tissue become detached in the form of a slough, leaving behind an ulcer. See for example Plate IV. (a), which has been drawn from a preparation in the Museum of the Royal College of Surgeons (No. in Catalogue, 2499). It is a portion of the ileum injected and everted. The large ulcer occupies the site of one of Peyer's patches. There are also several smaller circular ulcers formed by ulceration of the solitary glands. The time of the ulceration is so variable that no inference as to the age of the disease can be drawn from its presence. Ulcers have been met with as early as the second day, Louis, Hoffman, Murchison, Chomel, each record a case in which ulceration had not commenced on the twelfth day, in the majority of cases however ulceration will be found after the tenth day. The next stage is the separation of the sloughs and the cicatrization, a kind of interim period within which death often takes place. Seen at this stage Murchison gives the following characteristic marks by which the ulcers are to be distinguished from other ulcers. (1) They have their seat in the lower third of the small intestine, and their number and size increase towards the ileocæcal valve. (2) They vary in diameter from a line to an inch and a half. Close to the cæcum a number of ulcers often unite to form a mass of ulceration several inches in extent. (3) Their form is elliptical, circular, or irregular; they are elliptical when they correspond to. an entire Peyer's patch; circular when they correspond to a solitary gland; and irregular when they correspond to a portion of a Peyer's patch, or when several unite to form one. (4) The elliptical ulcers are always opposite to the attachment of the mesentery. They do not form a zone encircling the gut (as may be observed in the tubercular ulcer), but their long diameter corresponds to its longitudinal axis. An elongated ulcer, however, running transversely may result from the confluence of several ulcers originating in the solitary glands, especially in the larger bowel. See Plate V., Fig. 2, and Plate IV. (a). (5) Their margin is formed by a well-defined fringe of mucous membrane detached from the submucous tissue, a line or more in width and of a purple or slaty blue colour: this is best seen when the bowel is floated in water. After the separation of the sloughs, there is no thickening or induration of the edge as in the tubercular ulcer. (6) Their base is formed by a layer of submucous tissue, by the muscular coat or by the peritoneum. There is no deposit of morbid tissue at the base of the ulcer, although sometimes fragments of the yellow sloughs may be seen adhering both to the base and edges. The last stage is cicatrization. Usually in the fourth week the ulcers nearest the cæcum commence to cicatrize and the rest gradually follow, but they may become chronic, and then the convalescence is much delayed. The cicatrices are slightly depressed, less vascular, smoother, and the intestine is at that spot thinner than elsewhere. According to Chomel all traces of the ulcer in a short time disappear. The mesenteric glands are always enlarged, save perhaps at the very first commencement of the disease as in Meyer's case, and they become infiltrated with the same yellow matter as the glands of the bowels, the spleen is invariably enlarged, the liver and kidneys occasionally hyperemic. (373) Diagnosis of Typhoid. There may be difficulty in the diagnosis of typhoid during life, there can be none after death; the essential anatomical signs in the intestines, aided by a bacteriological examination of the spleen will in all cases give reliable results. It should also be noted that Gaffky found that in a case where he failed to demonstrate in the spleen micro-organisms, yet the bacillus could be raised by cultivating small portions of the tissue. During life typhoid has been confounded with typhus, remittent fever, pyæmia, influenza and various forms of tuberculosis, all of which occasionally closely simulate typhoid fever, besides which trichinosis has been mistaken for typhoid. Cases of the above have puzzled physicians of great experience, but as a rule, provided accurate thermometric observations are taken for a few days and the patient closely watched, the diagnosis of typhoid presents no difficulty. (374) Theory of the Propagation of the Disease. The modern theory is that the specific microbe, which according to Koch, Eberth, and Gaffky, is a bacillus, forms within the body spores, and these spore-holding bacilli are expelled in myriads with the stools; like all spore-bearing micro-organisms they are very resistant, and may be preserved for an unknown long period. The stools infect drains, cesspits, sewers, or the soil itself; if the excretal matter obtain access to food of any kind there is a liability to infect those taking such food; water of course may also be infected either directly or indirectly from the spring passing through already polluted earth. There can be no typhoid without the bacillus, but on the other hand we have no evidence to prove that the spore-holding bacillus must have passed through the intestine of a man before it infects a second; on the contrary, there is every probability that it has something of the same history as the bacillus anthracis, and that it can under appropriate conditions thrive as easily as it does in the incubator of the bacteriologist. Enteric fever has many a time attacked the traveller in tracts of country in the tropics which are not known to be inhabited, and in numbers of cases in this country the most exhaustive inquiry has failed to show traces of a pre-existent case. Typhoid fever does not arise de novo, for no cunning concoction of filth aided by warmth and moisture will create an Eberth's bacillus, the bacillus has sprung from some pre-existent colony, that colony from a previous one, and so on: but to say that an infective colony must have descended from micro-organisms flourishing in a human body is going beyond existing evidence, the balance of which points in the other direction. The most reasonable theory is that the cause of typhoid is a vegetable parasite capable of having an independent existence and propagating its kind, and completing its cycle of existence quite independent of the body; probably its normal existence is that of a saprophyte. Hence its endemic prevalence in certain parts, hence the impossibility of always tracing typhoid from one person to another, and hence the mysterious isolated outbreaks which from time to time occur. (375) The Ground Water Theory. Pettenkofer has laid great stress on the connection with the height of the ground water and the prevalence of typhoid. It is true that when typhoid most prevails the ground water is sinking or at its lowest, and when typhoid least prevails the ground water is rising or at its highest, but this may possibly be explained by the fact that in the one case the springs are more dilute and contain in a given bulk the least impurity, so that presuming a specific infection when the ground water is highest the infective colonies will be farther apart than in autumn, when the springs are low and any impurity concentrated. Whatever the explanation the fact remains, which whether essential or merely coincident, is too constant for the student to neglect. (376) Propagation of Typhoid. Occasionally typhoid excreta may be dried and blown about in dust, become breathed, and thus getting access to the mouth, be swallowed with the saliva; while admitting this as possible, there is no instance on record, in which this mode of transmission has been rendered more probable than other ways. The whole pathology of the malady points to the cause gaining access to the alimentary canal by drink or food. It is undoubtedly in some way or other swallowed, the chief agent being water. That water specifically polluted with typhoid excreta is liable to produce typhoid, is so well established by a mass of evidence that only a few examples need be cited. The outbreak of typhoid described by Dr. W. Budd,1 in 1847, may be referred to, at Richmond Terrace, Clifton, in which the inhabitants of thirteen contiguous houses drinking a mon polluted water supply were nearly all struck down at the same time with typhoid. Other families in the terrace under precisely the same conditions, but not drinking this particular water, escaped. There is again the particularly instructive outbreak detailed by Mr. Spear,2 in the Mountain Ash district, in which a portion of the water mains were found to be carried through an excessively foul sewage deposit, and the main being leaky, at times actually drew sewage matter into the pipes. The typhoid area in Mountain Ash strikingly coincided with the distribution of water by the particular branches supplied by this portion of the main, whereas the other portions of the village supplied with 1 Op. cit. 2 Public Health, vol. i. p. 183; L. G. B. Med. Off. Rep. 1887. the same water, but unpolluted, escaped.1 There is also the remarkable outbreak detailed by Gaffky,2 which will always hold a place in the literature of this disease, on account of the great minuteness and thoroughness with which the epidemic was investigated. The outbreak occurred in the summer of 1882 in the garrison at Wittenberg. It was practically confined to those who drank from a particular well, which well was polluted by a neighbouring cesspool. Into this cesspool in March and also in May the dejections of two isolated and successive cases of typhoid for several days had been cast; there followed in June and July no less than ninety cases. The interesting part of the history is that others drinking a spring not very far away, but considerably polluted, although not by this particular cesspit, did not suffer from typhoid. Gaffky was able to disprove infection carried by the atmosphere, or by the food, the specifically polluted water could alone be inculpated. Such cases as the foregoing, and they might be multiplied by some hundreds, are in the light of exact experiment, two neighbouring communities taking exactly the same food, the same milk supply, and breathing the same atmosphere, but differing in this one thing, that the one drink a specifically polluted watersupply, the other a water-supply which may be pure or impure, but is not specifically polluted; the one "the control," do not suffer from typhoid, the others are attacked. Among epidemics of enteric fever which are particularly instructive is the one at Bangor in 1882, which was investigated by Dr. Barry. The epidemic caused 548 cases of sickness, and 42 deaths. There was strong circumstantial evidence that the public. water supply bad on a particular occasion become polluted by river water flowing over the filter beds and carrying with it the accumulated dirt from the filtering surface, and also excrements which had been discharged into the river; some of these there was reason for believing were discharges from certain enteric fever cases. As another instance of the propagation of enteric fever by a public water supply, reference may be made to the Hitchin outbreak in 1883, which was investigated by Mr. H. Power. Here the water 1 Precisely the same kind of infection occurred recently in Alma Square, St. Marylebone. The epidemic is described by the author in the St. Marylebone Sanitary Chronicles, February, 1890. 2 Mittheilungen aus dem Kaiserlichen Gesundheitsamte. Berlin, 1884. |