typhoid death rate among the colored during the past ten years was 76.4, as compared with 47.4 for the whites.

Many of the factors concerned will be alluded to on page 120, and much may be done by uplifting influences and higher standards of living towards the removal of the predisposing causes of typhoid fever.

WHY IS THERE MORE TYPHOID FEVER IN WASHINGTON THAN IN NORTHERN CITIES?

Now that we have a pure water supply this very pertinent question has been asked, and among the answers so far given may be mentioned the following:

(1) Washington, like very many other southern cities, has a very large colored population, with their greater susceptibility to disease. This, however, accounts for only a certain percentage of the excess, as the rate for the white population is also abnormally high.

(2) It is a well-known fact that all intestinal diseases are especially prevalent in hot climates and seasons. This is probably due to the fact that the blood is kept too long at the periphery on account of excessive perspiration, and the stomach and other internal organs suffer in tone and nutrition for want of adequate blood supply, and can not exert their normal defensive forces.* So, for example, typhoid fever germs would be digested, like many other vegetable cells, as long as the digestive functions are normal, but if for any reason this function is impaired or arrested, this defensive force ceases, and the way for infection is open. Functional derangements of the stomach, together with the debilitating influences of heat, doubtless play an important role in increasing the general susceptibility to typhoid fever in all southern climes.

(3) Dr. Woodward, our Health Officer, suggests that the greater intensity of heat in the South leads to the ingestion of larger quantities of water than are consumed farther north, and, therefore, so far as water-borne typhoid fever is concerned, to increased chances of infection. He also suggests that "intensity of heat and the long duration of the heated season probably lead to a more rapid and more extensive lowering of the water in the streams and wells than occurs in cooler regions, and thus lead to a greater concentration of infectivity, if the water in such streams and wells are infected. The temperature of the water in such streams and wells may be better suited to the life of the typhoid fever bacillus than is the temperature of northern waters. Moreover, owing to the greater duration of the summer season, the fly season is longer, and the periods during which the diet of the people consists

*See page 78, Kober's "Industrial Hygiene."

largely of uncooked articles is correspondingly extended. The chances of infection are, therefore, correspondingly increased in so far as relates to infection through foods. Still it would be but poor comfort to know that, because Washington is a Southern city it must continue forever to pay its death toll to the typhoid fever Juggernaut; the problem must not be solved in that way. But the problem is not yet solved, nor is it likely ever to be solved until the investigation is taken up along broader lines than any that have yet been adopted; that is, until the investigation into the causes of the undue prevalence of typhoid fever in this District is made to include an investigation into the causes of the prevalence of typhoid fever elsewhere, so that by a process of comparison and exclusion the cause for the excessive typhoid fever rates in the District of Columbia can be ascertained."

PREVENTION OF TYPHOID FEVER.

The writer, in his report on typhoid fever in 1895, referred in his. concluding recommendation to thorough disinfection of the excreta from all typhoid fever patients and greater care on the part of those connected with the sick. We have known for over 25 years that the typhoid germs are conveyed chiefly through the feces and urine of infected persons, that they are capable of reproduction within and without the body, unless killed by certain physical or chemical agents. We have already mentioned that even the addition of four or five times the volume of boiling water to feces or urine will effectually destroy the vitality of the germs. If chemical agents are used the method must be thorough and exact. The attendant must prepare and use germicidal solutions of standard. strength, and unless this is done the whole process is a snare and delusion. So, for example, all vessels containing stools should be filled with a double volume of a solution of chloride of lime (6 ounces to the gallon), or a 5 per cent solution of carbolic acid, 6 ounces to one gallon of boiling water, or a corrosive sublimate solution, 60 grains of corrosive sublimate, 2 teaspoonfuls of table salt to one gallon of water, or any of the standard disinfectants; and kept in a covered vessel for at least one hour before emptying. Disinfection must also extend to the patient's soiled body, clothing and bedding, and to the hands of the nurse. If this is not done there is danger from so-called contact infection. Infected fingers may contaminate the food, while a fly alighting upon a soiled part may carry the germs on its feet to the food and drink of the other inmates or even to some neighboring houses. Prompt and efficient disinfection will destroy the principal sources of infection, and if carried out universally, would go far towards removing typhoid fever from the face

of the globe. That this is possible is shown by the fact that the typhoid rate in Berlin has been reduced from 142 per 100,000 of population in 1872 to 5 in 1906.

The causes of typhoid fever in this city are perhaps more complex and varied than elsewhere, no one factor can alone be held responsible for its undue prevalence, and in the prevention of the disease due attention must be paid to the removal of all the causes likely to influence its spread.

Among the sanitary measures which should be invoked are the following: The expenditure of $100,000 asked for by Major Cosby for the perfection of the quality of the filtered water. While the installation of the filtration plant has resulted in an improved water supply, it is found that during periods of great turbidity, especially during the months of December and January, the number of bacteria remaining in the effluent exceeds permissible limits. It has also been shown that the efficiency of the filters, as regards removal of bacteria, can not be increased without previous chemical treatment of the water at such periods. In view of the fact that the degree of danger varies with the number of bacteria left in the water, no effort should be spared to eliminate these high counts by the methods proposed by the engineer in charge.

The prevention of river pollution involves problems which should be solved in the interest of this and other communities using a public water supply from interstate rivers, under which circumstances the inhabitants of one commonwealth are powerless to protect themselves against the misdeeds of their neighbors.

The abandonment of public and private wells and box privies, wherever found; the removal of slums, insistence upon clean homes, back yards, basements, cellars, alleys, streets and vacant lots, and more stringent laws for the production and sale of milk and cream, together with the reclamation of the Anacostia Flats can not fail to diminish some of the contributory factors in the prevalence of the disease.

Many of these measures have been urged by the Commissioners and the Health Officer for years, and it is the duty of every good citizen to strengthen their hands in their well-directed efforts. In addition to all this, there is special need for more visiting nurses and social workers to instruct our neglected neighbors in higher standards of living, and finally, more attention should be paid in our schools to hygienic and sociological questions, so that the average child may learn the essentials for the preservation and promotion of health.

DIARRHEA AND DYSENTERY.

Whilst diarrhea is a symptom of very many diseases, there is reason for believing that certain forms, occurring in infants as well as adults, towards the middle or close of a hot, dry summer, are caused by the consumption of tainted food, milk, impure water, etc., superinduced by putrefactive bacteria, and that the serious forms of summer complaints are due to specific germs.

From what we know of the nature and cause of dysentery we are led to consider it an infectious disease, which is spread very much like typhoid fever. The tropical form of dysentery is caused by an ameboid organism, while the type most prevalent in this country is due to a bacillus.

In our present state of knowledge we may conclude that the virus of dysentery, whether of the bacillary or amebic type, proceeds from the intestinal discharges of a previous case, and the most usual mode of transmission of the germs is through the water supply. This is the opinion of Virchow, based upon personal experience in Egypt, and Uffelmann has frequently observed that persons using boiled water during a dysentery epidemic remained exempt, and that the simple closing of a suspicious well often checked the spread of the disease. It is also perfectly conceivable that the germs may be spread through soils strongly polluted and infected with excrementitious matter, and with particles of dust gain access to milk, fruit, fresh vegetables, etc., which are eaten raw. The agency of flies in carrying the germs from infected sources to the food supply cannot be ignored.

Temperature also plays an important role in the development of the disease. At all events, statistics show that in temperate climates the disease assumes epidemic proportions in July, August and September, and declines with the approach of cold weather; it goes hand in hand, therefore, with a maximum temperature of the air and soil. It is also a clinical fact that badly nourished individuals, and those suffering from indigestion or intestinal catarrhs, are especially liable to be attacked.

Prophylaxis: In the attempt to prevent epidemic extensions of these diseases the water supply should be looked after, and every source of contamination of wells, springs ard public reservoirs must be avoided, and suspicious supplies closed.

The public should be enlightened as to the nature of these diseases, and especially of the necessity for prompt disinfection of stools. It should also be informed that indigestion, the result of indiscretion in eating and drinking and chilling of the body, increase the susceptibility; that it is desirable during the prevalence of these diseases to use only

boiled water and milk, and to avoid the consumption of raw vegetables and fruit, unless they have been thoroughly washed with water previously boiled.

INFANTILE MORTALITY.

According to Oesterlein's statistics it is safe to assert that the average death rate during the first year of life is 188 out of 1,000 infants born. According to the census of 1900 the infantile mortality per 1,000 births in the so-called Registration States was as follows:

It will be seen that the rate of Vermont and Michigan is less than one half that of the District of Columbia.

The rates in foreign countries likewise vary considerably. In France the average rate from 1874 to 1893 was 167; in 1903 it had fallen to 137, practically the same as that of New Jersey.

According to Harrington* our highest rate about equals Russia, and it is not much greater than that of Austria. Rhode Island makes a better showing than Germany and Italy. The German rates for the five years 1901-1905 were as follows: 216, 184, 202, 204, 204. The Italian rates are 170. Maine stands with England and Wales, and better than Belgium and the Netherlands. The rates for England and Wales are 150; Belgium 156; The Netherlands 147. The rate of Vermont is lower than Scotland (126), Denmark (127), Finland (134), or Switzerland (144). Michigan is also lower than Scotland (126). The following countries have lower rates: New South Wales, 108; Victoria, 105; Ireland, 105; South Australia, 102; Queensland, 101; Sweden, 98; Norway, 90; New Zealand, 79.

These are mean rates for rural and urban districts. In towns and cities the mortality is always higher, amounting to 33.6 per cent, as compared with the rural mortality of 27.8 per cent.

The District of Columbia in 1900 had the unenviable reputation of leading the list of the Registration States in Infant Mortality, but the rate of Washington as a city compares favorably with other cities.

The census of 1900 gives a list of 106 cities and towns with infantile

*Harrington, Infantile Mortality, "Am. Jour. Med. Sc.," December, 1906.