Page:The Journal of Tropical Medicine, volume 6.djvu/220

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TYPHOID FEVER AMONGST THE NATIVES OF SOUTHERN CHINA.

By J. Preston Maxweut, M.B., F.R.C.S.

Burt little has been written, as far as I am aware, on the incidence, form and mortality of typhoid fever amongst natives living in tropical and subtropical regions.

As to the liability of Europeans to the disease known as tropical typhoid, and the increased seriousness of the disease as compared with the same affection met with at home, there is much known; but I have no intention of touching on the matter except in so far as it bears on the question of relative mortality.

In some quarters there is an impression, which was lately voiced by Dr. Clark,’ of Hong Kong, in a paper on the subject, that the adult Chinaman rarely sufiers from typhoid fever, and that the mortality amongst natives is so slight that some explanation must be found; and he suggested that many of the children had had typhoid fever in infancy or shortly after, and were thereby rendered immune.

He adduced in proof the number of deaths amongst children in Hong Kong from this disease as borne out by post-mortem statistics. I thik I shall be able to show that this view, if correct at all, is only partially so. Since the publication of Dr. Clark’s paper I have been keeping a sharp look out amongst children brought to me for treatment, or whom I have visited in their homes, for any confirmation of this theory. A great number of cases of fever have come before me, and simple diarrhoea and cholera nostras are not un- common, but I have yet to meet with a case of typhoid under the age of twelve in my practice in this region, and most of my cases have been adults. These patients have been met with in the indoor practice of the Amoy and Changpoo mission hospitals, or are taken from my own visiting list in an area oi country roughly about sixty miles long by thirty broad.

When I took up this question with a view to looking carefully into the matter, two or three questions at once obtruded themselves: (1) What are the con- ditions under which one may expect to find typhoid fever prevailing im this region, and are these conditions fulfilled in fact? (2) Is the diagnosis of typhoid fever in tropical countries as difficult as it has been made out to be? (3) Do typhoid fever and malarial fever run concurrently in the same patient? (4) Is the mortality of typhoid the same as amongst meat-eating races, in cool climates, and is there any difference in the ultimate cause of death in these cases, and in those specified above ?

(1) What are the conditions under which one may expect to find typhoid fever prevailing in this region, and are these conditions fulfilled in fact ?

To be able to answer this question, one must first look at the method of the disposal of excreta which prevails amongst the Chinese.

In the case of typhoid fever the excreta of importance are the feces and the urine. The other channels of

' British Medical Jowrnal, January 26th, 1901,

THE JOURNAL OF TROPICAL MEDICINE. = [June 15, 1903.

excretion may be disregarded in dealing with the ques- tion, as infection by their means is very rare.

How do the Chinese dispose of their faeces and urine ? It must be borne in mind that there is no water carriage system in China, and that with few exceptions the sewers are open. It must also be remembered that the power of the sun is very great.

Feces, and to a great extent urine also, are passed directly into large feecal pits with conereted sides and bottom. This concreting in due time becomes rotten, and allows leakage to take place, and if situated near a well may prove a source of contamination. In some cases when these pits are full, they are allowed to remain many months till the contents are thoroughly rotten, and then used as manure for the fields. In other cases the pits are emptied from time to time and the feeces carried and stored in fecal pits close to the fields themselves. In either case the material is not used till it has been well weathered and exposed to the sun.

At the same time each house has its large earthen jar standing in the courtyard for a urinal, several smaller pots in the house itself, and several wooden buckets for the use of the female portion of the family. These last are taken out and emptied at one of the feecal pits daily. The urine is kept by itself and used in a fresh condition for watering growing vegetables.

Take the case of a typhoid patient: unless very ill he will walk out to one of the fecal pits; if confined to bed, he will use one of the buckets before mentioned, or a bucket that has been used for carrying sewage. Probably in the course of maturation the bacillus dies, and unless the urine has been used on vegetables about to be gathered, then it too probably fails to carry infection.

In this region most of the houses have their own well, and it is rare for any large community to be supplied with drinking water from the same place.

It is clear that under these circumstances an extended epidemic was hardly to be looked for, but that the infec- tion might very readily hang about a house, and owing to the lack of cleanliness spread from inmate to inmate. As the feeces are never allowed to get dry in the pit there is little fear of infection being spread by dust. Flies, of course, may conceivably carry it to food.

Now what are the facts? Typhoid fever is endemic — throughout the whole region and I have met with cases _ in every quarter; but I have never seen or heard of anything approaching a serious epidemic. I haveseena _ family of three boys, a girl, and her father and mother all going down with the disease one after the other. And here is another case. One of the officials of the Changpoo Church fell ill and was nursed at home for | ten days, but as he was not getting on well I had him ~ moved into the hospital, isolated and specially nursed. One of the hospital coolies was appointed to clean the bedpan, and specially warned as to the risk of infection. He was careless and contracted the disease, and so_ did the hospital preacher, whom I had good evidence to prove had been meddling in the same matter. The students, who were obedient to instructions, escaped. This patient recovered and went home well. In a few

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