will last from generation to generation as master-pieces of literature, and immortalize the memories of their great authors?allusion is, of course, made to "A Treatise " on the Continued Fevers of Great Britain," and Tyof the Drs. Charles pens Fever," respectively from
phoid
Murchison, and William Budd?our knowledge
was very The attention of the profession was forthwith drawn to the subject by these books, both in the United Kingdom and on the Continent; and although some of the criticisms, from time to time, have been hostile, the amount of scientific and public good done by
limited.
yet
these two luminaries has been, and will be, immense As an instance of the universal respect witli which their names are associated, we know of the deep gloom cast the sudden and upon all parts of the scientific world by melancholy death of the first-named savant. In proposing to briefly summarize our knowledge of the subject of enteric (typhoid) fever, an apology is needed for the of
the
repetition
of what
this article
object pretence of attempting
is
are
already
far from
known:
possessing
any
feature in the affection, or of any special recommendations as to treatment or prevention ; but simply to indicate roughly and in general terms some of the directions in which our endeavours may be pursued with the desire and hope of succeeding to turn over some of the stones which
as
yet
seem
to advance any novel
to be untouched.
We know that it
was
Dr. Murchison who advanced
" theory that enteric fever originates from putrefythe media of ing sewage" which finds access through drinldng-water, other food, and breathing air into the system. This is this author's principal view, and which
the
will be found in page 482 (2nd. Ed., 1873, London, Longmans) ; but he does not seem to oppose the other view, which asserts that the disease is communicated from a previous case, in fact this is plainly allowed by a mode, but a rarer one. By reference to " enteric fever is in some page 465, we are taught, that way communicated by the sick to persons in health"; according to him the commoner mode, by far, is by
him to be
NOTES ON ENTERIC FEVER, OR ABDOMINAL TYPHUS. By Surgeon J. C. Lucas, M.D., F.R.C.S., Bombay Medical Service. That the diagnosis of enteric fever, in India, is encompassed with special embarrassments will be admitted by all: and that the attention drawn to the subject recently by the Army Sanitary Commission must sooner or later be productive of good results to settle the prime question of the existence, or otherwise, of the disease in this country; and in the progress of deciding this point, it is to be hoped that the investigators will at the same time hit upon the circumstances and conditions which aid in the importation of the contagium vivum of the malady, or those which foster the generation de novo thereof. Its etiology,
know, is still a burning question ; and opinions, even in the nineteenth century as to its origin, and to its modes and channels of dissemination, are divided. There is very little harmony amongst different observers; and, this being so, the difficulties in the way of
at an accurate conclusion are multiplied tenBefore the publication of the two works?which
arriving
fold.
we
putrid
sewage
polluting drinking-water, breathing-air,
Dr. Murchison shows himself believer of the purest water in spontaneous generation by his laying stress upon the important point that the sewage need not necessarily be of persons suffering from the disease, typhoid fever ; that is to say food
to be
(such
as
milk, &c).
a
that typhoid can be produced in a person from the fasces of another not suffering from it, but the proviso with him is that they be putrid. In other words, with the sine qua non of putrid sewage being taken into the
system, typhoid
or
enteric fever may be generated
de
spontaneously. His further clinical and literary knowledge, for he has often written on the subject, even novo, or
death, has not enabled him to alter his views. On the other side of the scale we have the anti-de novo-origin theory of Budd, whose views are opposed to those of Murchison. Dr. Budd teaches that every case of typhoid originates from another case of that disease.
up to the time of his
Independently of putrefying or putrid sewage?unless of a person suffering from that disease?a previous case
THE INDIAN MEDICAL GAZETTE.
3G
for liira is the sine qua non ; or in other words, he is a non-believer of the purest water in the spontaneous generation of the disease.
exhaustive study of what these two authors have had to say, and by a careful digestion of the views of some of their contemporary and other writers, the weight of the evidence, as yet brought forward, will be found on Budd's side of the scale. But it may be noted that there are many who still cling to Murchison, quite as much and nearly as many in number as those who have faith in Budd : while there are a third class of writers who tell us that typhoid fever is caused as often from a previous case as when no case had been discovered to have existed. Hygienically we would be
By
an
the safest side to belong to the ranks of these commandants. Let us for a moment animadvert to both these momentous aphorisms?(i.) no previous case discovered, but putrid sewage-contamination ; and ([ii.) on
discovered with, contamination?and attempt
previous case
or
without, putrid sewage-
putrid
[February 2,
1880.
sewage to be the
only condition or data for the typhoid, why, India would be endemically
causation of
liable to it, and fifty per cent, at least, of Indian towns and villages would never cease to be free from this zymotic disease ; and this, we know, is not the case. Are not the
"
rife in, at least, of the smaller and poorer towns and villages, at almost every turn we take, taking into consideration the other sanitary conditions, and notably the sites, &c of , wells, tanks, &c., wherefrom the people obtain their drinking water and cooking water, and wherewith the milk is adulterated and the great facilities for the contamination of the air ? Do not the inhabitants inhale the putrescent emanations, and drink them in solution for years, and how often have instances of epidemics therein been reported in the public Press? Transportability?alas! Are not village people constantly moving from village to village, from one place to another, and also going into and coming from military
pythogenic compounds" always
some
the extent of In reference to the first
and civil stations ? I have frequently made enquiries of sweepers employed for the removal and disposal of
we
night-soil
an
well
their state of health, and have learnt that they are no worse off than other people. Now, no one can say that these people, of the sweeper caste, take the least precautions ; they work, eat, and sleep in the same dress. Do they disinfect their hands with special germicides ?
to ascertain
tenability of these doctrines. might answer by the statement that the non-discovery of a previous case is no argument whatsoever that there was no previous case?a point often lost sight of, and inference often drawn.
say that if the
decapitated
In
analogy,
head
of
a
we
might
as
murdered victim
found a mile away from where the trunk was found, and if no murderer were discovered, the medical jurist would be justified in expressing an opinion that no murder was committed ; the point of which he would lose Bight, of by is the discovery of the culprit, with which he lias nothing to do. On the other hand we may say, with were
that although a previous case hapdiscovered, it by no means necessarily follows that it audit alone caused the disease in the case or cases which forms the subject of our enquiry ; whereas we are liable to be led away unconsciously by it, and bring our
perhaps equal force, pens to be
enquiry after the cause to a standstill. We must, therefore, view both sides with the most unbiassed eye, as if we
believed in Murchison as well as in Budd ; and were well cognizant of the shortcomings in the typhoid logic of both. Whether a case is discovered or not, whether or
apart
from
the
putrid
is discovered or
sewage-contamination
each other,
we
not, together with have to persist with our
discovery is nothing in itself, but we connect, or rather find out the connection, link by
enquiry ;
have to link, from
mere
effect,
to
from effect to cause ; if a search for them, taking care not to connect the links of another chain with those of the particular one which is disjointed. links
are
cause
missing
we
or
must make
It will be allowed that the sewage question is one of inconsiderable moment, in India more especially, considering the climatic, general sanitary and other conditions. The matter will become more and more important every day by the adoption of a drainage system for the disposal of sewage, and unless considerno
able medical and engineering skill is first on its original plan, and secondly,
working, farther,
disastrous results as
means
of
are
transport
power in land and in water.
If
likely are we
to bear its subsequent to ensue ; and
brought on
facilitated by steam grant putrefying or
with the
object
of
obtaining
information
as
to
That is in India.
The same was, and perhaps is, the the United Kingdom: and how about those men whose occupation it is to cleanse and repair sewers ? In thinking of some authority to consult on this point, the name of Parkes instantaneously suggests itself. I intended to have referred to Dr. Parkes's own writings, but I find tint it is not accessible to me at present, but on finding the identical passage in one of the journals received with
case
in
the last mail, which happens to be on the table before me, I content myself by quoting from it, and also beg to invite the attention of all who are interested in the subject of typhoid fever to the valuable contribution by
Dr. King. The following are the words of Dr. Parkes ''The air in many sewers in London is not very impure. The analyses of Letheby and Miller have shown that the amount of C02 is very little in excess of that in the external air, and that there is hardly a trace of H2S or effluvia. The air of house-drains is often, [ foetid organic more impure than that of the main sewers. in fact, | An inquiry lately conducted into the health of the of London did not detect any excess of disease among them, and I was informed that in Liverpool also the sewer-men have good health. The workmen employed at the various sewage outfalls, and who, though not in the sewers, breathe the effluvia arising sewer-men
from the settling tanks, do not find it an unhealthy occupation." The title of Dr. King's lecture, from which the above is taken from his quotation of Dr. Parkes, is " of Typhoid Fever," and is published, On the
Etiology
in extenso, in the Medical Times and Gazette, 1879, vol. ii, p 117. (at the commencement of the number for August 2nd.) In regard to the second aphorism, which turns on the supposition that a case of undisputed typhoid the problem being to find out a has been
diagnosed,
previous
case
from which it
caught
the disease, and
2, 1880.]
Ficr.niTATtY
NOTES ON ENTERIC FEVER.?BY SURGEON J. C. LUCAS.
not tills lias been done apparently which may or may How comes it to be that there were lie the case really. other people similarly exposed to the contagion or infection of this discovered case, and they did not catch
the disease ? Now, again, we will leave that alone and take the case which we ourselves pronounce to be one of typhoid fever?this is our diagnosis. Before we diagnosed it, our patient's evacuations were disposed of in the ordiof disinfection, nary way, that is without even the name for unlimited dissemination, lines, &c., men have labarracks, especially to common all, they dip their vessels (probably trines taken to the latrines 'or purposes of ablution) in the
affording
facility
every
where,
as
in
wells from which others draw water, for and purposes, we read and hear that cooking drinking perhaps besides this there occurred no other, or but one or two cases. Now, I beg to ask the advocates of the germ-tlieory how these facts can be reconciled with it ? If the poison, whatever its nature may be, spreads in one instance, and does not do so in another?so far as it is found out?it is required to ascertain (not by mere expressions of opinions, but by recording actual evidence and the process, and the length of time elapsed, by which it is obtained) under what conditions it severally did The and not spread and the extent to which it spread. reporter must not lie afraid of just criticism, for both his object and that of the critique is not to teach, but
public
same
pure and simple means of arriving at the truth. These are points to which future enquirers should direct their attention.
the
In tion
the
Germany, also, the subject has received much attenAmongst the indefatigable workers in that country,
Pettenkofer may be For him the cases of typhoid fever and th? movements of sub-soil water have certain relations ; this is his strong point. He admits, however, that a healthy person can be infected from sick with the disease; he does not a person deny the transportability of the disease from place to place ; but the way he looks at some of these poinrs is singular, name
mentioned
of Professor as
Max
von
most familiar.
and may, to the superficial and some of his vieWs are
observer,
seem
practically
absurd,
of
comparatively minor significance. Before touching upon his theory, let us for a moment consider the sense in which he employs the two terms with which he expresses his views?his definitions of the words, contagium and If a poison increases in the body of the human miasm. subject, he calls it a contagium; but if it adheres to clothes or other articles, and even to the human subject, provided it increases independently of the latter, he would call it a miasm. In application of these definitions to typhoid Dr. Pettenkofer does not believe that its virus is contagious, but is infectious. His theory, in short, is that the typhoid virus originates in the earth and sprea Is and of man.
developes through
the
instrumentality
Professor Wolfsteiner is a believer in Budd It is with him a contagious (in the ordinary sense) disease ; that it is transportable; and he also maintains that its principal channel of diffusion is by means of water.
He is Pettenkofer's strongst opponent
drinking
as
regards
his ground-water hypothesis, and also as regards his definitions and theory. Professor Von Gietl designates typhoid as a putrid intoxication; and in the main his views coincide with Murchison's.
While believing that putrid sewage is the inclined at the same time to
most common fact -r, he is
hold
(with Budd)
in favour
of
a
specific
cause?the
poison resulting from a previous case. Professoi' Ranke is a firm believer in the spontaneous, in one point generation and the putrid theory. He differs from Murchison?that typhoid spreads much
however,
through the air (by being inspired) than through (drinking). He at the same time thinks that, the ground-water-theory of Pettenkofer is true. I need scarcely observe here that this theory (of the mutations oftener water
rise and fall of sub-soil water) is also the Munich and hobby in respect to cholera : and that competent observers, Drs. Lewis and Cunningham, have tested the accuracy of this as regards this coun-
or
Epidemiologist's theory
try, but, as is well known, with negative conclusions.0 The above, it will be seen, is only a very brief and imperfect sketch of the views and opinions entertained by eminent authorities, in matters bearing upon the etiology of enteric fever. Before we proceed to find out the cause, we must make sure
of the
identity
of the disease.
This is
exactly
our
present position to which attention is drawn by the Army Sanitary Commission. That the correct
nobody and not
of cases is our terra Jirnuc putting the horse before the cart the latter before the former, in which latter case
can
deny
diagnos is
; thus
the driver will not find much progress made or much ground covered by his wheels in the direction he may wish, notwithstanding all the strenuous exertion which he .and his horse may have undertaken. It is by the bedside and in the dead-house, and not at the desk, that this Yet this is precisely what has been done can be done. by a writer, to whose work I shall have occasion presently to refer. Now in tli-i clinical part of the investigation there are manifold and endless difficulties to encounter. The onset of the disease, we know, is so very insidious. There are symptoms, no doubt, from which patients not invariably, at the beginning' of complaint; but as these?of malaise ?are not uncommon in nearly al. affections, in all countries, accompanied by pyrexia, much importance therefore cannot we attached to them. Again, there have been hundreds of
suffer, through the
in which these symptoms have not been complained of or felt, the sufferer going about his or her work or avocations as if there was nothing the matter. Here we are deceived and consequently omit to do what we might, had we only the means of prognosticating what the case really will and to be The intestinal excreta at this prove is, cases
period, to be
and
even
capable
of
sooner,
are
propagating
believed by Professor Parkes the disease. And, again, in
India, the case at this period and even later on may be and has been looked upon as ague ; and it may be stated * "The Soil in its relations to disease."?Indian Annals of Medical Science, 1876. vol. xvili., p. 144-179. Being a reprint from the "Eleventh Annual Report of the Sanitary Commissioner with the Government of
India.
TI-IE INDIAN MEDICAL GAZETTE.
38
that there is no reason why a person charged with the poison, malaria, cannot at the same time, and independently of this, 1)0 also charged with the materies morbi of typhoid. No antagonism, so far as I am aware, has been proved to exist. On this point what better testimony can be adduced than the reproduction of Dr. Murchison's own parting words to the profession ? I say parting words, for they are nothing else ; and an editorial writer of the Lancet, in announcing the melancholy of his ieath, wrote (April 26),?" One of the last acts of liis life was to place in our hands foi publication a clinical lecture which shall appear in our pages next week, and will be read with melancholy interest." The next nnil brought the first portion of his lecture, an I there in his parting words he repeats, that,?" I have known rare oases of enteric fever commence with all the phenomena of malarious auue?two
intelligence
?
rigors, heat and sweating. In some there had been reason to suspect that the patient h i I been exposed to the malaria of ague as well as to the poison of enteric fever But what is far more common?in fact of every day occurrence is this: For ten or fifteen days a patient presents all the usual symptoms of enteric fever, it may be in the Revere form, and including spots and diarrhoea. At the end of that time the attacks seem to abort: the pyrexia at first seems more remittent, and then it intermits. For a week or longer the morning temperature may be normal, or possioly at length sub-normal ; or
more
of these
attacks of
cases
?
so
that when the
patient
is
only
seen
by
the
medical
attendant early in the day, he might be pronounced free from fever. But in the afternoon, or towards evening, the temperature daily rises to lo3?, 102?, or 101?; the patient becomes flushed and restless, and very often in the night he perspires. As a rule the ebrile paroxysm becomes each day shorter and less severe, until at last it no longer occurs; but now and then ihis state of matters may go on for two or three weeks. Should the patient be seen for the first time during this stage, his case might be mistaken for one of malarious fever. Moreover, it may happen that cases of enteric fever, mostly mild, present the intermittent character from first to last; and that they are really cases of enteric fever is proved by their occurring in the same family, and possibly a the same time, as typical and perhaps fatal cases of that disease. It is scarcely necessary for me to add that enteric fever may be intermittent in another sense, viz., tliat after the fever has entirely ceased for several days, or for two or three
weeks, there may be one or more relapses.-' Cases, as a rule, do not come under observation until the
disease has advanced to at least the end of the first week when we are generally called in ; at this period from the case itself it will not always be easy to make a correct diagnosis ?we may suspect the disease in some cases ; if our visit be in the morning the temperature may be
normal, but sometimes,
is as
generally slightly above this point; and stated by Murchison, it may even be sub-
normal : on our evening visit it will be found to be higher. As to the other febrile symptoms?quickness of the pulse, dryness of the skiu, a furred state of the tongue, or white
[February 2,
1880.
fur with red
tip and edges, pointing to intestinal irritation, thirst, loss of appetite and perhaps also nausea and vomiting, constipation, or diarrhoea?cannot individually be considered of much import ; nor can they even
collectively be looked as pathognomonic. The more reliable signs, or those which should arouse our attention, are the other abdominal symptoms, on account of which
German clinicians have given the appropriate name of 'Typhus abdominalis' to the disease. Pnin may or may not be complained of, but there generally is some tenderness noticed in passing the hand over the belly, and
marked over the right iliac fossa; on perthis spot we have a more or less tympanitic note generally accompanied with a gurgling sound ; the spleen will be found enlarged and perhaps tender ; this is cussion
more
over
but in this country of what moment can this last mentioned symptom be considered ? There is diarrhoea
always, at this period, with or important for the medical man the stools hims If, and he should previously be well
sometimes,
but
not
without melosna. to see
It is
acquainted with what a typhoid evacuation is like ; these gradually become characteristic of the disease, but of course it must be remembe-ed that drugs are likely to alter their appearance. They are yellow and ochry, and have been compared by writers to pea-soup ; they have a very oifensive ammoniacal smell, and chemists have easily detected ammonia in thein
(also
vide the number of the
Medical Times and Gazette quoted paper
giving an alkaline reaction,
presence ot' salts of
above.)
due of
ammonia and soda.
The litmus
course
to
the
The
microscope reveals blood-corpuscles, mucus, epithelium ; and triple phosphates are also said to exist. At this period we would not expect to find head-symptoms?no delirium, but there may be some cephalalgia,
tinnitus aurium and restlessness nocturnally : these latter are in a measure due to the pyrexia. In the urine it may be said that there is nothing characteristic of the affection. Generally towards the close of the first week, or in the middle of the second, on uncovering the body, and with good light the spots peculiar to typhoid The parts to be searched are the abmay be found. domen, lumbar region, and lower part of the thorax. These appear and disappear in different lots, and as a rule there are very few in each lot, and sometimes these few are not very distinct, and are not readily made out especially when the parts have mosquito bites, or where we have a patient with very dark skin. Each spot on close examination will be found to be quite separate shape it is round, oval, or lenticular, ?rd to 2 lines in diame er : the level is slightly above that of the general surface; to the feel it is soft; the colour is red or pink ; and here is a point of importance, when we press these spots with our finger they disappear, and return again on the withdrawal of the pressure. After their disappearance they leave no sign behind, and are not found on the bodies of those who have died of the disease. Mosquito bites are found on the dead body. As the case progresses emaciation increases, and this is in direct proportion to the extent or height of pyrexia. The pyrexia of typhoid is characteristic, and, therefore, from another ; in and in size from
Febkuaiiy 2,
NOTES ON ENTERIC FEVER.?BY SURGEON J. C. LUCA.S.
1880.]
up and come under observation with poor, insufficient, or unreliable history that our clinical knowledge is most taxed, and the pons asinorum becomes difficult to cross over upon actual evidence and on logic, and not on mere
The imporin afforded aid the of by the clinical taiice diagnosis thermometer cannot be overrated or too strongly urged. Those who have had the opportunity of studying the
thermometry
is to be
carefully
attended to.
fancy or guess. In India, it is
valuable contents of Dr. C. A. Wiinderlich's great work, " On the Temperature in Diseases," translated from the German by Dr. B. Woodman, can vouch for the fact that medical science has been much advanced by this high and respected authority. The case needs to be seen at least
a day, and thermometric observations systematirecorded at 7 A. M. and 5 p. m. ; and also when possible at other times. Suppose at the commencement of the fever the morning temperature to be 98? or 99?, then in the evening of that day there is a rise of 1?, or 2? ; and next morning a fall of *5?, or 1?, followed by an evening rise like that in the previous day ; followed again by a similar fall like that in the previous morning. This continues for a few days till the chart shows the evening temperature to be 104? or 105?, and the morning 101? or 102?; or with fractional intermediations. After this the rise and fall remain in statu quo, that is to say if the morning temperature be 103*5?, in the evening it will rise to 105"5U ; and the next morning it will fall and go back to 103-5?, followed again by a rise to 105-5? But more commonly if the evening temor thereabouts. perature be 105-5?, next morning it will be found to remit only to 104-5?, and not to 103-5? like in the morning before
with remittent fever that it is generally fact of our not being able to differthe and confounded, entiate the two diseases is no proof whatever that the disease, enteric fever, does not exist in a land where at " putrefying sewage' is every turn almost Murchison's to be found. This is precisely what we are told by a
thrice
cally
even to 105? only ; and go back in the evening with similar slight rise to 105-5?. In severe cases the latter and in mild cases the former is the general rule. This is found in ordinary cases during the course of the second week. The subsequent markings on the chart have also a certain characteristic which is peculiar to the
that, or a
disease,and consequently
of considerable
diagnostic
value.
And this is the
steady fall (like the previous week's steady rise) from what the temperature had been during the previous week. This receding tendency is the reverse of what it had been the previous week. From an evening temperature of, say, 105-5?, it remits in the morning to 104*5?, in the evening of this day it will remain at this point, or with but a slight rise ; the next morning it remits again to, say, 103 5? ; and so on until it actually to fall in the
evening instead of even remaining This continues until the evening temperature reaches the normal point; but it is to be borne in mind that if there be too great a fall, or if the tempera-
begins
stationary.
sub-normal, it is indicative of threatening from hemorrhage into the peritoneum as a rule. syncope And, moreover, as Murchison again pointed out in his parting words, we may have relapses ; or the fever may abort as he says in his Treatise, and repeats in the lecture quoted. And finally it may be said that certain complications are likely to alter the appearance of the chart ; all these things are to be taken duly into
ture becomes
consideration. In the typical cases, of course, diagnosis is not a difficult thing, nor even in the less typical ones where we have had other cases in the same house or neighbourhood, or from the some barracks or lines of huts ; or an &c., of the disease clearly brought to light:
importation,
but it is in those
solitary
cases
which
now
and then crop
39
writer who asks us in the most self-satisfied tone and style to agree with him in the non-existence view of typhoid in this country. He even throws one off his guard, and in reality challenges all criticism by denying that there is, or can be, any putrid or putrefying sewage ! This is an assertion against which common sense recent
revolts. And as this subject is attracting attention, it will not be without interest to reproduce, for the information of those who may not have read this new publication, its author's own words,?"The conclusion to my mind," say Dr. Gordon, ''is self-evident that in the absence of specific causes of a specific disease, the specific disease itself does not, and cannot exist. Once again, therefore, we are forced to conclude that the phenomena stated of late years to constitute specific pythogenic fever are other than such as were known by old and experienced medical officers in India as pertaining to fevers of the country, endemic and climatorial." If any one none
takes the trouble to read the cases cited, to make out a in support of the novel view the author attempts,
case
but is far from succeeding to advance, cases which are commented upon by a very biased pen, a mind blind to strong evidence in very many of them, to evidence tolerably strong in others, and of doubtful import in but a few, he will be convinced that the book in virtue proves exactly that which it is the aim to disprove. When the temperature and other symptoms are taken into account and the etiology of the disease, so far as we at present know, as described by the various medical men who had seen the cases, and Dr. Gordon had not seen one of them, the inference on the mind of a reader will be irresistible that this writer puts even Wiinder-
lich, Parkes, Geitl, Wolfsteiner, Giinther, and Budd and Murchison, the last-named with his Indian experience, else in the corner, and declares to the in India is a myth. It is very doubtful whether Dr. Gordon will have many adherents to his singular and dogmatic doctrine. But we must admit that the book has done some good, and that is drawing attention to a disease the study of which be undertaken in a country wherein its causes are and every
body
world that the existence of typhoid
may so
unparalleled.
return to our text. As regards the postcases have little chance of appearances
Now let
us
mortem typical being mistaken for any other disease. The most important and reliable lesions or morbid changes are found in Peyer's and Lieberkiihn's follicles in the ileum; and if death took place when the disease was advanced these structures are enlarged and ulcerated. If death took place early, id est during the first week, therj is no
THE INDIAN MEDICAL GAZETTE.
40
ulceration then ; but in uncomplicated cases death does generally take place at this period ; and even now there will be alteration in the state of these glands, from congestion, deposition of a hard material, sometimes believed to be like tubercle (Buhl), which like it softens, breaks up, and discharges itself, causing the ulceration which afterwards takes place. Even in the very earliest stages in which bodies have been opened the glands of not
Peyer have always been found to be enlarged, more prominent and pink in colour (Gietl). When death has taken place in the later stages these glands are always to be found ulcerated. These typhoid ulcers have special characteristics. The shape of these ulcers has those peculiarities that they generally are round or oval; but of course the shape, as seen with the naked eye, would vary according as a single cluster conglomeration of these glands is ulcerated, or whether the ulcerative process of one coalesces with that of another group of glands, then the shape or
would not necessarily be round or oval. In their size the diameter of these ulcers is about an inch on an average ; the edges are even, and neither raised nor sloped
off, but they are of a darker oolour ; and in those ulcers which are oval-shaped the largest diameter is in the long axis of the gut. These ulcers may be perforated, or
may be in various stages of cicatrization : this latter would depend upon the length of time the patient
they
survived the attack, the process commences about the end of the third, or beginning of the fourth week. In the small intestines there may be some congestion (according to Gietl typhoid is a catarrh of the intestines), with contents similar to the evacuations voided during life. In the
spleen there generally are found structural changes uncommon to any other disease. If Peyer's patches do not decide the question, this organ does ; in the majority of cases it is found enlarged and softened, its colour becomes darker, and its substance semi-liquid. In some cases this is very marked, especially if previously diseased ; and there may even be rupture of the spleen and signs of peritonitis and death from this cause. Some authorities (as Rokitansky) tell us that in the spleen
similar deposition of material as that which in Peyer's glands ; this view plysiologically is feasible. While others (also German pathologists) hold that these bodies are only enlarged Malpighian corpuscles. Owing to these changes in the intestines there is
takes
a
place
and spleen, and the irritation caused by the inflammation in the former, it is not surprising that important changes of inflammation, &c., should be, and are found in the mesenteric glands, which enlarge?sometimes attaining very considerable size?soften and ulcerate. These, in short, are the principal changes found in the viscera ; l>ut there are others of minor importance, and which depend either on the mode of death, or the complications which accelerated it. In certain cases of remittent fever preceded or complicated by dysentery there may be ulceration of the intestines involving their glands. But there is great difference between these and the lesions found in typhoid. In dysentery the morbid process is as a rule limited to
[[February 2,
1880.
the colon and rectum, and therefore unlike typhoid in which they are most marked in, if not limited to, the ileum; if in dysentery, how ever, the ileum is found diseased, the
inflammatory process will involve the whole of the largei bowels and may extend to the smaller, and indeed to the entire alimentary canal up to the pharynx. So much for the appearance found in the dead-house. Now, before bringing this article to a close, it may be as well to say a few words on the subject of prevention. Murchison advises the obviation
of
all chances of
inhaling the putrid sewage gases, and the prevention of their contaminating the breatliing-air or drinking-water. He disinfects the discharges. Budd also disinfects, and in this measure he has great faith. He goes so far as to say that if the evacuations are thoroughly disinfected, typhoid does not spread. But then on the other side, as already stated, it may be said that there are scores of
cases
in which
yet the disease did
no
not
disinfection
spread,
or
was
employed,
and
at all events not more
than in those cases in which it was adopted. This fact would lead us to study the subject more carefully from this standpoint. Dr. Budd recommends the employment of Chloride of lime, Chloride of zinc, Carbolic acid and Sulphate of iron. He also thinks highly of a mixture of iron and Carbolic acid. do better, I think, than stick to his " to be lavish in the use of the chemicals mandate, rather than to run the terrible risk of failing by default." It may be added that in doubtful cases every precaution as to disinfection of excretions, clothing, &c., and when possible, the precaution of isolation of
of
Sulphate
cannot
We
the sick, whatever
points which should
are
never be neglected individual views may be; all those are to be looked upon as generic typhoid
our own
suspicious
cases
so
far
in
returning
preventive measures are concerned. But them some care ought to be exercised to separate and draw a line of demarcation between the doubtful cases from the typical ones. A good plan is to call these doubtful cases typho-malarial or malariotyphoid; but then strictly speaking these terms should be as
our
applied to those cases in which we have combined and intermingled typhoid and malarial elements?both causes
same constitution under the It will be preferable to make the note of ' interrogation ?' after the figures of the doubtful cases ; in order to enable the Surgeons-General and the Sanitary Commissioners, &c, to deal with such figures under a different category from those of ummistakeable nature. If some of the points here indicated, and those to which
having worked upon the circumstances.
attention is drawn
by the Army Sanitary Commission, are adhered to, and cases both typical and nontypical, with their apparent causative influence, placed at the disposal of this, or other journal, great benefit is
religiously certain to
accrue as
August
1879.
time rolls
on.