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ADENOID GROWTHS IN THE PHARYNX.
618 ADENOID GROWTHS IN THE BY SIR WM. B.
PHARYNX.
DALBY, F.R.C.S., M.B. CANTAB.,
AURAL SURGEON TO ST.
GEORGE’S HOSPITAL.
IN order to estimate the position which adenoid vegetations in the vault of the pharynx, in regard both to their diagnosis and removal, occupies in the domain of surgery at the present time, it must be borne in mind that, with the exception of two or three solitary observations, up to the year 1868 the existence and gravity of the disorder were not recognised It was in this year that Dr. Meyer of Copenhagen published’ his first account of the subject, and in the following year brought the matter before the Royal Medical and Chirurgical Society. At the International Medical Congress of 1881 several papers on adenoid vegetations were read, and the various methods in use for their removal were most fully discussed. Thus it will be seen that the intermediate twelve years had served to render familiar in 1881 what was practically unknown in 1868. Taking into consideration these papers and their discussion, as well as the number of surgeons who now habitually treat this affection ; the extreme facility with which the growths can be recognised by an examination with the forefinger gently introduced behind the soft palate may be said to be acknowledged ; and should anyone question this proposition, it is open to him to verify it in any case which presents the usual characteristics of the affection by first examining a patient in whom the vault of the pharynx is healthy, and immediately afterwards the adenoid case. The difference of the two is too striking to escape even the observation of one who does this for the first time. Indeed, it was by an examination of this sort that Dr. Meyer discovered the growths in his first case. A rhinoscopic examination may be regarded therefore as supplementary to this, and in many cases, even in the most skilful hands, as impracticable-as, for example, in the case of young children. As a complete account of the methods adopted by various surgeons to effect the removal of adenoid growths between the two periods which I have named- I viz,, 1868 and 1881-may be found in Mackenzie’s Manual, in the following brief remarks the history of the subject and the practice of others may be taken as read. If one thing more than another stands out in relation to what is written, said, and done in connexion with this matter, it is the necessity of tolerance for other methods whilst advocating our own, and for the following reason: that it is characteristic of the complaint that if the growths are removed in any way, so long as they are completely removed, the patients get well both as to nasal breathing and hearing. To illustrate what I mean, I may be permitted to refer to a point which interested me very much in 1883. At the Congress, Dr. Guye of Amsterdam had strongly recommended a plan of scraping away adenoid vegetations from the pharynx by the nail of the right forefinger, and he had I knew not limited himself in this to any class of cases. also that my friend Mr. Cresswell Baber of Brighton habitually practised this plan without any selection of cases., It had appeared to me that if this were possible, nothing could be more satisfactory than to have in their removal the guidance of the sensitive finger which had detected the presence and the position of the growths; and 1 could readily understand how in the case of young children, when the growths were soft and friable and not in very large quantities, this could be done. When, however, as often happens, these growths are very numerous, of great size, and extreme toughness, I could not understand how the finger-nail of anyone could so embed itself in the tissue as to I therefore had made for me a cut it clean away. species of mechanical finger-nail constructed of steel, on a principle similar to Capart’s spoon, but unlike it in action and construction (to which I shall refer presently), and with the help of this 1 could remove these growths with great completeness and with the most happy results. (See Fig 1.) On the date mentioned-viz., Oct. 1st, 1883—I met Mr. Baber, and in discussing this question of common interest no doubt was left in my mind as to the fact that some finger-nails (notably Mr. Baber’s) can be found sufficiently strong, and of such formation, to effect in the matter of operation all that is required without having resort to any other method. What, however, can be done with the finger - nail only in individual instances
(" individual" as applied to the operator) may be done by anyone if the steel nail is employed. There are several considerations which have commended themselves to me in this method of removing adenoid vegetations from the pharynx. In the first place, when the mouth is held open with a Mason’s gag, the pharynx can be most completely explored with the forefinger, and the amount of vegetations, their size and position, can be most satisfactorily estimated. The instant after this is done the steel nail can be fixed to the finger, and they can be scraped away at leisure. When I say "scraped away," I mean that the steel nail can be embedded in them and made to cut them away. The head being bent forward at the time by the left hand placed on the vertex, the blood, which ilows very freely, escapes by the nostrils. It will be observed that the instrument is so made that the tip of the finger is exposed, and this is most useful in estimating by touch what is being done. Although the whole proceeding does not occupy long, inasmuch as it is most unpleasant and in some degree painful, it is convenient and desirable in many cases, especially
in young and timid children, that ether should be given. position in which the head is held prevents the possibility of blood passing into the larynx during an inspiration. Although at one time I was inclined to repeated rather than to immediate operation, I am bound to say that latterly I have found not one of the least of the advantages of the steel nails is that the pharynx is frequently cleared at one sitting-in the case of young children, cleared so completely that a fortnight after the operation, when the swelling which follows it has subsided, the mouth can be kept closed both waking and sleeping; the "deadness" of speech, so indicative of the affection, disappears; the passage through the posterior nares is restored; the Eustachian obstruction, with its accompanying deafness and the liability to it, is gone. In short, the results of this method have recently proved so satisfactory that in five cases of children in which I employed it (Mr. Braine giving ether in each) during one week no further removal is now necessary. In older patients, where the growths are tougber, and very abundant, more than one sitting is generally required. The plucking away in pieces by Lowenberg’s forceps will no The
doubt succeed in getting rid of the vegetations, but this entails several sittings, and some patients and their friends are apt to shirk what is very disagreeable before the completion of the treatment. It is therefore better to avoid this when possible. Moreover, it is undoubtedly a great advantage to be able to feel with the finger the vegetations as they are being scraped off. This cannot be done with Lowenberg’s forceps (or with Woakes’ modification, which has the advantage of increasing the cutting surface), or with what is otherwise a most useful instrument-viz., a curved ring knife, which Mr. Hawksley constructed for me before the steel nail. (See Fig. 2.) With this knife, the ring being passed up into the pharynx behind the soft palate, the growths can be by a sweeping movement cut away. This knife is made on the same principle as Gottstein’s, and although I have found it more easily moved about in the pharynx, I have seen cases where, in other hands than
mine, the whole pharynx has been cleared at one sitting of abundant tough adenoid growths by Gottstein’s knife.
Notwithstanding the varieties in methods that are now in Meyer still, I believe, adheres (and with excellent
use, Dr.
619
results) to the plan which he described in what may be namely, a new development of the poison; and there is this truthfully said to be his classical paper on this affec- to be said for the latter view, that although the house tion in the Medical and Chirurgical Transactions-viz., his was cleaned the son continued to live in precisely the flexible ring knife passed through the nares into the same insanitary conditions which preceded his mother’s pharynx, guided throughout its movements by the fore- illness. Outbreak- No. l1.-Mrs. aged fifty, 23, Edwardof the left hand; but as the unpleasantness of having the ring knife passed through the nares can be avoided by street (West Central), half a mile from the last outbreak, was operating through the mouth in one of the many methods admitted on July llth, the fifth day of her illness, as a medical case. On the day after her admission she had a wellnow adopted, his mode of attack, so to speak, is, from what marked typhus rash. The attack was sharp and left patient I can learn, not followed out by others. Looking back to a period when this affection was un- very weak, although it terminated on the ninth day. The known, and the precise cause of the characteristic intona- only illness for a long time in the acquaintance or neightion in these patients was unsuspected, it is curious to bourhood of this patient happened to be in the next house, notice how absolutely familiar Dickens was with the pecu- where she frequently visited. In it there were two rooms liarities of voice which marks the subjects of adenoid vege- occupied by seven inmates. The head of this house had been, tations. He must have come in contact with some of them out of work for some time, and the family had therefore been when he so accurately reproduces the voice in one of the rather poorly fed, and two of his children had had febrile characters in " Oliver Twist." There he makes the boy illnesses, which lasted respectively (including convalescence) Barney (one of Fagin’s gang) say " stradegers id the four and seven weeks. These cases were not recognised as next roob," and " ah ! ad rub ’uds too, from the cuttry, but typhus, but there can be little doubt that they were so. subthig in your way, or 1’b bistaked." From the context While the children were ill Mrs. S-- visited them very we may fairly suppose he believed this intonation was infrequently, and helped their mother to nurse them. But a dicativeof race, and he introduces it by way of emphasising full and exhaustive investigation failed to connect this outthe generally disagreeable peculiarities of the characters he break with any preceding case. Outbreak No. 12.-A. T----, aged thirty-three, a Swedish so graphically depicts ; but in this particular he certainly does Barney an injustice, for adenoid vegetations are to sailor, arrived in Dundee on August 27th, having left be met with in "all sorts and conditions of men," living Quebec in a sailing vessel forty-eight days previously. under the most favourable or unfavourable circumstances, He sickened on August 19th, and was seen by Dr. Gibb and in many latitudes. That they are frequently present in on the 27th in the dark forecastle occupied by himself several of the same family cannot fail to be noticed (I have and four others. This place was very dark, had no seen four in one family), and from the recollection of parents portholes or windows, and emitted a stench so powerful as to render breathing in it very unpleasant. No other as to their own breathing and hearing in childhood, the tendency to abnormal adenoid development would seem to case of illness had occurred on the voyage. He was be inherited ; but as the parents have arrived at the time of immediately removed to the infirmary. 1 saw him on the life when this enlargement has disappeared, it is not easy to day after admission, and noted a dusky aspect, a typhus establish this point. Besides the departure of three symptoms odour from the breath and body, an enlarged spleen, and a -viz., the tendency to Eustachian obstruction, the con- typhus rash over the abdomen and back. The morning sequent deafness (which generally directs attention to the remissions of temperature in this case in the second week trouble), and the nasal obstruction-which follows the were much more pronounced than we usually find them in removal of adenoid vegetations, there are other advantages typhus. On the eleventh day the morning temperature was to be reckoned, such as the better prospects of recovery in 101°, the evening 104-4°; twelfth day, morning 100°, case of diphtheria or scarlet fever occurring, with an empty evening 101’2°; thirteenth day, morning 99°, evening 1026° ; rather than a blocked pharynx, as well as the better chances fourteenth day, morning 1004°, evening 102-8° ; fifteenth of the middle ear escaping destruction during these diseases. day, morning 99 8°, evening 1038° ; sixteenth day, morning The improvements also of the general health, with free 986°, evening 102’4°; seventeenth day, morning 984°, nasal breathing, as well as the diminished tendency tc evening 101’4; eighteenth day, morning 984°, evening 100°. bronchial affections, require only mention to be appreciated, On the twenty-first day the temperature both morning and Savile-row, W. evening was normal. On the fifteenth day of the fever I most
finger
THE ETIOLOGY OF TYPHUS
FEVER,
ILLUSTRATED BY A SERIES OF RECENT OUTBREAKS DUNDEE AND NEIGHBOURHOOD.
.
IN
BY ROBERT SINCLAIR, M.D., PHYSICIAN TO THE DUNDEE ROYAL INFIRMARY.
(Concluded from
p.
574.)
Outbreak No. 10.-:Mrs. 11-, aged fifty-three, resided 2, John-street (Central). She and her son occupied two small attic rooms, which, according to Dr. Stalker, were very close and ill-ventilated, owing to the windows not opening, and the only air that could reach them entering by the door after doing duty in the stairs and flats below. She had not been near any house in which there was illness for months, but she confessed to insufficient feeding. She sickened of typhus on July 3rd, was admitted on the 13th, and recovered. Dismissed Aug. 25th. Her son was admitted on Aug. 18th, the sixth day of the fever. Was the son infected directly from the mother? I think not. To accept this explanation would necessitate belief in a thirty days’ incubation-period, of which we have no collateral evidence. Was he infected by her indirectly through fomites ? Or was his a case of generation of the poison de novo? After the mother’s removal, the house, bed, personal clothing, and furniture ab
subjected to the usual cleansing and germicidal by the sanitary department. If my friend, Anderson, is prepared to certify that no infective
were measures
Dr. material remained in the house after these measures, we shall be free to accept the theory which, in my opinion, is the only tenable one for the origin of the mother’s attack-
dictated the following note which will sufficiently show the doubts which then existed in my mind :" Skin perspiring; copious eruption of sudamina on abdomen. Rash still obvious on back, but nowhere petechial. A few spots still somewhat papular, but rather less so than when first observed. No mottling from the first. Tongue coated with a
dirty yellow fur, and inclined to dry in centre. Aspect still rather dusky. Has taken milk better for the last twentyfour hours. Bowels not moved since three days ago, when
he had one rather loose stool, green in colour, certainly not pea-soupy, and without medicine. One small-formed stool, pale yellow, two days ago." Now sudamina are well known to be much rarer in typhus than in enteric fever, although less rare under than over forty years of age. The temperature remained above the normal standard until the evening of the twenty-first day; it was not only more decidedly remittent than we are accustomed to in typhus, but on the last five days it was truly intermittent; in all these three respects resembling enteric fever in its later stages rather than typhus. I do not raise the question whether there may have been in this case and in the case of S- a double infection of typhus and enteric. Where did this man get his typhus? The time that elapsed between the departure of his ship from Quebec and the onset of his illness-forty days-puts infection from Canada out of the question. Was it due to fomites ? It may have been; but if so, why did the poison lie dormant so long in this pestilential hole? Was it not more likely to have been generated in those conditions which Dr. Gibb describes, and which remind one of Howard’s description of our prisons a century ago ? Several months since, I asked the medical officer of health for Quebec if any typhus existed in that port during the sojourn of the ship there, but I have received no reply. I traced the ship for three weeks after she left Dundee, and no fresh cases -had occurred on board during that time.
PHARYNX.
DALBY, F.R.C.S., M.B. CANTAB.,
AURAL SURGEON TO ST.
GEORGE’S HOSPITAL.
IN order to estimate the position which adenoid vegetations in the vault of the pharynx, in regard both to their diagnosis and removal, occupies in the domain of surgery at the present time, it must be borne in mind that, with the exception of two or three solitary observations, up to the year 1868 the existence and gravity of the disorder were not recognised It was in this year that Dr. Meyer of Copenhagen published’ his first account of the subject, and in the following year brought the matter before the Royal Medical and Chirurgical Society. At the International Medical Congress of 1881 several papers on adenoid vegetations were read, and the various methods in use for their removal were most fully discussed. Thus it will be seen that the intermediate twelve years had served to render familiar in 1881 what was practically unknown in 1868. Taking into consideration these papers and their discussion, as well as the number of surgeons who now habitually treat this affection ; the extreme facility with which the growths can be recognised by an examination with the forefinger gently introduced behind the soft palate may be said to be acknowledged ; and should anyone question this proposition, it is open to him to verify it in any case which presents the usual characteristics of the affection by first examining a patient in whom the vault of the pharynx is healthy, and immediately afterwards the adenoid case. The difference of the two is too striking to escape even the observation of one who does this for the first time. Indeed, it was by an examination of this sort that Dr. Meyer discovered the growths in his first case. A rhinoscopic examination may be regarded therefore as supplementary to this, and in many cases, even in the most skilful hands, as impracticable-as, for example, in the case of young children. As a complete account of the methods adopted by various surgeons to effect the removal of adenoid growths between the two periods which I have named- I viz,, 1868 and 1881-may be found in Mackenzie’s Manual, in the following brief remarks the history of the subject and the practice of others may be taken as read. If one thing more than another stands out in relation to what is written, said, and done in connexion with this matter, it is the necessity of tolerance for other methods whilst advocating our own, and for the following reason: that it is characteristic of the complaint that if the growths are removed in any way, so long as they are completely removed, the patients get well both as to nasal breathing and hearing. To illustrate what I mean, I may be permitted to refer to a point which interested me very much in 1883. At the Congress, Dr. Guye of Amsterdam had strongly recommended a plan of scraping away adenoid vegetations from the pharynx by the nail of the right forefinger, and he had I knew not limited himself in this to any class of cases. also that my friend Mr. Cresswell Baber of Brighton habitually practised this plan without any selection of cases., It had appeared to me that if this were possible, nothing could be more satisfactory than to have in their removal the guidance of the sensitive finger which had detected the presence and the position of the growths; and 1 could readily understand how in the case of young children, when the growths were soft and friable and not in very large quantities, this could be done. When, however, as often happens, these growths are very numerous, of great size, and extreme toughness, I could not understand how the finger-nail of anyone could so embed itself in the tissue as to I therefore had made for me a cut it clean away. species of mechanical finger-nail constructed of steel, on a principle similar to Capart’s spoon, but unlike it in action and construction (to which I shall refer presently), and with the help of this 1 could remove these growths with great completeness and with the most happy results. (See Fig 1.) On the date mentioned-viz., Oct. 1st, 1883—I met Mr. Baber, and in discussing this question of common interest no doubt was left in my mind as to the fact that some finger-nails (notably Mr. Baber’s) can be found sufficiently strong, and of such formation, to effect in the matter of operation all that is required without having resort to any other method. What, however, can be done with the finger - nail only in individual instances
(" individual" as applied to the operator) may be done by anyone if the steel nail is employed. There are several considerations which have commended themselves to me in this method of removing adenoid vegetations from the pharynx. In the first place, when the mouth is held open with a Mason’s gag, the pharynx can be most completely explored with the forefinger, and the amount of vegetations, their size and position, can be most satisfactorily estimated. The instant after this is done the steel nail can be fixed to the finger, and they can be scraped away at leisure. When I say "scraped away," I mean that the steel nail can be embedded in them and made to cut them away. The head being bent forward at the time by the left hand placed on the vertex, the blood, which ilows very freely, escapes by the nostrils. It will be observed that the instrument is so made that the tip of the finger is exposed, and this is most useful in estimating by touch what is being done. Although the whole proceeding does not occupy long, inasmuch as it is most unpleasant and in some degree painful, it is convenient and desirable in many cases, especially
in young and timid children, that ether should be given. position in which the head is held prevents the possibility of blood passing into the larynx during an inspiration. Although at one time I was inclined to repeated rather than to immediate operation, I am bound to say that latterly I have found not one of the least of the advantages of the steel nails is that the pharynx is frequently cleared at one sitting-in the case of young children, cleared so completely that a fortnight after the operation, when the swelling which follows it has subsided, the mouth can be kept closed both waking and sleeping; the "deadness" of speech, so indicative of the affection, disappears; the passage through the posterior nares is restored; the Eustachian obstruction, with its accompanying deafness and the liability to it, is gone. In short, the results of this method have recently proved so satisfactory that in five cases of children in which I employed it (Mr. Braine giving ether in each) during one week no further removal is now necessary. In older patients, where the growths are tougber, and very abundant, more than one sitting is generally required. The plucking away in pieces by Lowenberg’s forceps will no The
doubt succeed in getting rid of the vegetations, but this entails several sittings, and some patients and their friends are apt to shirk what is very disagreeable before the completion of the treatment. It is therefore better to avoid this when possible. Moreover, it is undoubtedly a great advantage to be able to feel with the finger the vegetations as they are being scraped off. This cannot be done with Lowenberg’s forceps (or with Woakes’ modification, which has the advantage of increasing the cutting surface), or with what is otherwise a most useful instrument-viz., a curved ring knife, which Mr. Hawksley constructed for me before the steel nail. (See Fig. 2.) With this knife, the ring being passed up into the pharynx behind the soft palate, the growths can be by a sweeping movement cut away. This knife is made on the same principle as Gottstein’s, and although I have found it more easily moved about in the pharynx, I have seen cases where, in other hands than
mine, the whole pharynx has been cleared at one sitting of abundant tough adenoid growths by Gottstein’s knife.
Notwithstanding the varieties in methods that are now in Meyer still, I believe, adheres (and with excellent
use, Dr.
619
results) to the plan which he described in what may be namely, a new development of the poison; and there is this truthfully said to be his classical paper on this affec- to be said for the latter view, that although the house tion in the Medical and Chirurgical Transactions-viz., his was cleaned the son continued to live in precisely the flexible ring knife passed through the nares into the same insanitary conditions which preceded his mother’s pharynx, guided throughout its movements by the fore- illness. Outbreak- No. l1.-Mrs. aged fifty, 23, Edwardof the left hand; but as the unpleasantness of having the ring knife passed through the nares can be avoided by street (West Central), half a mile from the last outbreak, was operating through the mouth in one of the many methods admitted on July llth, the fifth day of her illness, as a medical case. On the day after her admission she had a wellnow adopted, his mode of attack, so to speak, is, from what marked typhus rash. The attack was sharp and left patient I can learn, not followed out by others. Looking back to a period when this affection was un- very weak, although it terminated on the ninth day. The known, and the precise cause of the characteristic intona- only illness for a long time in the acquaintance or neightion in these patients was unsuspected, it is curious to bourhood of this patient happened to be in the next house, notice how absolutely familiar Dickens was with the pecu- where she frequently visited. In it there were two rooms liarities of voice which marks the subjects of adenoid vege- occupied by seven inmates. The head of this house had been, tations. He must have come in contact with some of them out of work for some time, and the family had therefore been when he so accurately reproduces the voice in one of the rather poorly fed, and two of his children had had febrile characters in " Oliver Twist." There he makes the boy illnesses, which lasted respectively (including convalescence) Barney (one of Fagin’s gang) say " stradegers id the four and seven weeks. These cases were not recognised as next roob," and " ah ! ad rub ’uds too, from the cuttry, but typhus, but there can be little doubt that they were so. subthig in your way, or 1’b bistaked." From the context While the children were ill Mrs. S-- visited them very we may fairly suppose he believed this intonation was infrequently, and helped their mother to nurse them. But a dicativeof race, and he introduces it by way of emphasising full and exhaustive investigation failed to connect this outthe generally disagreeable peculiarities of the characters he break with any preceding case. Outbreak No. 12.-A. T----, aged thirty-three, a Swedish so graphically depicts ; but in this particular he certainly does Barney an injustice, for adenoid vegetations are to sailor, arrived in Dundee on August 27th, having left be met with in "all sorts and conditions of men," living Quebec in a sailing vessel forty-eight days previously. under the most favourable or unfavourable circumstances, He sickened on August 19th, and was seen by Dr. Gibb and in many latitudes. That they are frequently present in on the 27th in the dark forecastle occupied by himself several of the same family cannot fail to be noticed (I have and four others. This place was very dark, had no seen four in one family), and from the recollection of parents portholes or windows, and emitted a stench so powerful as to render breathing in it very unpleasant. No other as to their own breathing and hearing in childhood, the tendency to abnormal adenoid development would seem to case of illness had occurred on the voyage. He was be inherited ; but as the parents have arrived at the time of immediately removed to the infirmary. 1 saw him on the life when this enlargement has disappeared, it is not easy to day after admission, and noted a dusky aspect, a typhus establish this point. Besides the departure of three symptoms odour from the breath and body, an enlarged spleen, and a -viz., the tendency to Eustachian obstruction, the con- typhus rash over the abdomen and back. The morning sequent deafness (which generally directs attention to the remissions of temperature in this case in the second week trouble), and the nasal obstruction-which follows the were much more pronounced than we usually find them in removal of adenoid vegetations, there are other advantages typhus. On the eleventh day the morning temperature was to be reckoned, such as the better prospects of recovery in 101°, the evening 104-4°; twelfth day, morning 100°, case of diphtheria or scarlet fever occurring, with an empty evening 101’2°; thirteenth day, morning 99°, evening 1026° ; rather than a blocked pharynx, as well as the better chances fourteenth day, morning 1004°, evening 102-8° ; fifteenth of the middle ear escaping destruction during these diseases. day, morning 99 8°, evening 1038° ; sixteenth day, morning The improvements also of the general health, with free 986°, evening 102’4°; seventeenth day, morning 984°, nasal breathing, as well as the diminished tendency tc evening 101’4; eighteenth day, morning 984°, evening 100°. bronchial affections, require only mention to be appreciated, On the twenty-first day the temperature both morning and Savile-row, W. evening was normal. On the fifteenth day of the fever I most
finger
THE ETIOLOGY OF TYPHUS
FEVER,
ILLUSTRATED BY A SERIES OF RECENT OUTBREAKS DUNDEE AND NEIGHBOURHOOD.
.
IN
BY ROBERT SINCLAIR, M.D., PHYSICIAN TO THE DUNDEE ROYAL INFIRMARY.
(Concluded from
p.
574.)
Outbreak No. 10.-:Mrs. 11-, aged fifty-three, resided 2, John-street (Central). She and her son occupied two small attic rooms, which, according to Dr. Stalker, were very close and ill-ventilated, owing to the windows not opening, and the only air that could reach them entering by the door after doing duty in the stairs and flats below. She had not been near any house in which there was illness for months, but she confessed to insufficient feeding. She sickened of typhus on July 3rd, was admitted on the 13th, and recovered. Dismissed Aug. 25th. Her son was admitted on Aug. 18th, the sixth day of the fever. Was the son infected directly from the mother? I think not. To accept this explanation would necessitate belief in a thirty days’ incubation-period, of which we have no collateral evidence. Was he infected by her indirectly through fomites ? Or was his a case of generation of the poison de novo? After the mother’s removal, the house, bed, personal clothing, and furniture ab
subjected to the usual cleansing and germicidal by the sanitary department. If my friend, Anderson, is prepared to certify that no infective
were measures
Dr. material remained in the house after these measures, we shall be free to accept the theory which, in my opinion, is the only tenable one for the origin of the mother’s attack-
dictated the following note which will sufficiently show the doubts which then existed in my mind :" Skin perspiring; copious eruption of sudamina on abdomen. Rash still obvious on back, but nowhere petechial. A few spots still somewhat papular, but rather less so than when first observed. No mottling from the first. Tongue coated with a
dirty yellow fur, and inclined to dry in centre. Aspect still rather dusky. Has taken milk better for the last twentyfour hours. Bowels not moved since three days ago, when
he had one rather loose stool, green in colour, certainly not pea-soupy, and without medicine. One small-formed stool, pale yellow, two days ago." Now sudamina are well known to be much rarer in typhus than in enteric fever, although less rare under than over forty years of age. The temperature remained above the normal standard until the evening of the twenty-first day; it was not only more decidedly remittent than we are accustomed to in typhus, but on the last five days it was truly intermittent; in all these three respects resembling enteric fever in its later stages rather than typhus. I do not raise the question whether there may have been in this case and in the case of S- a double infection of typhus and enteric. Where did this man get his typhus? The time that elapsed between the departure of his ship from Quebec and the onset of his illness-forty days-puts infection from Canada out of the question. Was it due to fomites ? It may have been; but if so, why did the poison lie dormant so long in this pestilential hole? Was it not more likely to have been generated in those conditions which Dr. Gibb describes, and which remind one of Howard’s description of our prisons a century ago ? Several months since, I asked the medical officer of health for Quebec if any typhus existed in that port during the sojourn of the ship there, but I have received no reply. I traced the ship for three weeks after she left Dundee, and no fresh cases -had occurred on board during that time.