only, and not either the one fever or the other, according' to certain conditions, as some would have it ; although this much is admitted, many nevertheless hold that a primary blood poison is the cause, giving rise to certain specific lesions in the small gut secondarily as it were, the system throwing off the poison by means of the solitary and other intestinal glands. It is looked upon almost

by

as an

a

fever attended

the

skin, following a definite period of incubation and primary blood poison.

eruption

an

exanthem

course

after

due to

a

on

certain

a

Now I wish to shew that all this is false doctrine.

pathology of the

The

disease will not bear this

everything almost goes to accepted view. In fact it may be said to be the doctrine handed down by those who, having been taught to look upon the disease as a variety of typhus, and though afterwards convinced that they were specifically distinct, yet could not rid themselves of the idea that it was as much an exanthema as typhus fever. They point to the rash and say it must be so ; but will not fish and other things sometimes cause an eruption on the skin purely by the contrary disprove the generally out,

ON ENTERIC FEVER. By Surgeon W. E.

Saunders, a.m.d. (Continued from page 126.) VI.?Pathology. Having now discussed the history and clinical features of enteric fever, and accounted for

origin and spread, we must pass on to the pathological aspect of the disease. My views differ greatly on this, though far from original, doctrine the from generally taught. I shall endeavour to bring forward arguments and evi-

its

dence in favour of them, which prevent my acquiescence in the views generally entertained. Now the

question

tional disturbance

a

this.

is

mere

Is the constitu-

reaction

local disease of the intestines,

due to the

on

irritation to the intestinal tract ? When

we

termination. The

patients

a

then

occurs

most

of

us

are

mit that enteric fever is

a

ready enough

to

ad-

distinct disease from

that the poisons are quite typhus fever, distinct and capable of exciting the one disease and

disease,

and

very heavy duty, as frequently occurred during the Zulu war, coming to hospital only when

Although

may suffer from the

yet go about quite unconscious of anything being wrong with them, and may even perform

primary poison gives rise to the bowel lesions in the efforts of the system to throw it off?

of

which

blood

care-

the disease; the symptoms moreover may be very mild, and yet may be followed by a fatal

some

a

to examine the matter-

.fully we find that in reality there is very little similarity between the two diseases. The so-called period of incubation varies from io days or so to 6 weeks ; the onset is very insidious, and it is very difficult to fix the day of

is it the result

or

come

fatal

treatment

only

peritonitis that the

for

quite

a

had set in.

patient

enteric fever

now

on

the P. M. table that

present, the disease not life.

being suspected during

and

under may different disease, and it

becomes apparent was

It

come

even

THE INDIAN MEDICAL GAZETTE.

This does not look like do

we

fever,

not

meet

primary blood poison,

a

with it in

cases

mata.

typhus,

or

like

typhus fever does ; it may last 14 days, more often it is 28 ; and may be twice that. The eruption is often absent, and there are sometimes several relapses. course

To my mind it would be more rational to class enteric fever with septic diseases; the disease of the intestines

being the primary lesion, and the system symptomatically and secondarily affected. It is far more probable that the poison works primarily on the intestinal system, for we find digestive disorders and disturbance of the bowels in the first instance. "

The incidence is

tion is

the whole

over

It is not

the

on

possible

ileum,

short

typhus fever,

but this

in

of enteric fever.

the

case

can

typhus protects against in the

case

but the reflec-

body."?(Sir W. Gull).* to cut

a

attack of

an

undoubtedly

be done

One attack of

second

attack; whereas only lessens the of the disease by

in the first instance involved

affect-

are

ed, and the symptoms depend much in the intestinal tract that the

locality alights upon.

on

the

poison

ever

Furthermore in

the

septic

in enteric fever.

case

diseases the reaction

first to manifest itself

proceeds

-at

the

point

where the virus acts ; we therefore get disorders of the intestines?diarrhoea, or constipation?as first and

a

in enteric fever

prominent symptom

cases.

The

of virus makes

quantity

difference to the

specific zymotic quantity

absolutely.no

total of the reaction, or symptoms provoked in the instance of diseases ; whereas both the form and sum

of the

specific poison materially influence gravity of the reaction induced by septic poisons. -; The septic reaction travels from a focus, and as a rule gathers strength as it goes ; far otherwise is it with the zymotic poison, for from the first moment that the specific poisonous effects are manifested, there is no part of the body free from contamination ?(Dr. Sou they,)* We find a great variety, of conditions on the the

course

and

,

P.. M. table.

of enteric fever it

tendency to a second attack destroying the glands of the intestine for which the poison seems to have an affinity. In the second attack only those glands that were not

which is scarcely

of scarlet

indeed any of the exantheMoreover the disease runs no definite

or

[June, 1883.

The

mucous

membrane of the small intestine

is found in various stages of hypersem.iaj from tinge of redness to a deep brownish

the merest

purple

ash grey, and ulceration in all degrees solitary ulcer, no bigger than a pin's

or

from

one

head,

to

part

of the calibre of the bowel.

a

mass

of ulceration

involving the greater

is that the

remarkable thing

The most

congestion

and

Thus, if the upper part of the intestinal canal be attacked, we shall find vomiting

the

if the lower part of the small intestine and upper part of the large, then

large majority of cases this inflammation passes beyond the valve some short distance, but only

have much diarrhoea ; again should the solitary glands of the lower part of the large intes-

in very

a

prominent symptom

;

we

tine and rectum be teric

symptoms.

involved, we

shall find

dysen-

Tubercular disease of the small

lower part always simulates thus cntcric fever, shewing how much depends

intestine in its

on

the

locality

affected.

poisons, incubation, the poison manifests

period

its presence

and when this reaction takes

by symptoms; place, it is general throughout Lancet, June

far

protracted cases does the ulceration pass beyond the valve ; as a rule it is limited to

two

or

29,

1872.

the whole

body,

The ulcers

three ulcers.

are

found

to

and

occupy the seat of the solitary glands of the small intestine, passing

agminate through the

stages of infarction, eruption, and cicatrization.

Peyer's patches after the

In the case of zymotic of

inflammation is most intense in the lower part of ileum, close to the ileo-ccecal valve. In the

cases

that

occur

merely slightly

involved in

are

in

England,

raised

and

Dr.

1878.

Southey,

Lecture

on

all the

being surrounding more generally

the

submucous tissue thickened ; but *

nearly

sometimes

Hygiene, Lancet, 23rd

November

V

June,

SAUNDERS ON ENTERIC FEVER.

1883.]

a

which is sometimes very-

state of

ulceration, deep, extending down in

In many fatal

patches

cases we

not

are

to

the

peritoneal

find that

involved, only

some a

of

coat.

Peyer's

few of those in

the lower part of the ileum, and it is a remarkable fact that there is very often an abrupt termination

to the intestinal

lesion

(Murchison);

but when you come across the first involved patch all below are affected, and the lesion increases in

you descend to the coecum. Above the first affected patch all are perfectly

intensity

normal;

as

one

does not meet with

patches involved

These throughout the out do not bear are facts which certainly theory that the blood is primarily affected, and that the glands of the intestine are throwing off the poison from the system, on the contrary J* stamps the disease as a primary bowel lesion attended by a symptomatic fever. This bowel lesion comes out in crops, arising from the discharges of ulcers higher up, and sometimes prolongs the disease even to treble its usual length. the intestine.

here and there

The lesion of enteric fever consists in inflam-

mation, sloughing, and ulce ration of the agminate and solitary glands of the small intestine. A glance at the anatomy of the agminate and solitary glands will not be out of place here. They are blind, ductless glands imbedded in the submucous tissue, and covered over only by mucous membrane. The glands increase in number as we pass downwards, and attain their greatest aggregation near the ileo-ccecal valve. The solitary glands are found throughout the large intestine, being most numerous at the upper end. As regards the nature and function of these

glands

there have been

two

opposite views. By some they are regarded secreting cells which periodically discharge

as

their contents into the

generally adopted, view, teals,

and

bowel; but the most probably most correct

is that

they are connected with the lacand belong to the absorbent system. Now the object of the ileo-ccecal valve is to check the too rapid onward progress of the

chyle, these

and the

glands

are

waste

entailed

probably

very

thereby; numerous

and

in

153

locality to absorb as much as possible of escaped absorption by the lacteals, of certain materials again required by the

this

what has or

system. If this is correct, the view

generally

held that

the bowel lesion is the result of nature's efforts to eliminate

the

from the

blood, must be an erroneous one ; and that the deposition of a specific matter in, and its elimination by, these glands is the means of ridding the system of that poison which, circulating in the blood, produces the febrile symptoms, must also poison

We do not find the symptoms lessen after these glands have discharged their

be erroneous.*

contents; for if the

common

view be true, the

greater the bowel lesion the greater should be the relief, but we know well such is not the on

case,

the

more

the contrary the greater the lesion severe is the attack.

Resolution

moreover

sometimes takes

place,

and recovery follows without ulceration, which would not take place under the generally acHow is it then

cepted theory.

so

many stil

hold to the old view ? The

from the ulcerated

discharges

glands

carry the poison of enteric fever, and are capable of conveying the disease from one person to

another; nay disease to other

more

than

glands

as

this, they impart the they pass over them,

and set up their specific inflammation in more virulent form even. In short there is

lesion, the latter discharges of

bowel

the

by

a

primary and a secondary arising from inoculation the former

(Maclagan).

But the process is different in the former ques dures of Louis and Murchison), the

sloughs out; but (plaques molles)

in

still

a

(plamass

the

secondary affection it commences by superficial ulceration which may extend and perforate. The latter are more severe, partly from the debilitated condition of the patient, and ulcerate much more

rapidly?(Maclagan).

The extent of the intestinal

lesion,

as

re-

by post-mortem examinations, bears no relation to the severity of the diarrhoea during

vealed life. *

If there is diarrhoea the

products

of in-

Dr. T. J. Maclagan (Dundee), Lancet, January, 1872.

THE INDIAN MEDICAL GAZETTE.

iS4

carried

off, but if constipation exists they are retained, and work their full of local secondary injury. These amount are cases generally acknowledged to be the and Dr. Maclagan's explanation shews worst,

flammation

how it is

are

so.

With the

primary

seldom

lesions there is

much of

a

haemorrhage, and this when present, is not serious nature. A mild case at the onset,

by leaving more glands intact for secondary attacks, often turns out more severe in the end, and more liable to haemorrhage ; and perforation most frequently occurs low down in the ileum where the secondary ulceration is most abundant. The whole process of inflammation and destruction of the glands, primarily involved, and of the resulting

separation sloughs, pies more than 3 weeks ; beyond which the prolongation is due to secondary lesions. When death occurs during the first fortnight, it is not directly through the bowel mischief. never

occu-

In most cases, in which the bowel lesion.is the source

of

developed middle or the fourth

danger,

the

urgent symptoms

are.

late in the case, seldom before the end of the third week, generally during or

fifth ; exacerbations

due to the

are

of fresh

glands by the poisonous of those discharges primarily affected. The solitary glands of the large intestine sometimes become affected, but not frequently, owing to their sparse distribution ; and the contents are not delayed, except at the lower part, where the glands are sometimes attacked and give rise to dysentery as a sequel. The risk of inoculation

inoculation is less also.

period of life during which enteric fever is most prevalent and fatal, is that during which the intestinal glands are most prominent and active, i.e., early manhood and youth. It is more fatal amongst the better classes in England The

among the poor, and due to severity of the disease.

than

a

greater,

The better fed any one is, the richer and more abundant the chyle, therefore the activity of these

glands attacked by

is also greater and this disease.

more

prone to be

[June, 1883.

It is

agreed that enteric fever is a disease of youth and early manhood ; that certain ages form powerful predisposing causes ; and that the intestinal glands which form the nidus for the morbid process, cease to possess a ay physiological significance after middle age. raised in Inidia, The question has been whether the greatly increased physiological activity of the Peyerian glands, at certain ages (15?30), does not render them peculiarly liable under the influence of heat, climate, and the altered physiological relations of the skin, tq pass from the physiological to a pathological condition, in other words became infarcted with amaterial the subsequent changes in which result in the morbid lesions of enteric fever metwith in I do not think this

hot climates. The

simple course

ever.occurs

reaction.?Enteric fever

may have a of 14 to 21 days, or a prolonged of 28 days, 01* a double or triple course, course

the duration of which

attack

; or

attacks of

lastly, a ordinary

with another of

repetitions

post-mortem examination

found

on

pond

with fresh

affection

duration

These

shorter duration.

some

equals that of the previous complex course, one or two

outbreaks

have- been to

corres-

of the intestinal

; for in these cases, should death occur,

of the ulcers will be found

while others

are

Now in whatever

almost to

just beginning manner the poison

healed,

be affected. of enteric

fever is introduced into the system, there is concentration in the ileum ; but although the ileum is the focus of the

operation

it does not end there,

of the

poison, yet

for it is reflected

over

every organ of the body in consequence of the reflex relations between the lungs, heart, and

blood-vessels, through

pathetic The

nervous

body

the medium of the sym-

system.

reacts

to

these local

conditions,;

'

and the fever is a reaction to the local bowel' lesions. Every organ of the body; is affected1 if the disease be

severe.

r

?'

r

enlarged mesenteric glands may, and. do, suppurate from the excessive strain thrust upon them in checking the entrance of septic material into the system ; and the .'system becomes subject to purulent infection, pleurisy>; The

often

SAUNDERS

June, 1883.] &c.,

pyaemia. In fact any affected through the action in

as

come

venous,

organ may beof the nervous,

other systems. the first week of enteric and other

or

During

fevers there exists

a

less

more

or

by

morbid

a

of the vessels which contract

excitability

of

condition of dilatation

the tegumentary arteries, with redness of the skin, attended

exposure to the slightest current This often gives rise to rose-colored

of

'55

ON ENTERIC FEVER.

The various organs suffer and produce increasThe lungs beed deterioration of the blood. and retard oxidation ; the condition of the brain and nerves becomes altered ; come

in persons of the liver also ; and the secretions certain age ;

the a

spleen enlarges by congestion

retained

undergo changes.

The

non-elimination of

on

air.*

congested,

of tissue

products

give rise to cerebral sympinflammations, and if this reaches pitch it passes into the typhoid

metamorphosis

may

toms and local

blotches, round or in ovoid raised, slightly shape, and unattended by irritation. A scarlet unusual, tint of varying intensity is not

state.

unlike the rash of scarlet fever ; it appears, later in the disease, and does not desquamate. It is

consequent upon insufficient oxidation.

smooth but

common in

hot climates.

pyrexia is said to present three different forms, viz., continued, remittent, and intermittent,but thermometric observaFebrile state.?"Fever

tions have

now

shown that

lutely continuous, fevers'

are

typhoid

or

more

even or

fever for

no

fevers

the so-called

less remittent.

example

in

a

is in its range of temperature fever, as much so as the malarious cases

feyer," of tropical

a

or

remittent remittent

climatesf?(Murchison).

with all the phenomena of malarious ague?

(Murchison). Pyaemia also is a frequent cause of intermitting pyrexia ; moreover, as in malarious ague, the spleen is often more or less enlarged ; this may reason

for its

occurrence

in enteric fever,

and. what makes the matter more difficult is that quinine seems to have the same effect as in agues. Abscess of the liver also like ague. Tuberculosis

causes

also, especially

if

a

paroxysm

attacking

by absorption, probably of septic ces, by retention of excretions, and by rapid metamorphosis of tissue. *

Dr. Ch. Baiimler

m

cent

materials which

that,

if the noxious

accumulate in the blood in

fevers and extensive internal inflammations could be

more

fully oxidised, they

would

soon

oxidised materials from which

perfectly are

continue to

immediately produced, blood, the excreting

late in the

them

eliminate

Moreover the

after-

the

substanthe too

fur die med Wissench. No. r2,

t Dr, Murchison's Lecture, Lancet, May 3, 1879.

alter them

excreting

organs

organs cannot fast enough. o

"

cannot excrete

of these unoxidised animal matters, nor they be made to act, owing to the afferent

can

being in part paralysed. The kidneys may be sufficiently sound for the due performance of their functions in a state of health, although they are quite incompetent to discharge the additional work thrown upon The peccant material therethem in pyrexia. nerves

fore increases in the system and the result is the

typhoid

state. cases

in which the

strength is alreaespecially if the fever

exhausted, more yet long course to run, there would be great risk in pushing diuretics, purgatives, &c. There is then danger of the imperfectly oxidised substances accumulating in the blood and tissues to such an extent as to place the patient's life in great jeopardy, and the danger is twofold. dy

has

much

a

In the first 1873.

or

they

accumu-

some

In serious

ileum, simulates both ague and enteric feyer. The blood in enteric fever becomes contaminated

to think

reason

acid, and other excrementitious matters ; but while these excrementitious matters, or the im-

Enteric attacks may even become intermittent, not only when relapses occur, but commence

be the

good

continued

Enteric

"

is

There

wards be eliminated in the form of urea, carbonic

number of

large

have rather gone to prove that fever itself is due indirectly rather to changes

Investigations

abso-

are

"

certain

a

place

compounds,

and

many of the bodies

liable

to

are

decompose

unstable at

the

THE INDIAN MEDICAL GAZETTE.

156 temperature of the body.

The

of

products

set free in the

body would very matter of the tissues and

decomposition destroy the living blood, and paralyse and destroy

soon

and

nerve

centres, in which

die.

Secondly.?If not stored somehow, or they plasm of the blood increase

of

circulation, in the

body;

this

to

will

nerve

fibres

the patient must must

they decompose.

be

Bio-

takes it up, and the to

impeded capillary stagnation of the fluid

of all

substance

the

excreted

leads

and

case

the

tissues

the result of which must

be,

destruction to the part of the tissue if general, fatal to the whole organism.

of the if

local, involved,

of albuminous matter is al-

Decomposition necessarily fatal and rapidly so. By the growth of bioplasm this material is stored until the excreting organs right themselves; but should the bioplasm increase unduly, it may lead to a fatal result.?(Dr. L. Beale.) In romost

bust persons with abundance of muscle and fat there is more material to spare for disintethe febrile process; and they do not bear it so well, the attack being generally

gration during

it is that the febrile process once should ever become arrested, and in lighted up many instances after a definite duration, is a pro-

severe.

Why

blem in medical science of which solution has yet been

no

satisfactory

offered.?(Murchison.)

Typhoid""state.?The typhoid

state is common

pyrexia becomes adynamic,the patient becomes more feeble, the pulse sinks, there is great impairment of the heart's action and a tendency to collapse. The features become more pinched and shrunken, damp and ghastly, and the skin is covered with a cold clammy sweat. The tongue becomes dry, black, and tremu-

to many fevers. The febrile state

delirium, stupor the

or

coma

voluntary muscles,

prevails

; tremors affect

and the faeces and urine

pass unnoticed. It is customary to refer these symptoms to the action of the fever poison on the brain, but any cause by which the system becomes extensively vitiated will bring about this form of fever.

of the

Absorption

products

of inflammation

and ulceration may poison the fluids circulating in them, and by absorption may induce the state.

typhoid

The cerebral not

deranged,

functions the fever

by

accumulation in the

morphosis,

and

by

are

blood

the

more

poison, of

perverted

probably by the

but

tissue

meta-

and defective

nutrition of the brain itself; hence the symptoms in the advanced stage of many fevers

closely assimilated, although the primary poisons have been perfectly distinct.?(Parkes, are

Murchison.) It tends to death

by a complete sinking of circulation, and diminution and loss of animal heat, or deepening stupor with oppressed respiration supervenes, or the patient dies by combination of both conditions,?asthenia a

the

and

The

coma.

free action of the circula-

tion, besides retarding the formation of bioplasm, renders possible the removal of many noxious materials

tending to produce a parapoisonous influence upon the nerves lysing distributed to the capillaries, small arteries and veins of the skin, urinary organs, and bowels, and the nerve centres with which they are connected, and upon the integrity of which the or

condition of health is

(Dr.

L.

The true

or

lous ; sordes cover the teeth, and harden on the lips and angles of the mouth. Low muttering

[June, 1S83.

reasons

for the

pathology

1.

absolutely dependent?

Beale.) opinion that this is typhoid state are : pathologists are agreed

the

of the

All modern

that

the cerebral symptoms of most fevers are independent of any appreciable structural lesion of the brain

or

its membranes.

typhoid symptoms of febrile disclosely resemble those of uraemia' from disease of the kidneys. The resulting 2.

eases

two

The

often

conditions

in

are

fact often mistaken for

another, excepting that the temperature is increased in the one case and not in the other, it may sometimes be difficult' to distinguish them?(Murchison).* and

one

Another

probable

result of the non-elimina-

nitrogenous products in fever is the development of local inflammations, ulcers of tion

of

*

Dr.

Murchison,

B. M.

Journal,

Feb. '72.

SAUNDERS ON ENTERIC FEVER.

JvHE, 1883.]

157

to the enteric poison. I believe it to be the ?he larynx, &c. The half changed albuminoid chief cause of intussusception in children. matters circulating in the blood seem someDysentery is by no means so infrequent a times to be deposited in different organs, and sequel as generally supposed. In war times I there to excite secondary inflammations. feel convinced that this disease following shortly It is probable that the increased metamorafter an attack of so-called S. C. fever, or; phosis, the elevated temperature, and the inis really a sequel of enteric fever, creased frequency of the heart's action in fever, indisposition, the primary affection passing unrecognised; are due to paralysis of the sympathetic nerves the disease being really caused by the solitary and vagus. of the large intestine becoming affected Many clinical facts shew that the nervous sys- glands enteric the poison. In South Africa, during, tem exercises a powerful influence on the early by the last few years, dysentery occurred very phenomena of fever, such as rigors, the pain, the frequently as a sequel to enteric fever, and was languor and prostration which are among its in many cases followed by hepatic abscess. earliest

phenomena.?(Murchison).

Complicatio7is a?id Sequela mon complications are those

The most of the

com-

respira-

tory organs, bronchitis chiefly, but frequently broncho-pneumonia and pleuro-pneumonia; should this be and

the

severe

at the base of the

diaphragmatic

pleura

lungs

becomes

in-

I would say that this is the

common

form of

dysentery occurring among troops in the field or on active service. Collapse may occur at the early part of the the weather, when

disease in certain states of

is great heat and a saturated condition of the atmosphere, with, there

electrical disturbances, as met with for some vomiting. time before a thunderstorm. Intestinal haemorrhages,* perforation, periThis meteorological condition is very debitonitis, (serous or suppurative) without perto the vaso-motor system, and in my foration, are common complications, and will be litating rise to those fatal and sporadic described under the treatment. If the serous opinion gives cases of cholera so frequently met with in India. membrane covering the diaphragm is involved, Mr. Simon has long since drawn attention to there will be vomiting, but it appears later in close etiological affinity between cholera the the disease than the form noticed above, and is and enteric fever, and I believe that this is of graver import. Hiccough is generally present volved there will be troublesome

in this

the true

case.

in about

10 per cent, of cases, but this varies in different epidemics and cliSometimes it seems to be due to sudden mates. in the weather ; it is also said to be due

Relapses

occur

changes

to errors in diet and soon, but it most out any

commencing

solid food too

frequently

assignable

cause.

appears to be withThe attack generally

suddenly, the temperature rising rapidly, even as high as 105? F. in a few hours. The relapse has much the same features as the primary attack, and the eruption is often present, although it was not discernible in the primary attack ; the duration is much shorter, and the comes

disease

on

more

fatal than in the first attacks.

Intussusception is occasionally a complication of enteric fever, and it is not at all improbable that most of the

cases

of this affection

are

due I

occur at

explanation of certain outbreaks that particular seasons of the year in India.

of death :? By poisoning of

Modes 1.

the

blood

generally

(septicaemia.) 2.

Implication

of the

kidneys

at an

early

period (uraemia.) 3.

Failure

of the

heart

and

circulation

(syncope). 4.

Severity a.

of the local affection.

Exhaustion from

profuse

diarrhoea.

b.

Accidental haemorrhage tion of a large artery.

c.

Peritonitis, with or without perforation of mesenteric glands, abscess of the liver, &c.

from ulcera-

5. Sorbutic taint; giving rise to general haemorrhage, without ulceration of artery?and syncope is apt to prove the cause of death.

THE INDIAN :MEDICAL GAZETTE.

158

.

The mortality varies in different places and

different

about

I

lessened

epidemics.

In

Europe

it is

in

generally

(Tanner), but this appears to be certain forms of treatment.

in 6

by

In India it is about 40 per cent, of cases, whereas

To South Africa during active operations it

was

26 per cent, and afterwards only 1 5 per cent, when hostilities had ceased, and the cases wee treated in

buildings.

Septiccsinia,-?This is the cause of death in the great majority of case.s. The intensity of the fever is generally .great in those attacks in which the death occurs at an early date. 1.

during life by congestions of the important organs, lungs, brain, and in consequence of absorption of putrid inflammatory products. A sudden fall of the temperature qften occurs, which means a breakdown pf the powers, of the patient. Bronchitis is a common complication, and there is low muttering delirium, and afterwards the typhoid state. ?The diarrhoea may become profuse, and there is general sallowness of the skin, or even jaundice, and a purpuric condition of the skin, which is always strongly suggestive of blood poisonipg?(Wilks). The pathological conditions are as follows. Lungs, almost always implicated. Pleurisy generally exists from superficial lobular pneumonia of the lower lobes, which often becomes lobular. Liver,?lobular congestion passinto ing suppuration ; if on the surface'peritoniis often suppurative. Kidneys affectwhich tis1; ed in the same way. Spleen enlarged and friIt is marked

able, abscess often present. Abscess may be found in all parts of the body when the septicae-

mia has passed into pyaemia. Parotid bubo is occasionally met with. I saw it once in a severe case, .but the patient recovered after a and long illness, although there was considerable suppuration, the wound made to allow the pus to escape soon closed without leaving any fistulous opening. When inflammation of the sierous surfaces is found it has probably extended from the lungs, liver, &c. Before the body is cold there is often to be colouration

over

seen a

blue and red dis-

the.veins, from exudation of the

colouring

matter

of the

blood

disintegrating

the

into

tissues?(Wilks). Thrombosis may and occasionally be found.

occur

If death the

ing

[June, 1883.

very early from blood discoverable pathological

occurs

only

poisonchange lungs ; even

may be some lobular congestion of that may be absent, life being as it were sudden-

ly destroyed

and

ral softness of

leaving nothing beyond a genethe viscera, and slight purpuric

of the skin.

condition

The duration may be or it may in

3 days in these cases, only other cases last for 2 to 8 weeks. 2 or

A colorless masia

dolens)

enteric

of the leg

swelling now

and then,

sort of

(a

occurs, as

a

phlegsequel

It is

probably due to a local phlebitis, which may be regarded as an expression of a pyaemic tendency .; but is not ofvery serious import. Erysipelas occurs as a sequel sometimes. to

fever.

Urcemia.?This

2.

is

the

cause

of

death

in about 30 percent, of cases, but it is not always greatest in ? fatal cases, and is- often absent. Failure of the circulation from weak heart

3. is

not

unfrequent

an

cases occur on

the

would

place.

seem

when

affection.?Some-

are so

extensive that it

for

recovery to take

impossible

,

Death takes place or

local

the local lesions

times

death,

active service.

Severity of

4.

of

cause

probably

from

inanition

else;?

diarrhcea, which it is impossible to check, and the patient dies from the exhaustion attending the excessive There is excessive

a.

drain. b. It may be from ulceration through testinal arteries

are

haemorrhage arising

from

The

in-

an

artery.

distributed

the bowel'

on

peritoneal side, and subdivide in the' muscular coat, where the vessels are still of faiir size. ,Now if the ulceration, extends deep from the

enough, fatal

a

good

sized artery may be..involved and'

haemorrhage.take.place.

This seldom

_

happens.during the first two weeks, occur., during., .ifu ;fr:t

of the disease; should- haemorrhage I....? -

?"

'?

,

..

SIBTHORPE ON

June, 18,83.]

THE/PRESERVATION ,OF.

period, it is due to small and superficial vessels being ruptured b'y the excessive inflammation and sloughing present. that

The -fatal form seldom

week, and is always

a

whereas the former need

most

viz.,

a

commonly general oozing

a

complication

mean

>

with in the scorbutic form, of blood from the

mucous

surfaces. c.

perforation being

occur

from,several

the most

however without

common.

causes>

exten-

perforation by

through the intestinal coats, the mesenteric glands, or some of the viscera. The peritonitis is sometimes suppurative. Abscess of the liver may be the originating cause by rupture into the peritoneal sac ; but I remember seeing a localised suppurative peritonitis encapsuled between the upper surface of the liver and the diaphragm on two occasionsI feel convinced, the bottom of it,

confess, I

was

cause.

5.

now

that enteric fever the

although perplexed

much

at

to

was at

time, I must explain the ?

,

scorbutic taint is added, of there is much less chance of recovery,

When the

tendency to death is great, either from syncope, or haemorrhage, which takes the form of a general oozing. During life a small eruption (like flea bites) of a. purple hue is often present, chiefly on the lower extremities, though it. is .found on the body, arms, &c. Livid subcutaneous patches and spots may appear upon the skin, and spontaneous profuse haemorrhages frequently take place from the various mucous and the

The gums may also be spongy and the skin, discoloured. The patient sinks from the profuseness of the diarrhoea, or perhaps

surfaces.

sudden effusion followed

by equally

sudden

death. After death found

piatches of ecchymosis may be everywhere ; effusion of, serum, or. even

blood, may be found in the large serous cavities (chest, abdomen, &c). The spleen- is generally

enlarged

f Under 20 years. 21 I 25

-j

26

SO

I 31 LOver

35 35

8

15 22

Perforation of ileum ''

Hemorrhage (noperfn.) Exhaustion, &C. Peritonitis

Total

Total

f Under

of Enterit Fiver, iSyg-So.-

21

,,

28

?

29 35 .. Over 35 days Not known

...

30 7

:r. 'rt 3