- Email: [email protected]
ON RECENT TYPHUS IN LANCASHIRE.
174 the round ligament on its lower and inner side, the outer part of the ilio-femoral band on its upper and outer aspect, and both become tense at -the same time. As the force to be resisted in
town not far from Preston; and scattered attacks, still of true typhus, appear to have been observed at Salford and Black.
burn.
this position is very considerable, we are not surprised, strong As the chief interest centres on Manchester and Preston, I as the round ligament is, to find another structure placed so as shall not make any comments on the smaller outbreaks. to assist it in bearing the strain. I visited Preston first on the 29th of October, and found in Dislocation of the hip.-It is not difficult to explain why such special provision should be made to check rotation out- the House of Recovery (the parish fever hospital) fifty-twowards in the flexed position. A glance at the skeleton will cases of bonâ-fide typhus. In all the patients who were in the show that the acetabulum and femur are so directed that the of the disease for a rash to exist, the characteristic mulstage head of the latter has a natural tendency to be dislocated forwards by the outward rolling of the limb, as in standing or berry rash was present. In intensity, the fever appeared walking with the toes, as they usually are, more or less everted. pretty identical with the same disease as it is seen in the Indeed, unless in the rotated inward position, part of the ball London Fever Hospital. lies naturally out of the socket, pressing forwards against the The earliest case of distinct typhus which I could trace had front of the capsular ligament. The natural tendency, then, of occurred on July 7th, in a four-roomed cottage, (17, Castlethe hip joint, from its mechanism, is to dislocate forwards, at some distance from the centre of the town. It was street,) fact is that the the dislocations forwards are comalthough paratively rare. Very various notions are probably entertained not known that the first patient had been exposed to contagion. as to the way in which the direction that the dislocation of the In this cottage eight persons had crowded by night into a room hip shall take is determined. The backward dislocations are the utmost capacity of which was 800 cubic feet. They were not the most frequent because the back of the capsular ligaand underfed, and the boy who first fell ill had also been ment is comparatively thin, but, rather, the back of the capsule dirty is thin because the ball does not tend by the natural motions of much exposed to the weather. This boy was removed to hosthe limb to throw itself out backwards, and because the front pital, and returned home on his convalescence. In the last of the capsule, in the extended position, checks inward as well week of August, six other persons were attacked in this house: as outward rotation. My idea of the matter is, that the ordinary were removed, and the house was closed. Meanwhile, backward and upward direction of dislocation is determined they new cases of typhus had occurred in another part of the town, simply by the obliquity of the shaft of the femur, the force driving the bone out in that direction ; and we would expect the apparently without communication with the former. These dislocation as all the more likely to occur if the limb was caught were in a district that was afterwards subjected to the chief’ in the rotated inward position. Dislocation forward, on the violence of the epidemic-some very confined and dirty courts, other hand, whether pubic or obturator, we would expect to lying low, near the canal, and densely inhabited. The first happen from the limb being wrenched in the rotated outward case in this quarter was on July 28th, in a man who had reposition, carrying the natural motion so unnaturally far as to cently come to lodge there ; and after his removal, no one else rupture the strong ligaments which check rotation outwards. But whatever may be the explanation of the direction of the was attacked in that house. On August llth a young woman different dislocations, it is evident that the natural tendency is was attacked at 23, Foster-square, in an adjacent court ; and for the bone to throw itself out of the socket forwards Now, her friends not only refused to let her be removed, but five orto prevent this, there are two strong ligaments. In the exthem continued to occupy the same room and bed with six of tended position, as in standing with the toes turned more or less out, it is checked by the whole front of the capsular liga- her. Hence, on September 27th, three others of the family ment, including the entire ilio-femoral band. But by flexion came under treatment for the fever, and were sent to hospital. the front of the capsule is relaxed, allowing the outward rota- From this family numerous other cases of typhus were traced. tion to go farther, until it is checked by the round ligament, At the end of August a third neighbourhood, distant from and by the outer part of the ilio femoral band. The limb is in either of the other two, became affected with typhus, cases this position when it is lifted and advanced in walking, or in stepping up with the toes everted, in sitting with the knees occurring at short intervals in two common lodginghouses not apart, or wi h one leg laid across the other knee, or in the far from each other. In one of them (53, Leeming-street) six tailor posture, or on horseback. In all these and similar posi- persons were successively attacked during September, being. tions the hip joint is flexed and rotated outwards, and the always removed to hospital. A fourth outbreak, apparently ligament is called into play to prevent the ball starting forward unconnected with the rest, was seen in another central part from the socket. of the town in the middle of September. At 10, Green-street, a woman was found extremely ill of typhus, and both she and her husband died in the hospital. In some crowded dirty courts ON RECENT TYPHUS IN LANCASHIRE. adjoining, numerous cases of fever afterwards occurred. By BY GEORGE BUCHANAN, M.D., the end of September, cases of typhus had occurred in five PHYSICIAN TO THE LONDON FEVER HOSPITAL; ONE OF THE MEDICAL out of the six wards into which the town is divided. INSPECTORS FOR THE PRIVY COUNCIL. On September 5th an old man was admitted into the workhouse suffering from severe typhus. He was found to be so, I PROPOSE to give a short account of the typhus fever that weak that the medical officer was afraid to have him removed into the parish hospital, whither by rights he should have been, has been seen in the cotton districts of Lancashire since the sent in the first instance. He died on the 7th. On September commencement of the present distress. Since the great typhus 13th, 15th, and 21st respectively, three inmates of the workepidemic in Lancashire at the time of the Irish famine, in house were attacked with fever and removed to hospital The of typhus were not well marked in these; but on 1847-48, there has been scarcely any of this disease in the characters the 29th, three other inmates were found to have utdoubted cotton towns. Liverpool, indeed, resembles London, and typhus : they were removed to hospital, and in a week two of has formerly exceeded London, in its disposition to epi- them were dead. On the 30th another was removed, and she demics of typhus; but in the cotton towns proper all the also died. On the 2nd October three others were taken from medical men who best knew typhus, through their experience the workhouse, and of them one died in the hospital. During of the epidemic of 1847, assured me that this disease had been the first half of October six other cases of typhus appeared, and were promptly removed, none of these proving fatal. No other absent for many years. It appeared probable, indeed, that inmate was attacked with typhus till the last days of October, stray cases have been seen from time to time in Manchester, when two more were removed, and one of them died. and, considering the freedom of intercourse between this city During October the fever extended more widely over ther and other parts of the kingdom, it would be strange if some town, not only m intaining its ground in the districts first attacked, but also affecting distant streets, and often one or cases were not imported. in them. The total number of cases of true In 1862, however, positive maculated typhus made its two houses only and febricula, with the dates when excluding typhus, typhoid appearance afresh. The disease has been most prevalent ai they were first seen, was ascertained from the medical officers. Preston, and next at Manchester. Numerous cases have beer Subjoined is a summary of the new cases up to Nov. 1, with their mortality up to Nov. IS:met with at Accrington, and also several at Chorley,a
175 he could not say positively what cases had been admitted in former years ; but from his previous experience as a district surgeon, he felt confident that such numbers of true typhus cases as those now seen were altogether out of the ordinary experience of Manchester. There was difficulty in getting from any record a satisfactory separation of the different sorts of fever. In the Infirmary register the cases set down for typhus were very numerous, concerning which there was nothing distinctive to be learned from
cently appointed,
thecase-books; while in one or two the appearancesoftyphoid were
found post-mortem. The earliest instance recorded of mulberry rash was in a patient of Dr. Browne’s at the end of May. Of four cases admitted in June, the history of typhus appeared conclusive in two. From that time to September no patient was admitted with true typhus; but in September there were four cases, of which two were fatal ; in October one case, and in November three, of whom one died. In the Parish Fever Hospital, inasmuch as the pauper class here receives treatment, the cases of typhus had been, of course, more numerous. I made from the case-books a list of the patients admitted from Midsummer, whose disease appeared to have been typhus, and got the medical officer to revise the list for me. The typhus cases admitted from Midsummer to November 29th thus appeared to number 70, the admissions being distributed over the several months as follows :-In July, 7 ; in August, 8 ; in September, 12; in October, 20 ; in November, 25. The mortality among the 70 parish patients was 13; and among the 8 infirmary patients admitted since Midsummer, 3; the aggregate mortality being about 20 per cent. of the admissions. Besides these attacks, some typhus cases were treated at their own homes. Among other cases not above mentioned is And since then it is believed that there has been again a slight unhappily to be included the district surgeon of Ancoats, who fall in the numbers. I believe there has been no further out- died from it in October. Dr. Noble, who attended him, told me that no instance of this true typhus fever had previously break in the workhouse. The mortality of typhus in Preston up to the end of Novem- come under his notice for the last six or eight years. Dr. on this point is important, as coming from a ber, excluding those then under treatment, was 23 per cent. of Noble’s evidence the cases. In the House of Recovery the mortality was lower, physician known to the profession, by his account of the typhus epidemic in Manchester during the years 1847-4s, to be thosomewhat under 18 per cent. At the time of my visit at the end of October, the House of roughly versed in the characters of the various fevers. Recovery, which was constructed for forty patients, contained I The localization of the typhus cases in Manchester and the fifty-two cases of typhus, and afterwards there were upwards i occupations of its victims were not among the points specially of sixty inmates at one time. In some wards the space for I inquired into. The facts ascertained at the end of November as to the each bed fell short of 600 cubic feet, and the air was here very fotil. At the beginning of November a wooden building was prevalence of typhus in Manchester would not have warerected in contiguity to the House, capable of containing sixty ranted an expectation of the remarkable subsidence of the which has since been observed. The Infirmary, as it patients, with a space of 1500 cubic feet to each. This build- disease poor who are receiving parish relief, is not to be ing was put up in ten days, but there was a lamentable delay excludes the before the patients were removed into it at the end of Decem- appealed to as evidence of the amount of the fever. The Fever ber. In the meanwhile upwards of twenty persons in attend- Hospital of the workhouse, however, is a fair guide to the degree of its prevalence. In December there were only 17 ance on the sick had caught the fever, the medical officer and the master of the House of Recovery being among the number. cases admitted, and from December 29th to January 13th, not The occupations of the persons attacked by typhus in Preston one. On the last named day there were two new cases, and there have since been several more; but of these, some have conwas only ascertained in the case of forty of those who died before the end of November. Of these, fifteen were cotton-workers, tracted the fever in other wards of the workhouse adjoining the fever wards. It would, of course, be premature to reckon yet or their relations, nine were " labourers," four were engaged in various departments of iron-work, six were artizans uncon- on the complete subsidence of the disease. I have before mennected with the foregoing, two were employed about the canal, tioned how a similar lull, though not so complete, occurred in the fever of Preston in December, and that, nevertheless, the one was a pensioner, and the remaining three were not classified. The numbers here enumerated are not very far from the disease appears to be again on the increase_there.-Typhoid fever, it may be mentioned in passing, appears latterly to have proportion of each class of people living in Preston. It deserves mention, for the sake of those who refuse to prevailed in Manchester to less than its ordinary amount. At end of 1861,am told it was seriously more prevalent than acknowledge an epidemic influence that does not show itself on the the general death-rate, that in the September quarter of 1862 usual. I do not propose now to comment on the existence of those the mortality from all causes in Preston was very markedly below the average, 464 deaths only being registered against unwholesome circumstances that are most generally acknow’607 in the corresponding quarter of 1561. This subsidence was ledged as the causes of typhus. In a report to Government, those circumstances in some entirely, however, among children under six years old, and re- already in print, I have stated as a whole. Why the typhus influsulted, there is reason to believe, from the greater care bestowed detail for the cotton towns ence should have fallen on Preston most especially I am at a mothers on time their infants the of industrial deby during loss conclusively to explain. In Manchester, the presumably pression. greater frequency of imported typhus will, caeteris Paribus, I visited Manchester at the end of November, and found explain its prevalence here. It will be, however, well to point two institutions into which the typhus cases occurring in the out the causes to whiéh may be ascribed the comparative limitapublic practice of the town would for the most part be received. tion of the fever in these towns. That the strict removal of ’To the Fever Hospital attached to the workhouse, those in re- the cases to hospital has had a main share in the decline of ceipt of parish relief would come ; and here, on the 26th of the epidemic force cannot for a moment be doubted. InI found twenty-six patients, most of whom were deed, this would be abundantly proved by the spread that eases of typhus, ten having the rash well out. The Fever has been seen wherethe patients happened not to be so Hospital of the Infirmary receives no case that is getting reliefremoved. Next, the maintenance of a high standard of relief, from the guardians; but in it there were two cases of real increasing almost every month, and the more liberal distributyphus, and a third had just died. Dr. Roberts, physician to tion of bedding and clothing as the winter has advanced, may the Infirmary, assured me that until the present autumn he be credited with much of the good result. And of at least had not seen in Manchester more than two examples of thisequal importance is the circumstance that since November the disease. As the surgeon to the workhouse had been only re- weather has been singularly, almost unprecedentedly, mild.
November,
176 November, which was the coldest month since the distress passing the tube to a considerable extent up the colon, but began, witnessed the maximum of typhus cases both in Preston could not find any cause of obstruction. The injection subseand Manchester. quently administered was retained for a time, and then reIn conclusion, I would wish for a moment to advert to jected, but without any trace of fseca.1 matter in it. In the morning of Tuesday the condition of the patient becriticisms that have been passed on my statements regarding typhus in Manchester. In a Report on the Health of the came alarming. He was constantly vomiting matters of the Cotton Towns in Lancashire and Cheshire, a dozen lines com- consistence and appearance of pea-soup, though of brighter prise what appeared necessary to be there said on the subject of yellow colour from the presence of much bile, and having a typhus in all the towns. These dozen lines unfortunately strong feculent odour; and when not vomiting, he suffered appear to have been taken in certain quarters for the whole from constant distressing hiccough; the abdomen was free from report, and they have further been credited with all the glosses tenderness, but somewhat tympanitic ; the pulse about 120 that have appeared on them in the public prints. On going and thready; the surface cold, and the features pinched and over the matter again for this paper, 1 am sensible of no error haggard. It was qnite evident that unless relief were procured or exaggeration in the printed statement itself. In the the case must terminate fatally before the lapse of many hours. opinions that have been expressed against its correctness at Some hydrocyanic acid and chloric ether were given for the relief of the hiccough and gastric symptoms, and afforded some least five fallacies may be enumerated :1. A notion that the subsidence of the epidemic influence in alleviation. It was thought desirable to try the administration December and January disproves the existence of such an in- of opium, which drug had, in conjunction with calomel, given fluence in November. ,relief the first day or two of the attack ; but it was considered 2. An assnmption that a low aggregate death-rate excludes better to wait the result of a consultation which had been decided upon with Dr. Billing. the possibility of the existence of an epidemic. This consultation was held in the afternoon of Tuesday, and 3. The assumption that death-registers and records kept by busy practitioners, taking no interest in the distinctions of the following plan of treatment was resolved upon :-To give a fever, can furnish valid evidence as to the prevalence of typhus grain of opium every three or four hours, and to administer it in the form of powder rubbed up with a little sugar and placed as distinguished from other forms of continued fever. 4. The attempt to gauge the amount of typhus by the ex- upon the back of the tongue, as being more likely in this rather perience of the Infirmary, from which the pauper class, amongst than any other form to be absorbed in the then irritable state of the stomach. The hydrocyanic acid and chloric ether mixwhom typhus most prevails, is specifically excluded. 5. The special application to Manchester of observations ture to be given occasionally; also brandy and Seltzer water, made about Lancashire at large, even when such are stated to and milk and limp-water in small quantities, in the way of dietetic regimen. apply with less force to this city. Towards night the patient seemed more comfortable; the Gower-street, Feb. 1863. pulse was less frequent and a little fuller, the countenance less anxious and pinched, and the vomiting was less frequent, although the matters ejected were of the same character, and CLINICAL OBSERVATIONS there was almost continuous and distressing hiccough. He was ON enabled to retain the milk and lime water and the brandy-andDISEASES OF THE ABDOMINAL VISCERA. water. The opium was given with great regularity through the next and the following days ; it afforded the patient some intervals of sleep, very materially allayed the severity of the BY STEPHEN H. WARD, M.D. LOND., M.R.C.P., PHYSICIAN TO THE SEAMEN’S HOSPITAL "DREADNOUGHT," symptoms, and did not produce any unpleasant cerebral effects. ETC. Through the Wednesday and Thursday there was no action of the bowels. although there was several times a sensation as if (Concluded from p. 145.) such were going to take place; but the vomiting was much less frequent, the matters ejected less in quantity, and not so offenINTESTINAL OBSTRUCTION. sive, and there were considerable intervals between the attacks
CASE 4. Intestinal
obstruction from larye intestinal calculus; recovery.- A gentleman, in his sixtieth year, of bilious temperament and rather hypochondriacal tendency, on going to stool on Friday, January 2nd, found that h could pass but a very little faecal matter, and, after some straining, desisted from further effort. On the following morning, not having had any evacuation, and feeling uneasy in the bowels, he took an aperient. This, after a time, was rejected ; and bilious vomiting came on, and continued at intervals through the day and ensuing night. Feeling worse on the Sunday morning, he sent for me, and on my arrival I found him lying on the sofa, with a basin by his side, looking haggard and sallow, and constantly retching. A careful examination of the abdomen was made, and there was not found any trace of hernia, nor tenderness or undue distension. Looking at the case as possibly one merely of irritable stomach and liver, calomel and opium, and effervescing mixture with dilute hydrocyanic acid, were ordered, and the patient was directed to keep quiet in bed. On the Monday morning the patient was more comfortable ; he was free from pain, and the stomach had been quieter. Towards the evening of this day, however, the vomiting returned, and belching of gas with strong feculent odour came on. Later, the matters vomited began to have a pea-soupy character and distinctly feculent smell; the abdomen became somewhat tympanitic, but without tenderness; and the pulse increased in frequency and assumed a thready character. On careful toperbe cussion and palpation of the abdomen, there was found dulness about the ileo-caecal region ; and as the intestinal obstruction, now evident, might have been due to fascal accnmulation in this part of the canal, it was thought desirable to make an examination, and to try the effect of a copious injection administered by the O’Beirne tube. Mr. N. Ward was accord. ingly requested to give his opinion upon the case, and to make an exploratory examination of the colon. He succeeded in
of hiccough. The general condition of the patient also improved, and, throughout, the abdomen was soft, and free from tenderness. There appeared, however, to be some amount of fulness and dulness on percussion about the ileo-coeotl region. A second consultation was held on Thursday afternoon, and it was decided to persevere with the opium, and in other respects not to alter the treatment. The patient passed through the ensuing night with comparative comfort. In the afternoon of Friday he felt a desire to go to stool, and after some straining, passed a small quantity of semi fluid faecal matter. A few hours after, he had a tolerably copious and loose motion; but nothing could be detected in these or in subsequent evacuations that could have acted as a cause of obstruc-
tion. From this time the symptoms completely subsided, but for two or three days he was troubled at intervals with hiccough. The bowels continued to act once or twice a day, and, after a time, regularly every morning ; but the motions remained unformed, and occupied, on and off, an hour or two in passing. They were voided in detachments, and with difficulty, and it was evident that there was some obstacle to free evacuation. A dose of decoction of aloes daily, and the use of an enema of tepid water every morning, were suggested, with a view of bringing about an effectual emptying of the bowels; and although there was every day a full discharge of fsecal matter, still it was in the tedious and annoying manner just noticed. This state of things continued through February and March, until one morning towards the middle of April, when the patient felt a solid substance come down to the anus, but which he could not lay hold of with his fingers. Mr. N. Ward was accordingly requested to make an examination of the rectum. He did iso, and found a large oblong mass lyingin the hollow of the sacrum, between two and three inches from the outlet. By manipulation he succeeded in detaching from the nucleus a quantity of fetid old faecal matter, which formed the outer investment of the body, and which was found to contain some earthy matter, and a considerable number of seeds. He subsequently, on two occasions, endeavoured by means of forceps
town not far from Preston; and scattered attacks, still of true typhus, appear to have been observed at Salford and Black.
burn.
this position is very considerable, we are not surprised, strong As the chief interest centres on Manchester and Preston, I as the round ligament is, to find another structure placed so as shall not make any comments on the smaller outbreaks. to assist it in bearing the strain. I visited Preston first on the 29th of October, and found in Dislocation of the hip.-It is not difficult to explain why such special provision should be made to check rotation out- the House of Recovery (the parish fever hospital) fifty-twowards in the flexed position. A glance at the skeleton will cases of bonâ-fide typhus. In all the patients who were in the show that the acetabulum and femur are so directed that the of the disease for a rash to exist, the characteristic mulstage head of the latter has a natural tendency to be dislocated forwards by the outward rolling of the limb, as in standing or berry rash was present. In intensity, the fever appeared walking with the toes, as they usually are, more or less everted. pretty identical with the same disease as it is seen in the Indeed, unless in the rotated inward position, part of the ball London Fever Hospital. lies naturally out of the socket, pressing forwards against the The earliest case of distinct typhus which I could trace had front of the capsular ligament. The natural tendency, then, of occurred on July 7th, in a four-roomed cottage, (17, Castlethe hip joint, from its mechanism, is to dislocate forwards, at some distance from the centre of the town. It was street,) fact is that the the dislocations forwards are comalthough paratively rare. Very various notions are probably entertained not known that the first patient had been exposed to contagion. as to the way in which the direction that the dislocation of the In this cottage eight persons had crowded by night into a room hip shall take is determined. The backward dislocations are the utmost capacity of which was 800 cubic feet. They were not the most frequent because the back of the capsular ligaand underfed, and the boy who first fell ill had also been ment is comparatively thin, but, rather, the back of the capsule dirty is thin because the ball does not tend by the natural motions of much exposed to the weather. This boy was removed to hosthe limb to throw itself out backwards, and because the front pital, and returned home on his convalescence. In the last of the capsule, in the extended position, checks inward as well week of August, six other persons were attacked in this house: as outward rotation. My idea of the matter is, that the ordinary were removed, and the house was closed. Meanwhile, backward and upward direction of dislocation is determined they new cases of typhus had occurred in another part of the town, simply by the obliquity of the shaft of the femur, the force driving the bone out in that direction ; and we would expect the apparently without communication with the former. These dislocation as all the more likely to occur if the limb was caught were in a district that was afterwards subjected to the chief’ in the rotated inward position. Dislocation forward, on the violence of the epidemic-some very confined and dirty courts, other hand, whether pubic or obturator, we would expect to lying low, near the canal, and densely inhabited. The first happen from the limb being wrenched in the rotated outward case in this quarter was on July 28th, in a man who had reposition, carrying the natural motion so unnaturally far as to cently come to lodge there ; and after his removal, no one else rupture the strong ligaments which check rotation outwards. But whatever may be the explanation of the direction of the was attacked in that house. On August llth a young woman different dislocations, it is evident that the natural tendency is was attacked at 23, Foster-square, in an adjacent court ; and for the bone to throw itself out of the socket forwards Now, her friends not only refused to let her be removed, but five orto prevent this, there are two strong ligaments. In the exthem continued to occupy the same room and bed with six of tended position, as in standing with the toes turned more or less out, it is checked by the whole front of the capsular liga- her. Hence, on September 27th, three others of the family ment, including the entire ilio-femoral band. But by flexion came under treatment for the fever, and were sent to hospital. the front of the capsule is relaxed, allowing the outward rota- From this family numerous other cases of typhus were traced. tion to go farther, until it is checked by the round ligament, At the end of August a third neighbourhood, distant from and by the outer part of the ilio femoral band. The limb is in either of the other two, became affected with typhus, cases this position when it is lifted and advanced in walking, or in stepping up with the toes everted, in sitting with the knees occurring at short intervals in two common lodginghouses not apart, or wi h one leg laid across the other knee, or in the far from each other. In one of them (53, Leeming-street) six tailor posture, or on horseback. In all these and similar posi- persons were successively attacked during September, being. tions the hip joint is flexed and rotated outwards, and the always removed to hospital. A fourth outbreak, apparently ligament is called into play to prevent the ball starting forward unconnected with the rest, was seen in another central part from the socket. of the town in the middle of September. At 10, Green-street, a woman was found extremely ill of typhus, and both she and her husband died in the hospital. In some crowded dirty courts ON RECENT TYPHUS IN LANCASHIRE. adjoining, numerous cases of fever afterwards occurred. By BY GEORGE BUCHANAN, M.D., the end of September, cases of typhus had occurred in five PHYSICIAN TO THE LONDON FEVER HOSPITAL; ONE OF THE MEDICAL out of the six wards into which the town is divided. INSPECTORS FOR THE PRIVY COUNCIL. On September 5th an old man was admitted into the workhouse suffering from severe typhus. He was found to be so, I PROPOSE to give a short account of the typhus fever that weak that the medical officer was afraid to have him removed into the parish hospital, whither by rights he should have been, has been seen in the cotton districts of Lancashire since the sent in the first instance. He died on the 7th. On September commencement of the present distress. Since the great typhus 13th, 15th, and 21st respectively, three inmates of the workepidemic in Lancashire at the time of the Irish famine, in house were attacked with fever and removed to hospital The of typhus were not well marked in these; but on 1847-48, there has been scarcely any of this disease in the characters the 29th, three other inmates were found to have utdoubted cotton towns. Liverpool, indeed, resembles London, and typhus : they were removed to hospital, and in a week two of has formerly exceeded London, in its disposition to epi- them were dead. On the 30th another was removed, and she demics of typhus; but in the cotton towns proper all the also died. On the 2nd October three others were taken from medical men who best knew typhus, through their experience the workhouse, and of them one died in the hospital. During of the epidemic of 1847, assured me that this disease had been the first half of October six other cases of typhus appeared, and were promptly removed, none of these proving fatal. No other absent for many years. It appeared probable, indeed, that inmate was attacked with typhus till the last days of October, stray cases have been seen from time to time in Manchester, when two more were removed, and one of them died. and, considering the freedom of intercourse between this city During October the fever extended more widely over ther and other parts of the kingdom, it would be strange if some town, not only m intaining its ground in the districts first attacked, but also affecting distant streets, and often one or cases were not imported. in them. The total number of cases of true In 1862, however, positive maculated typhus made its two houses only and febricula, with the dates when excluding typhus, typhoid appearance afresh. The disease has been most prevalent ai they were first seen, was ascertained from the medical officers. Preston, and next at Manchester. Numerous cases have beer Subjoined is a summary of the new cases up to Nov. 1, with their mortality up to Nov. IS:met with at Accrington, and also several at Chorley,a
175 he could not say positively what cases had been admitted in former years ; but from his previous experience as a district surgeon, he felt confident that such numbers of true typhus cases as those now seen were altogether out of the ordinary experience of Manchester. There was difficulty in getting from any record a satisfactory separation of the different sorts of fever. In the Infirmary register the cases set down for typhus were very numerous, concerning which there was nothing distinctive to be learned from
cently appointed,
thecase-books; while in one or two the appearancesoftyphoid were
found post-mortem. The earliest instance recorded of mulberry rash was in a patient of Dr. Browne’s at the end of May. Of four cases admitted in June, the history of typhus appeared conclusive in two. From that time to September no patient was admitted with true typhus; but in September there were four cases, of which two were fatal ; in October one case, and in November three, of whom one died. In the Parish Fever Hospital, inasmuch as the pauper class here receives treatment, the cases of typhus had been, of course, more numerous. I made from the case-books a list of the patients admitted from Midsummer, whose disease appeared to have been typhus, and got the medical officer to revise the list for me. The typhus cases admitted from Midsummer to November 29th thus appeared to number 70, the admissions being distributed over the several months as follows :-In July, 7 ; in August, 8 ; in September, 12; in October, 20 ; in November, 25. The mortality among the 70 parish patients was 13; and among the 8 infirmary patients admitted since Midsummer, 3; the aggregate mortality being about 20 per cent. of the admissions. Besides these attacks, some typhus cases were treated at their own homes. Among other cases not above mentioned is And since then it is believed that there has been again a slight unhappily to be included the district surgeon of Ancoats, who fall in the numbers. I believe there has been no further out- died from it in October. Dr. Noble, who attended him, told me that no instance of this true typhus fever had previously break in the workhouse. The mortality of typhus in Preston up to the end of Novem- come under his notice for the last six or eight years. Dr. on this point is important, as coming from a ber, excluding those then under treatment, was 23 per cent. of Noble’s evidence the cases. In the House of Recovery the mortality was lower, physician known to the profession, by his account of the typhus epidemic in Manchester during the years 1847-4s, to be thosomewhat under 18 per cent. At the time of my visit at the end of October, the House of roughly versed in the characters of the various fevers. Recovery, which was constructed for forty patients, contained I The localization of the typhus cases in Manchester and the fifty-two cases of typhus, and afterwards there were upwards i occupations of its victims were not among the points specially of sixty inmates at one time. In some wards the space for I inquired into. The facts ascertained at the end of November as to the each bed fell short of 600 cubic feet, and the air was here very fotil. At the beginning of November a wooden building was prevalence of typhus in Manchester would not have warerected in contiguity to the House, capable of containing sixty ranted an expectation of the remarkable subsidence of the which has since been observed. The Infirmary, as it patients, with a space of 1500 cubic feet to each. This build- disease poor who are receiving parish relief, is not to be ing was put up in ten days, but there was a lamentable delay excludes the before the patients were removed into it at the end of Decem- appealed to as evidence of the amount of the fever. The Fever ber. In the meanwhile upwards of twenty persons in attend- Hospital of the workhouse, however, is a fair guide to the degree of its prevalence. In December there were only 17 ance on the sick had caught the fever, the medical officer and the master of the House of Recovery being among the number. cases admitted, and from December 29th to January 13th, not The occupations of the persons attacked by typhus in Preston one. On the last named day there were two new cases, and there have since been several more; but of these, some have conwas only ascertained in the case of forty of those who died before the end of November. Of these, fifteen were cotton-workers, tracted the fever in other wards of the workhouse adjoining the fever wards. It would, of course, be premature to reckon yet or their relations, nine were " labourers," four were engaged in various departments of iron-work, six were artizans uncon- on the complete subsidence of the disease. I have before mennected with the foregoing, two were employed about the canal, tioned how a similar lull, though not so complete, occurred in the fever of Preston in December, and that, nevertheless, the one was a pensioner, and the remaining three were not classified. The numbers here enumerated are not very far from the disease appears to be again on the increase_there.-Typhoid fever, it may be mentioned in passing, appears latterly to have proportion of each class of people living in Preston. It deserves mention, for the sake of those who refuse to prevailed in Manchester to less than its ordinary amount. At end of 1861,am told it was seriously more prevalent than acknowledge an epidemic influence that does not show itself on the the general death-rate, that in the September quarter of 1862 usual. I do not propose now to comment on the existence of those the mortality from all causes in Preston was very markedly below the average, 464 deaths only being registered against unwholesome circumstances that are most generally acknow’607 in the corresponding quarter of 1561. This subsidence was ledged as the causes of typhus. In a report to Government, those circumstances in some entirely, however, among children under six years old, and re- already in print, I have stated as a whole. Why the typhus influsulted, there is reason to believe, from the greater care bestowed detail for the cotton towns ence should have fallen on Preston most especially I am at a mothers on time their infants the of industrial deby during loss conclusively to explain. In Manchester, the presumably pression. greater frequency of imported typhus will, caeteris Paribus, I visited Manchester at the end of November, and found explain its prevalence here. It will be, however, well to point two institutions into which the typhus cases occurring in the out the causes to whiéh may be ascribed the comparative limitapublic practice of the town would for the most part be received. tion of the fever in these towns. That the strict removal of ’To the Fever Hospital attached to the workhouse, those in re- the cases to hospital has had a main share in the decline of ceipt of parish relief would come ; and here, on the 26th of the epidemic force cannot for a moment be doubted. InI found twenty-six patients, most of whom were deed, this would be abundantly proved by the spread that eases of typhus, ten having the rash well out. The Fever has been seen wherethe patients happened not to be so Hospital of the Infirmary receives no case that is getting reliefremoved. Next, the maintenance of a high standard of relief, from the guardians; but in it there were two cases of real increasing almost every month, and the more liberal distributyphus, and a third had just died. Dr. Roberts, physician to tion of bedding and clothing as the winter has advanced, may the Infirmary, assured me that until the present autumn he be credited with much of the good result. And of at least had not seen in Manchester more than two examples of thisequal importance is the circumstance that since November the disease. As the surgeon to the workhouse had been only re- weather has been singularly, almost unprecedentedly, mild.
November,
176 November, which was the coldest month since the distress passing the tube to a considerable extent up the colon, but began, witnessed the maximum of typhus cases both in Preston could not find any cause of obstruction. The injection subseand Manchester. quently administered was retained for a time, and then reIn conclusion, I would wish for a moment to advert to jected, but without any trace of fseca.1 matter in it. In the morning of Tuesday the condition of the patient becriticisms that have been passed on my statements regarding typhus in Manchester. In a Report on the Health of the came alarming. He was constantly vomiting matters of the Cotton Towns in Lancashire and Cheshire, a dozen lines com- consistence and appearance of pea-soup, though of brighter prise what appeared necessary to be there said on the subject of yellow colour from the presence of much bile, and having a typhus in all the towns. These dozen lines unfortunately strong feculent odour; and when not vomiting, he suffered appear to have been taken in certain quarters for the whole from constant distressing hiccough; the abdomen was free from report, and they have further been credited with all the glosses tenderness, but somewhat tympanitic ; the pulse about 120 that have appeared on them in the public prints. On going and thready; the surface cold, and the features pinched and over the matter again for this paper, 1 am sensible of no error haggard. It was qnite evident that unless relief were procured or exaggeration in the printed statement itself. In the the case must terminate fatally before the lapse of many hours. opinions that have been expressed against its correctness at Some hydrocyanic acid and chloric ether were given for the relief of the hiccough and gastric symptoms, and afforded some least five fallacies may be enumerated :1. A notion that the subsidence of the epidemic influence in alleviation. It was thought desirable to try the administration December and January disproves the existence of such an in- of opium, which drug had, in conjunction with calomel, given fluence in November. ,relief the first day or two of the attack ; but it was considered 2. An assnmption that a low aggregate death-rate excludes better to wait the result of a consultation which had been decided upon with Dr. Billing. the possibility of the existence of an epidemic. This consultation was held in the afternoon of Tuesday, and 3. The assumption that death-registers and records kept by busy practitioners, taking no interest in the distinctions of the following plan of treatment was resolved upon :-To give a fever, can furnish valid evidence as to the prevalence of typhus grain of opium every three or four hours, and to administer it in the form of powder rubbed up with a little sugar and placed as distinguished from other forms of continued fever. 4. The attempt to gauge the amount of typhus by the ex- upon the back of the tongue, as being more likely in this rather perience of the Infirmary, from which the pauper class, amongst than any other form to be absorbed in the then irritable state of the stomach. The hydrocyanic acid and chloric ether mixwhom typhus most prevails, is specifically excluded. 5. The special application to Manchester of observations ture to be given occasionally; also brandy and Seltzer water, made about Lancashire at large, even when such are stated to and milk and limp-water in small quantities, in the way of dietetic regimen. apply with less force to this city. Towards night the patient seemed more comfortable; the Gower-street, Feb. 1863. pulse was less frequent and a little fuller, the countenance less anxious and pinched, and the vomiting was less frequent, although the matters ejected were of the same character, and CLINICAL OBSERVATIONS there was almost continuous and distressing hiccough. He was ON enabled to retain the milk and lime water and the brandy-andDISEASES OF THE ABDOMINAL VISCERA. water. The opium was given with great regularity through the next and the following days ; it afforded the patient some intervals of sleep, very materially allayed the severity of the BY STEPHEN H. WARD, M.D. LOND., M.R.C.P., PHYSICIAN TO THE SEAMEN’S HOSPITAL "DREADNOUGHT," symptoms, and did not produce any unpleasant cerebral effects. ETC. Through the Wednesday and Thursday there was no action of the bowels. although there was several times a sensation as if (Concluded from p. 145.) such were going to take place; but the vomiting was much less frequent, the matters ejected less in quantity, and not so offenINTESTINAL OBSTRUCTION. sive, and there were considerable intervals between the attacks
CASE 4. Intestinal
obstruction from larye intestinal calculus; recovery.- A gentleman, in his sixtieth year, of bilious temperament and rather hypochondriacal tendency, on going to stool on Friday, January 2nd, found that h could pass but a very little faecal matter, and, after some straining, desisted from further effort. On the following morning, not having had any evacuation, and feeling uneasy in the bowels, he took an aperient. This, after a time, was rejected ; and bilious vomiting came on, and continued at intervals through the day and ensuing night. Feeling worse on the Sunday morning, he sent for me, and on my arrival I found him lying on the sofa, with a basin by his side, looking haggard and sallow, and constantly retching. A careful examination of the abdomen was made, and there was not found any trace of hernia, nor tenderness or undue distension. Looking at the case as possibly one merely of irritable stomach and liver, calomel and opium, and effervescing mixture with dilute hydrocyanic acid, were ordered, and the patient was directed to keep quiet in bed. On the Monday morning the patient was more comfortable ; he was free from pain, and the stomach had been quieter. Towards the evening of this day, however, the vomiting returned, and belching of gas with strong feculent odour came on. Later, the matters vomited began to have a pea-soupy character and distinctly feculent smell; the abdomen became somewhat tympanitic, but without tenderness; and the pulse increased in frequency and assumed a thready character. On careful toperbe cussion and palpation of the abdomen, there was found dulness about the ileo-caecal region ; and as the intestinal obstruction, now evident, might have been due to fascal accnmulation in this part of the canal, it was thought desirable to make an examination, and to try the effect of a copious injection administered by the O’Beirne tube. Mr. N. Ward was accord. ingly requested to give his opinion upon the case, and to make an exploratory examination of the colon. He succeeded in
of hiccough. The general condition of the patient also improved, and, throughout, the abdomen was soft, and free from tenderness. There appeared, however, to be some amount of fulness and dulness on percussion about the ileo-coeotl region. A second consultation was held on Thursday afternoon, and it was decided to persevere with the opium, and in other respects not to alter the treatment. The patient passed through the ensuing night with comparative comfort. In the afternoon of Friday he felt a desire to go to stool, and after some straining, passed a small quantity of semi fluid faecal matter. A few hours after, he had a tolerably copious and loose motion; but nothing could be detected in these or in subsequent evacuations that could have acted as a cause of obstruc-
tion. From this time the symptoms completely subsided, but for two or three days he was troubled at intervals with hiccough. The bowels continued to act once or twice a day, and, after a time, regularly every morning ; but the motions remained unformed, and occupied, on and off, an hour or two in passing. They were voided in detachments, and with difficulty, and it was evident that there was some obstacle to free evacuation. A dose of decoction of aloes daily, and the use of an enema of tepid water every morning, were suggested, with a view of bringing about an effectual emptying of the bowels; and although there was every day a full discharge of fsecal matter, still it was in the tedious and annoying manner just noticed. This state of things continued through February and March, until one morning towards the middle of April, when the patient felt a solid substance come down to the anus, but which he could not lay hold of with his fingers. Mr. N. Ward was accordingly requested to make an examination of the rectum. He did iso, and found a large oblong mass lyingin the hollow of the sacrum, between two and three inches from the outlet. By manipulation he succeeded in detaching from the nucleus a quantity of fetid old faecal matter, which formed the outer investment of the body, and which was found to contain some earthy matter, and a considerable number of seeds. He subsequently, on two occasions, endeavoured by means of forceps