cans. With respect to the open cistern within the pump case I may point out that its circumstances were similar in all essential points to those of the water cisterns in many London houses, where the waste-pipe opening above into the space between the water and the cistern cover is continued without any break or intervening trap into the house- drain, and is liable to carry up sewer-air into that interval, whence it may be absorbed by the water. There is abundant evidence to show that enteric fever has, in London, been frequently caused by the use of cistern water stored under such conditions. I have specially mentioned the circumstances under which the water used may have introduced a filth pollution into the milk by * " The low fatality which has attended the epidemic corresponds also with experience as to other epidemics of enteric fever due to milk, only two persons out of the 69 died." merely rmsing the cans with it, because former experience of milk epidemics of fever have demonstrated that given an infected water the small quantity of such water which may hang about a milk-can after rinsing with it is amply sufficient to infect the milk subsequently put in. The infection of milk by an infected water by no means implies fraudulent dilution of the milk with that water, of which, moreover, there is no evidence in this instance. To all this I may add that there is an accidental way in which filth may gain access to milk, which must never be overlooked, — namely, from the hands of the milker." He then asks: ^^ Had tJie ' filth ' that had access to the milk any opportunity of receiving specific infection ? — This is a further question some attempt to answer which will be expected by those who sub- scribe to the doctrine that (putting mere possibilities aside as not matters of scientific argument) enteric fever con- tagium as we now meet with it has an ancestry ; and how- ever long and widely and through whatever media it may have travelled about prior to finding a lodgment suitable for its development in a human system, that it or its ancestor at one time issued with excremental matter from some indi- vidual affected with the disease. It is a doctrine which I myself provisionally accept as most in accord with my own experience and also, so far as I have been able to judge, with that of the most competent and, let me add, most patient observers. With such as dissent from it I can agree in admitting that there is very much in the natural history of contagium in general, and of enteric fever contagium in particular, wrapt in an obscurity yet unpenetrated ; but I am hopeful enough to look forward to the time when the advance of scientific inquiry will render that clear which is now dark. " Lastly, he made investigations on this important point and came to the conclusion "that there were various oppor- tunities for the ' filth ' thus introduced into the milk to become specifically infected with the infective matter of enteric fever. " It is interesting to note that in the specifica- tion of works to be done at this dairy a brick dipstone trap (now quite obsolete) is specified and a sketch of it is given. An outbreak at St. Albans in 1884 was investigated first by Dr. 0. E. Saunders, the medical officer of health, and after- wards by Mr. Shirley Murphy for the Local Government Board. This was a simultaneous outbreak of typhoid fever in St. Albans and in London among the consumers of milk coming from a farm near the former city. Although the disease was undoubtedly traced to the milk, which must have been con- taminated, there was an absence of evidence that the milk at the farm had become infected in any of the commonly believed ways, but there was ' ' some reason for believing that the milk from this farm, which had in the summer of 1883 given rise to a serious outbreak of enteric fever in St. Pancras, had retained, although to a slight degree, power of infecting its customers in the interval between the two out- 'i 94 breaks." The great interest and importance of this con- clusion are obvious. Dr. Airy reported in 1885 that there was a severe outbreak of typhoid fever at Lower Sherringham (Norfolk) under circumstances pointing to contamination of milk-supply, but that the origin of the infection was uncertain. Mr. Harvey reported in 1886 that epidemic typhoid fever at Swanage (Dorset) was "associated at its commence- ment with the use of milk from a dairy situated on the polluted brook and without water-supply on the premises. " In 1886 Dr. J. Ashburton Thompson, then an inspector under the Board of Health of New South Wales, presented a report on an outbreak of typhoid fever in the municipal district of Leichhardt, which he had traced to polluted milk and in which he draws the following conclusion as to the cause of the outbreak: "All possible causes have now in turn been examined. It has been shown that its attack and decline were alike sudden ; that it occurred at a time when the district affected by it was practically free from fever ; and that it was almost entirely confined to customers of a particular dairy, cases of fever among others than customers being very few, and two having had ample opportunity at least of sharing the milk. It has been shown further that these customers lived under general conditions which were equally shared by all the inhabitants of the district, their number being 615 and against very nearly 10,000 who were not customers. It has been shown, therefore, that the con- dition common to the persons attacked must have been one to which the persons who escaped were not subject ; and that the only condition answering to this requirement is the consumption of milk supplied from the Helsarmel dairy to the former. " At the dairy the well water was shown to be practically sewage and it was highly offensive at the time of calling — in fact, the sewage of a number of houses anct the drainage water of a cemetery soaked into it, and Dr. Ashburton Thompson was able, moreover, to show that it was specifically infected from the excreta of a recent case of typhoid fever in the neighbourhood. In 1887 Dr. B. A. Whitelegge, then medical officer of health for Nottingham, reported on a small outbreak of typhoid fever which he had traced to a particular milk supply. The interest of the case consists in the fact that the customers were partly supplied by milk from the dairyman's own cows, which was taken round by cart, and partly by milk obtained from three other milk dealers in the town, which was served directly hy can from the dairy. "It became evident from the preliminary enquiries that a disproportionate number of the attacks were among those households supplied by cart. Of the 31 cases it finally appeared that 19 were in households supplied exclusively by cart, and only 3 in those supplied exclusively by can. Suspicion was thus directed to the dairy- man's own supply, and was confirmed by finding an almost complete absence of cases of enteric fever in households 95 supplied by the three dealers from whom the milk was obtained. Some of the six farms sending milk to these dealers also supplied other dairies in the town, but without any occurrence of enteric fever among their customers." On further investigation Dr. Whitelegge "came to the conclu- sion that the milk was probably infected by some person employed in its distribution," most likely a helper who came from the Union at the date of the probable beginning of the milk infection. Dr. Page reported in 1888 that an outbreak of typhoid fever at Spennymoor (Durham) was associated in time with pre- valence of fever at a farmhouse whence milk was distributed to a considerable number of the persons attacked. Dr. Bruce Low reported on an outbreak at Shildon and East Thickley (Durham) in 1893. There were scattered imported cases during May, June, and July, followed by a considerable out- burst of the disease in August and September, the number of cases gradually diminishing in October and November. ' ' The earlier cases were mild, anomalous, and irregular, the later cases typical and severe. Many cases admittedly escaped disinfection and established foci of infection. " A large share in the diffusion of the disease was attributed to a particular milk service. ' ' In the milk-seller's house there occurred three or four unnotified cases believed to have been enteric fever. The dairy where the milk was stored communicated directly with the sewer, without a bend or trap, by means of a four-inch pipe in the sink stone. History of flooding of milkman's cellar by sewage on two occasions in July after heavy rainfall. The public water-supply had nothing to do with the outbreak." In 1895 Dr. Bruce Low reported on a sudden outburst of typhoid fever in August in the town of Helmsley, North Riding (Staffs.), confined to the customers of a pajticular milk-seller, a member of whose family recovering from this fever came on a visit to his house from July 11th to August 24th. The outbreak suddenly terminated in September on the stoppage of the sale of the polluted milk. At the International Medical Congress of 1881 Mr. Ernest Hart read a paper on the Influence of Milk in Spreading Zymotic Disease in which he placed on record 73 outbreaks of disease as having been traced to the agency of milk, and of these no less than 50 were outbreaks of typhoid fever ; and in 1897 he published another report on the same subject in the British Medical Journal, giving short accounts of 95 more outbreaks (occurring between 1882 and 1896), of which 48 were those of typhoid fever, making together 98 outbreaks of typhoid fever traced to the agency of milk by the end of the year 1896. Dr. D. S. Davies, medical officer of health of the city of Bristol, read an important paper before the Epidemiological Society in March, 1898, "On an Outbreak of Milk-borne Enteric Fever in Clifton." In this outbreak the cases varied from the mildest, which would not otherwise have been recognised as typhoid fever cases at all, to the severest type of the disease, mild and severe cases being found in the same houses. The outbreak, as is so often the case with those due to milk, showed an excess of attacks among children under 15 years of age. There were 244 cases in all, of which 230 "were shown to have obtained either regular or occa- sional supplies from one or other of the three infected rounds." Of the remaining 14 cases four were accounted for in other ways. The connexion of the fever with certain milk- supplies may be considered to have been established without a doubt. In 1899 Dr. W. W. E. Fletcher reported on an outbreak at Coleford (Gloucestershire), which place was almost free from typhoid fever from 1895 to 1898, when an outbreak occurred which he found to have been "intimately con- nected with one particular milk-supply." In May, 1900, Dr. Fletcher reported to the Local Govern- ment Board on an outbreak of typhoid fever in the Urban District of Coleford and in the Rural District of West Dean (Gloucestershire). Dr. P. Buchanan, the local medical officer of health, had already ascertained that ' ' although the drainage and sewerage of the towns are highly unsatisfactory and the polluted state of the water-courses dangerous to health, the outbreak was caused by contaminated milk ; there was some difficulty in ascertaining how the milk had become contaminated. It appears most probable to have been either by washing the milk cans with polluted water from a well or by the fact that one of the workers in the dairy suffered from a mild attack of typhoid fever and that the milk he distributed somehow became infected from him." In the twenty-sixth report of the State Board of Health of Massachusetts for 1894 Dr. William T. Sedgwick reports on an outbreak at Marlborough as follows : ' ' While a very brief investigation had established the fact that the epidemic could not possibly be attributed to the public system of water-supply or sewerage the true source of the outbreak still remained to be found and I next turned to the milk-supply as a possible vehicle of the disease. But it soon became plain that many different milkmen were involved and that therefore ordinary milk could not have been the common carrier of the infection. Closer inquiry, however, finally disclosed the fact that very nearly in the middle of the infected district was a ' creamery ' which, although private, served in a manner as a milk-centre for the whole city. This creamery bought milk from 28 different farms which consti- tuted its regular supply. It also bought from time to time from the various independent milk-pedlers whatever milk they had left over and wished to sell after their daily rounds. On the other hand, the creamery sold to the various milk-pedlers whenever their own supplies 'ran short ' and in these ways served, as it were, as a kind of ' clearing-house ' for the milk-supply of Marlborough. My suspicions at once rested, largely because of its central location among the 97 cases, on the creamery and very soon after upon this special skimmed-miik service. I therefore made in the next place a house-to-house investigation which established beyond all possible doubt the fact that there was a common bond existing between most of the cases. It had not escaped observation that the disease was confined to those of slender means or in poor circumstances, and closer investigation showed that some who had attempted to economise in their milk-supply by using skimmed milk had suffered most severely." He ultimately satisfied himself that this skimmed milk was the cause of the epidemic and concludes his report with the following observations : "As far as I know the present is the first case on record in America in which an epidemic of typhoid fever has been apparently due to the use of infected skimmed milk ; but it is easy to believe that many obscure outbreaks of this disease may have come from a similar source. With the multiplication of creameries to which milk (or cream) is brought from numerous and various farms the possibility must be kept in mind of contamination of the whole product by one infected contributory portion ; and inasmuch as skimmed or ' separated ' milk, on account of its cheapness and freshness, is now much used not only for cooking but also for drinking, this product, as well as the ' whole ' milk, must henceforth be regarded as a possible vehicle of infectious disease. " Dr. Pistor of Berlin has kindly forwarded me copies of papers from which I extract the following : — I. Dr. Kicken of Malmedy (Rhine Province), writing on Typhoid Fever and Dairies, cites several instances of out- breaks traced to polluted milk ; thus at a place called Reuland a general distributing dairy for skim-milk was established in 1897, and an outbreak soon occurred producing 73 cases in 36 houses, with 10 deaths ; of these 22 houses were supplied by the dairy ; moreover, all the families of the employes of the dairy, except one, suffered from the disease and in each village where an employ^ lived it was in that family that the disease first broke out. At Biillingen a dairy was opened in April, 1899, and an outbreak soon occurred and was traced to the dairy having been supplied from four houses where there had been cases of typhoid fever shortly before. The results are stated as follows : — (a) Of 316 houses of customers of the dairy 48 were attacked, or 15 '2 per cent. (J) Of 210 houses not served by the dairy 20 were attacked, or 9 '5 per cent. , while in one of the villages (Wirtzf eld) of 34 houses of customers of the dairy 10 were attacked, or 29 5 per cent. , and of 50 houses not served by the dairy eight were attacked, or 16 per cent. Moreover, of the 116 cases in this village no less than 35 were children under 15 years of age. At Nidrum, in the district of Malmedy, an outbreak among the soldiers of the camp of Eisenbom which recently took place was traced to the use of infected milk, supposed to have been sterilised but evidently not efficiently so. The way in which the milk became infected was not traced but typhoid has been endemic in the district for some years. At Auto (district of Prtlm in the Eiffel) in 1898 a widespread outbreak was attributed to skim-milk distributed from the dairy there, because all the cases occurred in houses supplied by that dairy. In 1899 another outbreak occurred at Bleialf in the district of Prtim and was traced to another dairy (Zeitschrift fur Medizinalbeamte, Heft ii. , 1901). II. Dr. Schlegtendal of Aix-la-Chapelle has collected accounts of outbreaks traced to polluted milk-supplies in Strasburg, the Canton Lucerne, Connecticut, Montclair New Jersey, Liibeck, Aix-la-Chapelle, Hamburg, and a number of other places ; the one at Aix was particularly interesting as it was brought about by cases in the house of a dairyman, which were called by the medical attendant "gastric fever" and were not notified to the public authority and therefore no precautions were ordered ; the excremental matters of the patients were thrown on a dung- heap from which they soon soaked into the well, the water of which was used to wash the milk-cans. The outbreak ceased on disuse of the well-water and connexion of the dairy with the town water-supply. The circumstances of this outbreak were very similar to those of the Maryle- bone outbreak in 1873. (Deutsche Vierteljahrschrift fiir Offentliche Gesundheitspflege, vol. xxxii.). III. Dr. J. Adolf Kraemer gives a very interesting account of an outbreak in an infantry regiment. Tired out by a long march in July and very thirsty the soldiers came to a place where they were given plenty of milk. The result was that 142 of them fell ill about the end of the second or beginning of the third week after drinking the milk ; of these "81 had true typhus abdominalis, 31 febris typhosa sive gastrica, and 30 had indefinable symptoms." It appeared that in the house whence the milk was obtained there was a person suffering from typhoid fever and this case was at first regarded as the source of the outbreak, but it was found afterwards that it was contracted at about the same time as the cases among the soldiers and the poison appears to have been derived from a case which occurred in the previous year (Zeitschrift fiir Klinische Medicine). 99 LECTUEE III. Delivered on Feb. 27th, 1902. Mr. President and Gentlemen,— Other foods have been proved to become occasionally the vehicles for the poison of typhoid fever. In 1881, at the meeting of the British Medical Associa- tion at Cambridge, Sir Charles A. Cameron read a paper entitled " Sewage in Oysters," in which he pointed out that sewage which might perhaps contain the microbe of typhoid fever was sometimes present in oysters, and he had often found it in oysters taken from the shores of Dublin Bay. On March 29th, 1894, Dr. Newsholme, the medical officer of health of Brighton, reported to the Sanitary Committee of that town ' ' particulars of 8 cases of enteric fever which had occurred during the preceding quarter, and which were attributable to the consumption of oysters derived from oyster layings grossly contaminated by sewage." And on April 19th in the same year he brought before the Committee particulars of further cases arising from the same cause. " At the same time samples of mud from the market ponds in question were submitted to bacteriological examina- tion by Dr. Boyce (now Professor of Pathology, University College, Liverpool), who stated that the results pointed ' unmistakably to the presence in the immediate vicinity of the oyster beds of sewage matter contaminated with human excrement. ' ' ' On December 7th in the same year a deputation from the Brighton Town Council waited upon Sir Walter Foster, then Parliamentary Secretary of the Local Government Board, and brought the matter to his notice. " On December 11th, 1894, in the Seventeenth Annual Eeport of the State Board of Health of the State of Connecticut, U.S.A., Professor H. W. Conn reported on an outbreak of typhoid fever at the Wesleyan University there. After exclud- ing the drinking water, the ice used in ice-water, the milk, the ice-creams, the meat, and the groceries, it was found that oysters obtained from the dealers at Middletown were the cause of the disease. These oysters were served at certain suppers at which were a number of persons who were not students of the college, among whom cases of typhoid fever also appeared at the same time as those in the college. For instance, of five Yale students who attended the banquet two developed typhoid fever. It was found that those only suffered who had eaten the oysters raw. One 100 of the "fraternities" which had eaten the same oysters but had them cooked did not suffer from the disease. On examining the source of the oysters it was found ' ' that at the rising tide an eddy was found to be setting along the shore from the region of the sewer outlet up stream in the direction of the oyster beds. This condi- tion would plainly make it possible for typhoid contamina- tions from the sewer to be carried to the oysters. " It was also found that two cases of typhoid fever occurred in a house discharging into the sewer in question at about the time that would be necessary to bring the possibility of infection to the date when the oysters sent to Middletown were collected. Experiments were made by Mr. Charles J. Foote of the Yale Medical School which showed ' ' that the typhoid organism will live in the oysters long enough to have the oysters taken to Middletown and be eaten. In these experiments the bacilli typhi abdominalis were forced in between the shells of the oysters from the creek and were found alive and capable of growth at the end of 48 hours. This is all that is required to account for the outbreak at Middletown." Professor Conn says : "If one had planned beforehand a series of experiments designed to prove the possibility of oysters as distributing typhoid it would hardly have been possible to have davised a more satisfactory series of con- ditions than those which had attained in this outbreak." The following is his own summary of "the chain of evidence which leads to the conviction of the oysters as the cause of the Wesleyan epidemic." "1. The dates of the cases appearing at Wesleyan, all between Oct. 20th and Nov. 9th, plainly point to a single source of infection to which all the afflicted students were exposed at about the same time. This must have occurred a little more than a week earlier than the appearance of the first case, and the initiation suppers perfectly fill the conditions. 2. That these initiation suppers were the source of infection is rendered certain from the fact that four of the visitors who attended these banquets and have had no further connexion with the fraternities have developed typhoid simultaneously with the cases in college, and by the further fact that two visiting Yale students who attended the suppers have similarly suffered from typhoid. 3. The fact that only three out of seven fraternities holding suppers on that evening suffered from typhoid pointed to some article of food or drink used at these three suppers and not used in the other fraternities. 4. The fact that about 25 per cent, of the students attending the suppers have suffered from typhoid pointed to a universal and very active source of infection and not to an incidental one. Whatever article of food contained the infec- tious material must have been eaten by nearly everyone present to account for such a large percentage of cases. 6. Only one article of food or drink was used by the three societies which was not used equally by the 101 other four fraternities. This article of food was oysters and they were eaten raw. 6. These oysters came from a creek, where they had been allowed to fatten for a day or more, within 300 feet of the outlet of a private sewer and in such a position as to make contamination from the sewer a possibility. At the time that the oysters were there deposited there were two persons in the house supplying the sewer who were in the incubation period of typhoid fever, the period during which no attention would be paid to their excreta. 7. Typhoid germs are not injured by sea-water or oyster juices, and if they found their way into the oyster would certainly have lived long enough to be sent to Middle- town and be served on the tables of the fraternities. 8. Twenty-three cases of typhoid fever followed among the students in attendance on the suppers at which the oysters were eaten, and six cases among persons in attendance and not among the present students at Wesleyan. In all of the cases of undoubted typhoid it has been possible to trace either direct or indirect connexion with these oysters. The oysters were also eaten raw by one family in town and at least one severe case of typhoid followed. 9. The use of oysters from the same locality by the students at Amherst College produced, or all events was followed by, an outbreak of typhoid fever among the students who ate of them. These facts taken together form a chain of evidence practically complete at every point and leaving no room for doubt. Whatever may be said in regard to oysters in general the Wesleyan outbreak of typhoid was caused by a special lot of contaminated oysters. " (Supplement in continuation of the twenty-fourth annual report of the medical officer of the Local Government Board, 1894-95.) In "A Note on the Transmission of the Infection of Typhoid Fever by Oysters" Sir William H. Broadbent described several cases of typhoid fever occurring in houses with excellent sanitaiy arrangements, but traceable to oysters eaten from 10 to 14 days before the attacks. He also men- tioned cases of city men who had eaten oysters at lunch suffering while their families were not attacked, and he declared that "the evidence of communication of typhoid by this means has been of such a character as to produce a conviction in my mind" (^British Medical Journal, Jan. 12th, 1895). In a supplement in continuation of the report of the medical officer of the Local Government Board for 1894-95 is a veiy important report by Dr. H. T. Bulstrode on Oyster Culture in Eelation to Disease. In this report accounts are given with diagrams of the layings, fattening beds, and storage ponds in various counties round the coast of England and Wales, from which it appears that those belonging to the larger and more important oyster companies are "in the main free from the risk of dangerous sewage pollution ; and that, moreover, where security in this sense does not obtain it may, in not a few instances at least, 102 be easily brought about by the simple expedient of altering the position of the fattening beds or storage pits. " But, on the other hand, he showed "that there are cases where the risk of sewage pollution to oysters is so great and indefinable that nothing short of complete diversion of the sewers or drains or withdrawal of existing fattening pits or ponds from use can be regarded as satisfactory in the public interest." In his subsequent annual reports Dr. Newsholme showed "that 38-2 per cent. (1894), 33-9 per cent. (1895), 31 '8 per cent. (1896), and 30-7 per cent, (1897) of the total cases of enteric fever originated in Brighton were caused by sewage contaminated shell-fish." This induced the Brighton sanitary authority to attempt, in 1896, " to obtain Parliamentary powers authorising them to prohibit the sale within the borough of shell- fish known or suspected to be the cause of infectious disease," and in 1897 a memorial was presented to the Local Government Board that such powers might be conferred upon local authorities generally. A Bill to this effect was brought before Parliament in 1899, but was withdrawn. In 1896 Dr. R. Bruce Low reported on an epidemic at Southend, Essex, in which he found that there was ' ' some evidence of certain cases having been due to eating oysters which had been spread on 'layings,' or kept in boxes, along the foreshore, where they were liable to be con- taminated with filth from the pier water-closets and by sewage from the sewer outfall. " (Twenty-sixth report of the medical officer of the Local Government Board.) In June, 1896, Dr. Chantemesse read a paper before the Academic de M§decine of Paris on Oysters and Typhoid Fever. In this paper he described an outbreak in the little town of Saint-Andre-de-Sangoins, in the Mediterranean department of H6rault, which was caused by a barrel of oysters from Cette, which were eaten raw by 40 persons, all of whom became ill, while in the six houses where the oysters were eaten those members of the family and domestics who had not eaten any were not attacked. Of the 40 persons attacked eight suffered slightly from abdominal pains, vomiting, diarrhoea, and general malaise ; four others, the youngest, who had not eaten many, suffered severely from abdominal gurgling and pain with general malaise and great prostration. Two others, aged 20 and 21 years respectively, suffered severely from attacks of typhoid fever and one of them died. It was found that at Cette, where were the layings from which the oysters were brought, there was plenty of opportunity for them to be contaminated by sewage. Dr. Chantemesse collected from one of the chief merchants in Paris fresh oysters from different places as soon as they arrived in Paris and found that many of them con- tained the bacillus coli. He placed some of these, while living, in sea water intentionally mixed with typhoid excreta. 108 After leaving them for 24 hours in this water he removed them and kept them for another 24 hours to represent the time they would take in being delivered to the consumers. After this time they were still living without any particular smell and were of good appearance. Nevertheless, bacterio- logical examination showed that they contained in their bodies and in the water round them not only the bacillus coli but the living typhoid bacillus. In 1897 Dr. G. S. Buchanan reported on recent cases of typhoid fever at Brightlingsea and several urban and rural sanitary districts in Essex and Suffolk. There were 26 cases of which he says : " Each of these cases undoubtedly enteric fever, each ascertained to have been that of a person who had partaken of oysters at a date antecedent to illness con- sistent with occasion of oyster eating having been occasion of infection ; in which no conditions, irrespective of oysters, to which infection could be attributed." He found that the oysters came from "layings " on a foreshore in Brightlingsea Creek conspicuously exposed to pollution by the sewage of Brightlingsea which is discharged untreated into the creek. He further ascertained that "at sundry different periods during 1897 infectious matters from enteric fever cases in Brightlingsea must needs have been discharged from Bright- lingsea sewer outfalls." I find from Mr. Shirley Murphy's annual report for 1897, as medical officer of health to the London County Council, that the following cases in various London districts were referred in that year to the eating of oysters or other shell-fish. The medical officer of health of Paddington reported that of the 45 cases (of typhoid fever) recorded during the year three appeared to have been due to the patients nursing other cases and two to eating oysters (origin unknown). In two cases there were histories of consumption of ice-cream and mussels, but the information was too unreliable to be accepted without reservation. At Fulham in the same year three cases were thought to have been due to the consumption of shell-fish. In Marylebone one case ' ' pointed specifically to the consumption of contaminated oysters. " In Stoke Newington five cases ' ' were ascribed by the sufferers to the eating of oysters." In the Strand at least six of the 18 cases appeared to have arisen out of eating uncooked shell-fish, five of them at a seaside resort. At Holbom three out of the seven cases, which were contracted outside of the district, were probably due to the eating of oysters. There were two similar cases in Newington, one in St. Olave's, and three in Wandsworth. In one case at Plumstead "the patient had eaten whelks eight days before his attack." In 1898 one case in Westminster was attributed to oysters. In the Strand "in two instances the disease is believed to have been acquired through eating shell-fish. " In Wandsworth in three cases the disease was believed to have been contracted through eating oysters. In his report for 1899 Mr. Murphy gives the following summary under this heading: "In 104 several reports it is stated that shell-fish had been eaten shortly before the beginning of illness ; thus in one instance, in Paddington, cockles had been previously eaten at South- end. In Kensington, 'in several of the cases locally recorded, the sufEerers had partaken of oysters, mussels, &c. , at seaside resorts, within such periods of time antecedent to date of illness as to suggest a relationship of cause and effect. ' In Fulham ' in five cases the origin of the disease was ascribed to shell-fish. ' In Marylebone ' in several cases there appeared to be good evidence that the infection was taken in with such foods as oysters, mussels, or other shell-fish.' In Stoke Newington 'two cases doubtless con- tracted the disease outside London ; the disease appeared to be due to the consumption of cockles in one case and to the consumption of oysters in another case.' In Holborn * in three cases there was good evidence that shell-fish might have caused the disease. ' In Newington ' in quite one-half of the cases notified within this period (middle of September to middle of November) the friends of the patients attributed the disease to the eating of shell-fish, presumably mussels. Certainly the eating of the mussels had taken place about eight or 10 days before the illness commenced or within the usual incubation period. The mussels were the Dutch variety.' In Lambeth in six cases there appears to have been a causal relationship between the attacks and the previous ingestion (within the incubation period) of infected shell-fish, in three cases oysters, in two cases mussels, and in one case cockles being the suspected medium. In Wandsworth parish in five cases ' the patients had partaken of shell-fish shortly before.' In Greenwich 'it was found that a great number of cases had partaken of various sorts of shell-fish, such as oysters, mussels, and cockles.' In Plumstead ' in two cases eating insufficiently-cooked mussels may have been the cause and in one case oysters. ' " The following cases were described in The Lancet of March 3rd, 1900, p. 638 : "Two servants, a footman and a maid-servant, employed at a country seat in Cornwall, were attacked by enteric fever soon after consuming certain oysters and the maid-servant succumbed to the malady. At the same house was a shooting party and two of the guests left on Nov. 11th after having during their stay eaten freely of oysters. These gentlemen were taken ill with enteric fever at their respective homes, the one on Nov. 24th and the other on Nov. 26th. Moreover, a lady guest left this house on Nov. 28th for Ireland, taking with her a supply of oysters, some of which she gave to her brother on her arrival. On Dec. 17th this brother developed enteric fever. All the oysters here in question were procured from the same source. The suspected oysters were laid down in the Penryn river off the village of Flushing and opposite to the town of Falmouth " ; into this river much sewage is discharged and Dr. Bulstrode considers the oyster-layings in it " as occupying a dangerous position." 105 In a preliminary report on "Cockles as Agents of Infec- tious Disease " Dr. Klein detected the bacillus coli in three out of eight cockles which had been taken from a foreshore polluted with the discharge from a sewer outfall and also the typical virulent bacillus enteritidis sporogenes in four of them, and in eight out of a dozen raw cockles in their shells bought from a street hawker ' ' (1) no typical bacillus was found ; (2) bacillus coli (typical) was found in five out of eight cockles ; (3) virulent bacillus enteritidis sporogenes was found in four out of the eight cockles " (Report of the medical officer to the Local Government Board, 1899-1900). In their report on enteric fever in Chichester in 1899 Dr. Theodore Thomson and Colonel Marsh say: "During May and June, when the fever prevalence was at its height in Chichester, there was considerable suspicion locally that the consumption of cockles, infected with the specific con- tagium of enteric fever, was responsible for the occurrence of no small number of cases of the disease. As result of careful inquiry it appeared probable that certain persons had actually contracted the fever in this way. Investigations on this subject were made locally in late July and early August, by which time nearly 70 cases of enteric fever had been reported to the local authority. As regards these cases it appeared that in 20 instances cockles had been partaken of within a month of the onset of illness ; the remainder of the persons attacked by the fever had not partaken of cockles within that period. Of the 20 referred to 18 had eaten of cockles within three weeks of attack. In some instances, however, this relation in time between consumption of cockles and occurrence of the fever constituted the only apparent ground for attributing the latter to the former, but as regards 13 of these 20 persons probability of causal connexion was indicated by other evidence, such as nearly simultaneous onset of symptoms of the fever in two or more persons who had partaken together of cockles some 10 or 14 days previously, or the occurrence within 24 hours of consumption of cockles by several persons of sickness followed a week or two later by development of enteric fever in one or more of the consumers. In most instances it proved impossible to ascertain whence these cockles had been derived ; but, as noted in the body of the report, many cockles known to be obtained from mud-flats liable to pollution by sewage are sold in Chichester. The share of the fever, however, which can reasonably be referred to consumption of cockles is but small. The 13 cases referred to occurred in four houses, the remaining seven cases, regarding which evidence of causal connexion between the fever and consumption of cockles is less trust- worthy, involved other four houses." Cases of typhoid fever in Belfast have been said to be caused by eating cockles collected on the shores of estuaries contaminated by sewage (Otto JaflE6, The Lancet, Feb. 10th, 1900, p. 421). 106 Instances of poisoning by means of uncooked mussels have been recorded since 1827 and a number of cases since that date are mentioned by Dr. Bulstrode in his report on oyster culture already referred to. It was formerly thought that this poisoning was due to copper from the docks or from ships' bottoms but this view is not supported by any satis- factory evidence. In 1891 Sir Charles Cameron investigated an outbreak of mussel-poisoning which he considered was due to disease of the livers of the molluscs but it appears much more likely that most, if not all, of the cases of poisoning by mussels are due to sewage pollution. In his annual report for 1900 as medical officer of health of the London County Council Mr. Shirley Murphy mentions the following instances in which typhoid fever has been mentioned as caused by eating shell- fish in London during the year. ' ' Dr. Sykes refers to an inquiry by him into a localised prevalence of enteric fever in St. Pancras, com- prising 57 cases (of which a very few were in Hampstead) and occurring in November in a circle with a radius of three- quarters of a mile. He found that ' a large proportion of those falling ill gave a history of eating mussels from the same source. ' Dr. Newman states that in five cases occurring in Clerkenwell ' the only traceable source was the eating of oysters and other shell-fish, procured in each case from a particular stall in a certain street.' Dr. Caldwell Smith states that in six cases in Wandsworth ' the patients had eaten shell-fish within the period of incubation of the disease, ' and Dr. Millson, referring to special prevalence of enteric fever in Newington from the middle of September to the middle of November, reports that he came to the conclusion that the disease was due to some article of food and that shell-fish had been eaten by a large proportion of the persons affected. Dr. Kempster states that in a few cases in Battersea patients had consumed shell-fish but that it could not be proved that this had been the cause of the illness. Of cases occurring in Plumstead Dr. Davies writes that eleven cases had within a few weeks of the illness eaten shell-fish. Some of these were in the habit of frequently partaking of molluscs, while others had taken some just about two or three weeks before illness commenced. Five had taken celery shortly before the illness ; one was a greengrocer boy and one was a gardener who visited Stratford Market daily. Three of the remaining patients were people of markedly dirty habits." In Mr. Shirley Murphy's ninth annual report as medical officer of health of the London County Council is a report by Dr. W. H. Hamer on outbreaks of typhoid fever in St. George's, Southwark, Lambeth and Kensal Town in September, 1900. Dr. Hamer showed that the outbreaks were not due to water or to milk-supply or to defective drainage or to the use of a certain swimming-bath, to which the cases in Southwark had been attributed, or to ice-creams, or to any other foods with one curious exception. ' ' The only article of food or 107 drink emanating from one source which had been generally consumed by persons during the outbreak (in Southwark) was fried-Jish. The circle of a quarter of a mile radius covering the area specially attacked had at its centre a fried- fish shop," and Dr. Hamer showed that "49 per cent., or just about half the families in the portions of the area in which a house-to-house inquiry was made, contained one or more members who ate fried-fish from that shop, and of the whole population of those two areas 48 per cent, did not eat fried-fish, 16 per cent, ate fried -fish not obtained from the particular shop, and 42 per cent, ate fried-fish obtained from that shop." Similar inquiries produced somewhat similar results in Lambeth and in Kensal Town, and in both districts it was noticed that persons attacked by the disease obtained fried-fish from the particular shops, while other members of the household who escaped probably did not. The cause of the cases in Kensal Town was not so clearly traceable, but a number of those attacked purchased fish or shell-fish at a certain general fishmonger's shop. As Mr. Murphy says in his remarks on Dr. Hamer's report : "The question how fried-fish should be capable of conveying the infection of enteric fever is one to which no answer can at present be given. If due to surface contamination before cooking it is probable that this process would destroy the infection ; if due to infection within the fish it is improbable that the fish would be sterilised thereby. These points could be determined only by experiment. With respect to the question generally as to how the fish acquired infective property Dr. Hamer found no reason for thinking that specific contamination occurred on the Southwark premises, and if both the Southwark and Lambeth outbreaks were due to the consumption of fish this fact would strongly mitigate against the view that such contamination had occurred in either of these districts, and points to some earlier period at which the fish became infected. " A report by Dr. Turner on an outbreak of typhoid fever in south-east London drew attention to ''ice-creams" as a possible means of typhoid infection. The occurrence of Italian names among the sufferers led Dr. Turner to ascertain the source from which the makers of ice or ice-creams obtained the milk used in their business. Later he found that 87 per cent, of the patients had eaten ices purchased of itinerant Italians. " The centre about Coldbath-street being fairly compact, it was decided to make a house-to-house inspection there for the purpose of ascertaining the number and ages of the inhabitants, the number of those who ate ices, where the ices were purchased, and whether the fever attacked those who consumed the ices sold by any particular vendor. Seven streets were selected for this purpose. These were adjoining streets, in some of which there were many cases, in some few, and in one there was no fever at all. The result of this inquiry may be summarised thus. The number of inhabitants at all ages in this area was 1551, of 108 whom 627 persons lived in houses in which ices had been eaten and 924 lived in houses in which ices had not been eaten. Of the former (627), 61 had suffered from well- defined enteric fever or diarrhoea, while of the latter (924) who had not been in the haiait of eating ices none suffered from such illnesses. The 627 persons in this area who lived in houses in which ices were eaten are divisible into two groups : (a) 232, the ices being obtained from shops ; (b) 395, the ices being obtained from a particular ice-cream vendor whom I will call ' F ' and who came from Mill-lane. Of the former (232) none were attacked, but the latter (395) included the whole of the 61 persons who suffered from this illness, and, furthermore, all the 61 persons had actually eaten ices purchased of 'F.' Cases of enteric fever were found to have occurred in at least one house occupied by these Italians before the general outbreak of enteric fever in these districts. In addition, the sanitary conditions of the premises occupied by these Italian ice vendors were very defective. The evidence that enteric fever was distributed by the vendors of ice-cream is there- fore very strong. How the ices became specifically con- taminated is not, however, very clear, though the possi- bilities of infection were sufficiently numerous. " (Journal of PulliG Health, vol. iv., 1891-92.) Other beverages besides water and milk have been some- times proved to be the cause of outbreaks of typhoid fever. Thus a severe outbreak in the Stourbridge Rural Sanitary District (Staffordshire) was investigated and reported on by Dr. Parsons in 1888. • It was in a limited area in the town- ships of Pensnett and Bromley. There was a special incidence of the disease and young adult males employed at ironworks and at other occupations involved especially to heat. The beverage commonly in use by such persons was ginger -heer, made often at home from the water of polluted wells and not wholly boiled. Mr. Spear reported in 1890 that at Pemberton (Lancashire), where there was a smart epidemic of typhoid fever, almost confined to the village of Lamberhead Green, "the village under two separate systems of sewers, each of which embraced districts not affected by the epidemic. Water- supply in use, distributed over a much wider area. Method of excrement disposal (by privy middens) objectionable, but not serving to account for the sudden and widespread of fever outbreak ; neither school attendance nor milk-supply implicated. On July 22nd, at the Variety Fair, most, if not all, of the early sufferers drank ginger -leer, and ate 'pease- pndding ' that had been made in a room where a child was actually suffering from enteric fever." In 1898 a case in Westminster was attributed to ' ' con- taminated coooanut water. '' Professor Gualdi, Chief of the Bureau of Hygiene in Rome, points out that the seasonal curve of typhoid fever corre- sponds closely to that indicating the quantities of raw 109 vegetables sold throughout the different months of the year (The Lancet, Nov. 24th, 1900, p. 1540). An account is given of an outbreak among paying patients in the Insane Asylum, Northampton, Mass, U.S.A., which had before Sept. 9th, 1899, been singularly free from typhoid fever (only four cases in 10 years), but after that date had 40 cases in about two weeks. Dr. Morse of Massachusetts State Board of Health found that the paying patients had celery and that the non-paying patients had not, and that the celery was watered with filtered sewage ; one of the farm servants, acting against orders, ate some of the celery and quickly con- tracted typhoid fever (The Lancet, March 17th, 1900, p. 790, from the Springfield Republican of Dec. 14th, 1899). Mr. Francis E. Atkinson, medical officer of health of the Silsden Urban Sanitary District, reported on an outbreak in February, 1891. There were 17 cases, all children ; the cause was traced to two cases at an earlier date in the latter part of December, 1890. The excreta from these cases had been thrown into an ashpit. ' ' On the 5th and again on the 12th of January a quantity of decayed fruit, grapes and oranges (chiefly grapes), had been deposited by a greengrocer upon the same ashpit where the original typhoid excreta had been placed. This fruit was discovered by the children, who were all associated as playmates, and distributed and eaten to a greater or less extent by all of them " (^Public Health, vol. iii., 1890-91). In 1871 I was called on to inspect the house at which His Majesty (then Prince of Wales) was supposed to have con- tracted typhoid fever and I reported the results of my investi- gations in a letter which appeared in the Times of Jan. 22nd, 1872, in which I showed that although there were certain sanitary defects in the house in question there were no such defects as had been previously described. For instance, it had been said that the water-closet in their Koyal Highnesses' suite of apartments was directly connected with a cesspool underneath and that its soil-pipe was not ventilated. Neither of these statements was true ; there was no cesspool under the water-closet at all, nor, indeed, anywhere on the premises, and the soil-pipe was fully ventilated. There was, in fact, nothing the matter with that water-closet and it is certain that His Eoyal Highness did not get his attack of fever from any foul air in it. There was, however, a defect in another of the water-closets in the house and I was unable to say positively that the disease had not been contracted there. On looking carefully through my notes, made 30 years ago, I have come to the conclusion that although the outbreak was not caused by water or milk taken at the house it was in all probability caused by some beverage or food (such as oysters or salad) which was partaken of by His Royal Highness, the other gentlemen of the party, and some of the men-servants (perhaps at a shooting luncheon), but not by Her Royal Highness the Princess of Wales or by any of the ladies or female servants ; all the other cases were among 110 the gentlemen of the party and the men-servants. Had the outbreak of fever been caused by the insanitary condition of the premises it would certainly have attacked some of those who were most in the house, whereas, as a matter of fact, it attacked those who were most out of doors and some of whom did not sleep in the house at all. Many outbreaks of typhoid fever have been traced to direct infection from sewer air passing into houses. Among such are the following. In a remarkable report already referred to (see page 36) Dr. (afterwards Sir George) Buchanan showed that the only towns in which the mortality from typhoid fever had but slightly diminished or had even increased after improvement in water-supply and sewerage had been carried out were those in which means of escape for the sewer air were not provided, so that it forced its way into the houses. "But in these four towns (viz., Rugby, Carlisle, Chelmsford, and Worthing) and in no others sewage is received into pumping works at the outfall in such a way that sewer gases are necessarily much confined in the pipes. In the case of Worthing the defect of the outfall arrangement was most serious and in the absence of other exits sewer gases had demonstrably been forced into houses, and outbreaks of typhoid had occurred as the demonstrable result thereof. In the other towns, though to an inferior degree, there were facilities for the same accident occurring. So that it appears that the four towns where fever has not been greatly reduced are so far from constituting an exception to the rule — that removal of organic impurity from the air has been followed by reduction of typhoid — that they even add strongly to the presumption that the rule is absolute and universal. " (Ninth report of the medical officer of the Privy Council, 1866.) In another report by Dr. Buchanan on typhoid fever at Croydon he says : "In the course of my inquiry I examined a large number of houses — of course, not a large pro- portion of the whole, but in a variety of respects typical of the whole — including many where there had been no fever, as well as those where there had been fever, among the latter a probably large proportion where the circum- stances of fever production had been most obscure ; and I satisfied myself that in a very considerable majority of the Croydon houses that have had fever drain air charged with infection from, the commonest sewers of the town had had the opportunity of entering the houses. Oftentimes in a group of houses resembling each other in their general sanitary arrangements some particular drain defect was discoverable in certain houses but not in others ; and as often it was found that the incidence of the fever had been upon those which showed that drain defect and not upon the houses which did not show it. I quote from among other instances two examples of such diflEerentiation. They were cases of a less common kind, where the relation of the fever to the particular defect had not been at once obvious. 1. There Ill had been fever at some houses in St. Peter 's-street with no inside drains whatever, with outside water-closets and disconnected scullery sinks. The first seven of them were visited and it was found that the drain just outside the house was at four of them practically untrapped, but was efficiently trapped at the other three. In none of the latter had there been fever, but this disease was present last year in three out of the four former. 2. Howard and Birchanger roads, South Norwood, were visited because of a different prevalence of fever in the two. 13 houses in the former road, including seven that had had fever, were examined, and eight houses in the latter, including one of two that had had fever. Few of the houses were found with their drainage arrangements conforming in all respects to the standard, but one particular defect characterised the great majority of those where there had been fever. This was an overflow pipe going direct into the sewer from a cistern that was usually placed in a very confined situation under a bed- room floor. In the Howard-road this arrangement was seen in eight houses, the cistern furnishing more or less of the drinking-water in the case of seven of them and in six out of these seven there had been fever. It was not seen in the five other houses, only one of which (having a stinking water-closet) had had fever. In the Birchanger-road this particular defect was witnessed in two houses only out of the eight visited and one of the two had had a case of fever ; the houses where there was no such arrangement had escaped. (Facts as to the second fever house were not obtainable.) Other ways less direct than the foregoing by which excre- mental products bearing with them the contagium of enteric fever have produced the disease will immediately come under review. But there can, I think, be no doubt that the chief way in which enteric fever spread last year in Croydon was the most direct and commonplace way of all — viz., by the escape of infected air from the sewers and its inhalation by persons susceptible of the disease. " And he adds the following very definite and very important statement : ' ' The great intensity and simultaneousness of the fever epidemic over Croydon should be no hindrance to the acceptance of this view. Where sewers are small and ill-ventilated they constitute perfectly sufficient means for the rapid distribution of fever infection, and places having such sewers may not only show fever-rates maintained as high as before the sewers were made but they may show as smart outbursts of fever as are witnessed where conveyance through water or milk is in question. Croydon itself after it had made its sewers and before it attempted to ventilate them had this experience. So in other instances that have come under my personal knowledge fever has maintained itself after pipe-sewers, ill-ventilated, had been laid, as in Rtigby> Carlisle, in Chelmsford, in Penzance, in Worthing, in the last two places breaking out in severe, sudden, and diffused epidemics without there being any question of other 112 distribution than by sewers. And my personal experience is confirmed by that of others. Towns with larger sewers have not appeared to have had the same suddenness of out- break when spread by means of sewer air has been in question. In them the evil influence of sewer infection is more gradually manifested, as might be expected from the different physical circumstances of the two kinds of sewers. " ' ' While I admit for the most part the sewers of Croydon are well adapted for the removal of liquids and solids, they appear to me to be adapted, when infected by fever excre- ment, to facilitate the passage of infection into the vicinity of houses. The air of the sewers is, as it were, ' laid on ' to houses. It is arranged that every house drain and every house soil-pipe shall contain, up to the very wall of the house and up to the very trap of the water-closet, the common air of the Croydon sewers, not simply charged with impurities it may receive from the particular house but charged also with any dangerous quality that it may have brought from other houses ; for hardly anywhere in Croydon can there be found an arrangement for severing the sewer air from the air of the house-drain. So that wherever drain air has entered a house, no matter by how inconspicuous a defect and no matter whether it has given rise to stink or not, it has been the air of the common sewer, and this was throughout 1875 charged to an intense degree with the infection of enteric fever. " After showing that there was ' ' no ground for suspecting that milk has played any part in the epidemic " he gives a number of instances to prove that there were many local contaminations in parts of the water service and continues : " The evidence here adduced respecting the entry of foreign matters into Croydon water-pipes is independent of any view that may be taken as to the mechanism of their entry. Of this mechanism it is difficult for me to speak with any con- fidence, inasmuch as, even to engineers, the physical conditions of the passage of liquids along tubes are not universally known. It is clear that at Croydon there are some very awkward relations between sewers and drains on the one hand and water pipes on the other. First, the valves through which the sewers are flushed are direct openings from water mains closed by a diaphragm that is liable to leak, and through which it is, to say the least, conceivable that matters may pass from the sewer into the water-pipe on occasions when the water- service intermits. Secondly, the branch mains in particular streets and still more often the service-pipe of particular houses, sometimes lie in the same trench with sewers or house drains ; and it is suspected that in places both may be leaking. Thirdly, hundreds of water-closets are served direct from water mains by mere taps on the service-pipes without any interposition of cistern or other safeguard. Duriag times of full water pressure in the pipes these communications may not be hazardous, though 118 as pressure may be taken off a water-pipe by making an opening at the further end of the pipe ev^en more efficiently than by a partial closing of the calibre of the pipe, and as the object of these pipes is to have their further ends opened there is little safety in this consideration. It is no doubt mainly at times of intermission of water service that there arise the physical conditions under which suction of matters from without may take place into the water-pipes, but I have no reason to believe that such accident can take place only at those times." But he finally concludes " that water pollution played a viuch less considerable part than mas played by infection delivered from the sewers directly into the air of houses. " (Report of the medical officer of the Privy Council and Local Government Board, New Series, No. VII., for 1875.) This report of Dr. Buchanan's is especially interesting as in a note to it there are what I believe to be the first diagrams of a disconnecting- trap on a house drain. These are so interesting and important that I have thought it worth while to reproduce them. Dr. Buchanan's remarks about them are as follows : — " For the purpose of making the separation between the air of public sewers and of house-drains, an arrangement of the sort figured in the subjoined Diagram II. may properly be substituted for the existing arrangement which is shown in Diagram I. ' ' Under proper conditions of the public sewers, the trapping bend (f) will keep away from the house all air of the common sewer system, and a few houses in Croydon have recently been provided with such a trap. It is most desirable, how- ever, that with every such trap on a house drain there should be associated a ventilator as shown at g. ' ' Such a ventilating opening serves three purposes, (1) if the trap (fj be ever forced by pressure of air in the public sewer, an immediate exit of the sewer air away from the house is afforded ; (2) a continuous ample ventilation of the house drains is provided, — without such opening the pro- longed soil pipe merely affords relief to concentrated and urgent drain air ; and (3) a means for inspection of the trap (f) is provided, and a way to clean it out if ever it should become choked. It may be observed in Diagram III. the drain from the house to the trap is represented as on a higher level than the drain from the trap to the sewer, a longish piece of sharp slope just before the trap being thus obtained. With this contrivance and in duly proportioned drains stoppage in the trap is not to be greatly apprehended ; and, as before said, if it should occur, it can at once be detected and removed. ' ' The arrangement here shown isolates each set of house drains into a wholly distinct system as shown by the double lines in Diagram II. Even if there should be a little smell from the opening (g) it can only be derived from matters that have passed into the drain from the house, and cannot have any in a, Public Sewer. b. Ventilating shaft of the Public Sewer, habitually more or less blocked by char- coal trays, a, c, House drain. li, Ventilating pipe of house drain, now habitually too small and requiring to be of the full calibre of the soil pipe. e, Edge of house precincts. /', Trap, and gr, ventilator; shown of larger size in Diagram III. 115 fever infection with it, unless there be fever in the house itself. But in effect (I speak from experience of the arrange- ment under its most difficult conditions) there is seldom any smell whatever from this opening («;), for when the drains are in good order it habitually acts as an inlet for air that goes up the ventilating pipe (d) by the side of the house ; i the drains are not in good order, there may be smell from this lower opening, and such smell should be welcomed as an indication (otherwise wanting till ill-health occurs) of some- thing about the drains requiring amendment. "I, of course, leave constructive details to others, not professing to define the mechanical arrangements by which the principles here set forth may be fulfilled. " It ought to be no objection to this arrangement that the house-drain ventilators (d) can no longer serve for the ventilation of public sewers. It is not the business of house- holders to ventilate public sewers ; that is the affair of the authority in whom these sewers are vested. In Croydon the direct connexion between public sewers and the pipes that run up the sides of houses is not only dangerous to the houses, but in relation to public sewer ventilation, the arrangement is little more than a sham." Dr. F. R. Blaxall reported that in Truro in 1874 an out- break was caused by ' ' entrance of foul air from the sewers into houses. " Dr. Ballard reported in 1876 on enteric fever at the West Riding House of Correction. He says : ' ' Interior of prison polluted by sewer air in consequence of faulty construction of sewers and drains. Infection probably spread by the use of infected earth supplied to earth-closets." In the seventh report of the medical officer of the Local Government Board for 1877 is an abstract of a report by Dr. Blaxall on an epidemic of typhoid fever at Padstow in Cornwall, " associated with specifically infected sewer air" — "sewers very insufficiently ventilated and unprovided with means for flushing. " In 1880 Dr. Blaxall reported on an epidemic of typhoid fever in the Urban Sanitary District of Melton Mowbray in connexion with the sanitary condition of that town. He gives a table showing the incidence of the fever on various streets and adds : '♦ It will be observed from this table that on three or four occasions there was a simultaneous appearance of cases in several streets, indicating some cause in special operation over an extended area Thus it soon became pos- sible to exclude, a.« being primarily concerned, two of the ordinary means of fever propagation — viz., polluted wells and unwholesome privies, the injurious effects of these being limited to persons living in their immediate vicinity or otherwise exposed to their circumscribed operation. In the Melton Mowbray epidemic the invaded families resided in various parts of the town, getting their water from different wells and frequenting different privies. Again, there was no community with regard to milk, some of the infected 116 families not drinking milk at all, others getting it from various sources. On the other hand, the circumstances of the outbreak reflect grave suspicion wpon sewer air as having been mainly concerned in the ^read of the disease. It was found that the several streets which experienced the chief incidence of attacks occupy a portion of the town traversed by one particular line of sewers, and with this line of sewers were connected the houses in which the initial cases occurred and from which, as already explained, the sewer had certainly become con- taminated with the specific material of the fever. This suspicion receives confirmation from the fact that all the individuals attacked were found ic have been peculiarly exposed to the influence of air escaping from drain inlets or closets. Thus, excluding the initial cases, 23 out of the 36 families had untrapped drain-inlets close to their dwellings ; nine had imperfectly trapped inlets which were so offensive that the people used to throw chloride of lime down the drains to stop the stink. Besides this home exposure to the injurious effects of sewer-air the opportunity of similar danger incurred at schools cannot in the case of 14 children be entirely overlooked. Hence it is apparent that out of 36 infected families 32 were exposed to the influence of sewer- air through the medium of untrapped inlets to drains. The remaining four had closets situated out of doors but un- provided with means for flushing — an arrangement conducing to the escape of sewer-air into the closets owing to the traps not being kept duly filled with water. Moreover, the traps of the drains from these houses (like the other 32) were more or less defective " (Eleventh annual report of the medical officer to the Local Government Board, 1881-82). The prevalence of typhoid fever in the city of York in 1884 was attributed by Dr. H. Airy to sewer air for the following reasons, which I quote verbatim. ' ' The hypothesis that the fever outbreak was caused by sewer exhalations appears to explain the partial distribution of the disease, for the cases in the Micklegate district were almost entirely confined to the area of the Mount sewer, and those on the other side of the river were mainly confined to the Waringate district — that is to the area of the Foss sewers. Moreover, the com- parative isolation of the Hungate group agrees with the fact that Hungate forms a distinct subarea of the Foss sewer district. The greater prevalence of the fever in the Mickle- gate district towards the mouth of the Mount sewer may conceivably be explained by the early occurrence (in February, May, July, and August) of a number of typhoid cases, one of which, imported from Edinburgh, probably introduced new blood (so to speak) into the strain of infec- tion in that line of sewer. The simultaneous infection in Clementhorpe and Layerthorpe in August admits of explana- tion, I think, only by the state of the sewers, connected as they are below by the river which receives their outfalls, above by the atmosphere with its seasonal vicissitudes." 117 After considering the suggestion that the fever was spread by a pollution of the ground air and dismissing it because the polluted soil was not in any way specially characteristic of the dwellings in which fever appeared he says : "In conclusion, though under these complicated conditions there is much room for doubt, I am disposed to refer the recent prevalence of typhoid fever in York to exhalations from the ill -ventilated sewers under the influence of an exceptionally dry and warm season " (see also page 129). The following interesting account is given in Public Health, vol. i. , p. 319, of an outbreak of typhoid fever pro- duced by sewer air on H. M. S. Monarch and described in the Medical Statistical Returns of the Health of the Navy for 1887 : ' ' There were four cases in all ; three of these appeared to have been undoubtedly attributable to the berth alongside the New Mole at Gibraltar which was occupied by the Monarch in January — a situation to which sanitary objections have often been raised. The observations of the medical officer (Fleet-Surgeon Maxwell Rodgers, M.D.) are as follows : ' The Monarch arrived at Gibraltar from Lisbon on Jan. 18th and was moored alongside the New Mole at a point nearest the dockyard, where she remained till Jan, 24th, when she left for Port Mahon. Near the south corner of the dockyard and but a short distance from where the ship was moored one of the main sewers of the town empties itself into the sea. During the stay of the Monarch at the New Mole a strong wind, which increased to a gale on Jan. 21st, blew in a direction from the opening of the sewer in ques- tion towards the ship. A most offensive and sickening smell was complained of by those on board, so much so that some of the officers were obliged to shut their cabin ports in con- sequence. I am informed that frequent complaints have been made for years past of the insanitary condition of this part of the harbour and that cases of fever have from time to time occurred on board ships moored there and I have no doubt that the noxious emanations from the sewer referred to are quite sufficient to account for the three cases of enteric fever which occurred. Condensed water had been used for drinking and cooking purposes.' The first case occurred on Jan. 22nd, the second on the 29th, and the third on Feb. 6th ; this last case was in the person of a young officer who died in the military hospital at Gibraltar. The fourth case occurred at Lisbon in April ; the patient, an officer, had visited Oporto. 'Fleet-Surgeon W. D. Wodsworth, the medical officer of the Minotaur, also ascribes two out of the four cases that occurred in that ship to the influence of the same sewer at Gibraltar. He adds that ' its mouth had been damaged so that it was uncovered at low water, ' and that he has since heard that ' later in the year [this was in May] some cases of fever occurred among the men of the Rifles who on alternate days supply the Mole guard and were subject to similar conditions, so much so that the guard was discon- tinued for some time and the drain was mended. ' Two men 118 of the Minotaur were invalided for the disease. " For another case of spread of the disease by sewer air see note on Dr. Wheaton's report on Mold, under heading, ' ' Ground and Ground Water " (page 124). In 1889 Dr. J. Ashburton Thompson, chief medical inspector of the Board of Health of New South Wales, submitted a report on an outbreak of typhoid fever in the municipalities of Newtown and Macdonaldtown in which he cites cases produced by sewer air, one being produced by the air of an o^en sewer described as follows ; — "Over an open sewer in Redfern stood an hotel ; there was nothing between the stream of sewage and the air of the house except ordinary joists and ordinaryflooring boards which bridged the channel. This open ditch received drainage from the neighbourhood of Well Street, Redfern, taking its origin indeed near " a house where there had been a case of typhoid fever in April. ' ' The tenant, after he had been in occupation no more than nine weeks, reported that a lodger had recently been removed to hospital with typhoid fever and that his daughter, aged 11, then lay ill with the same disease (May, 1886). He also said that he had learned that the tenant before him had recently lost a son there from typhoid. He complained of the smell of the sewer which in favourable states of weather filled the house during the day and always filled it when it was closed for the night. How many other cases may have arisen among casual lodgers in this house of public entertainment there are no means of knowing. " An outbreak of 35 cases of typhoid fever occurring at the Foundling Hospital from Oct. 6th to Dec. 14th, 1891, was investigated by Dr. J. F. J. Sykes, medical officer of health for St. Pancras. He found that faecal matter from a soil-drain was washed back by the discharge of a flush-tank into a grease-trap into which a discharge pipe from cooking coppers also discharged above the water level, so that the grease-trap acted as an incubator and infected air from it got access to the coppers and to the kitchens ; hence the girls employed in the kitchens were mostly attacked — 33 girls, two boys. (Special Report and Public Health, vol. iv.) I may mention in this connexion that while investigating the causes of an outbreak of cases of diarrhoea and sore-throat at the Hos- pital for the Paralysed and Epileptic I found that the steam escape-pipes from the cooking ovens were connected with a pipe which joined the ventilating-pipe of a soil-pipe, which also acted as ventilator at the head of one of the main drains, so that when the ovens were cooling foul air from the drains was drawn into them and so into the kitchens. As instances connected with the washing of clothes I may cite the following. In November, 1900, Dr. R. W. John- stone, in a report upon an outbreak in Nuneaton and Chilvers Coton Urban District, says : ' ' One case was traced with a good measure of probability to infection derived from the washing of clothes soiled by a fever patient. " At University College Hospital in 1900 an outbreak of 119 typhoid fever occurred among the nurses. I found that it was due to their having been supplied, during the alterations occasioned by the rebuilding of the hospital, with water from a tap which had been newly fixed over a sink in the pantry of their temporary dining-room, this tap having been con- nected by the plumber with the nearest water-pipe, which happened to be one from a cistern in the water-closet of a ground-floor ward supplying the taps over the vats in which the typhoid linen was placed before being disinfected and washed. When the cistern in question was emptied and cleaned the taps were left open and the typhoid poison obtained access to the pipes and cistern and contaminated the water which next came into it. This is an instance of what Dr. G. V. Poore has called, in his interesting paper read before the Royal Medical and Chirurgical Society on Nov. 23rd, 1897, " pollution at the periphery." Dr. J. Priestley, medical officer of health of Lambeth, reported in 1900 on an outbreak of typhoid fever limited to three streets. Clothes soiled by urine and faeces of enteric fever patients had been mixed with other people's clothes at mangling houses (The Lancet, Nov. 3rd, 1900, p. 1289). This outbreak is part of the same one which Dr. W. H. Hamer referred to fried-fish. It is quite possible, however, that both causes may have been at work in the parish. Dr. Renon (Paris) found that the intensity of typhoid fever in a ward next to a creche (to which mothers with their infants were admitted) was miicli increased. His explanation was as follows : "Various forms of enteritis are common in the creche and despite every care it is only natural that the different organisms of infantile diarrhoea exist in enormous numbers both in the creche and in the adjoining ward. Probably, therefore, typhoid patients suffering from typhoid fever are infected secondarily by microbes from infantile diarrhoea " (The Lancet, Nov. 10th, 1900, p. 1389). We now come to the important question of the connexion between the ground and ground-water or subsoil-water with the spread of typhoid fever. In 1856 Professor von Pettenkofer of Munich, having failed to establish any connexion between the prevalence of either cholera or typhoid fever in that city with the drinking-water, com- menced his observations on the variations in level of the subsoil water, and he came to the conclusion that the outbreaks, both of cholera and of typhoid fever, occurred during the fall of the subsoil water after con- siderable rise, and this is graphically shown on the chart which he prepared, a copy of which has been kindly lent to me by Dr. C. Childs. His opinion was that for an attack of one of these diseases three things were necessary — first, the poison of the disease ; secondly, a polluted subsoil ; and third, ground water falling after a rise. An excellent summary of his views will be found in a paper by Dr. Childs in vol. xvii. of the Transactions of the Epidemiological Society, and a copy of Pettenkofer 's Chart in vol. xx. of the same. 120 Professor von Pettenkofer was so impressed with the immunity of the city of Lyons from cholera, which disease, although it has been introduced several times, has never spread there, that he wrote a paper accounting for this by his ground- water theory, but it must be remembered that typhoid fever was formerly extremely prevalent in that city, whereas by the same theory it ought to have been rare. My belief is that the immunity of Lyons from cholera is due to the fact that the poison has never got at the drinking-water, but that typhoid fever formerly spread there, and sometimes to an enormous extent, on account of the very defective sanitary arrangements, and especially the fact that the cesspools were under the courtyards of the houses and ventilated into the water-closets in the suites of rooms, there being no traps under the basins of the closets, such a method of infection being not only possible but frequent in the case of typhoid fever but being unknown in cholera. Dr. Buchanan, in a paper which he read before the Society of Medical Officers of Health in the session 1869-70, stated that in his opinion the evidence obtained by Pettenkofer ' ' told in an opposite direction ; the question is of two diseases which are more than any others commimicable by excremental matter in drinking- wat^r and it is just when soil water is sinking that wells sunk in various soils will furnish impure supplies. The presumption, then, is that the incidence of cholera and enteric fever with sinking soil water is directly operative through the drinking-water supplied by wells. " In support of this view Dr. Buchanan's experience furnished him with numerous instances of towns where, a water-supply from external sources having been previously obtained, works which had for one effect a con- siderable lowering of the soil water were undertaken without any outbreak of enteric fever. While admitting Pettenkofer's theory that subsidence of soil water is a condition favourable to the prevalence of enteric fever he would add this qualifica- tion ' ' where the supply of drinking-water is derived from the soil on which it stands. " But the decrease of typhoid fever in Munich under von Pettenkofer's advice was so remarkable, as seen by a table also kindly lent to me by Dr. Childs, that it requires special attention. This diminution was produced by the purifying of the subsoil, by making cesspools watertight, by extending the system of sewerage, and, finally, by the sudden abolition of the 800 slaughter- houses in the city in 1878. It is quite obvious that purifica- tion of the subsoil must have been attended by considerable purification of the water of the wells by which the town was supplied ' ' until 1883, three years after the epidemic waves had ceased when the high land water-supply was introduced. This supply has gradually been distributed to the whole city." I cannnot help thinking that the drinking water in Munich had more to do with the prevalence of typhoid fever there than Pettenkofer thought was the case. In the tenth report of the medical officer of the Privy 121 Council (1867) is an account of Dr. Thorne Thome's investi- gation of an outbreak of typhoid fever at Terling, in Essex. This was an epidemic which Sir John Simon describes as follows: ''The epidemic at Terling, in Essex, was one of extraordinary dimensions. In that village of only 900 inhabitants, and for the most part within a period of two months, fully 300 persons were attacked with typhoid fever and 41 of the number died. That is to say, the one prevent- able disease in that short time killed a larger proportion of the population than all causes of death put together ought to have killed there in two years. The conditions which ren- dered possible this most calamitous visitation of disease were, as in all our other experience, conditions of local filth. At Terling such conditions were at their worst. Bound what pretends to be the house accommodation of the tillers of the soil in Terling (a scanty, overcrowded supply of dwellings of the meanest description) every possible source of pollution for air and water was accumulated ; the peculiar porous soil which underlay all this filth was, of course, continuously absorbing it ; the water-supply of the population was derived from wells, most of them sunk m that excrement-sodden sponge of earth. Some 10 days before the outbreak of the fever, after an extraordinary period of drought, a sudden great rise in the water level of the wells was observed, and this, of course, denoted a long-delayed scouring of that foulest soil into the water-supply of the now poisoned popula- tion." Dr. Thorne Thorne remarks in his report : ' ' The general tendency of the evidence which I obtained is to the effect that the water-supply of Terling was the great infective influence and it will be observed that some of the following cases not only conduce to that general conclusion but also seem very definitely to connect the outbreak of disease with a particular change in the level of the surface (subsoil) water. Everywhere I was informed that the water in the wells had gradually sunk during the latter part of the summer and autumn ; in the shallow ones this had been unmistakeably seen, in some of the deep ones I found that the rope holding the bucket had to be let out to an unusual length, and in one instance I was told that after the latter had been lowered into the well such was the scarcity of water that it had to be oscillated to and fro in order to get any in. The date at which the water reached its lowest point varied according to the altitude on which the well was placed and also to its depth. One had been empty two months preceding my visit, a second three weeks ; in others the water had been gradually sinking until the latter end of November. Following this drought came a sudden flow of water into all the wells and this, I was informed, cook place about three or four weeks before I arrived at the village. In three cases, however, I was enabled to ascertain the exact period of its occurrence and thus to trace out the connexion which it bore to the disease. " 122 Shortly after the water rising again in these wells the out- break of fever occurred. In explanation of this Dr. Thorne remarks : "It is evident that for years the land springs supplying the village must have washed the foul materials which had soaked through the ground into the wells> although, owing to the water being very abundant, the con- taminated solution thus formed was very much diluted. In connexion with this I would call attention to the statement which I have made to the effect that typhoid fever had existed in Terling for at least five years. Recently, how- ever, although the soakage of filth into the ground has been going on there has been a deficiency in the water-supply. That filth must have accumulated until the rising surface water took place, when the whole would naturally be washed from the surrounding ground into the wells and thus give rise to an intensely saturated solution. Great interest, there- fore, attaches to the etiological relation which exists between this very severe outbreak of typhoid fever and the state of the water-supply, and it deserves the more notice because the facts observed are not in accordance with those noticed in Munich by Professor Buhl of that city, for the outbreak of the disease did not coincide with the period that the wells were low, but, on the contrary, dated from the time when the water was regaining a high level." (Tenth Report of the medical officer to the Privy Council for 1867.) Professor Buhl states that with the fall of the ground water typhoid fever makes its appearance in Munich, and that the magnitude of the outbreak depends upon the rapidity of the fall, but that when tne water again rises the fever disappears, and this quickly if the water rises quickly, slowly if the reverse occurs {Zeitgchrift fiir Bwlogie, vol. i.). My friend, Professor Dr. F61ix Putzeys, of Li6ge, has kindly sent me a copy of a report on an epidemic of typhoid fever which occurred at Liege in 1882-83. The outbreak was generally spread over the city, even in many of the best houses. After a careful inquiry the conclusion was arrived at that it was due to infection of the soil by numerous dejections of typhoid fever patients every year and that the germs were transported by the air into houses in the form of dust. The disease was especially spread in houses where the streets are the least cleanly and where the interstices between the stones are wide. Of 30 workers on the pave- ments no less than 10 had suffered attacks of typhoid fever. Although some of the wells were no doubt contaminated by leakages from cesspools the epidemic was so general that it could not be accounted for in that way. Sir Charles Cameron attributes the prevalence of enteric fever in Dublin, which city has an excellent water-supply, to foul subsoil, as he considers that defective sewers and drains, many of which, moreover, have been replaced by sound ones, are not sufficient to account for the unusual prevalence of disease in that city. To quote from his own report on the etiology of typhoid fever : • ' The zymotic death-rate has 123 greatly declined but still typhoid fever more than holds its own. I can only account for this by assuming that the microbes of the disease have established themselves in the soil, that they multiply therein, and that they issue occa- sionally from it into the atmosphere, which consequently becomes infected. It is only in this way that we can reason- ably account for the periodic character of the disease, for its seasonal intensity, for its epidemics In the soil there- fore we must look for the cause of the endemicity of typhoid fever in Dublin and in other places. This theory is greatly strengthened by the fact that the porous soils are to a much greater extent likely to be the habitat of the organism than the stiffer clays. The conditions of existence for all kinds of organisms are more favourable in loose soils than in adhesive dense clays in which air cannot freely circulate. The action of strong winds and the rising and sinking of underground water more readily cause movements of air in gravels and loose soils than in clays, and the escape of microbes from the former under such circumstances must the more freely occur. The streets of Dublin have lately been to a large extent paved with stone setts, which circumstance may, perhaps, account to some extent for the increase of typhoid fever. The underground air cannot now diffuse into the atmosphere over the roadway, and therefore may be drawn in larger quantities into the houses, the basement floors of which are rarely concreted. " In his annual report on the public health of Dublin for 1891 Sir Charles Cameron gave a map showing the dis- tribution of 1988 cases of typhoid fever in that city. He pointed out that on gravel soil the ratio of cases to the population was 1 in 92-8 and on clay 1 in 145-3. Thus the disease is much more prevalent on gravel, as is usually the case. He expresses his belief that these facts appear to show that the organisms that produced typhoid fever escaped into the air more readily from the gravels than from the stiff and usually moist clays. In a very interesting, though short, report on typhoid fever at Lawrence, Otsego County, New York, in 1891, the cause of the outbreak was described as follows : ' ' We have an epidemic of sudden development, lasting through two months, occurring now at one village and now at another, without a central focus. It occurred in a place having no common source of water-supply, no common system of drainage, and no common distribution of milk or other article of food. It appeared upon an infected site, one in which the disease is regularly recurrent and endemic, and in a locality where typhoid fever is common, other epidemics of severity having within a recent period occurred in neighbouring communities. The factor which determined this fulminant outbreak does not appear upon the surface. That it was one of general applica- tion is evident. The only one that can now be cited is in connexion with the soil water and the influence upon it of 124 the unusual drought. This has been sufficient to cause the wells to be low, some of them failing entirely. It is under this condition that the germs dormant in the soil are found to develop into activity. They were supplied from pre- existing cases of past seasons. There is good reason to believe that soakage of these into independent wells, under conditions of soil and of a season of the year especially favour- able to developing them, effected a widespread infection of the sources of water-supply and so produced the general and simultaneous occurrence of the disease. That the so-called 'ground theory' of the origin of typhoid fever thus finds expression — by infection of wells over an extended area rather than by pollution of the atmosphere — will, I believe, come to find acceptance." (Thirteenth Annual Report of the State Board of Health of New York.) In the eleventh volume of the reports and papers of the American Public Health Association for 1886 Dr. C. A. Lindslay, secretary of the State Board of Health of Connecticut, New Haven, gives an account of an outbreak of typhoid fever at Madison, in that State, in September of that year, of which he says : ' ' Indeed, nothing has been found bearing upon the special etiology of this outbreak except an unusually low elevation of ground water. To so marked a degree has the water level fallen that nine-tenths of the wells in the vicinity of the epidemic became dry. This is a measure of drought very much exceeding any previous drought within the memory of the old residents." Dr. J. Jamieson, medical officer of health of Melbourne, maintained at a meeting of the Australasian Association for the Advancement of Science that foulness of the soil from want of a sewerage system had much to do with the great prevalence of typhoid fever in Melbourne (The Lancet, March 24th, 1900, p. 891). In 1894 Dr. Wheaton reported on the prevalence of fever at Mold, Flints. This was a remarkable outbreak from the fact that ' ' the occurrence of multiple attacks in households and the association of the outbreak of fever with circum- stances of privation among sufferers had suggested the possibility of the disease in question being tjrphus fever. On inquiry it was found to be typhoid fever. The fever had in all instances occurred in houses where unwholesome con- ditions existed, chief among which was the contamination of the soil around the dwelling by the soakage of filth from open midden steads and from defective drains. The fever was not spread by means of water or milk, but in some instances probably by emanations from defective sewers, in others by means of privies which had become infected by the excreta of sick persons ; in others, again, by contagion within households." In 1895 Dr. G. S. Buchanan reported on the sustained prevalence of typhoid fever at Wycombe Marsh (Bucks). There was no evidence that it was spread by milk or other food. There was no common sewer or public water-supply 125 in the village. The outbreak was not traceable " to water from any one well or group of wells, or to contamination of wells in different parts of the village from any particular cesspool or cesspools," but, on the other hand, there were "indications of specific pollution of the whole body of ground water which supplies the wells of the village. " In 1896 Dr. Bulstrode reported on the continued pre- valence of a mild type of typhoid fever at Chichester, Sussex, after the inauguration of a new drainage system and a public water-supply. Dr. Bulstrode showed that the out- break was not due to the new sewerage or water-supply, as ' ' prior to the introduction of either of these new conditions enteric fever prevailed in a very pronounced fashion in Chichester" and "the localities mainly invaded during 1896 were those which have been r&peatedly invaded in former years." The evidence showed that '■'■polhition of the soil by defective privies and cesspools had operated as principal cause of the endemicity of enteric fever " (Twenty-sixth report of the medical officer to the Local Government Board). In the same year Dr. Bruce Low reported on the continued prevalence of the disease at Middlesbrough, North Eiding (Yorks), especially during the previous three years. This endemicity was attributed to the fact that there were ' ' over 3000 privy middens in the town in proximity to dwellings, a continual source of pollution of soil and air of the place, and affording favourable conditions for fostering of filthy diseases like enteric fever, Befoulment of the street surface during the process of emptying the middens constitutes continual source of danger. No suspicion attached to the public water-supply nor to the milk service " (see page 126). In 1896 Dr. Bruce Low reported on the sustained pre- valence of typhoid fever at Southend during many years. He found that there was no evidence of the spread of the disease by public water-supply or by milk service, but that " its persistence was associated with pollution of the porous soil, on which the town is built, by human excrement" (see also under heading " Oysters," page 102). In the Annual Keport on the health of the County Borough of Stockport for the year 1896 Dr. Charles Porter, the medical officer of health, sums up the result of his investigations of the behaviour of typhoid fever in that town during several years as follows : — "The chief causes of this disease in Stockport are: — ♦'1. Soil and ground air pollution by soakage of liquid filth from the many enormous foul privy pits which exist. " 2. Soil and ground air pollution by leakage of sewage from defective drains. "3. Infected dust and emanations from privy pits into which typhoid discharges have been thrown. " The evils of soil pollution are greatly accentuated by hot dry weather, and in the honest discharge of my duty I must 126 again record the opinion that the persistence of the tyiidden privy system in your town is a serious and C07istant source of injury and danger to healthy especially in hot weather." In 1897 Dr. Keece reported on the prevalence of "fever " at Aldborough, East Riding (Yorks). This was one of those interesting epidemics in which there were ' ' differing opinions as to the precise nature of the disease which was locally regarded both as Russian influenza and enteric fever. " It is reported that "the clinical symptoms point to enteric fever." The first person attacked lived on the highest point of ground in the village. The source of the infection was not traced ; nine houses were invaded : 28 persons were attacked and one died. Also a visitor to one of the invaded houses developed a similar disease on her way home and died. The houses were invaded at varying intervals extending over a year. ' ' The order in which these houses were successively attacked followed the direction in which the underground water may be expected to travel from the first house invaded, which was, moreover, not free from the disease for a period of at least five months. A leaking cesspool at the first house in- vaded received slop drainage from the dwelling. The con- tents of the cesspool were used on the adjoining garden for manure, as also the contents of the bog-hole privy. The well which was sunk in gravel soil was five feet from the cesspool and 15 yards from the privy. Similar sanitary defects through- out the village. " In 1898 Dr. Theodore Thomson reported on the marked prevalence of typhoid fever during several years in the district of Swinton and Pendlebury (Lanes. ). He found that the death-rate from typhoid fever and continued fever during the 10 years 1888 to 1897 was " more than double that in the 33 great towns and two and a half times that of England and Wales during the same period." There was no evidence tending to incriminate water-supply or sewerage conditions. He, however, found evidence from the localisation of the disease that it was associated with filthy conditions such as "unpaved and ill-paved yards, defective house and yard drains and leaky privy middens, all being conditions con- dueive to serious fouling of the soil." Of this the chief medical officer, Sir Richard Thorne, says in his report : "Well-nigh every possible source of nuisance with which this midden-privy system can be associated has been allowed to grow up, but I would observe that in the face of the knowledge of which this country has been possessed during the past generation such a system must be regarded as nothing short of a relic of ignorance and barbarism which ought not any longer to be imposed on or permitted within civilised communities" (Twenty- eighth Report of the medical officer of the Local Government Board). In 1899 Dr. Theodore Thomson and Colonel J. T. Marsh reported on the conditions of the city of Chichester, Sussex, which "has on several occasions attracted attention by reason 127 of its liability to repeated occurrences of enteric fever in serious amount " and where Mr. Power, the chief medical officer, says that it "may be considered endemic." After investigating the conditions favourable to the spread of typhoid fever the inspectors said "In our judgment, hypothesis that the prevalence of enteric fever in serious amount in Chichester is referable to the existence there of soil conditions especially favourable to the viability and growth of the infective material of this disease is not inconsistent with the facts ascertained by us and set out by us in this report. But, on the other hand, such hypothesis, while not inconsistent with these facts, does not at present afEord adequate explanation of features that have characterised the fever in its distribution in time and place in Chichester. Fuller knowledge of soil conditions in their relations with fever prevalence may account for these features ; without that knowledge it is not possible to arrive at definite conclusion " (see also page 125). The most remarkable instance of the passage of typhoid poison a considerable distance underground occurred at the village of Lausen, near Basle, in Switzerland, and was inves- tigated by Dr. Hagler of Basle (Beutsohe Vierteljahrsschrift fiir offentliche Oesundheitspjlege, Band vi. , S. 154, and sixth report of the Kivers Pollution Commissioners, p. 463). In this previously healthy village, which had never been known to be visited by an epidemic of typhoid fever, and in which not even a single sporadic case of the disease had been observed for many years, an epidemic broke out in August, 1892, which attacked almost simultaneously a large propor- tion of the inhabitants. About a mile (viertelstunde) south of Lausen, and separated from it by the mountain ridge of the Stockhalden, lies the small parallel valley of the Furlerthal. In this valley lived a farmer, in a solitary farmhouse, who was attacked on June 10th by typhoid fever, just after his return from a long journey. A girl was attacked in the same house on July 10th ; and in August the farmer's wife and son sickened of the same disease. There was no communication, so far as could be ascertained, between the farmhouse and the village of Lausen. On August 7th, 10 of the villagers in Lausen were attacked by typhoid fever, and within the next nine days the number of cases had risen to 57, out of a population of 780 living in 90 houses. Within the first four weeks of the epidemic the -number of cases rose to 100, and at the close of the epidemic, at the end of the following October, 130 persons — or 17 per cent, of the inhabitants — were attacked, besides 14 children infected in the village during their holidays who sickened with typhoid fever after their return to schools in other places. Except in six houses which were supplied with water from their own wells the cases were pretty evenly distributed throughout the entire village and the above six houses were exempt from typhoid fever. This remarkable fact threw suspicion upon the public water-supply which came 128 from a spring at the foot of the Stockhalden ridge, which is probably an old moraine of the glacial epoch, and such a source might reasonably be regarded as above suspicion of pollution. Observations upon a brook in the Fiirlerthal Valley and of the spring at Lausen showed, however, that there was a direct communication between the two. Among the observations it was noted that whenever the meadows — below a hole spontaneously formed 10 years before by the giving way of the soil a little below the farmhouse — were irrigated with water from the Fiirler brook the volume of the Lausen spring became greatly increased within a few hours. This irrigation had been carried on during the summer, from the middle to the end of July, the brook being polluted by the typhoid dejecta of the farmhouse patients. It was in direct communication with the closets and dung-heaps of the infected house ; all the chamber slops were emptied into it and the dirty linen of the patients was washed therein. It was observed, also, that the water supplied to Lausen was at first turbid, acquired an unpleasant taste, and increased in volume. Three weeks or so after the commencement of the irrigation the epidemic began in Lausen. But Dr. Hagler did not rest satisfied with this evidence and made the follow- ing experimental demonstration of the correctness of the assumption that the epidemic was due to the pollution of the Lausen water-supply by the dejecta of the typhoid fever patients in Fiirlerthal. The above-mentioned hole in the Fiirler valley was opened and the brook led into it ; three hours later the fountains of Lausen gave out double their previous delivery of water. A solution of 18 hundredweight of common salt in water was now poured into the hole and soon the Lausen water was found to react more strongly for chlorides than before ; the chlorine reaction went on in- creasing and the proportion of saline matter in the fountains had increased threefold. All doubt as to the passage of water from the fever-stricken Fiirlerthal to Lausen being thus removed the question as to whether the water found its way through natural fissures or percolated through porous strata was attempted to be solved by carefully and uniformly diffusing two a half tons of flour through water which was then thrown into the hole. But neither an increase in the amount of solid constituents nor any turbidity of the Lausen water was observed to result from the addition. This experi- ment, however, in the face of the previously observed turbidity of the fountains whilst irrigation was going on in the Fiirler valley is hardly conclusive against the possibility of the water finding its way from Fiirlerthal to Lausen by natural conduits. Two things this interesting epidemic does, nevertheless, prove beyond doubt ; first, that animal excreta do not, when taken in drinking-water, produce typhoid fever ; and next, that typhoid excreta may, when introduced into a water-supply, induce typhoid fever in a distant community when the water in its passage is not freely 129 exposed to the atmosphere (Stephenson and Murphy on Public Health, Vol. I., p. 270). In Puhlic Health for February, 1902, is an important paper by Dr. Edmund M. Smith, medical officer of health of the city of York, on the Incidence of Enteric Fever in York and its Relation to Privy Middens. In this paper he states that for many years past typhoid fever has been endemic in the city of York. In 1900 there was an unusually heavy outbreak which ' ' emphasised the observations and expe- riences of previous years chiefly that the disease tends to occur in certain midden privy districts. " One particular district where there are midden privies and a polluted soil has been the first in the city to be affected in the summer during each of the last three years. It has been impossible to connect the outbreaks in any way either with water or milk, oysters or ice-creams. He suggests that besides the pollution of the soil the poison is carried about by flies and other insects and also by cats, mice, rats, and birds (see also pages 116-7). Improperly managed earth-closets have in the two follow- ing cases been considered to be the cause of outbreaks of typhoid fever. Dr. Ballard reported in 1875 that at the West Riding House of Correction typhoid fever was probably spread by the use of infected earth supplied to earth-closets (Report of the medical officer of the Local Government Board, 1875). I once traced an outbreak among the boys of a union school to improper storage of the com- post from the earth-closets which was in a very foul semi- liquid mass under a shed near which the boys (but not the girls) used to play ; there were no cases among the girls. I have already stated the opinions of some of the most eminent writers on the subject with regard to the question of the communication of typhoid fever directly from one person to another — that is, through the medium of the air — but I will now proceed to cite some instances in which the disease was evidently spread to a considerable extent by means of direct contagion. Dr. W. Budd in his admirable treatise already referred to gives a long account of an outbreak of typhoid fever which he investigated in the village of North Tawton in Devonshire, where he lived and was in almost exclusive possession of the field as a medical practitioner. In the first place he points out that in this village "privies, pig-sties, and dungheaps continued hour after hour to e^ale ill odours without any subsequent effect on the public health" and states that he "ascertained by an inquiry conducted with the most scrupulous care that for 15 years there had been no severe outbreak of the disorder and that for nearly 10 there had been but a single case. For the development of this fever a more specific element was needed than either the swine, the dungheap, or the privies were in the common course of things able to furnish. In the course of time, as was indeed pretty sure to happen, this element was added 180 and it was then found that the conditions which had been without power to generate fever had but too ^eat power in promoting its spread when once the germ of fever had been introduced. On July 11th, 1839, the first case of typhoid fever occurred in a poor and crowded dwelling. Before the beginning of November in the same year more than 80 of the inhabitants had suffered from it under my care," He then describes the course of the outbreak, showing quite clearly over and over again that one person contracted the disease from another. Later in his book, after having mentioned some other outbreaks and quoted various authors to prove that the disease is contagious, he refers to North Tawton again as follows : "About two years ago — i.e., in 1873 — after an interval of 30 years' almost entire immunity this town was again visited by typhoid fever. Meanwhile a water company had been established by means of which drinking-water, brought from a considerable distance in iron pipes, is delivered under high pressure to every inhabitant. Contamination of this water by human excreta is an absolute impossibility, and yet in these two outbreaks of typhoid the population suffered even more severely than before. In the course of a few months out of a population of 1500 persons 120 were known to have had typhoid fever and 11 of their number died. " He considers that in this and in some other epidemics which he describes ' ' the air was the great medium through which the infection passed. " His final opinion as to the relative importance of water and air as media for communication of the poison of the disease is stated as follows : ' ' The exact proportion which the cases caused by infected water bear to those caused by infected air is not easy to determine and probably varies much under different conditions of soil, climate, season, water-supply, social habits, and sanitary arrange- ments. As far as my own experience goes I can state that the worst and most widespread outbreaks which I have ever witnessed occurred in communities where the drinking-water was absolutely blameless. " In the twenty -fourth annual report of the State Board of Health of Massachusetts for 1882 Dr. William T. Sedgwick, after attributing the epidemics at Lowell and Lawrence to polluted water, reports on three epidemics in Bondsville, Provincetown, and Milleville, each of which he attributes to " secondary infection, " having excluded infection by means of water and milk. He gives a graphic account of the way in which the poison of the disease gets handed about, and says, "It is easy for me to understood how dirt, diarrhoea, and dinner too often get sadly confused. Personal filth is apparently the principal agent of secondary infection." Of the epidemic at Milleville he says, ' ' The high mortality was probably due not so much to the severity of the disease as to utter neglect and dire poverty. The local conditions were very bad, and the people were mostly very poor. The cir- cumstances favoured the spread of the disease by secondary 131 infection, and to that, in my opinion, the epidemic was almost wholly, if not entirely, due." As an instance of direct contagion I may mention that Dr. H. F. Parsons reported on an outbreak of typhoid fever at Bedlingtonshire (Northumberland) when there was endemic prevalence of the disease in a colliery district in 1889. He found that most of it was referable to " a case which occurred in a close, confined, and filthy part of Bedlington town. The disease first spread to other families living in tenements under the same roof and then in the neighbouring streets, where want of air-space, privy and drain nuisances, and general want of cleanliness prevailed." Dr. Parsons reported in 1892-93 on a severe but circum- scribed outbreak of typhoid fever which occurred at Newfield Moira (Leicestershire) extended over two months and was limited to two rows of houses. The first cases were possibly contracted in Burton- on-Trent. The spread of the fever was not due to polluted water or milk nor to defects of drainage or common use of privies but was ' ' probably due to direct contact with specific infection favoured by common use of wash-houses, foul state of unpaved yard, and careless habits of mining population. " In the same year Dr. E. D. Sweeting reported on an out- break at Temple Cloud, Cameley parish (Somerset). In this district the early cases were "associated with grossly un- wholesome circumstances of water-supply and excrement disposal," but the later cases were "probably directly infected from the earlier owing to non-disinfection of stools." (22nd Ann. Eep. Med. Oflf. L. G. B.) In 1889 Dr. J. Ashburton Thompson, chief medical inspector of the Board of Health of New South Wales, submitted a report on an outbreak of typhoid fever in the municipalities of Newtown and Macdonaldtown, in which he gave a number of "examples of the spread of typhoid by the pollution of air." In the first example a woman suffering from the disease introduced the poison to the cesspit of a certain house which was generally in a very insanitary con- dition and the disease spread among that family. On their removal to another house in another street, also in a very filthy condition, they conveyed the poison there and the disease spread in that family also. The second example was very like the first, the filthy surroundings of the house ' ' did not, as far as was ascertainable, cause disabling illness until the first case of typhoid fever had been produced by outside contagion ; when that patient had nearly recovered it began to spread through the household rapidly. " The other cases are somewhat similar. Dr. Sweeting reported in 1893 on a localised outbreak of typhoid fever occurring during the first four months of the year on the outskirts of the town at Amlwch (Anglesea). He found that there was no common water-, milk-, or food-supply, and no drainage, but that the "disease spread from an imported case amongst tenants 132 and visitors in the absence of proper nursing, isolation, and disinfection." (23rd Ann. Rep. Med. Off. L. G. B.) In 1895 Dr. S. W. Wheaton reported on a remarkable out- break of typhoid fever at Quarry Bank (Staffordshire). This outbreak was almost entirely confined to a small portion of the district and especially to one particular street. «'This marked localisation of the fever and the fact that it had in some instances affected nearly all the members of certain families, suggested the presence of some fever (e.g., typhus fever) more directly contagious from person to person than enteric fever. The fever in question was found to be undoubtedly typhoid fever. The water-supply was in most instances from draw-wells subject to pollution by leaking privies, defective drains, and by surface washings." The spread of the disease was ' ' probably in part due to polluted water, partly to privies which had become infected, and to personal contagion. " (The italics are mine. ) In 1895 Dr. H. T. Bulstrode reported on an outbreak occurring at Potterspury (Northamptonshire) which com- menced in July and was still continuing at the date of the report in November. The evidence pointed to "polluted well water as a very important factor in causation, though personal infection had probably considerable influence in the spread of the disease." (The italics are mine.) In 1895 Dr. G. S. Buchanan reported on the continued prevalence of typhoid fever at West Bromwich (Staffordshire) for several years. In 1895 there was a heavy incidence of the disease on three small areas widely separated one from another. The prevalence of the fever was ' ' referred to the many opportunities of local spread from patients or invaded premises afforded by sanitary defects and by want of isola- tion hospital accommodation." (25th Ann. Rep. Med, Off. L. G. B.) Dr. J. Priestley, the medical officer of health of Lambeth, in 1898 reported that in that parish in three instances typhoid fever was conveyed from person to person during nursing. In 1899 Dr. S. M. Copeman reported on an outbreak at Shirebrook village (Derbyshire) that the disease was ^'mainly spread by personal contact, though in addition there appeared reason for suspecting that the milk-supply was con- cerned in causing extension of epidemic. " In August, 1900, Dr. Copeman reported on an inquiry into the continued prevalence of typhoid fever at Shirebrook, in the Blackwall Rural District, on the borders of Nottingham- shire and Derbyshire. He found ' ' that the annual recurring outbreaks of typhoid fever in Shirebrook have been in large measure dependent upon the polluted condition of the subsoil in the lower portions of the village arising from the impossibility of securing efficient isolation in the cottages. In the newer colliery village, situated as it is on considerably higher ground, typhoid fever had not made its appearance before 1899. In this portion of Shirebrook also the disease was undoubtedly spread by personal infection, although in 188 addition question arose as to whether the consumption of infected milk may not have played a part in the extension of the disease." (29th Ann. Rep. Med. OfiE. L. G. B.) In his annual report for 1900 as medical officer of health of the London County Council Mr. Shirley Murphy gives the following cases of infection from one person to another in different districts in London: "Dr. Reginald Dudfield observed this in four instances ; Dr. Parkes shows the extension of the disease in Chelsea from one person of a family to seven others ; Dr. Sykes gives account of two households in St. Pancras, in one of which the first case of the disease was followed by six others, and in the second by nine others ; Dr. Newman connects directly or indirectly nine cases in Clerkenwell with one or other of three cases occurring among children attending the same Sunday school ; Dr. Bryett gives particulars of six series of such cases occurring in Shoreditch ; Dr. Kempster attributes a group of cases occurring in a street in Battersea to the same cause ; and Dr. Bond mentions two nurses who were infected while in attendance upon cases of the disease. " An important paper was read before the Epidemiological Society in 1900 as an introduction to a discussion on the Infectivity of Enteric Fever by Dr. E. W. Goodall, medical superintendent of the Eastern Hospital of the Metropolitan Asylums Board. Dr. Goodall, who has had exceptional opportunities of studying the disease, has come to the con- clusion that, contrary to the opinion of many high autho- rities, the view held by Bretonneau, Trousseau, Gendron, Piedvache, Budd, Sir Thomas Watson, and Dr. Alexander Collie, the former medical superintendent of the Homerton Hospital, that the disease is directly infectious from one person to another is the correct one. He insists on the frequency with which those in attendance on the sick catch the disease, produces a number of instances of this having taken place among the nurses of the Metropolitan Asylums Board Hos- pitals, states that "enteric fever has attacked the staff in the three newest hospitals of the Asylums Board — the Brook, the Park, and the Grove, " and adds : ' ' Concerning the 10 cases at the Brook Hospital Dr. J. MacCombie has kindly informed me that five of them occurred in the persons of nurses working in the enteric fever wards, including an assistant nurse who came straight from the Broughton Sana- torium where she had been nursing enteric fever patients, and who joined the Brook Hospital during the incubation stage of the disease, while of the other five, two were men whose duty it was to keep the floors of the enteric fever wards polished. With respect to the three cases at the Grove, the most re- cently erected hospital, I am indebted to Dr. J. E. Beggs for the information that they were two assistant nurses and a wardmaid, all of whom for nearly two months had worked in enteric fever wards. It was the duty of the wardmaid to carry the soiled linen to the tank." He agrees with Dr. Collie's opinion, "that if enteric fever 184 amongst the staff of a hospital is to be attributed to faulty sanitary arrangements, especially in connexion with the drainage, we should find the disease occurring more fre- quently amongst the patients who are not suffering from the fever than appears to be the case. " With regard to the fact that other patients do not, as a rule, catch typhoid fever from patients suffering from that disease (although I am satisfied that they occasionally do so), he points out that it is rare, even for typhus fever, which everybody deems to be highly infectious, to be caught by one patient from another in a fever ward, and he concludes : ' ' Personally I am strongly inclined to Bide with those who hold that enteric fever is much more readily and directly communicable than is commonly supposed. " In the discussion which followed, Dr. F. Foord Caiger, medical superintendent of the South-Western Hospital, stated that the contagiousness of typhoid fever to those ' ' who are in the daily administration of a fever hospital into which enteric fever is admitted has become a matter of conviction," and he stated that in the South-Western Hospital, ' ' in the course of nine years during which enteric fever has been admitted there, 23 members of the staff have contracted it and three of them have died. Of these 23 members every one was a nurse and, with one exception, every one of these nurses was nursing in the enteric fever wards. When you consider that the proportion of enteric fever nurses to the whole of the nursing staff is only like one in 15 this fact is very striking. " Dr. Bulstrode is of opinion that "the view is certainly gaining ground that enteric fever is more directly com- municable from the patients to the nurses and attendants than was formerly supposed." Dr. Alfred Hill and Dr. Niven, the medical officers of health of Birmingham and Manchester, are of the same opinion. The latter traced 53 cases out of 484 to direct infection, and says, "it is also necessary to remember that, given certain conditions, such as crowding in a household, typhoid fever is terribly infectious," and he gives three remarkable instances, one being that of a number of nurses in a public institution among whom it was introduced by one of their number and who took it from one another, as he was able ' ' at once to dismiss the water and milk and also any condition affecting the drainage of the wards." None of the patients in the institution took it, (^Public Health, vol. iv., p. 202.) Dr. P. Manby quoted an interesting instance of com- munication of typhoid fever from one person to another in a hotel ; and Dr. Franklin Parsons, the President of the Society, one of the medical inspectors of the Local Government Board, gave several instances in his own experience in which, after careful investigation, "personal communication seemed the only agency" to which the disease could be attributed ; and as the result 185 of his great experience Dr. Goodall says: "I am quite sure that those are wrong who teach as is evidently taught by the leading text-books that there is no risk in nursing typhoid fever patients and that there is no necessity for removing an enteric fever patient from his home to hospital." In fact, the result of this discussion showed that there was great unanimity of opinion, not only among the inspectors of the Local Government Board, but among medical officers of health throughout the country, that communication by direct contagion is a much more common cause of the spread of typhoid fever than is commonly supposed. We now come to the consideration of the actual poison of the disease. I will first give you Mr. (afterwards Sir John) Simon's views in his own words. He said in his supple- mentary report for 1873, ' ' While, however, thus far there is only the familiar case of the so-called common chemical pnson, which hurts by instant action and in direct proportion to its palpable and ponderable dose, the other and far wider possibilities of mischief which we recognise in filth are such as apparently must be attributed to morbific ferments or contagia, matters which not only are not gaseous, but on the contrary, so far as we know them, seem to have their essence, or an inseparable part of it, in certain solid elements which the microscope discovers in them — in living organisms, namely, which in their largest sizes are but very minute microscopical objects, and at their least sizes are probably unseen even with the microscope, organisms which, in virtue of their vitality are indefinitely self-multiplying within their respective spheres of operation, and which, therefore, as in contrast with common poisons, can develop indefinitely large ulterior effects from first doses which are indefinitely small. ' ' As, apparently, it is by these various agencies (essential and incidental) that filth produces ' zymotic ' disease, it is important not to confound them with the foetid gases of organic decomposition, and the question what infecting powers are prevalent in given atmospheres should never be regarded as a mere question of stink. It is of the utmost practical importance to recognise in regard of filth that agents which destroy its stink may yet leave all its main powers of disease-production undiminished. Whether the ferments of disease if they could be isolated in sufficient quantity would prove themselves in any degree odorous is a point on which no guess need be hazarded, but it is certain that in doses in which they can fatally infect the human body they are infinitely out of reach of even the most culti- vated sense of smell, and that this sense (though its positive warnings are of indispensable sanitary service) is not able, except by indirect and quite insufficient perceptions, to warn us against risks of morbid infection." And further, in the same report : "It must be remem- bered that gases on the one hand and the particulate 186 ferments on the other stand in widely different relations to air and water as their respective media of diffusion. The ferments, so far as we know them, show no power of active diffusion in dry air, diffusing in it only as they are passively wafted and then probably, if the air be freely open, not carrying their vitality far, but as moisture is their normal medium currents of humid air (as from sewers and drains) can doubtless lift them in their full effectiveness, and if into houses or confined exterior spaces then with their chief chances of remaining effective ; and ill- ventilated low-lying localities, if unclean as regards the removal of their refuse, may especially be expected to have these fer- ments present in their common atmosphere as well as, of course, teeming in their soil and ground water. Considerations like some which I have stated in regard of infective air apply equally to infective water. In the latter, just as in the former, the zymotic malignity is but indirectly and most imperfectly suggested to us by qualities which strike the common sense,^or by matters which chemical analysis can specify. As any un- brutalised sense of smell will turn with disgust from certain airs, so will it, and common taste and sight, be repelled by certain waters, and as the chemist can show certain foulnesses in the one, so he can show certain foulnesses in the other ; but these tests, it must always be remem- bered, are tests only of the most general kind. Confessedly they do not touch the corpus delicti, but only certain con- ditions to which it is or may be collateral ; and their negative findings are consequently not entitled to the same sort of confidence as their positive. Chemical demonstration of unstable nitrogenous compounds in water is a warning which of course should never be disregarded ; but till chemistry shall have learnt to identify the morbific ferments thena- selves, its competence to declare them absent in any given case must evidently be judged incomplete, and waters which chemical analysis would probably not condemn may certainly be carrying in them very fatal seeds of infection. " Mr. Simon continues : ' ' Since the year 1849, when Dr. (now Sir William) Jenner made known his conclusive and masterly discrimination of this specific form of fever, successive studies have tended with singular uniformity to connect it in regard of its origin with nuisances of an excremental sort. ^ In illustration of that fact in the natural history of enteric fever I may refer to an abstract which I append of the experience of the Medical Department during the four years 1870-73 in this particular branch of disease- production, and such illustrations might be multiplied to any desired extent. The experience is, not only that privies and privy-drainage, with their respective stinkings and soakings, and the pollutions of air and water which are thus produced, 1 " The very able writings of Dr. Murchison, dating from a paper by him in the Medico-Chirurgical Transactions of 1858, have been of particular influence in that contention." 187 have in innumerable instances been the apparent causes of outbreaks of enteric fever, but, further, that they have seemed capable of doing this mischief in a doubly distinctive way ; first, as though by some aptitude which other nuisances of organic decomposition, though perhaps equally offensive, have not seemed equally or nearly equally to possess ; and secondly, as though this specific property, so often attaching to them in addition to their common septic unwholesomeness, were not, even in them, a fixed property. The explanation of this experience, the explanation of the frequent but not in- variable tendency of privy nuisances to infect with enteric fever, has seemed to consist in the liability of such nuisances to carry with them, not invariably, but as frequent accidental adjuncts, the 'specific' contagium of any prevailing bowel- infection, for presumably the privies of a population receive (inter alia) the diarrhoeal discharges of the sick ; and it has long been matter of fair pathological presumption that in any 'specific ' diarrhoea (such as eminently is enteric fever) every discharge from the bowels must teem with the contagium of the disease. Medical knowledge in support of this presumption has of late been rapidly growing more positive and precise, and at the moment of my present writing I have the gratification of believing that under my lords of the Council it has received an increase which may be of critical importance in a discovery which seems to give us for the first time an ocular test of the contagium of enteric fever ; in the discovery, namely, of microscopical forms, apparently of the lowest vegetable life, multiplying to innumerable swarms in the intestinal tissues of the sick, penetrating on the one hand from the mucous surface into the general system of the patient, and contributory on the other hand, with whatever infective power they represent, to the bowel contents which have presently to pass forth from him " (Keport of the Medical Officer of the Privy Council and Local Government Board, New Series, No. II., 1874). The investigations referred to by Mr. Simon were those made by Dr. Klein, and described in his report on the Intimate Anatomical Changes in Enteric, or Typhoid, Fever. (Keport of the medical officer of the Privy Council and Local Government Board for 1874; New Series, No. VI.). In this report Dr. Klein described the changes in various organs in typhoid fever, giving a number of plates in illustra- tion of these changes, and also described certain organisms found in the intestinal mucous membrane and some other organs in the early stages of the disease. After this other observers described various organisms found in the organs in fatal cases of typhoid fever, especially Klebs who announced the discovery of a long thread-like bacillus which he considered to be the cause of the disease, and in 1880 Eberth discovered the rod-shaped organism now known by his name as Eberth's bacillus, or the bacillus typhosus. It appears, however, that before Eberth's paper appeared Koch had found in about half the number of cases examined 188 by him typical colonies of short bacilli precisely similar to those afterwards described by E berth. It would appear, there- fore, that Koch first discovered the true bacillus typhosus, although his name has not become associated with it. This bacillus was subsequently investigated by Dr. GafEky, whose paper was published in the Mittheihmgen aus dem Gesund- heitsavite, vol. ii., 1884, and a translation of it by Dr. Pringle was published by the New Sydenham Society in its volume for 1886. Dr. Gaffky examined the organs of 28 fatal cases of typhoid fever and found the typical bacillar masses in 26 of them. He says : " My results agree entirely with the descriptions given by Eberth, Koch, and Meyer in regard to the shape and appearance of the bacilli. On the average they are about thrice as long as they are broad ; their length corresponds to about the third part of the diameter of a red blood corpuscle. In isolated spots one may see somewhat longer threads which on more thorough examination can, however, be seen to be made up of several members. Trifling differences in breadth occur even in different cases in the same epidemic, but this appearance is to be referred only to the greater or less intensity of the staining of the sections ; at least, I have never been able to observe it in preparations on cover-glasses in which the staining is always deep ; the extremities of the bacilli are distinctly rounded off. In several of the cases I examined the bacilli found in the internal organs contained unmistak- able spores which appeared as round portions, reinaining unstained, and occupying the whole breadth of the bacilli." In discussing the question as to whether these typhoid bacilli are specific pathogenic organisms he says : " If I range myself on the side of those who consider the typhoid bacilli as specific organisms and their origin from putre- factive bacilli as at least very improbable it is upon the following grounds. In almost all the cases of typhoid fever which I have examined, whether they came from Berlin hospitals, from St. Petersburg, or from Wittenberg, there was always present a definite form of rod-shaped organism in the internal organs, arranged in quite a characteristic manner, and undoubtedly the same as had previously been observed at various times and in various places by Eberth, Koch, Meyer, and C. Friedlander. Anatomical examination gives us not the slightest ground for thinking that these bacilli had anything whatever to do with putrefaction. To all appearance they did not proliferate after death, as one does not find that the masses are at all more numerous or larger in cases in which putrefaction has already set in than in those examined as soon after death as possible. Further, in an organ removed as early as possible from the body, although it may contain ever so numerous masses of bacilli, all coarse signs of commencing putrefaction perceptible to the senses are wanting. In the same way the microscopic appearance of the tissue presents nothing suggestive of that process. The nuclei in the vicinity of the masses stain 139 rather exceptionally deeply with aniline stains, whilst the bacilli themselves (apart from the conditions found in the intestine) always form limited masses and never permeate the organ in all directions, as we are accustomed to see in the case of putrefactive bacilli. I would also adduce as a very weighty argument against the view that typhoid bacilli have any connexion with putrefaction the fact that when cultivated outside the body they never become causes of putrefaction, as far as my researches permit of a judgment. I have carried out a great number of cultivations in succession with those derived from 13 different cases and the bacilli never produced putrefaction in substances extremely liable to putrefaction in spite of their luxuriant growth. Even when cultivated outside the body for more than a year nothing of the sort has occurred. As the bacilli always form the same masses in the internal organs, whether one examines fatal cases of typhoid fever in Russia, Germany, Switzerland, or England, so in the same way, cultivated outside the body on the same nutrient matter, they have hitherto always displayed the same manner of growth and the same mode of spore development, whether I obtained the cultivations from typhoid organs in Berlin or from the Wittenberg epidemic." M. A. Rodet and M. G. Roux (of Lyons) consider that there are intimate relations between the bacillus coli and Eberth's bacillus ; that the latter is, in fact, the former " in a state of attenuation or degeneration " ; they "think that the bacillus coli becomes virulent, typhigenic, without notably changing botanical characters ; and that it is within the organism, notably in the spleen, that it takes the type of the bacillus of Eberth, degenerating no doubt under the destructive acts of the organism." And they add : " It is not necessary to insist on the consequences which these facts entail relative to prophy- laxis, it is not only typhoid fever dejections, but faecal pollution of any kind which may engender typhoid fever. "^ This would have delighted Murchison's heart but it is a view which has not been generally accepted. For a detailed description of the characters and methods of isolating and cultivating the typhoid bacillus I only need refer you to Dr. P. Horton-Smith's excellent Goulstonian Lectures, 3 delivered in this College in 1900, but I wish to refer more particularly to a specially interesting account given in those lectures of the persistence of the typhoid bacillus in the body, especially in the bile or the bone- marrow, where it has been now shown it may remain for years. Dr. Horton- Smith quotes some cases from a paper by Hunner in the Johns Hopkins Hospital Bulletin for August and September, 1899, as follows : " In one case the bacilli were found in pure culture in the inflamed gall-bladder 2 Public Health, vol. ii., 1889-90 (from Comptes Rendus de la Society de Biologie, tome ii., No. 7, February, 1890). 3 The Lancet, March 24th (p. 821), and 31st (p. 910), and April 14th (p. 1050), 1900. 140 three months after the fever, in another eight months, and in a third after an interval of seven years." The most remarkable case of all, however, and one very carefully tested, is that recorded by von Dungem (Jililnohener Medioinische Woohensohrift, 1897, p. 699) in which 14^ years after the attack of typhoid fever the bacilli were still present in pure culture in the pus, and Dr. Horton-Smith very well adds : "Truly no longer can we say with Dr. Budd, that ' by destroying the infectious power of the intestinal discharges the disease may be in time finally extinguished.' So far, indeed, from the stools being the only agents by means of which the disease is spread they are but one of a series of agents. So far, too, from the patient ceasing to be a source of danger after his restoration to seeming health, he may carry about in himself the seeds of infection for months and even years." A useful account of the tests used for discriminating between bacillus coli and bacillus typhosus was given by Dr. A. C. Houston in introducing a discussion on Typhoid Fever in its Public Health Aspects at the Cheltenham meeting of the British Medical Association and will be found in the British Medical Journal of August 17th, 1901. Dr. Klein made an investigation on the Eberth-Gaffky bacillus which is described in the report of the Local Govern- ment Board for 1892-93. He could not find the bacillus in the blood of the living typhoid fever patient but in certain tissues of the bodies of those who had died from the disease he never failed to find it, especially in the mesenteric glands and in the spleen, and he describes its differences from the bacillus coli. The next year he reported that he had made experiments with this bacillus on monkeys. Two monkeys to whose food had been added a culture of the typhoid bacillus did not suffer in any way ; no pathological lesions were found in them after they were killed, neither could the typhoid bacillus be detected in their blood or spleen. On the other hand, eight monkeys having been inoculated with cultures of the bacillus the true typhoid bacillus was found in abundance in the spleen of one of them, the bacillus coli in that of another, and "a nondescript bacillus exhibiting characters pertaining some of them to bacillus coli, others to the typhoid bacillus " was found in a third. In inoculated calves the juice of the enlarged inguinal glands was always found to contain the typhoid bacillus in abundance. The next year Dr. Klein demonstrated that under certain con- ditions the typhoid bacillus readily multiplies in sewage, " while as regards drinking-water he shows not only that in many different waters this bacillus may persist longer than has hitherto been demonstrated, but also that in certain of them which are to be thought of as affording pabulum for the microbe the typhoid bacillus is able on occasion to proliferate in abundant fashion." With regard to the relative frequency of the bacillus typhosus in the intestinal discharges and in the urine I may 141 quote the following important communications, which threw a new light on that question. In a paper entitled "Etudes sur la Fifevre Typhoide Experim^ntale " published in the Annates de VInstitut Pasteur for April, 1894, by Dr. Joseph Sanarelli of Rome, among the conclusions drawn from his researches, which were carried out in the laboratory of Professor Metchnikof at the Pasteur Institute are the following : — ' ' In experimental typhoid fever as in human typhoid fever the bacilli of Eberth are not ordinarily found in the contents of the intestinal canal. This the more confirms the fact that the intestinal lesions peculiar to this disease have an excessively toxic origin, and that removes all value from the old idea according to which typhoid fever should be con- sidered as a process infectious in origin and with intestinal localisations. " ' • This absence of the bacillus of Eberth in the intestine of man or animals is explained by the two following reasons. 1. Because typhoid fever is only an affection of the lymphatic system. It is there alone that the virus is localised by pre- ference, multiplies, and produces its poison. 2, Because as soon as this poison has made its influence felt on the in- testinal walls in determining the commencement of the grave anatomical and functional changes already described, the bacillus coli of the intestinal canal becomes pathogenic, multiplies to an extraordinary extent, and tends to become the sole representative of the intestinal flora by annihilating the other species of microbes. " In the same Annates for April, 1895, is a paper by Dr. A. Wathelet of the University of Li§ge, on the bacteriological examination of the intestinal discharges in typhoid fever. He points out that Gaffky himself had acknowledged that it was almost impossible to find in the intestinal discharges the specific bacillus which is found in the spleen, and explained this by the difficulty of finding that bacillus in the midst of the intestinal saprophytes. The result of Dr. Wathelet's experiments was that ' ' in 600 colonies collected from typhoid stools and having characters common to the bacillus coli (transparent variety) and to the typhoid bacillus, the latter was only found ten times. Many patients did not yield the bacillus typhosus on any one occasion." " What a difference," he remarks, "from the almost pure cultures of the specific microbe which one sometimes finds in cases of cholera ! It must be confessed that this extreme rarity of the bacillus of Eberth in the intestinal canal con- forms badly with the current theories of typhoid fever, and that one explains the facts better by considering with M. Sanarelli that in this disease the microbe at first attacks the lymphatic system (spleen and mesenteric glands) and is only found accidentally eliminated in the discharges on the other side of the intestinal walls. " "We have in these researches again found the facts so 142 often observed, viz. , that at the autopsy the digestive canal is found filled with bacillus coli to the exclusion of the bacillus typliosus, whilst it is just the opposite for the spleen." These papers were followed by one published in the Lancet of July 27th, 1895, by Dr. A. E. Wright, Prof essor of Pathology in the Army Medical School, Netley, and Surgeon-Major D. Semple, Assistant Professor of Pathology in the same school, •'On the presence of the typhoid bacillus in the urine of patients suffering from typhoid fever." After referring to and commenting on the papers from which I have just quoted they give the results of the examina- tion of the urine of 7 cases of typhoid fever as follows : — "We thus see that in 6 out of 7 cases examined the typhoid fever bacilli were easily detected in the urine. In view of this fact it seems to us that the bacteriological examination of the urine ought not to be neglected in any doubtful case in which typhoid fever is suspected. It is hardly necessary to do more than merely advert to the hygienic aspect of the matter. It was only a natural outcome of the intestinal intoxication theory of typhoid fever that the greatest pre- caution should have been enjoined with regard to the stools of the patient suffering from typhoid fever, while the disinfection of the urine was neglected. If, however, the recent observations on the almost constant absence of typhoid fever bacilli from the stools are to be trusted, the disinfection of the feeces will have to rank not as an article of faith, but as a mere ' counsel of perfection.' On the other hand, the most careful attention will have to be given to the disinfection of the urine. In some cases the urine even before incubation is absolutely turbid with typhoid bacilli." Dr. Edmund Cautley made a research on the behaviour of the typhoid bacillus in milk and his account of it will be found in the report of the medical officer of the Local Government Board for 1896-97. He found that in un- sterilised milk to which the typhoid bacillus was added it was recovered in considerable numbers from the milk which had been kept for six or seven days and had turned com- pletely sour ; and in sterilised milk to which the typhoid bacillus and some other microbes were added he found that the typhoid bacillus will live in the presence of the bacillus lactis for a week but will not actually multiply under these conditions. He says "that the presence of the oidium lactis in sterilised milk does not interfere with the growth and multi- plication of the typhoid bacillus " and that yeast did not inter- fere with the growth of the typhoid bacillus, as ' ' both micro- organisms increased in number and neither appeared to be modified in its growth by the presence of the other." He considers that "the typhoid bacillus will live in milk under conditions which ordinarily prevail in a household. When this bacillus has been artificially added in large amount to milk in the condition in which it commonly reaches the consumer the presence of the microbes in the living state 143 may be demonstrated after the milk thus treated has been kept for several days. There is no indication from the above investigations that this microbe is capable of multi- plication under the conditions in question. Judging from the results obtained it is very probable that the number present rapidly diminishes in milk which is kept." The observations with regard to the bacillus lactis and to sour milk "indicate that it is quite possible for the typhoid bacillus to exist in curd-cheeses." In a report by Dr. Klein on the behaviour of certain patho- genic microbes in milk, cream, and cheese he says : "It is well known that the typhoid bacillus grows luxuriantly in milk both at 20° C. and at 37° C. It does not alter the fluid character of the milk, although it produces acid, as is well known by the reddening produced when litmus milk is used as the culture medium. " His experiments on cream showed ' * that cream kept at as high a temperature as 37° 0. is not a suitable medium for the growth and multiplication of the typhoid bacillus, but that it is a suitable medium when kept at 20° C. He further found that the typhoid bacillus does not grow and multiply when planted on Cheddar cheese either at 37° C. or at 20° C. (Twenty-ninth report of the medical officer of the Local Government Board for 1899-1900). In the Archives de Medecine Experimentale et d'Anatoniie Patholoffiqiie, No. 1, Jan. 7th, 1889, is an account of a re- search made by M. J. Grancher and M. E. Deschamps on the behaviour of the typhoid bacillus in the soil. Their conclu- sions are as follows : " 1. It does not pass through soil with irrigation water. 2. It is stopped by from 20-40 centimetres of thickness of soil. 3. It retains its life in the midst of all the organisms soil contains, five and a half months after it has been sown. 4. It does not penetrate into healthy vege- tables." (^Public Health, vol. ii., 1889-90.) A most interesting series of investigations has been made by Dr. Sidney H. C. Martin on the Growth of the Typhoid Bacillus in Soil and his accounts of them will be found in the reports of the medical officer of the Local Government Board for 1896-97 and onwards. He first found that the bacillus when planted in organically polluted soil, ' ' as, for instance, the samples of earth from Chichester," speedily increased and spread abroad, whereas in an unpolluted soil from an uninhabited and cultivated area ' ' it languished and quickly died out " under like conditions of temperature and moisture. It was then determined to test in unsterilised soil of both classes the ability of the typhoid bacillus to contend with the other microbes already present in such soil and Dr. Houston was associated with Dr. Martin in this investigation. 21 samples of various soils were examined. In eight of these no bacillus coli was found. In the remaining 13 bacilli with more or less resemblance to the true bacillus coli were found and in four of these the typical bacillus coli itself was present ; these four soils, however, were shown 144 to have been polluted with excrement ; while the spores of bacillus enteritidis were found in five of the soils and in exceptionally large quantity in two of them which were shown to have been polluted with excrement. Dr. Martin then showed that when the typhoid bacillus was inoculated on a soil containing bacteria belonging to the bacillus coli group it was recoverable after 50 days from this soil at the point at which it had been inoculated. ' ' It had survived in competition with the bacillus coli-like micro-organisms but had not multiplied. " One of Dr. Martin's most important conclusions is ' ' that the soils which are favourable to the growth of the typhoid bacillus are those which have been cultivated, more particularly soils of gardens and the entourage of houses. In these soils the bacillus was found to be alive and to have retained its vegetative properties for as long as 456 days ; this being found true for sterilised soil which was moistened throughout with water. On drying this soil, even when it had become so dry that it could be made into a fine powder, the typhoid bacillus could still be obtained from it and had retained its vegetative properties, although it grew more slowly than when obtained from the same soil in its moist condition." Again, "In favourable soils in a moist con- dition the bacillus not only grew at a temperature of 37° C. , but it flourished when the soil was exposed to much lower temperatures ; for example, the temperature of the laboratory, which varied between 9° and 24° C. and the temperature of an outside shed between 3° and 16° C." On the other hand, virgin soils, sandy or peaty, " are absolutely inimical to the growth of the typhoid bacillus. " Dr. Martin's further investigations were made on natural " unsterilised soils which in the sterilised condition were found favourable to the growth of the bacillus. In not a single instance, however, was the typhoid bacillus regained, although laborious and prolonged experiments were made with this object. The obvious conclusion, therefore, was that under the conditions of the experiments the presence of the bacteria of the soil had either prevented the detection of the bacillus or had inhibited its growth and so led to its ultimate death and disappearance. It must be remembered that the typhoid bacillus does not form spores, so that its continued vitality depends on its power of multiplication and division. There is no resting-stage of this micro- organism as far as is known, and although in sterilised soil the bacillus will retain its viability for a while if the soil be dried at a low temperature to a powder, yet soon afterwards it dies and can never be re-vivified. Placed, therefore, amidst other bacteria under certain conditions of moisture and temperature the bacillus may in unsterilised soils be beaten out of the field by the other bacteria present. " Dr. Martin's further experiments brought him to the conclusion that * ' there is some evidence to show that under the condi- tions of experiments the disappearance of the bacillus has 145 taken place pari passu with an increase in the number of the putrefactive bacteria. " In these experiments Dr. Martin has adopted a method of isolating the typhoid bacillus from the other bacilli present in the soil which appears to give more satisfactory results than the methods which have been previously adopted. In a long and elaborate paper by Dr. Justyn Karlinski, published in the Arehivfilr Hygiene, Band xiii., Heft iii., the author details a number of careful experiments on the behaviour of the typhoid bacillus in earth and he draws the following conclusions : — " 1. The longest life-duration of the typhoid bacillus in earth did not exceed in his experi- ments three months. 2. The life duration of the bacillus buried with typhoid excreta and hence under natural condi- tions is essentially shorter than bacilli in the blood buried in earth at the same time. 3. In the deeper layers of the earth the typhoid bacilli bid defiance to moisture, to alternations of temperature, and to the activity of other micro-organisms, 4. Exposed to moisture and sunshine on the surface of the ground the bacilli quickly die. 5. Alternating and copious moisture, whether the moisture rises into or falls on to in- fected earth, essentially shortens the life duration. 6. In layers of earth in which there are the active roots of plants the life duration is very short. 7. The typhoid bacilli may be recognised three months after death in certain conditions of delayed putrefaction and when the specific micro- organisms of putrefaction are denied access." (Journal of Public Health, vol. iv., 1891-92.) Dr. Klein made some experiments, the results of which will be found in the report of the medical officer of the Local Government Board for 1898-99, on the Fate of Pathogenic and other Infective Microbes in the Dead Animal Body. He was unable to find the bacillus typhosus, or the bacillus coli, or the proteus vulgaris or any other aerobic microbe in the bodies of guinea-pigs which had been pre- viously inoculated with those bacilli, buried, and exhumed 30 days or more later. His experiments showed "that the typhoid bacillus is even less resistant than the cholera vibrio. In 20 days after burial, no matter in what form this had taken place, typhoid bacilli could not be recovered from any of the bodies ; from a guinea-pig buried in sand they could not be recovered after 14 days." "The German Commission exhumed the animals not earlier than one month after burial, and their examinations of the dead bodies for typhoid bacilli were in all cases negative. " In the Journal of the Pasteur Institute for February, 1897, is a paper by M. P. Kemlinger and M. G. Schneider of the Val-de-Gr^ce laboratory on the Ubiquity of the Typhoid Bacillus. The authors attempt to answer the question, ' ' Does the bacillus of typhoid exist in nature outside the sick man and the products which emanate from him ? " A series of experiments extending over many months was carried out on various materials, such as the public water-supplies and L 146 wells of several towns having epidemics of typhoid, the soil and dust from different localities, the discharges from the digestive tract of persons not affected with typhoid, &c., and a bacillus giving all the principal laboratory reactions of that of typhoid was obtained from all these sources. The following illustrations are of special interest. In 13 samples of soil and dust the bacillus typhosus was found seven times, (a) in the refuse from barracks where there were some cases of typhoid ; (J) in dust from the laboratory floor ; (c) in the space between the joists of a room in other barracks ; {d) in four specimens of soil, both superficial and a metre in depth, from the courts and gardens of Val-de-Gr^ce. These in three instances were pathogenic for animals. In the examination of the fasces of 10 persons treated at the hospital for affections which had nothing in common with typhoid, five reacted like the bacillus typhosus. Thus (a) in a case of leuksemia specimens examined at intervals of 15 days gave each time a positive result, (J) in one case of acute tuberculosis without intestinal lesions ; (c) in a case of premonitory dysentery ; (d) in two cases of chronic malaria. None of these patients had ever had typhoid fever. Of the bacilli from these five cases four were pathogenic for guinea-pigs. In many additional cultures from water, soil, and the intestines, bacilli with every charac- teristic of bacillus typhosus were found, except that they were not pathogenic for animals and were not agglutinated by the serum from a typhoid patient. In other words they seemed the same species but attenuated as to virulence. After some remarks illustrated by comparisons with the variations of the cholera vibrio, these investigators state : " It is allowable to suppose that facts of a similar kind repro- duce themselves in connexion with the bacillus typhosus. The species of the bacillus of Eberth comprehends, perhaps, varieties more or less numerous which do not probably react similarly under the influence of the serum of an animal immunised against a determined variety. The belief in the invariability of type in pathogenic microbes is to-day much weakened by many facts. The question of race, descendants from a common stock but differentiated by unknown vicissi- tudes, acquires an importance which must not be underrated. Why should not this theory, which is acknowledged to be true for certain pathogenic bacteria, apply to the bacillus typhosus 1 We incline to think that bacilli not pathogenic and indifferent to the serum test which are encountered in water, soil, &c. , are only varieties of the bacillus typhosus ; at least, the parentage is evident even if the identity is not absolute. This diversity of fundamental type will perhaps serve to explain the variable forms of typhoid infection which are becoming recognised. If this interpretation of facts is exact the following conclusion will result. The bacillus typhosus is distributed in nature outside the human body ; it is found in potable waters, in soil, in the intestines of persons not attacked with typhoid, and without doubt forms 147 a part of the microbic flora of the media which surround us. This idea is not subversive of recognised facts as to the general etiology of typhoid, but rather enables us to con- ceive and comprehend facts otherwise inexplicable. Daily observations, especially noted in rural places, have set in relief the part played by contagion in the formation and extension of certain epidemic centres ; their value remains. Modern researches have demonstrated the prime importance of impure waters in its development and spread ; the character of the proof defies all question. But all the cases must originate from contagion or water polluted with the dejections of typhoid patients. Many times it breaks out in patients or groups worn out with fatigue, overwork, or privations, or after eating various foods, without its being possible to trace the origin of the contagion or the use of a badly polluted water. The facts conform more easily with the idea of the widespread presence of the bacillus typhosus, which accounts for its dispersion in surrounding media and its presence eventually in our natural cavities. A water reputed pure may carry it. Thus introduced into the organism it will live there unoffensive till some depressing circum- stance, a fortuitous assistance, perhaps the result of some associated microbe, will open to it a career of action. " Dr. John Kobertson, the medical officer of health of Sheffield, made a number of experiments with soil ' ' out-of- doors. " The results of these experiments ' ' prove that the typhoid organism is capable of growing very rapidly in certain soils and that apparently under certain conditions the organisms can survive from one summer to another. The rains of spring and autumn or the frost and snows of winter do not kill them off. Sunlight has a most powerful bactericidal influence on the typhoid organism." But this action is limited strictly to the organisms actually on the surface, a layer of soil one-sixteenth of an inch in thickness protecting them. ' ' Cultures of the typhoid organism planted at a depth of 18 inches grew to the surface ; so also patches inoculated on the surface showed that at least the organism could grov/ downwards to a depth of three inches." (^British Medical JouTTUcl, Jan. 8th, 1898.) According to Liebermeister "the curves representing the frequency of typhoid correspond to the curves of average temperature, only with this difference — the different points of the typhoid curve follow those of the temperature curve by an interval of some months," and he suggests that it takes two or three months for the changes of temperature to penetrate to the breeding places of the typhoid germs. (Ziemssen's Cyclopaedia, vol. i., p. 65.) The present war in South Africa has lent additional interest to the question of typhoid fever in armies and the ways in which it spreads under the circumstances of camp life. In an article on Typhoid Fever in Armies in the Field, by Surgeon-Major Vincent, professor agr6g6 at Val- de-Grace, Paris, he states that • ' the predisposing causes were 148 tne average age of the soldier ; the time of year chosen for military operations, summer or autumn ; imperfect feeding and the digestive troubles which resulted therefrom ; the inevitable deficiencies as to hygienic conditions as regards both the soldier's body and his clothes ; a hot climate, as is the case in colonial wars ; the shutting up of troops in camps or besieged towns ; a very prolonged war and the demoralisa- tion of an army when conquered. The immediate cause was the ubiquitous bacillus typhosus. This bacillus was able to live in a latent condition in the digestive tract and thence under favourable conditions to multiply itself and give rise to the appearance of a spontaneous epidemic. " (The Lancet, August 11th, 1900, p. 437.) Some information on the matter is to be derived from the report of Dr. G. Pratt Yule on the camps in the Orange Kiver Colony, published in the Times of Dec. 16th, 1900, the most important sentence in which from our point of view is the following. After referring to the fouling of the ground round the tent doors by urine and slops, he says : " Practices such as these have undoubtedly proved the source of a large proportion of the typhoid cases, and these will certainly greatly increase during the coming summer and autumn. In this particular it is important to remember that urine of convalescent typhoid fever patients often contains a pure culture of the typhoid germ which by methods of disposal like the above becomes blown about in the dust ot the camps. I am of opinion that the typhoid infection of the camps is principally air-borne." In the British Medical Jourrial of Nov. 10th, 1900, is an article on an outbreak of typhoid fever at Quetta, India. At this place the water-supply is derived from the hills and is above suspicion. There was, as usual, freedom from typhoid fever up to May but from May 2nd to 13th there were dust- storms with sore-throat and tonsillitis, followed by an out- break of typhoid fever, some of the cases commencing with sore- throats. The night-soil was placed in pits to the north- west, from which the prevailing wind blew, and in the dry air the deposited matters were dried and blown about as dust. Those companies suffered most who were nearest to the filth-pits ; the air from the quarter where the filth-pits were contained ' • large numbers of germs that are invariably present in faecal matter and not in pure air, although the enteric bacillus itself was not isolated." It appears from a subsequent article on Sept. 14th, 1901, that ' ' the outbreak ceased on removal of this source of infection." It is also stated that in Jhansi, Nasirabad, Mhow, and Rawal Pindi typhoid fever prevails during the dry season and the dust- storms, and that, on the other hand, Roorkee has very little typhoid fever and is comparatively free from dust. Dr. H. E, Leigh Canney has published an interesting paper on Typhoid, the Destroyer of Armies, and its Abolition. He holds the view that nearly all the cases of the disease on service are water-borne and in order to prevent it 149 he propounds a scheme for boiling the whole of the water used and suggests the formation of a Royal Water Corps to be devoted to the work of supplying sterilised water, boiling the milk, and "the disinfection of all salads after they have been washed in ordinary water," the watchword of the water corps on a campaign to be " boiled water or nothing." These suggestions met with considerable support at the meeting of the Royal United Service Institution, where the paper was read. Sir William Broadbent, the chairman, pointed out that "whatever importance might attach to dust and flies they were subsidiary to the infection by water. With regard to the efl&ciency of the method proposed by Dr. Canney, Sir William Broadbent thought that if it could be secured that no soldier drank anything but boiled water they would get the upper hand entirely of typhoid. The whole question turned upon the practicability of the scheme which had been well thought out and was not brought forward in a nebulous condition. Although, of course, they must bear in mind that after a long march or after the excitement and exertions of a fight a soldier could not be prevented from drinking the first water he came across, yet if he started with his bottle full of pure water and the water-carts contained nothing but pure water,' whilst only pure water was drunk in the camps, an enormous gain would have been secured." Major R. H. Firth, the pro- fessor of military hygiene at Netley, expressed great sympathy with the proposed scheme. He considered that sanitary officers should undergo a special training and they must be supplied with properly instructed men to carry out the work. Dr. J. W. Washbourn insisted that the disease was also con- veyed by flies and dust and thought that it was not difficult to provide for a proper disposal of excreta and so to prevent much of the distribution of the poison of the disease by the agencies just mentioned. A discussion on the Recent Epidemic of Typhoid Fever in South Africa was opened at the Clinical Society of London by Dr. Howard H. Tooth and reported in The Lancet of March 16th, 1901, pp. 771, 786. He is of opinion that the disease is spread in South Africa not merely by polluted water but also by dust and flies, and he says of the flies that ' ' they naturally infest persons who are ill but seem to be peculiarly attracted to enteric fever patients, hanging in loathsome groups around their mouths and feeding-vessels. They were all over our food, and the roofs of our tents were at times black with them. It is not unreasonable to look upon flies as a very possible agency in spreading the disease not only abroad but at home." He also points out "that with the first appearance of the frost enteric fever almost entirely disappears it seems hardly credible that the almost sudden cessation of an epidemic can be due to the effect of cold upon the enteric fever bacilli only. But there can be no doubt in the mind of anybody who has been living on the open veldt, as we have for three or four months, that the flies 160 are extremely sensitive to the change of temperature and that the cold nights kill them off rapidly. On consideration of these points it is surely justifiable to assign an important share to flies in the spreading of infection." In the British Medical Journal of Feb. 15th, 1902, is a paper by Lieutenant-Colonel E. H. Quill, E.A.M.C., senior medical officer, Ceylon, on Air-borne Typhoid Fever. He maintains that the disease is frequently air-borne and gives his experience of it at the camp of Diyatalawa in the hills of Ceylon, which was formed in August, 1900, for the Boer prisoners of war. There occurred at this camp an outbreak of typhoid fever which was certainly not due to the water or milk, the water-supply and filtration arrangements having been changed in no way since the cessation of the epidemic among the prisoners, and there have been no cases of typhoid fever since 1900. No uncooked food or vegetables were used in the camp. All men leaving the camp for purposes of duty or pleasure were obliged to take with them a water-bottle filled with filtered water. The aerated waters used in the camp were identical with those used at the sanatorium where there was no typhoid fever. Lieutenant-Colonel Quill was driven to the conclusion that the affection was air-borne, being derived from the adjoining camp for prisoners of war, 'where at the time an epidemic of typhoid fever was raging. After giving his reasons for that opinion he submits that he has shown ' ' (1) that all water avenues through which typhoid fever could have been conveyed to the military camp at Diyatalawa were efficiently guarded and that therefore a water-borne origin must be abandoned ; and (2) that the affection was air-borne, resulting from emanations from specifically infected latrines, infected dust, or bacilli-laden flies." Dr. A. Elliot and Dr. Washbourn contributed a paper on Typhoid Fever in South Africa to The Lancet of Jan. 18th, 1902, p. 139. They conclude "that the type of typhoid fever met with in South Africa does not differ in any essential respects from that met with in England and America. The mortality and the incidence of complications are much the same as in the variations which are met with elsewhere ; the only complication which appears to be espe- cially prominent is phlebitis which occurred in 5-6 per cent, of our cases We do not feel that inoculation has any marked influence either in preventing or in modifying the disease. " I may add that the hitherto published results of anti-typhoid inoculation are so contradictory and, moreover, are based on such small numbers of cases that I do not think any good end would be attained by further alluding to them. Since then Dr. George Turner, the medical officer of health of the Transvaal, has contributed a paper to the British Medical Jourruil of Feb. 15th, 1902, on Typhoid Fever in South Africa, its Cause and Prevention, In it he states that he should not advance his opinion on the matter if he "did 161 not feel that the growing tendency to attribute enteric to wind and flies was not becoming a source of danger. " He maintains from six years' experience ' ' that the causation of epidemics in South Africa is practically similar to that which gives rise to the majority of cases in England — viz. , a polluted water-supply. " He states that only on one occasion has he ' ' had any grounds for supposing that dust was con- cerned in the production of typhoid and on that occasion the dust appeared to have acted through the agency of the water used for drinking." He does not deny absolutely the possi- bility of typhoid infection by means of wind-borne dust but he says that it is rare. " As a matter of fact, typhoid cases are less frequently met with just at the period at which diist- itOT^iiB prevail and are more numerous when, on account of heavy rain, dust is less troublesome. This, to my mind, is conclusive proof that dust does not exert much injurious influence as regards typhoid. As regards flies I can only say that I hold a similar opinion. The possibility of the conveyance of enteric through these pests is un- deniable, but in this instance also the supposed cause, the flies, begin to be troublesome long before typhoid prevails and continue to annoy us long after it has subsided. If the flies were really important agents in the spread of typhoid fever one would expect that even if the disease did not commence to prevail soon after these nuisances commenced to be numerous, because it is conceivable that at the time typhoid-infected stools would be rare, yet when once typhoid became common the flies should carry on the infection which should continue as long as, or longer than, the flies continue." Finally, he strongly maintains that "typhoid in South Africa is almost entirely due to polluted water." He admits that filters were sent out with the troops but states that they were not generally used ; while, on the other hand, ' ' where the commanding ofl&cer had a ' fad about water ' the case incidence of typhoid was insignifi- cant. " To show that he does not underrate the diflSculty of supplying an army with water when on the march he adds : ' ' My private opinion is that if the army had been supplied with the best sanitary expert advice on the march from Paardeberg to Bloemfontein one of two things would have resulted, either the army would never have reached Bloemfontein or it would, as it did, have suffered from fever ; one or other of these results was inevitable. " The report of the Commission sent to South Africa, consisting of Professor J. Lane Notter, Professor W. J. R. Simpson, and Lieutenant-Colonel Bruce, has not yet been published, so that unfortunately 1 cannot avail myself of the information contained in it for the purpose of this lecture. I have, how- ever, Professor Lane Notter's permission to state as his own personal opinion that he considers "that while water was a very frequent cause of typhoid fever among the troops it could not, I think, be said to be the only cause of it. Others were the aggregation of men on limited areas — density of 152 population — without any of the usual methods of drainage and the disposal of excreta and refuse which exist where numbers are usually congregated together in towns and villages in civil life ; this state of things is always present in standing camps ; the transference, too, of the contagion by flies, which constitute a real danger unless food is properly stored and kept from them, especially where trench latrines are used. The soil, too, is an important factor ; the ground seems wanting in nitrifying organisms, the result being that animal refuse remains long without undergoing that process of disintegration and oxidation that is usual in this country. Perhaps this is due to the absence of lime or like base, for lime is seldom found in large tracts of the Orange River Colony and Transvaal." I originally intended the subject of these lectures to be merely the "Etiology of Typhoid Fever," and this would have been quite sufficient, but I afterwards thought that it would add to their interest if I showed how the mortaj^ty from this disease has been diminished in this and in some other countries by suitable methods of prevention. The methods of prevention themselves are those which apply to any infectious disease and have been described so frequently that there is no need for any further account of them, the only peculiarity in the case of typhoid fever being that less attention need, as a rule, be paid to the methods of pre- venting direct infection, whilst the greatest attention should be given to the prevention of indirect infection by the channels which have been already described in these lectures. As the disease is no doubt chiefly conveyed by drinking- water it is of the highest importance that this water should not be contaminated with the typhoid poison, or, as Sir John Simon puts it, "It ought to be an absolute condition for a public water-supply that it should be uncontaminable by drainage." Suitable precautions, too, must be taken to prevent other foods, such as milk, oysters. Sec. , from becoming contaminated. The soil under houses and the air in and around them must be kept pure by the adoption of methods for the removal of excreta from the vicinity of habitations speedily and continuously. The late Sir George Buchanan showed us that the death-rate from typhoid fever was especially lowered in towns where refuse matters were removed most quickly. Among these methods for the prevention of the con- tamination of the soil and the air are the provision of water- tight house drains, their disconnexion from the public sewers or cesspools, their proper ventilation, and the provision of sanitary appliances and pipes which insure the speedy removal of the foul matters from the houses and prevent the escape into them of any foul air from the drains or sewers. All these matters have been so thoroughly discussed by me in other public lectures that it is quite unnecessary for me further to enlarge on them here. There appear to be differences of opinion with regard to the disinfection of typhoid excreta ; some advocate mixing 153 them with sawdust or other absorbent material and burning them, whilst others are in favour of boiling them. On this subject I may quote Lieutenant-Colonel G. H. Younge, RA.M.C, who wrote in the British Medical Journal of Jan. 18th, 1902 : ' ' When in India I tried the process of incineration of enteric excretions mixed with sawdust, but the attempt had to be discontinued as it was found impossible completely to bum the wet sawdust in any incinerator that could be extemporised. On the whole, there- fore, I have a decided preference for sterilisation by boiling, as it is quite as effective, less expensive, and more rapid and convenient than incineration." This seems to me to be unanswerable and it is, in fact, obvious that the simplest and quickest way to disinfect liquid excreta must be to boil them. In May, 1899, Dr. Saltet, professor of hygiene in the University of Amsterdam, read an important paper before the Epidemiological Society on a Study of Enteric Fever in the Netherlands during the period 1875 to 1894. He stated that ' ' during the last decade the number of deaths from typhoid fever has been, generally speaking, on the decrease " and this to a greater extent than the decline in the general death-rate, for while he shows that the general death-rate in the Netherlands declined in the period under review from 23 '3 per 1000 living during the quinquennium 1875 to 1879 to 20-0 during the quinquennium 1890-94, or an improvement of 14 per cent., that from continued fevers has declined from 60 per 100,000 to 22, or an improvement of 63 per cent., thus show- ing "that typhoid fever as a preventable disease ^r exoellenGe has yielded more favourably to the improved con- dition of the times than other diseases. " He then discusses the influence of density of population and comes to the con- clusion that ' ' the favourable factors of town life appear thus to outweigh the unfavourable conditions due to density of population." With regard to drinking-water he arrives at the interesting and unexpected conclusion that the death- rate from continued fevers is higher in communes supplied with water from the sandhills than in those with a river- supply, although it has decreased considerably in both ; thus in those with the water-supply from the sandhills the death-rate from continued fevers was 60 per 100,000 in the first quinquennium and fell to 19 in the fourth quinquennium, whereas that in communes with the river- supply was 32 in the first quinquennium and fell to 15 in the fourth. Professor Saltet's explanation of this anomalous state of affairs is that ' ' in communes on rivers a sufficient quantity of fresh water is always to be obtained independent of water systems. A number of communes with the ground-water system were, however, frequently suffering from a want of water. Now want of water means want of cleanliness, and it is not at all unlikely that and a better quality aTid a more adequate quantity of the drinking- water supply as well as the more liberal use of it have greatly assisted in bringing down the death-rate from fevers. The 154 striking fact remains, however, that in communes with the ground-water system the death-rate from general causes is lower, whilst the mortality due to continued fevers is higher than in the river-water communes. This phenomenon impresses us even more forcibly if we consider that Asiatic cholera, a disease especially propagated by drinking-water, has in the Netherlands played the greatest havoc along the course of the rivers." This would make it seem probable that the increased amount of typhoid fever in communes with a water-supply from the sandhills was due to some other cause than the water, or else that the sources of water-supply are liable to surface contamination. From a paper on Enteric Fever Mortality in Copenhagen by Dr. N. P. Schierbeck I find that there has been no im- portant outbreak of typhoid fever there since 1857, when the mortality from it there reached 175 per 100,000 persons living ; after that there were, as is usual, a few years of low mortality. It then rose to 77 in 1864 and has since steadily gone down until it only averaged 9*4 per annum during the quinquennium 1891-95 and 7-3 during the three years 1896-98. "The central water-supply was commenced in 1854 and completed for the whole town in 1859, when such water was first made use of. The general sewerage system commenced in 1859. " The author is nevertheless of opinion that the statistics do not show that the diminution of the death-rate is due to those sanitary improvements, as that diminution began long before those improvements were carried out, but it must be remembered that the previous diminution was not a steady one, as the death-rate from typhoid fever suddenly went up to 175 in 1857, as before stated. (Transactions of the Epidemiological Society, vol. XX., new series, 1900-01.) In the same volume is an interesting account of the ' ' Effect of Sewerage and Water-supply on the Behaviour of Enteric Fever in Buenos Ayres " by Dr. James T. E. Davison. The typhoid fever mortality was at its highest, 106 per 100,000 inhabitants, in 1890, after which year there was a large and continuous increase in the number of houses supplied with water and connected with the sewers ; this was accompanied by a steady decline of the typhoid fever mortality to 14 per 100,000 persons living in 1899. In preparing Tables III. to VI. and the Chart following, I have been able to include the statistics for 1900 and so to make the tables complete to the end of the last century, owing to the courtesy of my friend Dr. J. F. W. Tatham, chief of the Statistical Department of the General Kegister Office. Table III. shows the remarkable diminution in the general death-rate of London during the last half of the last century. It will be seen from it that the average general death-rate from 1851 to 1870 was 241 per 1000 per annum and that it had gone down to 18 "8 in the quinquennium 1896 to 1900 ; the dates at which the important Acts relating to the public health were passed are shown in the table. 155 Table III. — London. Years. Average death- rates per 1000 per annnm. 1851-1870 24-1 Nuisance Removal Act, 1855, Sanitary Act, 1866. 1871-1890 22-5 Public Health Act, London, 1891. 1891-1895 20-2 1896-1900 18-8 In Table IV. the corresponding figures are shown with regard to the general death-rate in England and Wales. The average from 1849 to 1875 was 22-4 per 1000 per annum. The Public Health Act was passed in 1875 and after that the table shows a steady diminution of the death-rate until in the quinquennium 1896 to 1900 it was only 17-6. Table V^ .—England and Wales. Years. Average death- rates per 1000 per annum. 1849-1875 22-4 Public Health Act, 1875. 1876-1880 20-8 1881-1885 19-4 1886-1890 18-9 1891-1895 18-7 1896-1900 17-6 Dr. Bulstrode prepared a most interesting chart and maps showing the annual death-rate from typhoid and continued fevers per 100,000 living in the counties of England and in North and South Wales during each of the decades 1871-80 and 1881-90. They show ' ' that whilst enteric fever has been undergoing enormous diminution in this country, the areas of both its maximum and minimum incidence have remained practically the same during the 20 years 1871 to 1890, which have witnessed such great improvements in the sanitary circumstances of our towns and villages. The chart shows, amongst other things, that whereas this (typhoid and con- 156 tinued) fever death-rate in England and Wales was 43 per 100,000 living during the decennium 1871 to 1880, it had fallen to nearly half — viz., 22 per 100,000 — during the decen- nium 1881 to 1890. " (Sir K. Thorne, twenty-sixth report of the medical officer of the Local Government Board, 1896-97. ) Table V. — Average Anrnial Death-rates from contimied Fevers and Diarrhoea per 1,000,000 Persons living in England and Wales. Years. Continued fevers (chiefly typhoid). Diarrhoea. 1861-70 1871-80 1881-90 1891-95 1896-1900 885 482 235 185 180 1076 935 674 630 788 Table VI. — Average Annual Rates of Mortality from Typhoid Fever per 1,000,000 Persons living in each Quinquennium from 1871 to 1900. In England and ) Wales S London 1871-75, 354 256 1876-80. 278 234 1881-85. 218 1886-90. 180 150 1891-95. 176 136 1896-1900. 176 148 Table V. shows that the rate of mortality in England and Wales for continued fevers (chiefly typhoid) has been reduced from 885 per 1,000,000 persons in 1861-70 to 180 in 1896-1900 and for diarrhoea from 1076 in 1861-70 to 630 in 1891-95, but that the latter rose again to 788 in 1896-1900 ; and Table VI. shows the steady diminution of the death-rate from typhoid fever alone during each quinquennium from 1871 to 1895 both in England and Wales and in London. It will be noticed that during the last quinquennium (1896-1900) the death-rate from this disease was the same in England and Wales as in the previous quinquennium (1891-95), thus showing no diminution, while in London there was actually an increase in 1896-1900, when the average rate was 148 per 1,000,000 persons, over that in 1891-95, when it was 136. This, as well as the increase in the diarrhoea rate, was due to an unusual prevalence of both these diseases in the years 1899 and 1900. I have prepared the following chart showing the annual TYPHOID FEVER CHART. Showing the Annual Rate of Mortality per Million Persons living from 1871 to 1900. In London ^^i ; in England and Wales 400 ^ C\i CO "^"a^K 000^-5 ^ CVC<^^1^^ f^00O^i^N.CM(yi^^^ K QoOsi^ 300 200 100 159 rate of mortality from typhoid fever (not including simple continued fever) per million persons living in England and Wales and in London from 1871 to 1900, which demonstrates in a graphical manner the remarkable diminution of the death-rate from this disease in England and Wales since 1875, and in London since 1883. It will be noticed that the only years in which the typhoid death-rate in London was higher than that in the country generally were the three years 1881-82-83. I have already referred to the remarkable diminution of the death-rate from typhoid fever at Munich owing to the improvements carried out under the advice of the late Professor Pettenkofer, a diminution which is even far more remarkable than the diminution in London and in this country generally. The diminution at Munich was, in fact (in the mean annual mortality per million inhabitants), as follows : — 1851-60 1861-70 1871-80 1881-90 1891-1900 2024 1478 1167 160 52* From a paper on the ' ' Diminution of Typhoid Fever in Paris, " published in the Revue Munioipale of Dec. 29th, 1900, I find that the death-rate from that disease per 1,000,000 persons living in that city has diminished in a very notable manner, as shown by the following figures. In 1882 it was 1430 ; from 1883 to 1888 it was 581 ; from 1889 to 1894 it was 293 ; and from 1895 to 1900 it was 172. And this in spite of a recrudescence in 1899 and 1900, which was brought into prominent notice on account of the great Exhibition held in Paris in 1900, but which was shared by London and England generally (see chart), and would not have been specially noticed had it not been for the Exhibition. I hope that these lectures may be of some permanent use, especially as a concise summary of reports of outbreaks of typhoid fever scattered throughout public health literature. * This figure has been kindly supplied to me by Professor Halm, of Munich. Printed at The Lancet Office, 428, Strand, W.O. RETURN TO the circulation desl< of any University of California Library or to the NORTHERN REGIONAL LIBRARY FACILITY BIdg. 400, Richmond Field Station University of California Richmond, CA 94804-4698 ALL BOOKS MAY BE RECALLED AFTER 7 DAYS • 2-month loans may be renewed by calling (510)642-6753 • 1 -year loans may be recharged by bringing books to NRLF • Renewals and recharges may be made 4 days prior to due date. DUE AS STAMPED BELOW JAN 26 1999 12,000(11/95) General Library LD 21-50m-8,'r.7 University of California (,C8481sl0)476 Berkeley