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The Milroy Lectures ON CHANGES OF TYPE IN EPIDEMIC DISEASES.
FEBRUARY 25, 1893. and other causes than attenuation arrest it. Malarial fever shows, too, the real meaning of infectiveness and the purely relative character of sus-
epidemic prevalence,
The Milroy Lectures CHANGES OF TYPE IN EPIDEMIC DISEASES.
Under favourable condiand unsuseeptibility. tions it becomes more and more capable of infecting man ; first the more susceptible, then the less susceptible. Thus the attacks grow more and more numerous, for greater and Delivered at the Examination Hall, Victoria Embankgreater resistances are overcome ; and meanwhile the most on Feb. 21st, 1893, ment, susceptible no longer escape with slight attacks. The B.Sc. LOND. BY B. A. intensity of the contagium is increasing, and now that the less susceptible suffer mild attacks the more susceptible are stricken with fever of a graver type. LECTURE I. Had the disease been infectious from person to person bet7veen Quantity and Quality in ipide-rnic increased prevalence would naturally be attributed to Prev
ceptibility
WHITELEGGE, M.D.,
abundantly
during
NO. 3626.
_
400
DR. B. A. WHITELEGGE ON EPIDEMIC DISEASES.
other diseases may be rapidly intensified in the process. In types will, however, be considered more fully in the nextDr. Thorne Thorne’s words : "There is reason to believe lecture. It will be sufficient to take scarlet fever and smallthat attacks of so-called sore-throat exhibit under certain pox for present reference. Scarlet fever is one degree further favouring conditions aprogressive development of the removed from malaria. It is by no means certain that under property of infectiveness,’ culminating in a definite specific ordinary circumstances soil has much to do with the present type which is indistinguishable from diphtheria." Such stage of its epidemiology. It is infectious, and although we. conditions are found in the aggregation of susceptible children cannot affirm that no other cause than direct or indirect’ at school, in localities where sore-throats are common, and infection from another case of scarlet fever can possibly include some of potentially diphtherial character. The type bring about the disease it is at all events clear that the of disease is mobile and capable of rapidly assuming an sporadic cases in which it is open to us to suspect other intense form if the virus is repeatedly transferred from one origins are far fewer than in diphtheria, and, moreover, with abnormally susceptible throat to another. There seems to be advancing knowledge of the possible channels of infection, the apparent exceptions are becoming still more rare. no reason to doubt that the intensification thus brought about is comparable to that of the purely telluric diseases, Severity of attack and infectiousness rise and fall together, except in causation. There are other changes of type of far as is shown by statistical evidence on a large scale (to be wider range. Diphtheria was in abeyance, in name at all considered later on) and also by the common clinical expeevents, during the first half of the present century ; but from rience that malignant cases are more infectious than others 1855 onwards it again became virulent and prevalent. Since under equal conditions. Sometimes the quality of scarlet then it seems that a less intense type has prevailed on the fever will change almost as suddenly as that of diphtheria, and whole ; but in the earlier part of this period diphtheria this is true of epidemics as well as of individual attacks. But,. mortality rose and fell at intervals of about five or six years, whilst abrupt changes are the rule in diphtheria, they are the as Dr. Longstaff has shown, and from analogy with the exception in scarlet fever. An epidemic lasting only weeks or almost exactly parallel course of scarlet fever it may be months is usually fairly constant in type, without the intensifisuspected that this cycle was one of varying quality as well cation of the kind seen in malarial or diphtherial outbreaks;:e: as quantity, although statistical proof is wanting. (Several the type is more stable, though occasionally showing signs of other diseases present a similar curve of mortality, amongst instability. The "progressive increase in the property of them erysipelas, puerperal fever and acute rheumatism.) Of infectiveness " occurs no less certainly in scarlet fever than late years the mortality from diphtheria has again increased,in diphtheria, but it is seldom rapid, and extends usually over but it has not yet been conclusively shown how far this is duee .a term of years. The type may be persistent for a long ’ to any increase in the average virulence of the disease and period at either the maximum or minimum intensity, and at !any phase in its cycle epidemic diffusion may take place, its how far to the greater facilities for diffusion. Erysipelas comes near to diphtheria in many of its charac-quality being governed by that of the prevailing phase, and teristics, and especially in its inconstancy of type. Wide-its quantity or extension by the climatic, social or other spread epidemics are not common, but something approachingaccidents which give facilities for its distribution. to a pandemic occurred in Ameiica from 1840 to 1860, and Small-pox differs from scarlet fever in possessing still greater i was characterised by malignancy no less than by extent. Instability of type, still slower variations in intensity, and still this country it is better known in the sporadic form or in veryless evidence of any dependence upon saprophytic stages of limited epidemics. Not long ago it was familiar in hospitalexistence. It is highly infectious, and apparently dependent experience, and especially where surgical cases were crowdedIentirely upon infection for its continued existence. Severe. together in wards with insufficient care for cleanliness andand mild cases may occur side by side, owing to difference in I natural or acquired ; but unequivocal transiventilation-conditions not dissimilar to those under whichsusceptibility, diphtheria is liable to assume increased activity. There is 1tions from mild to severe type, apart from this, are rare, and aggregation of susceptible persons in a confined space, andabrupt changes of epidemic type equally so. There is no. the open wound in the one instance may be regarded as Isign of the progressive development of infection on a small analogous to the catarrhal condition of the fauces in the,iscale, but nevertheless there is a slow change in virulence, obother, aftording a ready nidus. However this may be, vious enough in its extreme manifestation in 1871, for example. erysipelas habitually made its appearance under such condi-Although the records prove to demonstration the inhibitory tions, often without clue to its origin, and increased inde-
DR. B. A. WHITELEGGE ON EPIDEMIC DISEASES. in many
.nimala.
401
respects. It affects comparatively few of the lower e lthority for the statement that it is of flequent occurrence It is conveyed by milk, but not apparently by i England. A similarly far-reaching suggestion has been Relapses are not unknown ; in hospital practice they I ade by Dr. Foxwell,12 who is inclined to recognise in
water. met with in about 4 per cent. of the cases, but the pro- E )idemic pneumonia simply a variety of a, general infective portion in private practice would seem to be far smaller, ( utarrhal fever, a "constitutional pyrexial state which has ,ince comparatively few practitioners seem to meet with it at r spiratory, cutaneous, intestinal, meningeal and renal all. Possibly this tendency may prove to be due to hospitali lrieties, just as there are pulmonary, anginous, nephritic, - conditions, a faint manifestation of the effects of aggrega-conditons, ieumatic, pyaemic and cutaneous varieties of the constituttion, which are found in diphtheria and erysipelas. On the 1 onal pyrexial state called scarlet fever." Dr. Sadler also other hand, scarlet fever approximates to the older group inother cognises an ordinary febrile catarrh of infectious quality, its lasting protectiveness and in the stability of type which c ses of which are often associated with pneumonia, bronit usually, but not always, displays. The seasonal curves of 4 titis and diarrhcea in other members of the hoiisehold.13
are
confirm the suggestion of similarity hese views will be considered later. They are mentioned ,of habit amongst the members of the respective groups. l ere as tending to show that in pneumonia and influenza, ’Diarrhoa and English cholera are most fatal in July andi 3 in diphtheria, the range of possible variation includes August ; Asiatic cholera a little later ; plague (seventeenth )rms not generally recognised as akin to the more severe century) and dysentery in September ; enteric fever is most aes. But pneumonia must in any case be classed with the iseases of changeable type. Its epidemics are attended with fatal in September in New York, but in October and November in London ; diphtheria, erysipelas, puerperal igh case mortality, whether in outbreaks limited to one or avo households, or widespread epidemics like that which raged ever and rheumatic fever are as closely allied with each t Middlesbrough in 1888 and was found by Dr. Ballard to other and with scarlet fever in their seasonal curves as The more ill twenty-one out of every hundred attacked.l4 He quote Úl the annual course between 1855 and 1880. rom Dr Grimshaw figures which show that the fatality of stable and more purely parasitic diseases are most fatal, and in first half of in this lublin Hospital cases varied in different years from 2’6 to most the the year presumably prevalent, country, with the exception of the occasional second maximum 44 per cent. Epidemic pneumonia has come to be regarded
-mortality,9 on the whole,
of measles in December. They do not, however, hold very closely together in this respect. From the clinical standpoint, too, there is confirmation of the distinction between 6he constant and inconstant types, apart from variation in virulence. The former are more orderly in the course of the individual attack, more regular in the duration of the successive stages and the character of the symptoms, and less ,liable to erratic complications, relapses and indefinite continuance in chronic form. Implication of the nervous system especially is a characteristic of many of the mobile class, and
filth disease, aggravated if not originated by insanitary onditions, and this was confirmed by Dr. Ballard. tjniike he other filth diseases, however, it is most fatal in spring, a s a
ircumstance which raises a suspicion that its real affinities 3ay be with the typhus fever group rather than with erysipelas r epidemic diarrhoea. It is saprophytic, in the sense that it can e cultivated in artificial media. Enteric fever on the whole ’elongs to the same group. The contagium has been cultiated and is capable of living in water and in milk as well s in soil. A probably saprophytic character is also implied Its seasonal )y its notorious affinity for filth conditions. iurve is not unlike that of erysipelas, diphtheria and carlet fever. The maximum is in October and November, )ut in New York it comes earlier and approximates nore closely to the season of the more purely telluric liseases. Little is known of its transmissibility to lower animals, and even as regards man the transmission seems ;o be usually of an indirect kind, like that of cholera rhe protection conferred by an attack is slight, and relapses lfe common. Dr. Spottiswoode Cameron has found reason ;0 suspect that in the Leeds Fever Hospital a larger proportion of relapses and a higher case mortality occurred when Ghe number of patients in a given ward-space was doubled. There is little constancy of type in the instances where infection can be traced from one person to another, a slight attack being often the antecedent of a severe or fatal one, or There are abundant records of both mild even an epidemic. and severe outbreaks, some of which will come under consideration in connexion with milk and water epidemics. The death-rate from enteric fever has for many years been falling, and hospital statistics show that there has been some decline in severity of hospital cases, insufficient, however, to account for the less mortality. Apparently, therefore, there has been lessened prevalence as well. The statistics published by the Metropolitan Asylums Board show that the case-mortality has varied considerably in different years, but neither the hospital records nor the death-rates show any clear trace of the five-yearly cycle which at one time was so conspicuous in regard to erysipelas, diphtheria and scarlet-fever. On the whole, therefore, enteric fever may be regarded as decreasing in severity and still more in prevalence, but exhibiting irregular fluctuations in both respects. Many other examples might be given, but the above may serve to illustrate the broad principle that the contagia which are most changeable in type are those which remain in closest touch with the saprophytic forms to which they are allied. 12
The Practitioner, July, 1881. THE LANCET, July 14th, ]888. Supplement to the Eighteenth Annual Report of the Local Govemment Board, 1888-&9, p. 196 et seq. Is
14
PROPOSED NEW HOSPITAL FOR NEATH.-A letter read at a special meeting of the Neath Town Council last week, in which Mrs. Griffith Llewellyn offered to place at the for the purpose of 9 Buchan and Mitchell : Journal of the Scottish Meteorological disposal of the Council the sum of .&500 Society. Longstaff : Studies in Statistics. Registrar-General: Annual founding a hospital for the benefit of the poor of the Neath summary for 1890. district. The gift was thankfully accepted and the question 10 Report on the Influenza Epidemic of 1889-90, p. 103. of a site was referred to the Streets Committee. 11 Parsons, loc.
cit.
was
selecting
DR. A. SMART ON THE TREATMENT OF ANAEMIA AND CHLOROSIS.
402
when she left the hospital cured, they had increased to. ON THE TREATMENT OF ANÆMIA AND 5,500,000 per c. mm. and the haemoglobin to 76 per cent. Treatment.-These cases of treatment by the carbonate’ CHLOROSIS BY THE CHIEF IRON PREof iron may be taken as fairly showing the effects of this PARATIONS COMMONLY IN USE. preparation of iron in cases of symptomatic anaemia and chlorosis. As a remedy it is well borne in all cases, and is F.R.C.P. BY ANDREW SMART, M D., EDIN., rapid and curative in its effects. It is on these accounts PHYSICIAN TO THE ROYAL INF IRMARY OF EDINBURGH ETC. ( Concluded from page
355.)
CASE 10. —M. M-—. aged twenty-two, was admitted to Ward 30 on July 19th, 1892, with symptomatic ancr,mia,, the red corpuscles being about 2,000,000 per c mm. and the haemoglobin 20 per cent. The patient was on admission, prescribed sulphate of iron, seven grains thrice daily. In fourteen days the corpuscles had increased to 3.200,000 per
-
entitled to rank as among the best of our iron remedies, and second only to the sulphate of iron, if not, indeed, upon a par with it. CASE 12.-J. S--, aged twenty, was admitted to Ward 3$ on Oct. 24th, 1892, with well-marked symptomatic anæmia and a progressive history of the disease. The red corpuscles. were 3,400,000 per c. mm. and the hemoglobin 52 per cent. The: CASE 12.’
diet being she
was
daily c.mm.
and the
to 40 per cent., and at the end of treatment the patient, was discharged
hemoglobin
thirty-five days’ the corpuscles being 5,700,000 haemoglobin 62 per cent.
cured,
per
c.mm.
and
the
Treatment.—Sulphate of iron : This case well shows the superior efficacy of this iron sait in its comparatively quick
and reliable effects in all anæmias and in chlorosis, and in the uniformity of its beneficial effects alike upon the blood cells and hæmoglobin.
CASES 11 AND 11A.—J. C- and A. C-- were admitted to Ward 33, the one on Nov. llth and the other on Nov. 28th, both suffering from symptomatic anæmia and nearly in the same degree, except that it was somewhat more advanced in the former and consequently somewhat longer delayed in recovery. Both patients were put upon the same remedy—viz., the saccharine carbonate of iron, twenty grains being given to each, thrice daily, with meals. Between Nov. llth and Dec. 13th the red corpuscles had increased from CASE 11.
3,400,000 per c.mm. to 6,000,000 per c.mn. inJ. C-’s case, and the hæmoglobin from 52 per cent. to 68 per cent., at which time the patient left the hospital cured, the duration of treatment being thirty-two days. The red corpuscles in A. C- ’s case at the date of admission (Nov. 28th) were 3,800,000 per c.mm. and the hæmoglobin 5; per cent., and on Dec. 17th,
carefully arranged to suit her impaired digestion, upon the protochloride of iron, one drachm thrice
put
after meals.
Treatment.-This
treatment was continued for sixtyfive days, with the result that at the end of that time the red blood cells had increased to 6.500.000 per c mm. and the hæmoglobin stood at 79 per cent. The drawback to the remedy was its. causing sickness with vomiting, on account of which it had. to be more than once suspended for a few days at a time, whereby the duration of the treatment was protracted. Toavoid this it should be given in smaller doses to begin with, until toleration of the remedy is induced, increasing it half a drachm to one drachm. Making allowance for thi& drawback in the use of the protochloride and the consequent delay in effecting cure, it should be ranked as one of the most efficient remedies.
from
CASE 13.--M. W---, aged eighteen, was admitted to on Nov. 5th, 1892, suffering from advanced chlorosis. Her condition was characterised by unusual pallor, prostration, palpitation, with loud hæmic murmurs in the neck and. at the base and apex of the heart, amenorrhcea, and a severe type of atonic dyspepsia-the gastriccontents showing absence, in a marked degree, of free hydrochloric acid. An examination of the blood showed 3, 000, 000 per c.inm. of red blood corpuscles, with only 32 per cent. of hemoglobin. The patient’s condition presented a suitable opportunity of testing how far her anæmic state had been brought about in consequence of the atonic dyspepsia which had preceded and accompanied it-more especially with reference to the absence of free hydrochloric acid—so marked a feature in her dyspepsia. I accordingly decided to treat her with hydrochloric acid in the first instance. The treatment was begun on the sixth day after her admission, 100 minims of the dilute acid being given daily in 25 minim doses at a time. Between Nov. llth and 13th-that is, seven days after the commencement of treatment-the enumeration of red corpuscles. and percentage of haemoglobin remained stationary, the patient, however, taking food much better and her dyspepsia being entirely relieved. From that date to Dec. 16th the red corpuscles increased to 4,000,000 from 2,000,000 per <’. mm. , but the haemoglobin remained at 36 per cent., .the latter having only increased by 4 per cent. during period of thirty-six days. This increase was no doubt
Ward 33
a
epidemic prevalence,
The Milroy Lectures CHANGES OF TYPE IN EPIDEMIC DISEASES.
Under favourable condiand unsuseeptibility. tions it becomes more and more capable of infecting man ; first the more susceptible, then the less susceptible. Thus the attacks grow more and more numerous, for greater and Delivered at the Examination Hall, Victoria Embankgreater resistances are overcome ; and meanwhile the most on Feb. 21st, 1893, ment, susceptible no longer escape with slight attacks. The B.Sc. LOND. BY B. A. intensity of the contagium is increasing, and now that the less susceptible suffer mild attacks the more susceptible are stricken with fever of a graver type. LECTURE I. Had the disease been infectious from person to person bet7veen Quantity and Quality in ipide-rnic increased prevalence would naturally be attributed to Prev
ceptibility
WHITELEGGE, M.D.,
abundantly
during
NO. 3626.
_
400
DR. B. A. WHITELEGGE ON EPIDEMIC DISEASES.
other diseases may be rapidly intensified in the process. In types will, however, be considered more fully in the nextDr. Thorne Thorne’s words : "There is reason to believe lecture. It will be sufficient to take scarlet fever and smallthat attacks of so-called sore-throat exhibit under certain pox for present reference. Scarlet fever is one degree further favouring conditions aprogressive development of the removed from malaria. It is by no means certain that under property of infectiveness,’ culminating in a definite specific ordinary circumstances soil has much to do with the present type which is indistinguishable from diphtheria." Such stage of its epidemiology. It is infectious, and although we. conditions are found in the aggregation of susceptible children cannot affirm that no other cause than direct or indirect’ at school, in localities where sore-throats are common, and infection from another case of scarlet fever can possibly include some of potentially diphtherial character. The type bring about the disease it is at all events clear that the of disease is mobile and capable of rapidly assuming an sporadic cases in which it is open to us to suspect other intense form if the virus is repeatedly transferred from one origins are far fewer than in diphtheria, and, moreover, with abnormally susceptible throat to another. There seems to be advancing knowledge of the possible channels of infection, the apparent exceptions are becoming still more rare. no reason to doubt that the intensification thus brought about is comparable to that of the purely telluric diseases, Severity of attack and infectiousness rise and fall together, except in causation. There are other changes of type of far as is shown by statistical evidence on a large scale (to be wider range. Diphtheria was in abeyance, in name at all considered later on) and also by the common clinical expeevents, during the first half of the present century ; but from rience that malignant cases are more infectious than others 1855 onwards it again became virulent and prevalent. Since under equal conditions. Sometimes the quality of scarlet then it seems that a less intense type has prevailed on the fever will change almost as suddenly as that of diphtheria, and whole ; but in the earlier part of this period diphtheria this is true of epidemics as well as of individual attacks. But,. mortality rose and fell at intervals of about five or six years, whilst abrupt changes are the rule in diphtheria, they are the as Dr. Longstaff has shown, and from analogy with the exception in scarlet fever. An epidemic lasting only weeks or almost exactly parallel course of scarlet fever it may be months is usually fairly constant in type, without the intensifisuspected that this cycle was one of varying quality as well cation of the kind seen in malarial or diphtherial outbreaks;:e: as quantity, although statistical proof is wanting. (Several the type is more stable, though occasionally showing signs of other diseases present a similar curve of mortality, amongst instability. The "progressive increase in the property of them erysipelas, puerperal fever and acute rheumatism.) Of infectiveness " occurs no less certainly in scarlet fever than late years the mortality from diphtheria has again increased,in diphtheria, but it is seldom rapid, and extends usually over but it has not yet been conclusively shown how far this is duee .a term of years. The type may be persistent for a long ’ to any increase in the average virulence of the disease and period at either the maximum or minimum intensity, and at !any phase in its cycle epidemic diffusion may take place, its how far to the greater facilities for diffusion. Erysipelas comes near to diphtheria in many of its charac-quality being governed by that of the prevailing phase, and teristics, and especially in its inconstancy of type. Wide-its quantity or extension by the climatic, social or other spread epidemics are not common, but something approachingaccidents which give facilities for its distribution. to a pandemic occurred in Ameiica from 1840 to 1860, and Small-pox differs from scarlet fever in possessing still greater i was characterised by malignancy no less than by extent. Instability of type, still slower variations in intensity, and still this country it is better known in the sporadic form or in veryless evidence of any dependence upon saprophytic stages of limited epidemics. Not long ago it was familiar in hospitalexistence. It is highly infectious, and apparently dependent experience, and especially where surgical cases were crowdedIentirely upon infection for its continued existence. Severe. together in wards with insufficient care for cleanliness andand mild cases may occur side by side, owing to difference in I natural or acquired ; but unequivocal transiventilation-conditions not dissimilar to those under whichsusceptibility, diphtheria is liable to assume increased activity. There is 1tions from mild to severe type, apart from this, are rare, and aggregation of susceptible persons in a confined space, andabrupt changes of epidemic type equally so. There is no. the open wound in the one instance may be regarded as Isign of the progressive development of infection on a small analogous to the catarrhal condition of the fauces in the,iscale, but nevertheless there is a slow change in virulence, obother, aftording a ready nidus. However this may be, vious enough in its extreme manifestation in 1871, for example. erysipelas habitually made its appearance under such condi-Although the records prove to demonstration the inhibitory tions, often without clue to its origin, and increased inde-
DR. B. A. WHITELEGGE ON EPIDEMIC DISEASES. in many
.nimala.
401
respects. It affects comparatively few of the lower e lthority for the statement that it is of flequent occurrence It is conveyed by milk, but not apparently by i England. A similarly far-reaching suggestion has been Relapses are not unknown ; in hospital practice they I ade by Dr. Foxwell,12 who is inclined to recognise in
water. met with in about 4 per cent. of the cases, but the pro- E )idemic pneumonia simply a variety of a, general infective portion in private practice would seem to be far smaller, ( utarrhal fever, a "constitutional pyrexial state which has ,ince comparatively few practitioners seem to meet with it at r spiratory, cutaneous, intestinal, meningeal and renal all. Possibly this tendency may prove to be due to hospitali lrieties, just as there are pulmonary, anginous, nephritic, - conditions, a faint manifestation of the effects of aggrega-conditons, ieumatic, pyaemic and cutaneous varieties of the constituttion, which are found in diphtheria and erysipelas. On the 1 onal pyrexial state called scarlet fever." Dr. Sadler also other hand, scarlet fever approximates to the older group inother cognises an ordinary febrile catarrh of infectious quality, its lasting protectiveness and in the stability of type which c ses of which are often associated with pneumonia, bronit usually, but not always, displays. The seasonal curves of 4 titis and diarrhcea in other members of the hoiisehold.13
are
confirm the suggestion of similarity hese views will be considered later. They are mentioned ,of habit amongst the members of the respective groups. l ere as tending to show that in pneumonia and influenza, ’Diarrhoa and English cholera are most fatal in July andi 3 in diphtheria, the range of possible variation includes August ; Asiatic cholera a little later ; plague (seventeenth )rms not generally recognised as akin to the more severe century) and dysentery in September ; enteric fever is most aes. But pneumonia must in any case be classed with the iseases of changeable type. Its epidemics are attended with fatal in September in New York, but in October and November in London ; diphtheria, erysipelas, puerperal igh case mortality, whether in outbreaks limited to one or avo households, or widespread epidemics like that which raged ever and rheumatic fever are as closely allied with each t Middlesbrough in 1888 and was found by Dr. Ballard to other and with scarlet fever in their seasonal curves as The more ill twenty-one out of every hundred attacked.l4 He quote Úl the annual course between 1855 and 1880. rom Dr Grimshaw figures which show that the fatality of stable and more purely parasitic diseases are most fatal, and in first half of in this lublin Hospital cases varied in different years from 2’6 to most the the year presumably prevalent, country, with the exception of the occasional second maximum 44 per cent. Epidemic pneumonia has come to be regarded
-mortality,9 on the whole,
of measles in December. They do not, however, hold very closely together in this respect. From the clinical standpoint, too, there is confirmation of the distinction between 6he constant and inconstant types, apart from variation in virulence. The former are more orderly in the course of the individual attack, more regular in the duration of the successive stages and the character of the symptoms, and less ,liable to erratic complications, relapses and indefinite continuance in chronic form. Implication of the nervous system especially is a characteristic of many of the mobile class, and
filth disease, aggravated if not originated by insanitary onditions, and this was confirmed by Dr. Ballard. tjniike he other filth diseases, however, it is most fatal in spring, a s a
ircumstance which raises a suspicion that its real affinities 3ay be with the typhus fever group rather than with erysipelas r epidemic diarrhoea. It is saprophytic, in the sense that it can e cultivated in artificial media. Enteric fever on the whole ’elongs to the same group. The contagium has been cultiated and is capable of living in water and in milk as well s in soil. A probably saprophytic character is also implied Its seasonal )y its notorious affinity for filth conditions. iurve is not unlike that of erysipelas, diphtheria and carlet fever. The maximum is in October and November, )ut in New York it comes earlier and approximates nore closely to the season of the more purely telluric liseases. Little is known of its transmissibility to lower animals, and even as regards man the transmission seems ;o be usually of an indirect kind, like that of cholera rhe protection conferred by an attack is slight, and relapses lfe common. Dr. Spottiswoode Cameron has found reason ;0 suspect that in the Leeds Fever Hospital a larger proportion of relapses and a higher case mortality occurred when Ghe number of patients in a given ward-space was doubled. There is little constancy of type in the instances where infection can be traced from one person to another, a slight attack being often the antecedent of a severe or fatal one, or There are abundant records of both mild even an epidemic. and severe outbreaks, some of which will come under consideration in connexion with milk and water epidemics. The death-rate from enteric fever has for many years been falling, and hospital statistics show that there has been some decline in severity of hospital cases, insufficient, however, to account for the less mortality. Apparently, therefore, there has been lessened prevalence as well. The statistics published by the Metropolitan Asylums Board show that the case-mortality has varied considerably in different years, but neither the hospital records nor the death-rates show any clear trace of the five-yearly cycle which at one time was so conspicuous in regard to erysipelas, diphtheria and scarlet-fever. On the whole, therefore, enteric fever may be regarded as decreasing in severity and still more in prevalence, but exhibiting irregular fluctuations in both respects. Many other examples might be given, but the above may serve to illustrate the broad principle that the contagia which are most changeable in type are those which remain in closest touch with the saprophytic forms to which they are allied. 12
The Practitioner, July, 1881. THE LANCET, July 14th, ]888. Supplement to the Eighteenth Annual Report of the Local Govemment Board, 1888-&9, p. 196 et seq. Is
14
PROPOSED NEW HOSPITAL FOR NEATH.-A letter read at a special meeting of the Neath Town Council last week, in which Mrs. Griffith Llewellyn offered to place at the for the purpose of 9 Buchan and Mitchell : Journal of the Scottish Meteorological disposal of the Council the sum of .&500 Society. Longstaff : Studies in Statistics. Registrar-General: Annual founding a hospital for the benefit of the poor of the Neath summary for 1890. district. The gift was thankfully accepted and the question 10 Report on the Influenza Epidemic of 1889-90, p. 103. of a site was referred to the Streets Committee. 11 Parsons, loc.
cit.
was
selecting
DR. A. SMART ON THE TREATMENT OF ANAEMIA AND CHLOROSIS.
402
when she left the hospital cured, they had increased to. ON THE TREATMENT OF ANÆMIA AND 5,500,000 per c. mm. and the haemoglobin to 76 per cent. Treatment.-These cases of treatment by the carbonate’ CHLOROSIS BY THE CHIEF IRON PREof iron may be taken as fairly showing the effects of this PARATIONS COMMONLY IN USE. preparation of iron in cases of symptomatic anaemia and chlorosis. As a remedy it is well borne in all cases, and is F.R.C.P. BY ANDREW SMART, M D., EDIN., rapid and curative in its effects. It is on these accounts PHYSICIAN TO THE ROYAL INF IRMARY OF EDINBURGH ETC. ( Concluded from page
355.)
CASE 10. —M. M-—. aged twenty-two, was admitted to Ward 30 on July 19th, 1892, with symptomatic ancr,mia,, the red corpuscles being about 2,000,000 per c mm. and the haemoglobin 20 per cent. The patient was on admission, prescribed sulphate of iron, seven grains thrice daily. In fourteen days the corpuscles had increased to 3.200,000 per
-
entitled to rank as among the best of our iron remedies, and second only to the sulphate of iron, if not, indeed, upon a par with it. CASE 12.-J. S--, aged twenty, was admitted to Ward 3$ on Oct. 24th, 1892, with well-marked symptomatic anæmia and a progressive history of the disease. The red corpuscles. were 3,400,000 per c. mm. and the hemoglobin 52 per cent. The: CASE 12.’
diet being she
was
daily c.mm.
and the
to 40 per cent., and at the end of treatment the patient, was discharged
hemoglobin
thirty-five days’ the corpuscles being 5,700,000 haemoglobin 62 per cent.
cured,
per
c.mm.
and
the
Treatment.—Sulphate of iron : This case well shows the superior efficacy of this iron sait in its comparatively quick
and reliable effects in all anæmias and in chlorosis, and in the uniformity of its beneficial effects alike upon the blood cells and hæmoglobin.
CASES 11 AND 11A.—J. C- and A. C-- were admitted to Ward 33, the one on Nov. llth and the other on Nov. 28th, both suffering from symptomatic anæmia and nearly in the same degree, except that it was somewhat more advanced in the former and consequently somewhat longer delayed in recovery. Both patients were put upon the same remedy—viz., the saccharine carbonate of iron, twenty grains being given to each, thrice daily, with meals. Between Nov. llth and Dec. 13th the red corpuscles had increased from CASE 11.
3,400,000 per c.mm. to 6,000,000 per c.mn. inJ. C-’s case, and the hæmoglobin from 52 per cent. to 68 per cent., at which time the patient left the hospital cured, the duration of treatment being thirty-two days. The red corpuscles in A. C- ’s case at the date of admission (Nov. 28th) were 3,800,000 per c.mm. and the hæmoglobin 5; per cent., and on Dec. 17th,
carefully arranged to suit her impaired digestion, upon the protochloride of iron, one drachm thrice
put
after meals.
Treatment.-This
treatment was continued for sixtyfive days, with the result that at the end of that time the red blood cells had increased to 6.500.000 per c mm. and the hæmoglobin stood at 79 per cent. The drawback to the remedy was its. causing sickness with vomiting, on account of which it had. to be more than once suspended for a few days at a time, whereby the duration of the treatment was protracted. Toavoid this it should be given in smaller doses to begin with, until toleration of the remedy is induced, increasing it half a drachm to one drachm. Making allowance for thi& drawback in the use of the protochloride and the consequent delay in effecting cure, it should be ranked as one of the most efficient remedies.
from
CASE 13.--M. W---, aged eighteen, was admitted to on Nov. 5th, 1892, suffering from advanced chlorosis. Her condition was characterised by unusual pallor, prostration, palpitation, with loud hæmic murmurs in the neck and. at the base and apex of the heart, amenorrhcea, and a severe type of atonic dyspepsia-the gastriccontents showing absence, in a marked degree, of free hydrochloric acid. An examination of the blood showed 3, 000, 000 per c.inm. of red blood corpuscles, with only 32 per cent. of hemoglobin. The patient’s condition presented a suitable opportunity of testing how far her anæmic state had been brought about in consequence of the atonic dyspepsia which had preceded and accompanied it-more especially with reference to the absence of free hydrochloric acid—so marked a feature in her dyspepsia. I accordingly decided to treat her with hydrochloric acid in the first instance. The treatment was begun on the sixth day after her admission, 100 minims of the dilute acid being given daily in 25 minim doses at a time. Between Nov. llth and 13th-that is, seven days after the commencement of treatment-the enumeration of red corpuscles. and percentage of haemoglobin remained stationary, the patient, however, taking food much better and her dyspepsia being entirely relieved. From that date to Dec. 16th the red corpuscles increased to 4,000,000 from 2,000,000 per <’. mm. , but the haemoglobin remained at 36 per cent., .the latter having only increased by 4 per cent. during period of thirty-six days. This increase was no doubt
Ward 33
a