ENTERIC FEVER AT BLOEMFONTEIN.

THE WAR IN SOUTH AFRICA,THE EPIDEMIC OF ENTERIC FEVER AT

BLOEMFONTEIN.By A. CONAN DOYLE, M.D.

To the Editor of the BRITISH MEDICAL JOURNAL.]The Langman Hospital, South African Field Force,

Bloemfontein, June 5th, 1900.DEAR SIR,-You were good enough to suggest when I left

England that Ishould send you some notes upon any

ipoints which might strike me. The pressure of work hasprevented me from complyingwith your request, and even

now I feel that you will find these comments of a very

~scrappy character.When the nation sums up its debt of gratitude to the

men who have spent themselves in this war I fear thatthey will almost certainly ignore those who have (lone thehardest and the most essential work. There are threeclasses, as it seems to me, who have put in more solid andunremitting toil than any others. They are the com-

missariat, the railway men, and the medical orderlies. Ofthe three, the first two are the most essential, since the

war cannot proceed without food and without railways.'But the third is the most laborious, and infinitely the most

dangerous.THE OUTBREAK oF ENTERIC FEVER.

The outbreak of enteric among the troops in SouthAfrica was a calamity the magnitude of which had not

been foreseen, and which even now is imperfectly appre-

ciated. We naturally did not dwell too much upon itwhile the war was in progress. But it was appalling inits severity, both in quantity and quality. I know of no

instance of such an epidemic in modern warfare. I have

,not had access to any official figures, but I believe thatin one month there were fromIo,ooo to 12,000 men down

with this, the most debilitating and lingering of con-

tinued fevers. I know that in one month 6oo men were

laid in the Bloemfontein Cemetery. A single day in this-one town saw 40 deaths. These facts wouldhave stiffenedthe resistance at Pretoria if they had been generally known.It is only now, when the worst is past, that they can betalked of.

THE HOSPITAL ORDERLY.How was this unforeseen and unprecedented crisis

grappled with? Entirely by the efforts of the medicalmen and by the devotion of the orderlies. When a depart-ment is confronted by a task which demands four times

more men than it has, the only way of meeting it is for

each man to work four times as hard. This is exactly whatoccurred, and the crisis was met. In some of the generaliiospitals orderlies were on duty for thirty-six hours inforty-eight, and what their duties were-how sordid andobscene-let those who have been through such an epi-demic tell.He is not a picturesque figure, the orderly, as we know

him. We have not the trim, well-nourished army man,

but we have recruited from the St. John Ambulance men,who are drawn, in this particular instance, from the millhands of a northern town. They were not very strong to

start with, and the poor fellows are ghastly now. Thereis none of the dash and glory of war about the sallow,

tired men in the dingy khaki suits-which, for the sake of

*the public health, we will hope may never see England:again. And yet they are patriots, these men; for many ofthem have accepted a smaller wage in order to take on

these arduous daties, and they are facing danger for twelvehours of the twenty-four, just as real and much more

repulsive than the scout who rides up to the strange

kopje or the gunner who stands to his gun with a pom-pom

quacking at him from the hill.Let our statistics speak for themselves; and we make no

[ THU BXITSrUDIcLL JOURNAL 49

claim to be more long-suffering than our neighbours. Wehave 3 on the staff (Mr. Gibbs, Mr. Scharlieb, and myself).Four started, but one left us early in the proceedings. Wehave had 6 nurses,5 dressers, I wardmaster, I washerman,and iS orderlies, or 32 in all, who actually came in contactwith the sick. Out of the 6 nurses, i has died and 3 othershave had enteric. Of the 5 dressers, 2 have had severeenteric. The wardmaster has spent a fortnight in bed withveld sores. The washerman has enteric. Of the IS

orderlies, i is dead, and 8 others are down with enteric.So that out of a totalof 34 we haveI7 severe casualties-50per cent.-in nine weeks. Two are dead, and the restincapacitated for the campaign, since a man whose hearthas been cooked by a temperature over 1030 iS not likely todo hard work for anotber three months. If the war lastsnine more weeks, it will be interesting to see how many are

left of the original personnel. When the scouts and theLancers and the other picturesque people ride in processionthrough London, have a thought for the sallow orderly,who has also given of his best for his country. He is not a

fancy man-you do not find them in enteric wards-but forsolid work and quiet courage you will not beat him in allthat gallant army.

ANTITYPHOID INOCULATION.There is one mistake which we have made, and it is one

which will not, I think, be repeated in any subsequentcampaign. Inoculation for enteric was not made com-

pulsory. If it had been so I believe that we should (and,whatis more important, the army would) have escaped from mostof its troubles. No doubt the matter will be fully threshedout in statistics, but our strong impression, from our ownexperience, is that although it is by no means an absolutepreventive it certainly modifies the course of the diseasevery materially. We have had no death yet (absit omen)from among the inoculated, and more than once we havediagnosed the inoculation from the temperature chartbefore being informed of it. OF our own personnel only one

inoculated man has had it, and his case was certainlymodified very favourably by the inoculation.

THE SOLDIER IN HOSPITAL.Of the courage and patience of the soldiers in hospital

it is impossible to speak too highly. We have had 500cases pass through our hands, and can speak now from afairly large experience. I had always imagined that inevery large army there must be a minority of skulkersand shirkers, but they are singularly absent in the SouthAfrican Field Force. I have not had more than two orthree cases in my wards which bore a suspicion ofmalingering, and my colleagues say the same. They areuniformly patient, docile, and cheerful, with an inex-tinguishable hope of "getting to Pretoria." There is agallantry even about their delirium, for their delusioncontinually is that they have won the Victoria Cross.One patient, whom I found the other day rummagingunder his pillow, informed me that he was looking for"his two Victoria Crosses." Very touching also is theircare of each other. The bond which unites two soldierpals is one of the most sacred kind. One man shot inthree places was being carried into Mr. Gibbs's ward. Ilent an arm to his friend, shot through the leg, who limpedbehind him. "I want to be next Jim, 'cos I'm lookin'after him," said he. That he needed looking after him-self seemed never to have occarred to him.

THE SPECIAL HosPITALS.I do not think that any men have ever expended money

better than those who fitted out the private hospitals. Theofficers of the Army Medical Department freely admit thatthey do not know what they would have done withouttheir aid. They arrived out here at the very momentwhen the sickness was becoming alarming, and they tooktheir share of the strain when the epidemic was at it3

JULY -7, 1900.]-- - .1 I I

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50 MEDICAL JOURNALJ 9C

height. The large general hospitals fouDd it difficult toget to work on account of the pressure on the line whichprevented them from getting up their bulky equipment,but the private hospitals, more compact and mobile, got towork almost at once after their arrival. The pressure wassevere. Our, own hospital, with equipment and personnelfor ioo cases, hadISO cases, most of them virulent Paarde-burg enterics, shot upon them, and had to cope with themas best theymight. But the men had come out to work,and the orderlies, though untrained, never once grumbledat the great exertions which were called for. Without theYeomanry, the Portland, the Irish, the Scotch, the Welsh,and the other hospitals fitted up by private effort, andmanned by volunteers, it is difficult to see how theepidemic could have been met.

THE WORK OF THE R.A.M.C.There is sure to be some adverse criticism of the Army

Medical Department after the war, because they have hadto meet so difficult a situation with such inadequateresources)that.it is impossible that there should not beparticular instances where the machinery has broken down.A captious critic could quote cases of an overfilled,undermanned hospital without medical necessities in oneplace, or of hardships endured by the sick and wounded inanother. How can it be otherwise, when a Departmentwhich is sufficient for the needs of two army corps has toprovide for the wantsof 200,000 men with typhoid ragingamong them? Taking it on the whole, the Departmenthas been well organised and well worked, and has met anunforeseen and-exceptional state of things with remarkablesuccess.

"SIMPLE CONTINUED FEVER."The statistics of the campaign are likely to be vitiated by

the employment of the vague and unscientific term," simple continued fever," so largely used in the army re-turns. A great number of cases were classified under thishead, and such terms as " veld fever," " camp fever," etc.,were freely used. I think that nearly all medical men havecome to the conclusion that all, or at least most, of thesecases were really enteric of varying types and degrees ofseverity. Our senior surgeon, Mr. Gibbs, performed post-mortems on several cases which presented abnormal fea-tures, but never without finding the characteristic ulcers.

A. CONAN DOYLE.

THE ADMINISTRATION OF A GENERALHOSPITAL.

THE following letter from Lieutenant-Colonel R. T. Beamish,R.A.M.C., the Principal Medical Officer of No. 8 General Hos-pital, will be read with interest at the present time. It givessome insight into the nature of the emergency created inBloemfontein by the epidemic of enteric fever and of the wayin which it was met in the general hospitals. lt would appearto have been written at a date subsequent to Mr. Burdett-Coutta's departure from Bloemfontein, but of course long ante-cedent to the publication of his letter in the Times which gaverise to the debate in theHouse of Commons lastweek. The open-ing passages of the letter, however, have reference to one of theearlier letters of the series " Our Wars and Our Wounded,"all of which we are now given to understand have been writtenby Mr. Burdett-Coutts. It will be seen that Lieutenant-Colonel Beamish quite bears out the justice of the criticismpublished in the BRITISH MEDICAL JOURNAL on April 8th.Our contentions, in commenting on these letters, were

simply as follows: It is not the case-as was inferred-that strictly professional competence is officially con-sidered secondary to administrative functions; the twoare inseparably bound up, administrative ability beingan outcome of true professional competence; no amountof civil professional skill can ensure administrative successwithout previous military training and experience; thediscipline and administration of a military hospital can onlybe fully and properly carried out by an experienced militarymedical officer.

The establisbment ofi theee propositions, we conceive,entirely negatives the oft-revived faliacy that medical labourcould or should be conEerved by setting up a dual militaryauthority in army hospitals-sueb, in fact, as history painfullyproves was Po disastrous in former wars. Who, indeed, but athoroughly-trained medical officer accustomed to militarydetails could have grappled with the work suddenly thrownon the Bloemfontein Hospital, as described in the letter?We trust this discussion will prove to the official as well as

to the public mind that the successful military medicaladministration of base hospitals is not only of prime import-ance as a link in the military machine, but of vital interestto the sick and wounded soldiers themselves. Wehope, also,it will remove misconceptions as to what has been termed"wasted energies" of medical officers and men, forsuccessful hospital administration is synonymous withefficient professional organisation. There can be no wastein perfecting the autonomy of the Army Medical Service, andno going back by insidiously inserting dual authority inmilitary hospitals on the pretext of conserving professional( nergymSir,-yn your issue of April 28th there is an editorial discussing certain

letters of the Capetown Correspondent of the Times, concerningthe organ-isation and administration of general hospitals. etc., and there is nodoubt that some conclusions of the writer are, as you say, " apt to be mis-construed.'In contrasting the relative merits of marquees and " tortoise" tents as

sick wards, the latter, in my opinion, do not iu the least "reigntriumphant," and whilst I agree that they are pretty and convenient i-side, and suited for a perfect, temperate* limate, they cannotforamomentcompare with the lofty, substantial, and serviceable marquees, subjovefervido vel fJrigido.Then as to the "lavish expenditure" on civil hospitals securing a

"higher class of professional assistance," I am quite certain that the ex-penditure referred to is wholly unnecessary; for although we are allpleased and delighted with the presence of a famous consulting surgeonor physician, our experience proves to us that the average RIA.M.C.officer is quite capable of meeting confidently and successfully anyemereency which may arise, while for al the thousand and one details ofduty in cantonments and in camps he is absolutely indispensable and in-comparably more safe and efficient than any civil officer, howevereminentin civil society. The foregoing Is a truism of which anyone acquaintedwith the working of military hospitals and with the maintenance of thehealth and welfare of the soldier must be perfectly aware, and the uni-versal experience of this campaign proves how indispensable are the edu-cation and the discipline imparted at Netley and Aldershot and in theservice generally.With regard to the observations re the duties of the principal medical

officer of a general hospitaL the writer is entirely mistaken if he imaginesthat these duties are confined solely, or even chiefly. to administration.MY experience of the position is that whilst the P.M.O. must be theadministrator and commandant of the institution, he is also in the posi-tion of, as it were, senior divisional officer, and that at every hour ofthe day his professional knowledge and experience are in requisition.For instance, he must see and approve of every operation requiring an

ansesthetic, and must sanction the operative measure; he must makehimself acquainted with all serious cases of disease or injury, and mustcarefully select and inspect every man about to be transferred to the baseor other site; the greater portion of his time being occupied in theseduties and in the supervision and sanitation of the camp.Administration in a great general hospital is really nothing more than

higher and more responsible professional duty, and without a soundknowledge of the profession it could not be properly or successfullyexercised; and, after all, many years of his service must have been passedin the position of divisional officer, that is, in charge of large stationhospitals at home or abroad. There is scarcely an hour of the day, andoften of the night, that he is not consulted personally or on paper, atidthere is not an hour on field service when his professional and adminis-trative interference are not required.Take for example my own command. We came out equipped for $20sick and wounded and pitched the marquees, etc., about two miles outside

Bloemfontein upon an illimitable, sloping, and breezy upland, probablythe finest position in South Africa. ILmmediately, owing to urgent exi-gency the hospital was rapidly increased, till now It is equivalent tonearly four general or upwards of eighteen field hospitals in accommo-dation.An idea of the work to be done may be gathered from a single occur-

rence. One evening at 7 o'clock in the dark a convoy of ig9 sick andwounded arrived, an hour afterwards 80 more, and again 95 before xo P.M.,andyoucanimaginewhat thismeantiniinquiry, examination, arrangement,dietary, dressings, etc., and how everybody had to be on duty far into thenight. Rarely does a convoy numbering less than Icc arrive, and forweeks they were chiefly from the Modder and round about Paardebergand ThabaNchu, almost all enteric fever patients ; so that there are neverfewer than from 6cc to 8cc diagnosed cases of this disease under treatment,many of a very severe type. With a diminishing staff through illness theduty on officers, nurses, and men has been heavy and continuous, but allwork well and pluckily under immense pressure and determined to per-form their several parts with credit and success.The immense ocean of snowy canvas composed of stately marquees and

bell tents arranged in mathematical order covers a wide area indeed abdpresents a most imposing spectacle from a distance: while the generaldisposition, order, cleanliness, and efficiency are the theme of universalcomment and admiration.

R. T. BEAxISH,Lieutenant-Colonel R.AM.C.

Bloemfontein, May 31st. P.M.O. No. 8 General Hospital

LJULY 7; 190c-AD..IAINIbTRATION OF A 6ENERA.L HOSPITAL.

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JULY 7, I900o1 MEDICAL ASPECTS OF THE WAR.THzDJD. BRr ank

METC&u BOIRNm 51

THE MEDICAL ASPECTS OF THE WAR.BY A SOUTH AFRICAN CAMPAIGNER.

XXIV.TYPHOID FEVER IN SOUTH AFRICA.

THE bane of tropical and subtropical towns has also provedthe bane of military camps in South Africa. Typhoid hasclaimed more victims than war itself and is still the mostdeadly of our enemies. In various South African towns,especially Kimberley and Johannesburg, in the vicinity ofthe various mines, and wherever else men are congregatedtogether in South Africa during war or peace, this diseaseoccurs.The alarming prevalence of typhoid among young soldiers

and civilians in the East is well recognised, but it is not sogenerally known that the disease prevails in a like manneramong young emigrants to South African towns during thefirst two or three years after their arrival. Fortunately theliability appears to diminish with length of residence. Asortof acclimatisation orhabituationis presumablyestablishedwith time.On the question of the prevalence of typhoid among Euro-

peans in tropical countries there is an admiral chapter in Dr.Patrick Manson's Tropical Di8eases. He specially dwellsupon the relative exemption of the native races, which hebelieves is due to the immunising effect produced by livingin constant contact with typhoid and similar toxic agents.Thus he says:On visiting native cities-Chinese cities for example-one is fllled with

amazement at the state of filth in which the people live and tlhrive. Thestreets are narrow and never cleansed; the common sewer lies beneaththe flagstones paving the streets, and through the interstices between thestones can be seen the black stinking slush in the sewer. In everycorner are filth and rubbish. And yet in such ctrcumstances-circum-stances in which the sanitarian would prophesy typhus and typhoid-thepopulation seems to thrive.

'The same state of things exists in a measure in SouthAfrica. In the native kraals the arrangements are notaltogether insanitary; but very similar conditions occur inthe native quarters of all the big towns, such as Capetown,Port Elizabeth, Kimberley, and Johannesburg. In thesenative quarters typhoid does occur, still it is nothing like socommon as among the white races.According to my experience of typhoid fever in SouthAfrica, I

should say that as a rule it is grave from the outset, and thatit is liable to relapse, but that it certainly is not as deadly asit apparently is in India. The death-rate among typhoidcases in the Kimberley and Johannesburg hospitals is approxi-mately I in 4 or 5 cases.With regard to the etiology of typhoid fever, there are two

questions which in this connection appear to be of paramountimportance: Can typhoid be transmitted only from man toman? or, Can it also be derived from some micro-organismwhich has a saphrophytic existence in no way dependingupon an actual passage through the human body? If anoccasional passage through the human body be essential, itis obvious that theoretically, with sufficient precaution, thedisease should be entirely preventable; if, on the other hand,an occasional passage through the human body is not essen-tial to the continued existence of the parasite, it is equallyobvious that prevention of the disease, though still possible,must nevertheless be more difficult of accomplishment.Testimony from India on this subject as adduced by Dr.Patrick Manson is to the effect that sanitary safeguards,which are found to be practically sufficient in Eng-land, are by no means so effective in India. Itwould appear that soldiers on the march contract the dis-ease in passing through uninhabited country in spiteof-the fact that the camp may be pitched in spots which pre-sumably have never before been occupied by man, and al-though the men may have drunk from springs and streamsthat were above suspicion of frecal contamination. Similartestimony comes from Australia, where typhoid has occurredin the back country in lonely spots hundreds of miles fromhabitations, and very similar evidence is forthcoming in SouthAfrica. I am therefore disposed to admit, first, that typhoidattacks different races, and different individuals of the samerace, at different ages,with a very varying degree of virulence;secondly, that the etiology of typhoid has not been absolutelycleared up; thirdly, that exposure to insanitary conditionsdqes confer an undoubted degree of immunity, and that, con-

versely, the improved sanitation of English towns to-dayseems to render young Englishmen particularly liable toattack when exposed to the virus.

TYPHOID IN THE CAA PAIGN.The occurrence of typhoid in the South African campaign

has been alarmingly great, but while the actual occurrence ofthe disease is undoubtedly high, it must be admitted that themortality among cases, which is stated at something like I in5, is as low as that obtained in hospital practice in Kimberleyand Johannesburg in times of peace. This in itself is satisfac-tory from more points of view than one. It is satisfactory tothose who may be unfortunate enough to have friends nowsuffering from typhoid in South Africa, and it is satisfactoryas primd facie evidence against the allegation that the medicaltreatment and nursing of many of these cases has been so un-

warrantably deficient, for if deficient medical and nursing aidis to be manifest at all in the results we are surely justified inlooking for it in the case mortality. What is deplorable froma public standpoint, then, is the incidence of typhoid, not thehigh mortality from that typhoid among cases where it hasactually occurred.An officer in a South African regiment to which I was once

attached as surgeon called upon me only a few days ago andreported that he had arrived by the last steamer from SouthAfrica. He was himself a patient iu Bloemfontein, and hadcomrades, some of whom were personally known to me, laidup in Bloemfontein with enteric. He had read Mr. Burdett-Coutts's letter shortly after landing, and callel upon me toexpress strongly his dissent from the strictures and generaltone of that letter, which he assured me he regarded as anunfair and distorted picture of the medical arrangements ashe had seen them and known them. This young officer wentup with General Brabant from Sterkstroom, and was with himup to Thaba Nchu, from which he went with a squadron toBloemfontein, reaching it on May gth. He spent nine daysthere, and visited several of the buildings used as hospitalsin Bloemfontein itself. He found them, as he considered, wellappointed and the men in them thoroughly satisfied. Oneman in particular, a trooper suffering from enteric, who ispersonally known to me, and who is by birth and education a

gentleman, expressed himself as specially satisfied with thetreatment he had received. My informant tells me that withthe Colonial forces under Brabant practically no enteric hadoccurred, and this he attributed to the fact that they were

continually on the move. If this be indeed the true explana-tion, it is significant evidence of the spreading character oftyphoid when once established in a camp, whether thatspreading occurred merely by pollution of water or also bypollution of dust, or through some other unknown channel.It is, however, to be borne in mind that the Colonial troopsare men accustomed to the country, and probably more im-mune to typhoid and other saprophytic diseases than theirEuropean comrades.With regard to the incidence of typhoid, my informant

states that latrines undoubtedly have, not always been care-

fully managed, and that in particular there is very apt to bea carelessness about throwing the earth into the ditches usedin the latrines in a regular and efficient manner. This is a

practical point of the greatest importance, and cannot be toorigorously insisted upon by the officers responsible for seeingthis duty carried out.

THE PRINCESS CHRISTIXN HOSPITAL ATDURBAN.

THIs hospital, which has been built, equipped, and main-tained by Mr. Alfred Mosely at his sole charge, was formallyopened on May 2sth, by Colonel Morris, the Commandant ofDurban, on the occasion of the celebration of the PrincessChristian's birthday. The site, the gift of Mr. Frank Stevens,is on a bracing elevation in his grounds at Pinetown Bridge.It is considered to be one of the most beautiful andsalabriousspots near the railway line, and has near it an excellent watersupply. The hospital itself consists of four -largeand fivesmall wood and iron pavilions, which were taken out underthe care of Mr. Mosely, and of the permanent buildings, theproperty of Mr. Stevens. The beds number 210, of which 34are for officers. The wardi are built on piles, and lined over

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THz BRITISH152 MEDICAL JOURNAL] THE MORTALITY OF TYPHOID FEVER. LJrLY 7, 1900.

walls and ceilings for coolness; the ventilation and electricligbting aye on the most approved mt thods, and the operatingtbeatre, dispensaries, storerooms, and kitchens are admirablyappointed. There has also been provided the most recentimprovements for X-ray work. Patients are received from thePrincess Christian Hospital twain at the Ptnetown Bridgestation, and conveyed on Major McCormac'a wheeled stretchersto the hospitals. Surgeon-Mlvajor Mathiam, D.S O., R.A.M.C.,is the military medical officer, and the senior surgeon is Pro-fessor Paul Bush, of Bristol. There is a full staff of surgeons,nursing sisters, and 30 St. John Ambulance attendants. Thegenerous donor himself superintends the administrative de-partment. The flist batch of patients were received onApril gth.

MEDICAL OFFICERS OF THE FIELD FORCE.ADDITIONAL APPOINTMENTS.

FoR the following list of medical officers who have recentlyproceeded, or are proceeding to South Africa, we are indebtedto the courtesy of the Medical Department of the War office:Table showing the Personnel ol Medical Units on the Lines of

_ _Communnication.

Unit and Placeof Mobilisation. Detail. Remarks.

Royal Army Me4ical Corp8.Major S. Butterworth (a)Lieutenant F. W. Cotton I quarter-

, F. M. Parry master to join, W. J. P. Aciye-Curran the unit in,, J. G. Foster South Africa, X9, E. G. Ford warrant officer,, L. M. Panser and 144 D01-

No. 14 General ,, H. H. Fawcus commissionedHospital T. E. Fielding officers and(Depdt, T. Emen (including

R.A.M.. 52 men St. JohnAldershot). Civ-il Surgeons. Ambulance

Mr. W. J. I. Bruce Brigade), I,, W. J. Collins warrant officer

J. G. F. Hosken to join the unit, A. W. Izard on its arrival, M. E. O'Dea in South,, L. E. Owen Africa,,, W. M. Power I special cook.,, R. B. Williams J

(a) secretary ana Registrar. and to act as omcer coinmanaing the unittill its arrival in Natal.

The P.M.O., Natal, will arrange for a Lieutenant-Colonel, R.A.M.C., inBouth Africa, to be detailed as officer in charge of the unit.

THE ARMY NURSING RESERVE.AT the present moment the following particulars, which maybe accepted as quite trustworthy, with regard to the ArmyNursing Reserve, will be read with interest.Strength.-The Reserve is officially stated to consist of ioo or

more nursing sisters, but it is not limited to ICO, and as amatter of fact there are at the preeent moment 465 employed inSouth Africa, 7 in the Mediterranean, and 83 at home-a total of5555Tra-aining.-The requirement of three years' training in a civilhospital is invariably adhered to, and it is not the case, as hasbeen asserted, that "female and children's ward" service willbe accepted. Further, the committee are careful in theirscrutiny of the hospital eertificates produced by candidates-the institution granting them must be of sufficient size to in-sure varied training. This training does not include thespecial feature of gunshot. wounds (and except during a warwhere can they be studied?) or of tropical diseases, but it doesinclude the attention, the tact, the tbousand and one pointswhich go to make up the essential qualities of good nursing-obedience to the pbysician or surgeon being a sine qua non.

election.-This rests with a sub-committee (of the CentralBritish Red Cross Committee) which consists of PrincessChristian as President, the matron of a large London hospital,aipractisinig physician and a r0presentative of the War Office.Certificates and credentials are carefully examined, and a per-sonal inspection of each candidate is made whenever pnssible-in the majority of cases this has been done by PrincessChristian. That the selection has been judicious may begathered from the fact that the work of theEe ladies in SouthAfrica has been beyond all praise.

THE MORTALITY OF TYPHOID FEVER.THE Under-Secretary of State for War in his speech in thedebate in the House of Commons on June 29th stated that the"percentage of mortality in enteric cases during this war, and(more especially at Bloemfontein, has been 2I per cent. of theadmissions to hospitals." He compared this not only withthe percentage in other campaigns (Nile campaign of i898, 2&per cent.; Dongola campaign of 1896, 50 per cent.; Matabelewar of 1896.97, -32 per cent.; Chitral campaign of 1895, 28 percent.; Soudan campaign of 1884-85, 39 per cent.), but- also-with the percenta9e mortality in the British army in India.and in the United Kingdom. As Mr. Wyndham did not give.the figures in full it may be interesting to reproduce themfrom the annual reports of the Army Medical Dtepartment.

Year. Ads is:

BRMTISH ARMY.United Kingdom.

sions. Deaths. Mortality Per Cent.

1889 140 25 27.8x85)o 126 30 23.91891 2c9 17 I5.61892 132 23 17.41893 15I 22 14.62894 124 21 26 91895 137 35 25 52896 94 22 23.41897 8$ 21 23.92898 89 12 23.5

2,290 228 19 z6

i Z__ ____ -.__v1t A , .-.. & - l h.0 ,.0 .... su{o«v* Excaudmig troops Irom Khartoum expeiituou, wnIiLI 2au go90ases, Iodeat8s, I1. I nortality per cent.

Year. Admissions.

1889 I,O932890 9961892 998I892 I 130X893 2,076, 894 2,069,895 2,544.2A9 .,A95x896 In795,89, 2,050I898 2,375

214,3I26

In7ia.Deaths. Mortality Per Cent.

283 25.92;Q 26.0268 26.8270 23 9276 25 6300 28.0383 24 8445 24.8556 27.1657 27.7

3,697 26.I7

in eetimating the siguiln-ance of these figures, it should beborne in mind that the majority of soldiers are young menbetween the ages of I9 and 30, and that in fact from 8o to-85 per cent. are under 30 years of age. The mortality oftyphoid fever at ages from 20 to 30 is in excess of the averagefor all ages, and this well-known fact may be illustrated bythe following tables of the percentage mortality in the LondonFever Hospital and in the hospitals of the Metropolitan Asy-lums Board. The figures for the Metropolitan Asylums Boardare taken from the report for 1898, and deal with a period oftwenty-seven years, Those for the London Fever Hospitalare for an earlier period of ten years (I848-57).

London Fever Hospital.Admission, Deaths, and Mortality Per Cent. of Enteric Fever Patients

during 23 Years.*

Males.

Ages.Admitted. Deaths. PMortCality

All ages 3,001 5C4 I6.79

15-19 744 95 22.76

20-24 545 127 23.30

25-29 297 51 17.17

A 1 T5 naush rn use UA0fl270U JDCT UJ ns 0nt Tt5 . R ler*A Treatise on the C;ontinued seve-rs of uleaw Ertzatn. "y %,juar-wMurchison, M.D., LL.D., F.R.S. T)ird edition. Edited by W. Cayley.M.D., F.R.C.P. London, 1884. Pp. 6 06 .

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JULY 7, 900.] R.A.M.C. SOUTH AFRICA FUNP. TIEDICAL JOUERNAL 53

Metropolitan Asylume Board.Admissions, Deaths, and Mortality per cent. of Enteric Fever Patients

in the years 1871 to 1898.

Males.

Ages.Admitted. Deaths. MortalityPer cent.

All ages 6,346 1,092 17.2

15-20 1,356 208 15-3

20-25 937 209 22.3

25-30 733 17 24.4

Dr. Victor C. Vaughan, Professor of Hygiene in the Uni-versity of Michigan, has recently published in the Phila-delphia Medical Journal, June gth, igoo, some of the resultsof an inquiry made by a Committee appointed for the purposeof ascertaining the causes of the existence and spread oftyphoid fever among the American soldiers assembled inNational Encampments during the brief war between theUnited States and Spain in I898. He states that every regimentin theUnited States service in I898 developed typhoid fever,andthe disease appeared in nearly all regiments within less thaneight weeks after going into camp. It not only appeared inevery regiment, but it became epidemic both in smallencampments of not more than one regiment and in tbe largerencampments.Professor Vaughan concludes that the main cause of the

dissemination of the disease was the greater difficulty ofdisposing of excreta in camps than in civil life, and observesthat a single man attacked by typhoid fever may scatter theinfection in every latrine of a regiment before the disease isrecognised in himself. In a general way the number of casesof typhoid fever in the different camps varied directly withthe efficiency of the method of disposing of exereta. He con-siders that flies undoubtedly were one of the means by whichtyphoid fever was disseminated, but that personal contact wasalso operative, and that it is probable that the infection wasdisseminated to some extent through the air in the form ofdust. He gives some statistics, from which it appears thatabout one-fifth of the soldiers in the National Encampmentsdeveloped typhoid fever. The number of cases of the diseasewhich were studied for the purposes of this report was 9,660,and the number of deaths was 713, a percentage mortalityof 7.38. This mortality, as we understand the report,occurred among men attacked in camp in the United States,and treated in hospital there, and not at the seat of war. Hecompares it with the extremely favourable mortality of 7.8per cent. shown in the series of 19,017 collected by Brandttreated by cold baths, and with the mortality of 9.2 among2,293 cases treated in some of the larger hospitals in theUnited States in 1897.

LONDON ASYLUMS: A DEADLOCK.THE London County Council at its last meeting discussed fortwo hours, but with a singularly inconsequential result, animportant report of its Asylums Committee in regard tobetter and newer methods of treating the insane wbo arecommitted to its care. So long ago as October 27th, 1896, theCouncil resolved:That, having regard to the growing demands upon the ratepayers of the

county of London in connection with the care of pauper lunatics, it bereferred to the Asylums Committee to consider and report as to the expediency of adopting a better and less expensive method of housing andtreating such persons, and that, in dealing with the question, the Com-mittee do consider the systems adopted in the principal European andAmerican cities.In the spring of I897 the Council was informed that the

Special Subcommittee to which the above reference had beenmade had come to the conclusion that it was impossible toproceed further in forming any definite or practical opinionas to the merits of the modern Continental system of housingand treatment without personal inspection of some of theforeign asylums, where special methods, other than those

obtained in this country, are in vogue, and that for this pur-pose it would be desirable to send a Commission to visit cer-tain asylums abroad. This report was duly approved by theCouncil, and the travelling and out-of-pocket expenses of suchCommission were authorised. Owing, however, to certaihtremarks made in the Council Chamber suggesting that cer-tain members of the Council-which has justly earned arepu-tation for its austerity-were to have a trip abroad at theexpense of the rates, it was difficult to find any Councillor toundertake the inquiry except at his own expense.The sporadic information thus obtained, together with re-

ports obtained from medical superintendents who had visitedContinental and Amexican asylums during their holidays, ap-peared only to have served to whet the appetites of the in-quiring Subcommittee for more. Accordingly last July thematter was again brought before the Council and the Councilsanctioned the expenditure of £[,coo-For inquiries and preparation of preliminary designs in connection

with further asylum accommodation, such estimate to.include cost, if any,of visiting foreign asylums.Notwltw4tandingthiR specific authority the Subcommittee stillhung fire; the fear that party or electioneering use might bemade of rate-aided excursions appears to have operated in theirminds. If Councillorswere to go at all it appeared essential thatthey should do so at their own expense or sacrifice their self-respect, oratleast the respectof their colleagues, soscrupulouslyaustere is the London County Council. At length a discussionin May last, to which allusion was made in these columns,appears to have stung the Committee into action, and yester-day, though replete with ample authority to go and to spend,the Committee again invited the Council to express an opinionon their roving Commission. They proposed that the Com-mission should consist of the Chairman of the Committee(Dr. Forman) and Mr. Hunter, together with one MedicalSuperintendent, the Asylum's Engineer, and the AssistantClerk. An amendment to refer the matter back to the Com-mittee was proposed by Mr. Benn, and after debate the Councildivided; there being 52 for and 52 againtt the amendment,the Chairman gave a casting vote ior the amendment. Whenhowever the amendment was subsequently put to the CounciLas a substantive motion the Council by 54 to 5o rejected themotion. Accordingly nothing whatever was achieved. Theresult was further complicated, it appears, by two members forthe City, who are not entitled to vote on asylum matters,having passed through the lobbies.

THE R.A.M.C. SOUTH AFRICA FUND.WE have received the following notification:Mrs. Skey Muir (Honorary Secretary) wishes to notify all those who

have been interested in this work that the offices, 77. George Street, Port-man Square, W.. will be given up early in July, and that no parcels can bereceived after JuJy 7th, though gifts in money may still be sent to thebankers, Messrs. Holt and Co., 3, Whitehall Diace. Should it be folnddesirable to resume this work in the autumn due notice will be given.

THE HALF CROWN FUND.In consequence of the above notification it would seem that

the time has come for closing, or at least suspending, theHalf-crown Fund, to which so many medical men in almostevery part of the United Kingdom and in some of the colonieshave so readily responded. To those gentlemen who havetaken a great deal of trouble to collect the subscriptions in somany localities the thanks of the R.A.M.C., and ilideed of theprofession generally, are due. We shall be much obliged ifthey will now send in their final lists.

LiPROSY IN PORTUGAL.-Dr. Zepherino Falcao has pre-sented to the Royal Academy of Sciencs at Lisbon a com-munication on the extension of leprosy in Portugal. Sincethe suppression of leper houses in that country the diseasehas gradually spread, and it is estimated that there are nowsome I,500 lepers in the country; this is a considerable pro-portion in a population of 4,700,000. The lepers are scatteredthroughout the country, no district being exempt; most ofthem, however, are on the coast and in the deep valleys.There are, however, also foci in the mountain regions. Dr.Falcao considers that the disease as it is met with inPortugal is very slightly contagious, special conditions beingnecessary for ',transmission to take place from'Ione patient toanother.

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