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THE LIBRARY

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THE UNIVERSITY

OF CALIFORNIA

PRESENTED BY

PROF. CHARLES A. KOFOID AND

MRS. PRUDENCE W. KOFOID

7/^ uwc/

MILITARY MEDICAL MANUALS

General Editor : Sir ALFRED KEOGH, G.C.B., M.D., F.R.C.P.

DYSENTERY, ASIATIC CHOLERA

AND

EXANTHEMATIG TYPHUS

Digitized by the Internet Arciiive

in 2007 with funding from

IVIicrosoft Corporation

http://www.archive.org/details/dysenteryasiaticOOvincrich

DYSENTERY

ASIATIC CHOLERA AND

EXANTHEMATIC

TYPHUS

BY

H, VINCENT AND L. MURATET

Surgeon-General in the French Army Director of Studies in the Faculty

Member of the Academy of Medicine, Bordeaux

of Medicine

WITH AN INTRODUCTION BY

ANDREW BALFOUR, C.M.G., M.D.

Director Wellcome Bureau of Scientific Research Temp. Lieut. -Col. R.A.M.C.

EDITED BY

GEORGE C. LOW, M.A., M.D.

Assistant Physician Royal Albert Dock Hospital, London

School of Tropical Medicine, Lecturer London School

of Tropical Medicine, Temp. Captain I. M.S.

LONDON

UNIVERSITY OF LONDON PRESS

18 WARWICK SQUARE, E.G. 4 1917

N/S

GENERAL INTRODUCTION

The infinite variety of injuries which any war pre- sents to the surgeon gives to military surgery a special interest and importance. The special interest and importance, in a surgical sense, of the great Euro- pean War lies not so much in the fact that examples of every form of gross lesion of organs and limbs have been seen, for if we read the older writers we find little in the moderns that is new in this respect but is to be found in the enormous mass of clinical material which has been presented to us and in the production of evidence sufficient to eliminate sources of error in determining important conclusions. For the first time also in any campaign the labours of the surgeon and the physician have had the aid of the bacteriologist, the pathologist, the physiologist, and indeed of every form of scientific assistance, in the solution of their respective problems. The clinician entered upon the great war armed with all the resources which the advances of fifty years had made available. If the surgical problems of modern war can be said not to differ sensibly from the cam- paigns of the past, the form in which they have been presented is certainly as different as are the methods of their solution. The achievements in the field of discovery of the chemist, the physicist and the biologist have given the military surgeon an advan- tage in diagnosis and treatment which was denied to his predecessors, and we are able to measure the effects of these advantages when we come to appraise the results which have been attained.

But although we may admit the general truth of these statements, it would be wrong to assume that modem scientific knowledge was, on the outbreak

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ii GENERAL INTRODUCTION

of the war, immediately useful to those to whom the wounded were to be confided. Fixed principles existed in all the sciences auxiliary to the work of the surgeon, but our scientific resources were not immediately available at the outset of the great campaign ; scientific work bearing on wound prob- lems had not been arranged in a manner adapted to the requirements — indeed, the requirements were not fully foreseen ; the workers in the various fields were isolated, or isolated themselves, pursuing new researches rather than concentrating their powerful forces upon the one great quest.

However brilliant the triumphs of surgery may be — and that they have been of surpassing splendour no one will be found to deny — experiences of the war have already produced a mass of facts sufficient to suggest the complete remodelling of our methods of education and research.

The series of manuals, which it is my pleasant duty to introduce to English readers, consists of transla- tions of the principal volumes of the " Horizon " Collection, which has been appropriately named after the uniform of the French soldier.

The authors, who are all well-known specialists in the subjects which they represent, have given a concise but eminently readable account of the recent ac- quisitions to the medicine and surgery of war which had hitherto been disseminated in periodical literature.

No higher praise can be given to the Editors than to say that the clearness of exposition characteristic of the French original has not been lost in the render- ing into English.

MEDICAL SERIES

The medical volumes which have been translated for this series may be divided into two main groups, the first dealing with certain epidemic diseases, in- cluding syphilis, which are most liable to attack soldiers, and the second with various aspects of the

GENERAL INTRODUCTION iii

neurology of war. The last word on Typhoid Fever, hitherto " the greatest scourge of armies in time of war," as it has been truly called, will be found in the monograph by MM. Vincent and Muratet, which contains a full account of recent progress in bacteri- ology and epidemiology as well as the clinical features of typhoid and paratyphoid fevers. The writers combat a belief in the comparatively harmless nature of paratyphoid and state that in the present war haemorrhage and perforation have been as frequent in paratyphoid, as in typhoid fever. In their chapter on diagnosis they show that the serum test is of no value in the case of those who have undergone anti- typhoid or anti-paratyphoid vaccination, and that precise information can be gained by blood cultures only. The relative advantages of a restricted and liberal diet are discussed in the chapter on treatment, which also contains a description of serum-therapy and vaccine-therapy and the general management of the patient.

Considerable space is devoted to the important question of the carrier of infection. A special chapter is devoted to the prophylaxis of typhoid fever in the army. The work concludes with a chapter on pre- ventive inoculation, in which its value is conclusively proved by the statistics of all countries in which it has been employed.

MM. Vincent and Muratet have also contributed to the series a work on Dysentery, Cholera and Typhus which will be of special interest to those whose duties take them to the Eastern Mediterranean or Mesopotamia. The carrier problem in relation to dysentery and cholera is fully discussed, and special stress is laid on the epidemiological import- ance of mild or abortive cases of these two diseases.

In their monograph on The Abnormal Forms of Tetanus, MM. Courtois-Suffit and ^ Giroux treat of those varieties of the disease in wliich the spasm is confined to a limited group of muscles, e.g, those of the head, or one or more limbs, or of the abdomino-

iv GENERAL INTRODUCTION

thoracic muscles. The constitutional symptoms are less severe than in the generalized form of the disease, and the prognosis is more favourable.

The volume by Dr G. Thibierge on Syphilis in the Army is intended as a vade mecum for medical officers in the army.

Turning now to the works of neurological interest, we have two volumes dealing with lesions of the peripheral nerves by Mme. Atanassio Benisty, who has been for several years assistant to Professor Pierre Marie at La Salpetri^re. The first volume contains an account of the anatomy and physiology of the peripheral nerves, together with the symptomatology of their lesions. The second volume is devoted to the prognosis and treatment of nerve lesions.

The monograph of MM. Babinski and Froment on Hysteria or Pithiatism and Nervous Disorders of a Reflex Character next claims attention. In the first part the old conception of hysteria, especially as it was built up by Charcot, is set forth, and is followed by a description of the modern conception of hysteria due to Babinski, who has suggested the substitution of the term " Pithiatism," i.e. a state curable by persuasion, for the old name hysteria. The second part deals with nervous disorders of a reflex char- acter, consisting of contractures or paralysis follow- ing traumatism, which are frequently found in the neurology of war, and a variety of minor symptoms, such as muscular atrophy, exaggeration of the tendon reflexes, vasomotor, thermal and secretory changes, etc. An important section discusses the future of such men, especially as regards their dis- posal by medical boards.

An instructive companion volume to the above is to be found in the monograph of MM. Roussy and Lhermitte, which embodies a description of the psychoneuroses met with in war, starting with ele- mentary motor disorders and concluding with the most complex represented by pure psychoses.

GENERAL INTRODUCTION

SURGICAL SERIES

When the present war began, surgeons, under the influence of the immortal work of Lister, had for more than a quarter of a century concerned them- selves almost exclusively with elaborations of tech- nique designed to shorten the time occupied in or to improve the results obtained by the many complex operations that the genius of Lister had rendered possible. The good behaviour of the wound was taken for granted whenever it was made, as it nearly always was, through unbroken skin, and hence the study of the treatment of wounds had become largely restricted to the study of the aseptic variety. Septic wounds were rarely seen, and antiseptic surgery had been almost forgotten. Very few of those who were called upon to treat the wounded in the early autumn of 1914 were familiar with the treatment of grossly septic compound fractures and wounded joints, and none had any wide experience. To these men the conditions of the wounds came as a sinister and dis- heartening revelation. They were suddenly con- fronted with a state of affairs, as far as the physical conditions in the wounds were concerned, for which it was necessary to go back a hundred years or more to find a parallel.

Hence the early period of the war was one of earnest search after the correct principles that should be applied to the removal of the unusual difficulties with which surgeons and physicians were faced. It was necessary to discover where and why the treat- ment that sufficed for affections among the civil population failed when it was applied to military casualties, and then to originate adequate measures for the relief of the latter. For many reasons this was a slow and laborious process, in spite of the multitude of workers and the wealth of scientific resources at their disposal. The ruthlessness of war must necessarily hamper the work of the medical scientist in almost every direction except in that of

vi GENERAL INTRODUCTION

providing him with an abundance of material upon which to work. It limits the opportunity for de- liberate critical observation and comparison that is so essential to the formation of an accurate estima- tion of values ; it often compels work to be done under such high pressure and such unfavourable conditions that it becomes of little value for educa- tive purposes. In all the armies, and on all the fronts, the pressure caused by the unprecedented number of casualties has necessitated rapid evacua- tion from the front along lines of communication, often of enormous length, and this means the transfer of cases through many hands, with its consequent division of responsibility, loss of continuity of treat- ment, and absence of prolonged observation by any one individual.

In addition to all this, it must be remembered that in this war the early conditions at the front were so uncertain that it was impossible to establish there the completely equipped scientific institutions for the treatment of the wounded that are now available under more assured circumstances, and that progress was thereby much hampered until definitive treat- ment could be undertaken at the early stage that is now possible.

But order has been steadily evolved out of chaos, and many things are now being done at the front that would have been deemed impossible not many months ago. As general principles of treatment are established it is found practicable to give effect to them to their full logical extent, and though there are still many obscure points to be elucidated and many methods in use that still call for improvements, it is now safe to say that the position of the art of military medicine and surgery stands upon a sound foundation, and that its future may be regarded with confidence and sanguine expectation.

The views of great authorities who derive their knowledge from extensive first-hand practical ex- perience gained in the field cannot fail to serve as a

GENERAL INTRODUCTION vii

most valuable asset to the less experienced, and must do much to enable them to derive the utmost value from the experience which will, in time, be theirs. The series covers the whole field of war surgery and medicine, and its predominating note is the ex- haustive, practical and up-to-date manner in which it is handled. It is marked throughout not only by a wealth of detail, but by clearness of view and logical sequence of thought. Its study will convince the reader that, great as have been the advances in all departments in the services during this war, the progress made in the medical branch may fairly challenge comparison with that in any other, and that not the least among the services rendered by our great ally, France, to the common cause is this brilliant contribution to our professional knowledge,

A glance at the list of surgical works in the series will show how completely the ground has been covered. Appropriately enough, the series opens with the volume on The Treatment of Infected Wounds ^ by A. Carrel and G. Dehelly. This is a direct pro- duct of the war which, in the opinion of many, bids fair to become epoch-making in the treatment of septic wounds. It is peculiar to the war and derived directly from it, and the work upon which it is based is as fine an example of correlated work on the part of the chemist, the bacteriologist and the clinician as could well be wished for. This volume will show many for the first time what a precise and scientific method the " Carrel treatment " really is.

The two volumes by Professor Leriche on Fractures contain the practical application of the views of the great Lyons school of surgeons with regard to the treatment of injuries of bones and joints. Sup- ported as they are by an appeal to an abundant clinical experience, they cannot fail to interest English surgeons, and to prove of the greatest value. It is only necessary to say the Wounds of the Abdomen are dealt with by Dr Abadie, Wounds of the Vessels by Professor Sencert, Wounds of the Skull

viii GENERAL INTRODUCTION

and Brain by MM. Chatelin and De Martel, and Localisation and Extraction of Projectiles by Pro- fessor Ombredanne and R. Ledoux-Lebard, to prove that the subjects have been allotted to very able and experienced exponents.

ALFRED KEOGH

CONTENTS

PAOB

Introduction .9

DYSENTERIES

PART I

CLINICAL SURVEY

Chapter I. Symptomatology 15

Bacillary Dysentery . . . . .18

Clinical Forms of Bacillary Dysentery . 20

Complications 24

Amoebic Dysentery 25

Complications 26

Dysenteries caused by Various Etiological

Agents 28

Chapter II. Diagnosis of Dysentery . . . .31 Diagnosis of the Dysenteric Syndrome . 31 Diagnosis of the Nature of Dysentery . 33

Chapter III. The Treatment of Dysentery . . .44

PART H

THE EPIDEMIOLOGY AND PROPHYLAXIS OF DYSENTERY

Chapter I. Epidemiology of Bacillary Dysentery . 55 Dysentery in Armies . . . .57

5

6 CONTENTS

Pi^OB

Chapter II. Etiology 63

The Predisposing Causes of Bacillary

Dysentery . . . . .63

The Determining Causes of Bacillary

Dysentery . . . . . ,65

Indirect Contagion . . . . ,69

The Spread of Epidemics . . . .77

Chapter III. Epidemiology of Am(ebic Dysentery . 79

Chapter IV. Prophylaxis of Bacillary and Amcebic

Dysenteries 89

Chapter

ASIATIC CHOLERA

PART I

CLINICAL SURVEY

I. Symptomatology

Accidents and Complications Relapses, Recurrences Clinical Forms .

Chapter II. Diagnosis . Chapter III. Treatment

99 112 114 114

118

124

PART H

EPIDEMIOLOGY AND PROPHYLAXIS OF CHOLERA

Chapter I. Historical 129

Chapter II. Etiology of Cholera. Favouring Causes 133 The Determining Causes of Cholera . .136 The Carriers of Cholera Vibrios . .139

CONTENTS 7

PAOB

Chapter III. Etiology of Cholera — continued

The Modes of Propagation of the Cholera

Vibrio ...... 146

Chapter IV. Prophylaxis of Cholera . . . .158 Prophylaxis of Favouring Causes . .158

Prophylaxis of Cholera on Board Warships 1 59 Microbic Prophylaxis . . . . l60 Specific Prophylaxis : Vaccination against

Cholera l68

EXANTHEMATIC TYPHUS

PART I CLINICAL SURVEY

Chapter I. Symptomatology . . . . ' . 177 Complications . . •. . . .184 Clinical Forms 185

Chapter II. Diagnosis 187

Chapter III. Treatment 192

PART II

EPIDEMIOLOGY AND PROPHYLAXIS OF TYPHUS

Chapter I. Medical History and Geography . .193

Chapter II. Etiology of Typhus. Predisposing Causes 202

Chapter III. Etiology of Typhus — continued

Determining Causes ..... 206

Chapter IV. Prophylaxis of Typhus . . . .217 The Campaign against Lice . . .219

INTRODUCTION

Leaving the Western Front out of account, but taking all the other war areas together, there can be no doubt that dysentery, that scourge of campaigns, has been the most common of the communicable diseases which have had to be faced and fought. In certain areas, as, for example, Gallipoli and Mesopotamia, it has been very much in evidence. On the Peninsula indeed it was extremely prevalent, and accounted for a great deal of the sickness and invaliding which militated so seriously against military operations. In all the war areas the bacillary form has been much the more frequent, but there has been a certain amount of amoebic infection, probably not more than twenty per cent, of the whole, followed, in not a few instances, by the occurrence of hepatic abscess.

Save in Mesopotamia, cholera has fortunately not made its appearance to any extent, and even in Mesopotamia it was speedily got under control. Nowa- days, unless the conditions are very exceptional, a well-equipped army need not fear cholera, for there is no disease the spread of which is so easily checked by efficient sanitary administration.

Despite the great prevalence of lice in all, or nearly all, the war areas, there has, so far as the British forces are concerned, been very little typhus fever. Cases have not been lacking, but there has been nothing in the nature of an epidemic, at least amongst white troops. 9

10 INTRODUCTION

This is a gratifying fact which can in some measure be attributed to the good provision made for disinfection and for delousing, not only the troops, but the prisoners taken in action. Although cholera and typhus have not bulked largely amongst the British forces during the present war, they are at all times important diseases. Typhus has taken toll of native labour corps in Egypt, and both cholera and typhus may at any time assume epidemic proportions amongst the civil populations of several of the countries in which we are waging war. Hence it is highly satisfactory to find these two dis- eases adequately described along with the dysenteries in this volume by MM. Vincent and Muratet. Further, it is interesting, and cannot fail to be useful, to obtain in this handy form the opinion of French authorities on these maladies, to compare their views with our own and to learn what they consider the best means of preventing and of treating them.

There has indeed been a far-flung battle-line and, as a result, the war has taught us much regarding many ailments and has even unearthed a few, previously unrecognised or possibly non-existent. Our knowledge of the dysenteries, and more especially of the cause and methods of spread of the amoebic form, has notably increased. We now know better how to treat severe cases of bacillary dysentery, and we are able to deal fairly effectively with the cyst-excreting carriers of the amoebic form. The intestinal protozoa generally are also better understood. Some of the British work on these subjects has been published so recently that the French authors have apparently not had time to incorporate it in their review, but doubtless full justice will be done to it at a later date, for its importance cannot be gainsaid.

INTRODUCTION 11

Unfortunately there is, so far, no wholly satisfactory method of preventive inoculation for bacillary dysentery, which is one reason why its incidence has remained high as compared with the enterica infections. Yet the latter are due to similar causes, such as contact, carrier cases, drinking water, the dust of dried dejecta and the repulsive regurgitation, dangerous droppings and filthy feet of faecal-feeding flies. Hence in the case of dysentery the prophylactic measures are chiefly of a sanitary nature, but there is good reason to hope that ere long an efficient and non-toxic dysentery vaccine will be forthcoming.

There is little new to record as regards cholera, but the war has afforded an opportunity of testing to some extent the efficacy of preventive inoculation, and has enabled us to come to a more definite conclusion about the bacillary dosage required. It has also been possible to gather information regarding some of the more modern modes of treatment.

Most of the important discoveries anent typhus fever had been made before hostilities commenced, but the war has led to the confirmation of some of them and the revision of our views on certain aspects of the etiology and prevention of this fever, one of the most interesting of the exanthemata. Its morbid histology has been discovered and a great impetus has been given to the study of its insect vectors.

Thus in wellnigh every direction progress has been made, and we are in a better position to grapple with these foes of armies in the field.

Perhaps the most remarkable feature of MM. Vincent's and Muratet's work is the astonishing amount of information they have been able to gather within a

12 INTRODUCTION

small compass. With the exception of their patho- logical anatomy, every aspect of the diseases is con- sidered, and though the book might perhaps have gained in practical value if the historical sections had been shortened and those dealing with prophylaxis some- what expanded, and though here and there we note a few omissions and statements which require to be altered or modified, there can be no doubt that this little volume in its English garb will receive a hearty welcome. It is specially intended for the army doctor, and there are few medical men nowadays to whom this term cannot be applied ; but it will be useful also to all those whose work lies in countries where the three diseases of which it treats imperil the public health.

Andrew Balfour.

DYSENTERIES

PART /.—CLINICAL SURVEY CHAPTER I

SYMPTOMATOLOGY

The term dysentery serves to denote a symptom com- plex which indicates an ulcerative colitis, acute or chronic, which may be due to various pathogenic agents, such as dysentery bacilli, amoebae, etc.

These affections, etiologically quite distinct, are con- tagious. They present some common symptoms, and each of them possesses its special symptoms.

The dysenteric syndrome comprises three essential symptoms common to all dysenteries :

1. Abdominal pains.

2. Tenesmus.

3. Stools presenting a characteristic appearance.

1. Abdominal Pains. — ^The abdominal pains are spon- taneous or provoked. The spontaneous pains manifest themselves as colics, sometimes generalised throughout the abdomen, sometimes localised in the umbilical region or the left iliac fossa, and by extremely severe griping pains (tormina), which follow the entire course of the colon as far as the rectum. In slight cases the griping pains are transient, occurring at the moment of alvine evacuation, diminishing immediately after evacuation and then disappearing. In more serious cases they are much more frequent, and may occur in the absence of any evacuation. Pressure exerted on the large intestine causes a more or less acute pain, especially in the region of the left iliac fossa. It is often possible, by the localisation of the pains thus produced, to map

15

16 DYSENTERY, CHOLERA, AND TYPHUS

out the extent of the intestinal surface affected. Ab- dominal pains may be absent in cases which are from the first very serious (Dutroulau). They become progressively less severe, having at first been rather violent, to disappear completely when gangrenous lesions occur.

2. Tenesmus. — The patient is aware, in the slighter cases, of a feeling of weight, of a foreign body in the rectum ; but most frequently there is a painful feeling of tension and constriction in the region of the anus, with an incessant call to pass stools. Sometimes a number of false calls are followed by fruitless efforts (tenesmus) ; sometimes the straining results in the expulsion of a very small quantity of excrement (barely a teaspoonful). Each attempt causes extremely violent pains (smarting, burning, tearing sensations), recurrences of these being provoked by the slightest incidents, such as coughing, sneezing, deglutition, etc.

The simi of these sensitive disorders, localised in the terminal portion of the rectum, constitutes rectal tenesmus, which, in a number of cases, is accompanied by analogous symptoms affecting the bladder {vesical tenesmus).

Rectal tenesmus is frequently complicated byparalysis of the sphincter and the levator ani (Trousseau, Colin) ; repeated efforts to defsecate may cause prolapse of the rectum, an accident common in children.

The intensity of the tenesmus varies greatly in different patients. In hot countries tenesmus is said to be often absent, or transient, and is confined to a mere sensation of smarting ; it is said to be infrequent in India. According to Sir Patrick Manson, the nearer the lesion to the rectum, the more severe the tenesmus ; the nearer to the caecum, the more violent the colic. These two symptoms, in addition to the presence of painful spots, constitute, in the majority of cases, a reliable guide to the localisation of the lesions and to an estimate of their extent.

SYMPTOMATOLOGY 17

3. Dysenteric Stools. — Constipation being the general rule in confirmed dysentery, the true dysenteric stools contain little or no faecal matter. Their varying aspect has given rise to numerous comparisons. Sometimes they consist of transparent and whitish mucus, diffluent, of a membranous aspect, twisted, or wound into viscous masses, and have been compared to scrapings of the bowels (Jaccoud) ; sometimes the mucus is flaky, or in rice-like grains, or in punctiform debris, or the matter excreted has the appearance oi frogs^ spawn or the white of raw eggs. The stools are usually blood- stained, owing to the extension of the ulcerative process to the vessels of the intestinal wall. In these cases the blood merely streaks the mucus, or appears on its surface in the form of patches of varying extent, or again, it is so intimately mixed with the mucus that the stool resembles the rusty sputum of the pneumonic patient.

Sometimes the mucus, scanty and sanguinolent, floats in a serous Hquid, of a pink or reddish colour; it has been described as resembling water in which raw meat has been washed. In other cases the haemorrhagic stools consist of almost pure blood, red and fluid or black and mingled with clots. Lastly, they may be gangrenous. Shapeless shreds of sphace- lated mucus float in a serous liquid, reddish, brown, or black, with a horrible smell.

Kelsch has very justly remarked that the alvine dejecta reflect, by their aspect and their nature, the degree and the nature of the intestinal lesions.

The number of stools is always considerable in dysentery : 10, 30, 50, and even more in the twenty- four hours ; 160 to 180 in a case of Trousseau's ; 200 in twelve hours in a case of Zimmerman's.

The stools are more frequent at night than in the day. The matter expelled each time is by no means abundant, especially at the outset ; it becomes more copious as the malady develops. Barely a hundred grammes (about 3 J oz.) in benign cases, it may amount to several litres in cases of bilious dysentery.

18 DYSENTERY, CHOLERA, AND TYPHUS

The mucus has a stale or putrid odour, and its reaction is alkaline.

Such is the dysenteric syndrome common to all dysenteries, whatever their infectious agent. Many of these exist, and they can be determined only by investigation in the laboratory.

We may distinguish, in the first place, among the acute forms of dysentery, two forms which are clearly defined, and which are by far the most frequent :

1. Bacillary dysentery.

2. Amoebic dysentery.

In the second place, we find dysenteric conditions due to various other etiological agents : spirilla, cocco- bacilli. Bacillus pyocyaneus, Balantidium coli, Schisto- soma mansoni, Chilodon dentatus, etc., which have all to be investigated.

We shall here consider bacillary and amoebic dysentery.

I. Bacillary Dysentery

The clinical development of bacillary dysentery com- prises a period of incubation, a period of onset, an acute dysenteric period, and a terminal period.

1. Period of Incubation. — ^This period is generally of brief duration : forty-eight hours (Strong and Musgrave), or two to three days (Lentz). In experimental in- fections of man effected by Strong and Musgrave and others, the first symptoms manifested themselves twenty-four hours after the ingestion of the culture of dysentery bacilli.

2. Period of Onset. — Very rarely a prodromal period is observed, characterised by mucous or bilious diarrhoea. In reality it constitutes the first stage of the infection. This premonitory diarrhoea, when it exists, lasts barely twenty-four to thirty- six hours.

As a general rule, dysentery makes its appearance suddenly, without prodromes, and in a few hours the acute period is established.

SYMPTOMATOLOGY 19

3. Acute Dysenteric Period. — In the slightest cases the affection amounts to a diarrhoea of ordinary appear- ance. The stools are not numerous and contain only traces of mucus. In this category are contained a certain number of cases of summer diarrhoea, with abdominal and rectal pains which are scarcely notice- able, a fair number of cases of infantile diarrhoea, and also certain cases of " trench diarrhoea."

Most usually the patient experiences, at the outset, vague abdominal pains, followed by more violent colics, with a sensation of fulness in the region of the rectum, which brings on a more and more imperative call to stool. Then the dysenteric syndrome sets in in all its intensity : colics, straining, tenesmus and character- istic stools. At this stage the patient may suffer from nausea, hiccough and mucous or bilious vomiting. The abdomen is retracted and painful ; the urine, which is diminished, often contains albumin ; the tongue is dry ; the liver congested, and increased in volume, and painful under pressure, especially in the region of the gall- bladder.

Fever may be regarded as exceptional during dysen- tery. When it is present it rarely exceeds 102-2° F., and shows itself orjy during the first three or four days of the disease.

The malady may develop with a grave prognosis, and may even terminate in death, without a considerable rise of temperature ; hypothermia may be observed in the very toxic forms.

The pulse is generally frequent, small, and often irregular. The face is pale and dejected ; emaciation is often rapid and very pronounced.

4. Terminal Period. — In favourable cases, after an average of three to ten days, the colic and tenesmus become less severe. The stools, less frequent, lose their dysenteric character and become faecal. Occasion- ally there is an intestinal flushing, of a bilious or sero- bilious nature, which continues for some days. Then

20 DYSENTERY, CHOLERA, AND TYPHUS

the stools gradually resume their normal appearance and consistency. At this stage constipation may be met with, and after this a relapse may occur.

Sometimes, at the beginning of the convalescent period, increased sweating and an increase in the amount of urine is observed ; these may even assume the characters of a true crisis.

The patient's strength recuperates slowly ; some- times the convalescence is longer than the malady.

Bacillary dysentery is benign, of medium severity, or severe. In certain cases the dysentery is serious from the outset ; in others grave complications may appear during the course of a benign dysentery, which modify its development. It ends in recovery or death.

Clinical Forms of Bacillary Dysentery

1. The Light Form. — ^Dysentery may often present the appearance of an ordinary diarrhoea. The patient suffers from a certain amount of nausea, the tongue is clammy and resembles that seen in indigestion, and the abdominal pains are not very pronounced ; the stools are not very frequent — 4 to 6 per diem — and contain only traces of mucus, which may easily pass unperceived. The affection lasts a few days only, and its dysenteric natm'c is most frequently unrecognised.

2. Bilious Form. — ^The malady commences with a violent gastric disturbance, with congestion of the liver, vomiting, and very abundant bilious diarrhoea. After the lapse of a few days the stools, turgid and frothy, contain slimy mucus coloured with bile. Jaundice is generally observed.

3. Fulminating Form. — ^The onset is sudden, in the middle of the night, with more or less violent rigors, vomiting, severe headache, and a rise of temperature to 102° or 104°. At the same time the stools assimie the dysenteric character. In the space of two or three days to a week (approximately), the fever persisting to the

SYMPTOMATOLOGY 21

end, collapse sets in with hypothermia, and the patient expires. In certain cases death may occur even before dysenteric stools are passed, so virulent is the intoxication (Manson).

4. Ulcerative Form. — The stools, after a benign commencement, become fetid, and contain not only blood, but also a more or less voluminous gangrenous debris, of a greyish hue, with a putrid odour.

This denotes the existence of deep ulcerations, which are slow to cicatrise, and tend to set up a relapsing dysentery.

5. Gangrenous Form. — ^This is observed in tropical regions ; very rarely in temperate countries. From the outset it is a very serious malady. The stools are incessant ; the pains, which are excruciating, spread in all directions, not only through the abdomen, but also along the course of the sciatic nerve and in the region of the testicles (Le Dantec). Tenesmus is very severe ; the temperature may be febrile, the face pale, shrunken and altered, the eyes sunken. The general condition is bad, the voice feeble, the pulse small and thread-like and slower than the normal. There is incessant vomiting and a pathognomic hiccough sets in.

The stools, at first blood-stained, shortly assume the gangrenous type described above. At the same time the pains abate, even disappearing completely, and the patient feels better. This improvement is deceptive, for the vital powers are failing ; the heart grows weaker and the pulse becomes barely perceptible. The skin grows cold and cyanosed, and is covered with a clammy perspiration. The mind remains clear, though a little less active, and the patient slowly expires without a death struggle, without suffering, unless he is suddenly carried off by a syncopal attack. Death is the usual termination of gangrenous dysentery. However, in rare instances, recoveries have been reported (Dutrou- lau, Laveran, Berenger-Feraud, etc.).

22 DYSENTERY, CHOLERA, AND TYPHUS

6. Choleraic Form. — In Cochin-China a form of dysentery is occasionally observed with vomiting, cyanosis, collapse, algidity, muscular cramps, suppres- sion of urine, and a " broken" voice, these giving the patient an aspect comparable to that of cholera. During the present war P. Remlinger and J. Dumas have observed in 4 per cent, of cases — in benign cases as well as in those which were serious from the first — at the outset, or when the malady is estab^ lished, or during convalescence, an acute supra-renal syndrome recalling cholera. In a few hours the patient literally " melts away." He appears fleshless, skeleton- like, the eyes sunken, the nose sharp, the abdomen hollowed like a boat. There is cyanosis, the tempera- ture falls ; the pulse, frequent and compressible, is im- perceptible or nearly so. The heart sounds are remote and muffled, often of an embryocardiac type. The tongue is dry ; the patient has an inextinguishable thirst, with hiccough, nausea, vomiting ; his voice is broken ; he has cramps ; and there is abundant and very liquid diarrhoea. The evacuations are sometimes involuntary. There is oliguria, or even anuria. The patient becomes prostrated and plunged into a condi- tion of semi- somnolence. Death follows rapidly. The above-named authors have found histological lesions in the supra-renal capsules, which are two to three times larger than usual.

7. Typhoidal Form. — ^This form is characterised by high temperature, dryness of the tongue, abdominal meteorism, stupor, delirium, ataxo-adynamic pheno- mena, and in children by convulsions. The stools, dysenteric during the first week, afterwards become diarrhoeal. Although these forms occur most frequently apart from any association with typhus or typhoid fever, it must not be forgotten that in the course of all wars, and notably during the present war, cases of mixed infections have been recorded, such as those of typhoid fever and dysentery (Remlinger).

SYMPTOMATOLOGY 28

8. Haemorrhagic Form. — ^This form of dysentery, which is haemorrhagic from the commencement, is rare. Le Dantec has observed one case, which was quickly fatal. Most frequently the haemorrhage is intestinal ; it has the same pathogeny as the haemorrhage of typhoid fever. It may occur at any stage of the dis- ease, and is usually accompanied by typhoid-like symptoms. A sudden collapse may result, even in cases otherwise benign. Kelsch and Kiener include under this form all cases with marked or serious haemorrhage, whether of the intestines, the mucous membranes, the cellular tissue, or the skin.

9. Long-continuing or Relapsing Form. — ^Recovery after severe or serious cases of dysentery may be appar- ent only. Often the stools become irregular, while digestion is difficult and painful, accompanied by colic and slight diarrhoea of variable aspect (mucous, bilious, serous, sanguinolent, sometimes fetid). The abdomen remains sensitive, the patient slowly becomes cachectic, and dies at the end of a few weeks, or else, after a de- parture from strict diet, or after a chill, or fatigue, an actual relapse occurs, which develops as in the original attack. Thus there may be alternate periods of quiescence and recrudescence, which may continue for a varying space of time. Recovery may be established after several months, but death is only too often the outcome either of a serious relapse or of a progressive cachexia.

10. Chronic Form. — Bacillary dysentery may some- times, though much less frequently than amoebic dysentery, give rise to a chronic condition (H. Vincent). The patient, after an acute period of varying duration, continues, for several months, a year, or longer, to pass fluid and lienteric stools.

Their number is 3, 4 or 5 per diem, with more marked inflammatory attacks, straining, and tenesmus provoked by errors of diet, chills or fatigue. This form of dysentery is often unrecognised, above all when the

24 DYSENTERY, CHOLERA, AND TYPHUS

initial period of mucous and sanguinolent stools has been very short or has passed unperceived. The patient grows steadily thinner, his muscles become wasted, and he falls into a condition of marasmus, often confounded with intestinal tuberculosis.

Complications

In the course of bacillary dysentery intestinal hcemorrhage may be met with; this may be primary or secondary, as in typhoid fever. Peritonitis is not exceptional, with or without intestinal perforation. The most usual position of the latter is said to be the rectum, and after that the sigmoid flexure.

Nervous disorders (peripheral neuritis, paraplegia, monoplegia, general paralysis more rarely) are fairly frequent (Zimmermann, Trousseau, Bouillaud, Ridoux, Moutard-Martin, Gubler, Delioux, Pugibet).

Arthropathies : these may occur at any stage of acute dysentery. Sometimes they amount merely to polyarticular manifestations of brief duration ; some- times to mono- or bi-articular localisations of a more persistent character. Dysenteric arthritis sometimes assumes the character of infectious pseudo-rheumatism (Brault, Boudet) ; it is most frequently characterised by a painful swelling of the joints with or without effusion.

Combay has recorded a case of thrombosis of the left iliac artery with gangrene of the corresponding limb. Cicatricial strictures of the intestine, especially in the region of the rectimi, are comparatively frequent com- plications. Invagination, intestinal occlusion, and internal strangulation have also been reported. Remlinger has noted certain rare complications : epididymitis, and general dropsy without albuminuria. Acute nephritis is fairly common.

SYMPTOMATOLOGY 25

II. Amoebic Dysentery

Amoebic dysentery presents the same essential symptoms as bacillary dysentery. Long regarded as peculiar to tropical or semi-tropical regions, it has been observed in all parts of Europe, and during the present war numerous cases have been observed in France (Ravaut and Krolunitsky, Job, Richet junior, Rist, Rathery, Rives and Huet, Lian and Lyon-Caen, Orticoni and Ameuille, Job and Hirtzmann, etc.). It is characterised by its tendency to relapse or assume the chronic form, by its irregular development, con- sisting of periods of quiescence and exacerbation, and, lastly, by the frequency of hepatic complications (simple congestion or abscess of the liver).

It may commence suddenly, develop in an acute form, and end in death or recovery in a comparatively short time. This is the less usual form.

The commencement is almost always insidious, often marked only by a simple diarrhoea, painless and hardly inconvenient. The dysenteric syndrome makes its ap- pearance in the course of a few days and the patient appears to improve. But as a rule this improvement is only apparent. After a period of varying duration a series of relapses occurs, and the malady becomes chronic. Abdominal pains along the course of the large in- testine are constant. They may be elicited by pressure, especially in the region of the ulcerations — namely, the caecum, the hepatic flexure, and the sigmoid flexure. When they are localised in the latter portion of the large intestine the ulcerations are particularly painful, provoking rectal and vesical tenesmus, and frequently recurring efforts which are not always followed by evacuation.

Alternatively, the patient passes diarrhoeal stools, sometimes absolutely liquid, sometimes soft and doughy, and then frequent dysenteric stools, especi- ally during the night, with tenesmus and colic. The mucus evacuated is whitish or greyish, more or less

26 DYSENTERY, CHOLERA, AND TYPHUS

streaked with blood on the surface. In it we find red corpuscles and leucocytes, many of which are eosino- phile (Billet). This latter fact has not, however, always been confirmed. The odour of the mucous discharges is sometimes stale, sometimes fetid ; their reaction is alkaline (H. Vincent). Jaundice is common. Diges- tion is painful and difficult, and there may be frequent vomiting. The general condition of the patient grows worse and worse, his emaciation more and more per- ceptible, although the appetite may be fairly well maintained. If complications are of some duration, the patient becomes cachectic. His skin is dry, wrinkled, and assumes a bronzed and earthy tint ; there is no perspiration, the urine is scanty, and its emission is sometimes painful. The temperature may sink below the normal, as low as 93-2° in the axilla. The patient is like a living skeleton, and he dies of inanition, unless he is carried off by an acute crisis, an attack of intestinal gangrene, tuberculosis, or a secondary infection.

Chronic dysentery is of extremely variable duration, lasting from a few months to many years. ^ It may ultimately end in complete recovery, without sequelae. Very frequently relapses are observed after a few days, a few months, or even a year (H. Vincent). Chronic and long-continuing forms are particularly refractory, often leaving behind them severe dyspepsia, extreme weakness, emaciation, and even lesions (destruction of glands, thickening of the intestinal walls, cicatrices, adhesions, strictures, etc.), so that the health of the patient afflicted with them is usually jeopardised.

Complications

The fact that the development of amoebic dysentery is generally prolonged explains the multiplicity and the nature of the complications which have been observed in the course of this disease.

^ Cases have recently been reported where the infection had lasted for 20, 26, and 30 years.— Ed.

SYMPTOMATOLOGY 27

Among these complications may be mentioned peritonitis^ localised, extensive, or general, which is often discovered at autopsy, with or without perfora- tion ; intestinal perforation, which is of very frequent occurrence (being found in 12 out of 77 autopsies con- ducted by Strong), and which is localised principally in the neighbourhood of the sigmoid flexure ; thrombosis of the large blood-vessels ; partial paralysis ; infarctions, and abscess of the spleen, the brain, etc.

The most frequent complication, which makes the prognosis of amoebic dysentery peculiarly gloomy, is abscess of the liver. It is never met with in the course of bacillary dysentery. The abscess is very often localised in the right lobe, which is hypertrophied. The only constant clinical indication is the excruciating pain, which must always be looked for, and which is provoked by pressing deeply at any point in the region of the thorax, principally between the ribs. "V^en the abscess begins to form the patient experiences and complains of discomfort and pain in the liver, very often radiating to the right shoulder, and a painful heaviness in the region of the right hypochondrium. The swelling may be apparent. There is emaciation and jaundice, the latter in one case out of every four. There is now reason to suspect suppurative hepatitis, especially if there is fever. Pleurisy of the base is rarely absent. Diagnosis is sometimes facilitated by radiography and, if needful, by deep exploratory punctures, but it is often difficult to localise the abscess if of small volume or in an early stage of development. It is useful to examine the blood. In the course of amoebic dysentery sometimes a very appreciable eosinophilia of the blood is noted (4 to 47 per cent.) (Billet, Chantemesse and Rodriguez, Dopter, Hoyt, C. Mathis and M. Leger). This eosinophilia is not, however, constant. ^ When it exists its disappearance

^ It has probably nothing to do with the dysentery per se and more likely is due to helmenthic or other complications. Certainly many cases of amoebic dysentery never show it. — Ed.

28 DYSENTERY, CHOLERA, AND TYPHUS

enables one to mark the moment at which the dysentery becomes compHcated by suppurative hepatitis. The amoebic abscess of the liver, in short, causes the dimi- nution or even the absolute disappearance of eosinophile leucocytes in the circulating blood.

The development of the abscess is sometimes in- sidious, without increase of temperature, without any appreciable pain, and is marked only by emaciation, dyspepsia, and vague pains in the region of the liver. Abscess of the liver may supervene, although not always, in patients suffering from slight attacks of dysentery who have, until the formation of the abscess, undergone no treatment, or in patients treated only during the acute periods of the disease — ^that is to say, in an in- sufficient manner (Faure, Maute). Finally, there are cases in which suppurative hepatitis constitutes the initial and even the only localisation of amoebic infection, the enteritis having been absent, or quite ephemeral. Rogers has noted the particular frequency of hepatic abscess in alcoholic subjects.

Abscess of the liver tends to effect a spontaneous external opening, either through the skin or the intes- tine, or into the peritoneum, or into the bronchi through a vomica ; more rarely into the pelvis, the stomach, etc.

Death often ensues through cachexia or secondary infections.

During the present war abscess of the liver has often been observed to occur as a sequel of ill-defined intestinal affections treated as enteritis or " trench diarrhoea." The exact diagnosis of amoebic dysentery was only come to by the formation of the abscess and the therapeutic success of emetin (Rives and Huet, Rathery and Bisch, Lian and Lyon-Caen, Rist and Roger, etc.).

III. Dysenteries caused by Various Etiological Agents

We shall confine ourselves in this section to the enumeration of some of the varieties of dysentery

SYMPTOMATOLOGY 29

attributed to various agents, and some of which, as we have already said, require to be made the subject of fresh investigations before their individuaHty can be confirmed.

Spirillum dysentery. — Le Dantec has described a dysentery in which microscopic examination of the mucous discharges reveals the presence of a pure culture of spirilla. This spirillum dysentery is said to be fairly common in the south-west of France, principally in the region of Bordeaux. It develops without fever or hepatic complications. It may become chronic, but always ends in recovery.

Cocco-hacillary dysentery. — Lesage (in China, Cochin- China, Algeria, and Toulon) and Metin (in Cochin- China) have described two cocco-bacilli, very nearly related, which may be isolated from the blood of dysenteric patients.

Dysentery due to Balantidium coli. — ^This has been observed by Strong and Musgrave in the Philippines, by Solaviev and Klimenko in Russia, and by Ernrooth in Finland.

Dysentery due to Bilharzia {Schistosoma mansoni). — This has been observed in the Congo by Firket. It is not uncommon to find the eggs of the parasite, not only in the stools of the patients, but also in the urine. 1

Dysentery due to Chilodon dentatus.'^ — Observed by Guiart.

Various dysenteries. — Lewkowicz and Simonin believe that the enterococcus of Thiercelin plays an active part in many dysenteriform processes. The Bacillus pyocyaneus, the Proteus vulgaris (Mace, Mougniet), and other microbes have also been incriminated.

Finally, dysenteries have been reported as resulting

^ The original case was described by Manson : a man from Antigua, West Indies. It is excessively rare to get lateral-spined bilharzia ova in the urine. — Ed.

2 Ghilodon dentatus is a protozoon commonly found in water. There is no proof that it can live as a parasite or produce symptoms of dysentery. — Ed.

30 DYSENTERY, CHOLERA, AND TYPHUS

from Trichomonas (Billet, Simonin, Escomel), Cer- comonas, Lamblia intestinalis (C. Mathis, C. Fairise, and Jacquot, etc), Tetramitus {Chilomastix) mesnili (Brumpt), Pentatrichomonas ardindelteili (Derrieu and Raynaud), etc. The symptomatology of these affections is similar to that of the other forms. Their development is in general chronic. ^

^ The flagellates of the intestine may produce diarrhoea, though some observers even deny this role to them. They certainly do not produce dysentery in the strict sense of the term. — Ed.

CHAPTER II

DIAGNOSIS OF DYSENTERY

I. Diagnosis of the Dysenteric Syndrome

It is necessary, in the first place, to diagnose the dysen- teric syndrome. The character of the stools, their frequency, colics, cutting pains, straining, and tenesmus, are by themselves, when they are united, symptoms characteristic enough to render diagnosis easy. But it must not be forgotten that there are cases of larval dysenteries, hardly defined, of which " trench diarrhoea " is sometimes one of the forms, in the course of which the syndrome is represented by only one or two symptoms, which are not always pathognomic. The development of these cases, the complications which accompany them, and notably the occurrence of hepatic abscesses, permit of the establishment of a retrospective diagnosis.

It must be remembered that rectal polypus in children, hcemorrhoids in adults, and neoplasms in the aged, may provoke sanguinolent stools, tenesmus, and the expul- sion of mucous discharges.

Retroflexions and retro-uterine phlegmons may, by their concomitant symptoms, simulate attacks of dysentery, and the same is true of affections of the bladder, especially of lithiasis.

The pernicious dysenteriform access [malarial dysen- tery], the existence of which is contested by certain authors, presents a great similarity to dysentery. The stools may be mixed with blood and mucus. There is straining, colic and tenesmus, and the temperature is often very high. Under treatment by quinine and opium the intestinal flux is replaced by abundant 31

32 DYSENTERY, CHOLERA, AND TYPHUS

perspiration, the end of the access is determined, and the diagnosis established. It is possible that the symptoms observed may be due to an association of dysentery and malaria. The examination of the blood and the stools yield valuable indications.

The chronic diarrhoea of hot countries (synonyms : Cochin-China diarrhoea, tropical diarrhoea, sprue, spruw, pilosis linguse, white diarrhoea, tropical aphthae, Ceylon sore mouth) sometimes presents certain of the char- acteristics of chronic dysentery. According to Sir Patrick Manson, it may be primary or secondary to other infections, notably to chronic dysentery. It is characterised by irregular alternations of exacerbation and comparative quiescence of symptoms, by erosive and inflammatory lesions of the tongue, mouth, and pharynx — ^very painful erosions, causing abundant salivation ; by dyspepsia, usually very severe, accom- panied by abdominal tympanism, borborygmi and vomiting, with or without nausea ; by the evacuation of discoloured stools, which are extraordinarily abund- ant, frothy and fetid, without tenesmus, and without mucous discharges or blood ; by extreme emaciation, anaemia, and a tendency to relapse on the occasion of the slightest exciting cause (exertion, or a chill, or a slight departure from diet, etc.).

All these specific symptoms will, as a rule, enable the physician to make a diagnosis.

Cases of amoebic dysentery, associated with cholera (Yakimov and Damidov) and with typhoid fever or typhus, have been reported, particularly in time of war. Laboratory research alone can enable one to arrive at a correct diagnosis in such cases.

Subcutaneous injections of salts of mercury and the ingestion, voluntary or otherwise, of certain berries (notably that of one of the Euphorbiacece, Hura crepi- tans) may simulate a dysenteric attack (Pierre).

DIAGNOSIS OF DYSENTERY

II. Diagnosis of the Nature of Dysentery

In the presence of a plainly characterised dysenteric syndrome, one should always be able to determine its cause. Clinical examination by itself will set one on the right road. Bacillary dysentery, it will be re- membered, often develops, in cases of average or extreme gravity, with a more or less elevated tem- perature, although this is not constantly the case, while amoebic dysentery is generally apyretic, except when complications are present. The chronic develop- ment of the disease and the knowledge that it i^ epidemic (in hot countries) enables us to form certain presumptions, but bacteriological examination is always necessary.

Sero-diagnosis may be useful. The serum of patients suffering from bacillary dysentery habitually agglutin- ates the dysentery bacillus which has caused the in- testinal infection, but it agglutinates no other bacillus. In cases of medium or extreme severity, the agglutina- tion does not appear until about the eighth or tenth day of the disease. It lasts as long as the disease lasts, is observed during convalescence, and often persists until two or three months after recovery. The agglutina- tion index varies from ^V ^^ tIu- ^^ slight forms of dysentery agglutination is, as a rule, absent, for such cases recover before the agglutinative power of the serum can make its appearance. If they are prolonged it may appear, even in cases of simple diarrhoea occurring during an epidemic, side by side with well-defined attacks of dysentery (Braun, Job, Dopter).

In cases of mixed infection by dysenteric amoebse and bacilli, the agglutinative power of the serum may appear under ordinary conditions.

The following table summarises the chief differential characteristics of amoebic dysentery and bacillary dysentery.

34 DYSENTERY, CHOLERA, AND TYPHUS

Am(ebic DysENTERY Bacillary Dysentery

Etiology

Pathogenic amceba, inoculable Dysentery bacilli,

into the rectum of cats.

Usiuil Methods of Propagation

More particularly, drinking Direct contagion

water.

Direct contagion. Contagion by encysted forms.

Indirect contagion, from stoola (latrines), flies, vegetables, in- fected soil, manure, dust, drinking water.

Epidemiology

A disease of hot or tropical countries, where it is endemic. Prevalent in summer and winter. Indo-China, Tonkin, Saigon, United States, Brazil, Philippine Islands, Cuba, South America, Madagascar, Egypt, Sudan, Senegal, Morocco [India], etc.

A disease prevailing chiefly in summer and in temperate countries ; less frequent in hot or tropical countries.

Occasionally sporadic.

Usually epidemic, spreading rapidly, and highly contagious.

Prevalent in late summer and autumn.

Clinical Symptoms

Tendency to chronicity.

Immunity does not result from a previous attack.

Hepatic abscesses are frequent.

Serum does not agglutinate dysentery bacilli.

Alkaline evacuations.

Eosinophilia [sometimes].

Onset sudden, development acute, sometimes chronic.

Previous attack confers im- munity.

No hepatic suppuration.

Serum agglutinates dysentery bacilli.

The dejecta are acid or neutral.

Eosinophilia absent.

Anatomical Lesions

Deep lesions often occur ; ragged ulcers with detached [undermined] edges, localised in the large intestine.

Lesions extending over the whole of the large intestine, and often to the lower portion of the ileum.

Superficial lesions : Yellow or greyish erosive spots, with hyper- semia of the mucous membranes.

An early and exact diagnosis can be established only by means of a simultaneous search for the incriminated parasites in the stools. In all cases of dysentery, there-

DIAGNOSIS OF DYSENTERY 35

fore, a certain amount of systematic research must be undertaken in the laboratory.

Laboratory Research. — These investigations will com- prise microscopic investigations with and without staining and cultivation. The former will permit of the cytological examination of the mucous discharges, and the discovery of amoebae or amoebic cysts ; the latter will enable the investigator to isolate and identify the dysentery bacilli and the germs which may be associated with them.

Microscopic examination should deal with faeces very recently passed. By means of spreading and separat- ing, smears may be taken from the most purulent portions of the mucous discharges. These smears may be fixed and coloured by the ordinary cytological methods (fixation by alcohol and ether, stained with thionin and eosin, hematein and eosin, Giemsa's stain, etc.). In the case of bacillary dysentery the prepara- tions will show very large numbers of neutrophile poly- morphonuclear leucocytes, normal or but slightly abnormal mononuclear leucocytes, and a varying number of bacilli.

In amoebic dysentery the preparations of mucus should be examined in the fresh state, between slide and cover-glass, taking care not to crush them unduly. Far fewer polymorphonuclear leucocytes occur than in bacillary dysentery, but they are greatly altered ; eosinophile leucocytes are sometimes found among them in considerable numbers, and the preparations are very rich in various bacteria, infusoria, etc. The number of these various elements is such that even if we do not meet with amoebae we may sometimes pre- sume the diagnosis to be that of amoebic dysentery. Only the discovery of amoebae or their cysts can establish the diagnosis with certainty however.

Certain writers advise the passing of the stools into warmed vessels. H. Vincent has ascertained that the amoebae remain motile for ten to thirty minutes, some- times for an hour even, at the temperature of

36 DYSENTERY, CHOLERA, AND TYPHUS

the laboratory.! Job and Hirtzmann have observed motihty in amoebae five to six hours after the emission of stools in Morocco. The examination must be made, if not at the patient's bed-side, at least as rapidly as possible after the passage of the stool.

A portion of blood-stained mucus is selected, and, with the assistance of a pipette, a fragment is placed on the slide. This is covered with a cover-glass ; the examination can then be made without staining, but if the amoebae are rare, their discovery is favoured by the following procedure. A small drop of an aqueous solu- tion of methylene blue, 1 per cent, in strength, is placed at the edge of the cover-glass. All elements other than amoebae (leucocytes, epithelial cells, bacteria, etc.) are rapidly stained by the blue, but the amoebae alone re- main colourless, and at first they stand out from the rest owing to their bright appearance against the blue background of the preparation. They are motile. Then their movements become slower and cease, and the parasite finally becomes coloured (H. Vincent).

The dysenteric amoeba was discovered by Losch, of Petrograd, in 1875, in the dysenteric stools of an aged Russian, the writer giving it the name of Amoeba coli. This amoeba was pathogenic, as it was able to infect one dog out of four experimented upon. Since that time the same amoeba has been described by different writers under various names : Entamoeba dysenterice (Council- man and Lafleur, 1891), Amoeba coli felis (Quincke and Roos), Entamoeba histolytica (Schaudinn, 1905), E. tetragena (Viereck, 1907), E. africana (Hartmann), E. brasiliensis (Beaurepaire, Arago), E. nipponica (Koidzumi), etc.

According to the rules of zoological nomenclature, the pathogenic amoeba should therefore bear the name of Amoeba coli (Losch), but Schaudinn finally gave this name to the non-pathogenic amoeba. Hence confusion is possible. It seems preferable to us to denote the

^ Or longer if the temperature is high. When cold they may often be resuscitated by heating. — Ed.

To face page 37

Explanation of the Plate

1, 2, 3. — Living dysentery amoebas. [E. histolytica.]

4. — Non-pathogenic living amceboe. [E. coli.]

5, 6, 7, 8, 9, 10, 11. — Dysentery amcebsB. Stained with iron hema- toxylin (from a preparation by Dr Langeron).

12. — Non-pathogenic amoebae. Stained by iron haematoxylin.

13, 14, 15, 16, 17. — Cysts of dysentery amoebae [E. histolytica] with four nuclei ; 15, 16, 17, containing chromatoids.

18. — Cysts of non-pathogenic amoebse with eight nuclei. [E. coli.] One of these cysts contains chromatoids.

1 9 . —Balantidium coli.

20. — Lamhlia [Giardia] intestinalis.

21a. — Cysts of Lamhlia intestinalis.

21b. — Cysts of Lamhlia intestinalis. Stained with iron haema- toxylin.

22. — Trichomonas intestinalis.

23. — Egg of Schistosoma mansoni.

24. — Tetramitus [Chilomastix] mesnili.

37

38 DYSENTERY, CHOLERA, AND TYPHUS

specific amoeba of dysentery by the name of Amoeba coli dysenterice, or that of Entamoeba, the latter being proposed by Councilman and Lafleur. E. histolytica and E. tetragena are to-day regarded as phases of E. dysenterice (Job and Hirtzmann, C. Mathis and L. Mercier, etc.), not as distinct species.

In Morocco Job and Hirtzmann have usually found the E. tetragena at the moment of the dysenteric crisis. It is this type also — ^long regarded as more peculiar to African regions — ^which has been reported in France by Ravaut and Krolunitsky.

The E. histolytica type is characterised by its ex- tremely active movements — so active that one cannot always draw the contours of the transparent chamber. It emits pseudopodia in considerable numbers, which are rapidly protruded and withdrawn.

The endoplasm, a greenish-yellow, is crammed with cellular and alimentary debris, and especially with red corpuscles.

It also contains bacteria, and, more rarely, chromatoid bodies.

The ectoplasm is transparent and refractile.

The living amoeba appears to be without a nucleus, but when its movements become less rapid, or cease, the nucleus appears, round, and provided with a nucleolus. The endoplasm and the ectoplasm seem less differentiated, and one can plainly recognise the red corpuscles or their debris.

In fixed and stained preparations E. histolytica appears round, confined by a clear outline, and containing numerous vacuoles which enclose red corpuscles ; the nucleus appears round and excentric, with a peripheral ring of chromatin granules and a single centriole.

E. tetragena ^ is found only in the faecal evacuations (Ravaut and Krolunitsky). Its movements are much less rapid than those of the amoeba just mentioned,

^ The small forms found in the fseces are usually spoken of as the E. minuta type by English authorities ; they are generally regarded as the immediate precursors of the cysts. — Ed.

DIAGNOSIS OF DYSENTERY 39

the endoplasm and the ectoplasm are less distinct, the red corpuscles included are less numerous, and the nucleus is very apparent.

In the immobile condition it is hardly to be dis- tinguished from E. histolytica when the latter has become immobile.

In addition to the pathogenic amoeba one very often meets with another, E. coli, which is regarded as normal to the colon. Its movements are very slow, the endo- plasm and the ectoplasm are poorly differentiated, the nucleus is very plainly visible, and it encloses no red corpuscles.

In fixed and stained preparations the nucleus presents the same structure as in E. dysenterice, but there are generally several centrioles.

The living amoebae are easily recognisable, but when the stools are examined some hours after being passed, they have become immobile. It is then more prudent to search for the cysts. While the amoebae are found in the living condition only during crises the cysts are [may be. — ^Ed.] visible during the whole course of the disease. They are sought for by direct examination, between slide and cover-glass, with or without colora- tion. According to Langeron, the addition of a little Lugol's solution to the preparation notably facilitates the examination. C. Mathis fixes fresh, undried pre- parations by exposure to the vapour of osmic acid (1 per cent.) for thirty seconds. He then stains, for a few seconds, with haematoxylin (1 in 200). The envelop and the nuclei of the cysts' are stained a deep brown, thus becoming plainly visible.

To identify the cysts we must note their dimensions and the number of their nuclei.

The cysts of Entamoeba dysenterice [E. histolytica of English authors — Ed.] measure at most 10-14 fi in diameter, and possess 1 to 4 nuclei, never more (E. Job and L. Hirtzmann). In the protoplasm one very often sees agglomerations of a refracting substance, which occurs in thick rod-like bodies or irregular masses ; it is

40 DYSENTERY, CHOLERA, AND TYPHUS

known as chromidium, and according to C. Mathis is characteristic of this variety of cysts.

The cysts of E. coli (non-pathogenic) measure 16-25 /x and even more ; they possess 1 to 8 nuclei. The cysts of E. dysenterice [E. histolytica], like those of the non- pathogenic amoeba, may or may not contain chromatoid bodies.

For purposes of diagnosis one should observe only the ripe cysts — ^that is, those containing 4 and 8 nuclei.

The number of cysts is very variable ; sometimes very abundant in each preparation, they are, on the con- trary, very rare in other cases. Ravaut and Krolunitsky facilitate their elimination by the artificial production of a temporary attack of enteritis, either by means of a saline purgative or a saline enema, or, better still, by the intravenous injection of 1 to 4 centigrammes of cyanide of mercury.

Noc, with the same object in view, administers an enema of boiled water (500 c.c). When this has taken effect he employs an irrigation or instillation, lasting thirty minutes, with J per cent, solution of thymol (in boiled water).

A. Maute administers, in the morning, an irrigation with :

Iodine . . . . . . .1 gramme

Iodide of potassium . . . .2 grammes

Water . . . . . .1 litre

The amoebae and cysts are looked for in the diarrhoeal, or merely soft, or sometimes even formed stools, which the patient passes during the evening or the next morning.

The cysts remain intact in the stools for at least two days. If the investigation has to be undertaken later than this, the addition of formol will preserve them perfectly.

Maut6 attaches very great practical importance to the investigation of associated parasites, the super-

DIAGNOSIS OF DYSENTERY 41

addition of these seeming to maintain and augment the resistance of the amoebae.

One should, according to him, look for protozoa (the trichomonas especially) and intestinal worms (ascaris, trichocephalus, etc.).

The final disappearance of cysts in the stools is the only criterion which we at present possess of recovery from amoebic dysentery.

The bacteriological diagnosis of hacillary dysentery necessitates the culture and isolation of the bacillus, as well as its identification.

1. Culture. Isolation. — A flake of mucous or muco- purulent matter is washed several times in sterile bouillon or physiological serum, in order to free it of gross impurities.

The culture is then made on several Petri's dishes, into which some litmus lactose agar, and also Endo's agar, has been poured. The agar is inoculated by spreading the flake of mucus on it and moving it gently to and fro by means of a platinum wire or a bent glass rod. After twenty-four hours in the incubator, at a temperature of 37° C, the inoculated portions are examined. On the agar containing litmus, red and blue colonies will be found ; on the Endo's medium some red colonies will be seen, and others which are colourless. The red colonies are eliminated ; it is in the blue and colourless colonies that the dysentery bacilli will' be found.

2. Identification. — ^The dysentery bacillus is a short rod-shaped bacillus, rounded at its extremities, easily absorbing all the aniline stains, but negative to Gram's stain. It does not form spores, but shows polar granulations. Its movements are feeble, confined as a rule to slight oscillations like those of a compass-needle settling to the north. This motility, which Flexner ob- served in his bacillus, is very slight even in the case of recent cultures made directly from dysenteric stools ; in sub- cultures it progressively diminishes, finally disappearing.

42 DYSENTERY, CHOLERA, AND TYPHUS

Principal Differential Charaoteristics of the Four Types OF Dysenteric Bacilli

BACILLUS	Shiga	■ Flexnbr	His (Y)	Strong
Production of	No indol	Indol	Indol	Indol
indol
Litmus milk	Reddens very slightly: turns ame- thyst after twenty -four hours	Reddens more perceptibly than Shiga's	As Flexner's	As Flexner's
Neutral red media	No change	No change	No change	No change
Litmus agar and	No fermenta-	No fermenta-	No fermenta-	No fermenta-
dulcite, litmus	tion	tion	tion	tion
agar and lactose
Litmus agar and	Turns red	Turns red	Turns red	Turns red
glucose, litmus
agar and galac-
tose,litmusagar
and Itevulose
Litmus agar and	No fermenta-	Turns red	Turns red	Turns red
mannite, litmus	tion
agar and raffl-
nose
Litmus agar and	Turns an in-	Turns red	Red tinge ob-	Change to red
maltose	constant red		tained rarely	capricious
	after several		and with	and slow
	days		difficulty
Agglutination	With Shiga	Agglutination	Same as	Agglutinated
	serum only	with the	Flexner's	only by
		Flexner and Y serums, but not with Shiga and Strong serums		Strong serum
Experimental	Subcutaneous	Subcutaneous	Same as	Same as
pathogenic ac-	injection pro-	injection pro-	Flexner's	Flexner's
tion	duces dysen- tery in the rabbit, dog, rat, and mouse, but not in the	duces no pathogenic results. In- jected under the periton- eum it pro- duces fatal
	guinea-pig
		peritonitis in
		the guinea-
		pig, rat, and
		mouse

DIAGNOSIS OF DYSENTERY 43

According to Sir Patrick Manson, Shiga's bacillus displays two to six terminal flagella, rather short and thick; those of Flexner's bacillus are said to be longer.

The dysentery bacillus does not coagulate milk ; on gelatine the isolated cultures are shallow and trans- lucid, their edges being " pinked," while they are crossed by furrows which give them the appearance of vine-leaves.

There are races of dysenteric bacilli, just as there are races of cholera vibrios and typhoid bacilli. These races comprise types which are steadily increasing in number. At the present time there are only four races which present characteristics definite enough to enable us, whenever a germ is isolated, to refer it to one of them for identification. Between these four types there are a great number of varieties which are more or less differentiated one from another.

In addition to these we also encounter a certain nimiber of so-called pseudo-dysentery bacilli, which, by their histological characteristics and their reactions are more or less differentiated from the true dysentery bacilli.

The table given on p. 42 sunmiarises the essential characteristics of the four principal types.

CHAPTER III

THE TREATMENT OF DYSENTERY

The diagnosis of dysentery being established, the patient should immediately be put to bed and kept warm, and as far as possible be prevented from leaving his bed, even to visit the commode. The alimentary canal should be kept in a state of repose.

All solid food must be suppressed. Foods must be selected which, while possessing high nutritive qualities, leave a minimum of faecal residue. Milk, beef-tea, white of egg, barley water or rice water, and peptonised milk should constitute the basis of alimentation (Manson).

Vegetable bouillon, which has yielded such good results in the treatment of diarrhoea in children, has been employed with success by Boudet. To assuage thirst, weak lukewarm tea is welcomed by the patient.

Alcohol and alcoholic beverages are only to be given in cases where collapse is to be feared.

Liquid nourishment, more or less abundant according to the case, and at times bordering upon full diet, should be continued until the stools are no longer numerous, and simply diarrhceal. At this stage one may give very light puries of dry vegetables or potatoes. Meat diet is to be resumed only with the utmost prudence.

Treatment must be subordinate to the diagnosis given by the laboratory. Some of the various cases which may present themselves will now be considered.

1. In Cases of Bacillary Dysentery. — ^We now have a specific treatment for this form of dysentery. Shiga, in Japan, in 1898, was the first to utilise the curative

U

TREATMENT OF DYSENTERY 45

properties of the serum of animals immunised against the dysentery bacillus. Simultaneously Rosenthal and Gabritchevski in Moscow, Vaillard and Dopter, and Auche and Coyne in France were undertaking investiga- tions of the same nature. Vaillard and Dopter, by weekly inoculation's of living cultures of dysentery bacilli into the veins of the horse, obtained a serum which possesses preventive and curative effects in cases of experimental dysentery in animals.

Injected into the human sufferer from bacillary dysentery this serimi diminishes mortality, attenuating and causing the rapid disappearance of the dysenteric phenomena. A few hours after the injection of the serum the patient usually experiences a genuine feeling of improvement, the abdominal pains, the tenesmus and the straining already abating, and, except in very serious cases, they almost always disappear during the ensuing twenty-four hours. Recovery takes place in forty-eight hours, five or six days or ten to fifteen days, accordingly as the case is slight, average, severe, or very severe. Convalescence is shorter and easier. The serum is given by subcutaneous injections. Its effects are more rapid and decisive in proportion as it is administered more promptly after the onset of the disease. The dose varies according to the moment of intervention, the severity of the attack, and the age of the patient. The following indications are given by the inventors of the serum treatment : For adults in dysentery of average severity, taken at the outset, 20 c.c. will usually suffice to produce an immediate arrest of all the symptoms. If these still persist after the lapse of twenty-four hours, another injection of 20 c.c. should be given. In severe forms, or cases of several days' standing, a third injection of 10 c.c. will be useful.

In serious cases 40 to 60 c.c. should be injected at once, and the physician should not hesitate to repeat the injection daily, even to the length of administering a dose of 100 c.c. per diem, in two injections, until

46 DYSENTERY, CHOLERA, AND TYPHUS

the intestinal disturbances abate. The treatment is then carefully continued, with diminishing doses, until the number of stools falls to a few in the course of the twenty-four hours.

For children the above doses are to be reduced by one-half, two-thirds, or three-quarters, according to age.

In certain cases which are refractory to serotherapy, and in chronic forms, enemas of serum, reaching as high a point of the colon as possible, have been re- commended.

Medical treatment by means of Segond's pills (vide, p. 49) (2 to 6 per diem), or by sulphate of sodium (10 grammes per diem), together with opium, leads to a quick recovery in dysenteries of average severity, in default of the serum treatment.

2. In Cases of Amoebic Dysentery. — Hydrochloride of emetin is at present regarded as the most active remedy in the treatment of amoebic dysentery, but although it acts rapidly on the inter-organic amoebae lodged in the liver or the walls of the intestine, it has no action on the extra-organic amoebae — that is, those which are free in the intestine. Moreover, the treatment is often followed by relapse. It has been proposed to continue the treatment by subcutaneous injections (Chauffard) and also to complete the cure by injection by means of local treatment (irrigations) which would reach the amoebae remaining in the intestine, but this latter treatment is usually ineffectual.

Certain writers give two intravenous injections of 0-15 to 0*20 grammes of hydrochloride of emetin in 100 c.c. of physiological serum, and then, during a period of one or two weeks, subcutaneous injections of 0-10 to 0-12 grammes. Lastly, supplementary cures are administered every three or four weeks. The dejecta are examined periodically for some months with a view to the discovery of amoebic cysts, after an iodated enema.

Maute, during the first three or four days, gives two

TREATMENT OF DYSENTERY 47

subcutaneous injections of hydrochloride of emetin, the dose being 4 centigrammes per injection; then, during the three or four subsequent days, he gives a single injection.

Generally speaking, the dysenteric phase is then over, and the patient no longer passes more than one or two stools in the day. If, on the contrary, the diarrhoea persists, one should suspect parasitic associations, and should look for them and treat them (with worm-seed, santonin, thymol, turpentine, etc., according to the case).

Maute then gives five series of five injections, each leaving an interval of a week between each series. If after the administration of an iodated lavage he dis- covers no more cysts in the stools, he regards the patient as cured. Despite these long series of injec- tions, however, it often happens that one still discovers evidence of amoebic development.

In these cases, following the method of Ravaut and Krolunitsky, Maute employs novarsenobenzol. Every six or seven days he gives an injection of -15, -30, -45, •60, to -75 grammes. If cysts are still found in the stools a few days after the end of the treatment, he gives two series of five injections each of emetin (two injections of 8 centigrammes and three of 4 centi- grammes), each series following the preceding series at an interval of eight days. About 6 per cent, of dysen- teric subjects are still infected after this treatment. Maute is of opinion that it is to the interest of such patients to continue the treatment by emetin and novarsenobenzol .

This is also the opinion of Milian, who employs hydrochloride of emetin and "606" concurrently; of Ravaut and Krolunitsky, who employ arsenobenzol, and of Noc, who employs "' 914," which he regards as a remedy of great utility in improving the general con- dition, superior to the ordinary arsenical compounds.

Despite its incontestable value, hydrochloride of emetin does not always succeed. It has little or no

48 DYSENTERY, CHOLERA, AND TYPHUS

effect on the cysts. ^ In the chronic and refractory forais of amoebic dysentery the physician may profitably resort to the treatment indicated on p. 50.

3. In Cases of Mixed Dysentery, Baeillary and Amoebic. — The physician will successively administer injections of hydrochloride of emetin and of anti-dysenteric serum, and will be guided by the indications already given.

4. {a) When the Results of Examination in the Laboratory are Negative. — Reserving treatment by emetin and serum for serious cases, the physician may resort to the older remedies. There are a certain number of remedies which gave proof of their value in the days when etiological diagnosis was unknown. These remedies may be recommended either as auxiliary to the treat- ments reputed to be specific, or in cases where, for whatever reason, the physician cannot or does not wish to employ the specific treatment. These are : ipec- acuanha, the saline purgatives, calomel, and opium.

Ipecacuanha may be administered in several ways : alone, or in association with other drugs, notably with calomel and opium. Alone, it is given in fractional doses, according to the so-called Brazilian method. It is prepared and administered as follows : — 250 grammes of boiling water are poured upon 4 to 8 grammes of the powdered root ; this is left undisturbed for twelve hours, then decanted; in the same way a second and a third infusion is made, followed by maceration.

Each of these infusions is taken per day, at the rate of a spoonful every hour. The first infusion sometimes

^ Recent researches have shown that a large proportion of cases treated by emetine hydrochloride relapse and become chronic cyst carriers. Oral administration of emetine, in the form of Emetine bismuth iodide grs. iij. nightly for twelve nights — e.g. 36 grains in a course — has been found to be much more efficacious in sterilising cases, and recent reports by Dobell claim 80 to 90 per cent, of cures by this method. Alcresta ipecacuanha has also been tried by Stephens, and Wenyon suggests a combined oral and hypodermic treatment with emetine hydrochloride. — Ed.

TREATMENT OF DYSENTERY 49

causes vomiting, and often numerous stools. The second rarely produces vomiting, but more frequently nausea ; it does not perceptibly affect the number of stools. The third, as a rule, produces no incidental effects.

Saline purgatives^ sulphate of sodium in particular, are in current use. They may be administered until the stools . contain no more mucus and have become fsecal. The treatment commences with 30 grammes of sulphate of sodium, progressively diminishing doses being given day by day, or small doses of 5 to 10 grammes may be administered, repeated several times in the day, until the purgative effect is produced, or 15 grammes may be given for the first two days, and 10 grammes the third and fourth days.

Segond's pills may be tried, their composition being as follows :

Ipecacuanha (pulv. ) . . . 0*05 grammes

Calomel ..... 0-02 „

Extract of opium . . . . 0*01 „

White honey q.s.

To make one pill

These pills should be recently prepared. They are very efficacious. Four to six are to be given daily, the number being steadily diminished as the stools improve. Their employment should be discontinued inmiediately appearances of stomatitis set in.

Calomel has often been employed alone also, the daily dose being 1 gramme to 1 gramme -20, or doses of 30 centigrammes are administered every six or eight hours, or fractional doses hourly. The doses are diminished and the intervals between them increased when im- provement is obtained. Mercurial stomatitis is of frequent occurrence after such treatment.

Opium, by itself, should be employed with reserve, and only as a temporary remedy.

Suppositories of cocaine or morphia ease the tenesmus. Belladonna calms the pains without producing con- stipation, and may therefore be employed, but with

50 DYSENTERY, CHOLERA, AND TYPHUS

prudence. Kho-sam, the oleaginous seeds of Brucea sumatrana, is said to cause the rapid disappearance of dysenteric phenomena (Mougeot, Lemoine).

4. (b) In Cases of Chronic Dysentery. — First of all a purgative should be given (calomel or sulphate of sodium).

The systematic employment of Segond's pills or of sulphate of sodium (10 grammes in the morning) yields good results. It is necessary, however, to supplement these by medicinal enemata.

Manson recommends a brief preliminary treatment with ipecacuanha, preceding the administration of castor oil.

To produce an alternative effect on the ulcerated intestinal surfaces, local dressings have been proposed.

Guido Izar examines the rectum and the sigmoid colon directly, with the aid of an instrument con^ structed by Melocchi, which bears the name of the recto-sigmoidoscope, and which is a happy modification of the endoscope of Desormeaux. He then applies dressings directly to the dysenteric ulcerations, paint- ing them with a 2 per cent, solution of permanganate of potassium, or a 1 per cent, solution of nitrate of silver, or oxygenated water, or powdering them with dermatol, or a mixture of charcoal and kaolin, accord- ing to Ascoli's method. It is manifest that this treatment can only be applied to ulcerations con- fined to the lower portion of the large intestine. It cannot, therefore, be employed in all cases.

Intestinal irrigations or enemata may be administered — a solution of nitrate of silver, 0-5 per 1000, boric acid, 20 per 1000 (Le Dantec), permanganate of potash, 0-5 per 1000 (Gastinel), oxygenated water containing ten times its volume of oxygen diluted with five times its volume of tepid sterilised water (Rocaz), tincture of iodine, 1 per 1000, sulphate of copper, and creosote, 1 or 2 per cent. (Zanardini). These latter are toxic, however, owing to absorption in the region of the ulcerations.

TREATMENT OF DYSENTERY 51

Le Dantec also employs what he calls an irrigation dressing, always preceded by a cleansing irrigation. He employs sub-nitrate of bismuth, 20 grammes to the dose, the bismuth being in suspension in a litre of tepid water ; or else the following mixture : —

Dermatol . . . . .20 grammes

Bicarbonate of soda . . . . 2 ,,

Water ..... 1 litre

The most effectual disinfection for rapidly accom- plishing the destruction of the amoebae and their cysts is obtained by the following enema (H. Vincent), pre- ceded by a detergent intestinal irrigation with physio- logical water (lukewarm) : —

Labarraque's Solution , . 10 to 12 grammea

Nacl ...... 5 ,,

Distilled water .... 1000 „

These enemata may be given daily, drop by drop (by the goutte d goutte method), without pressure, the patient retaining them as long as possible. At first, 20 to 30 drops of tincture of opium may be added.

The enema should be given warm (98-4° to 104° R), very slowly, with the long rectal tube, the patient lying on his right side.

At the same time the patient is given 6 to 10 grammes of sulphate of soda each morning, and during the day a draught consisting of :

Syrup of ipecacuanha . . . 5 to 6 grammes

Extract of opium . . . O'OStoO'lO ,,

Water . . . . . 120 „

a spoonful being given every two hours, no liquid nourishment is to be taken within thirty minutes of taking the dose.

Warming the abdomen by means of the electric apparatus of Laroquette greatly assuages the colics.

The preceding treatments sometimes give rapid recoveries from amoebic dysentery.

52 DYSENTERY, CHOLERA, AND TYPHUS

In patients suffering from chronic dysenteries of amoebic origin, who frequently suffer from malaria as well, the physician must never neglect the simultaneous administration of quinine, preferably by subcutaneous injection. Malarial attacks, even when slight or attenuated, very often cause returns of amoebic dysentery in tropical patients.

PART 77.— THE EPIDEMIOLOGY AND PROPHYLAXIS OF DYSENTERY

As has been noted in the foregoing chapters, dysentery is a syndrome common to several infections. If by dysentery we understand the contagious process characterised by the painful and repeated emission of bloody and mucous stools, determined by the lodgment of a parasite in the large intestine (and sometimes in a portion of the small intestine), we must include, under this heading :

1. Bacillary dysentery.

2. Amoebic dysentery.

3. The dysenteries due to Balantidium coli, Tricho- monas intestinalis, and Schistosoma mansoni ; and, lastly, other forms as well, of a more exceptional kind, such as the dysenteries due to spirilla, to Chilodon dentatus, to Leishmaniasis, etc.

The etiological conditions which govern each of these dysenteries are subordinated to the biological char- acters of their pathogenic germs, their degree of resist- ance in the external environment, and the degree to which desiccation, the oxygen of the air, light, etc., are able to affect them.

All these dysenteries, which in reality differ greatly from one another, none the less possess, when con- sidered from the epidemiological standpoint, a number of fundamental characteristics which form a common link — namely, the fact that their infectious agent vegetates in the lower portions of the alimentary canal ; that it propagates itself in the mucous membranes, the glandular tissue, and the tunicae of the intestine ; that it provokes ulcerative lesions there ; that it is eliminated in profuse quantities with the repeated 53

54 DYSENTERY, CHOLERA, AND TYPHUS

dejecta of the patient ; and, finally, that the pathogenic agent residing exclusively or principally in the faeces always constitutes, whether directly or indirectly, the fundamental agent of contagion.

From our knowledge of the plurality of dysenteries it results that, when considered as a whole, the epidemio- logical rules of these fundamentally different maladies none the less offer a large number of common features. In reality, however, there are two of these various forms of dysentery which, owing to their frequency and their gravity, greatly predominate over all the rest — namely, bacillary dysentery and amoebic dysentery.

These two affections, then, from the epidemiological point of view, as from the clinical standpoint, are those which should more particularly receive our attention. We shall consider them, therefore, in succession.

CHAPTEK I

EPIDEMIOLOGY OF BAOILLARY DYSENTERY

Bacillary dysentery is caused by a special bacillus seen by Chantemesse and Widal, and described in a specific manner by Shiga, then by Kruse, Flexner, Strong and Musgrave, Rosenthal, etc., etc., and finally by L. Rogers, Vedder and Duval, Dopter and Vaillard, etc. It constitutes, in reality, one species of syndrome resulting from different races of the same microbe. At least four groups of these are recognised (see Part I.), excluding the pseudo-dysentery bacilli, which react in a specific manner in the presence of sugars and form, or do not form, indol, and whose other biological characters (agglutination, bacteriolysis, and the specific action of immunising serums) are more or less distinct. We have already discussed these groups.

Bacillary dysentery is a ubiquitous malady. We find it in all countries, in all climates, but it is especially a malady of cold or temperate countries. In this respect it is unlike amoebic dysentery, which is more common in hot climates.

On the other hand, each epidemic of bacillary dysentery seems to possess its own variety of microbe (Shiga). The bacillus of the type discovered by Shiga was isolated in Korea, in the Japanese army, as well as in Manchuria, and also in Russian soldiers at Port Arthur and the sailors of the Baltic squadron.

At the time of the Tokio epidemic this original bacillus was extremely rare, and the bacilli encountered were those of the other races.

In the Kobe epidemic of 1906 Amako found Shiga's bacillus, or its varieties, in all the invaded quarters,

55

56 DYSENTERY, CHOLERA, AND TYPHUS

At the end of the epidemic only the varieties were found.

Shiga's bacillus is rega^rded as the most dangerous, but Flexner's may give rise to very severe forms of dysentery.

Epidemics due to bacilli of the Flexner type are common in the Philippines, the United States, and Porto Rico ; the same bacillus is foimd, however, in epidemics in Central Europe, France, Tunisia (Nicolle and Cathoire), Russia, Algeria, Morocco, India, etc.

In some epidemics bacilli of several races may be found (the Shiga type, the Flexner type, the Y type, etc.).^

In Delhi dysentery due to the Y bacillus is pre- dominant (Kurnen).

In Paris the bacilli isolated are sometimes of the Shiga type, sometimes of the Strong or Flexner types.

During the present war certain epidemics have been reported in Galicia and Russian Poland, in whicli bacteriological examination has in the great majority of cases failed to isolate the germ. In the examination of more than 1000 stools Shiga's bacillus was isolated only six times, Flexner's twice, and the Y bacillus once, nothing being found in the other cases.

Generally speaking, bacillary dysentery is prevalent everywhere in Europe, but more particularly in the Mediterranean basin (Greece, Turkey, Italy, Sicily, Spain, Gibraltar, and Catalonia).

Certain countries, as the north of Italy, for instance, are sometimes visited by serious epidemics of bacillary dysentery. Celli has described the epidemic of Belluno, where, in 1894, out of 5700 inhabitants, 2564 were attacked. Galli-Valerio has published an account of the epidemic in the Valtellina (1897), in which the mortality amounted in certain localities to 20 per cent, of those attacked. In Switzerland a serious epidemic visited Leuk, in 1893 ; it lasted three months, with a mortality of 25 per cent.

^ Morgan's type was also found in cases of dysentery at the Pardanelles, —'^d.

EPIDEMIOLOGY OF BACILLARY DYSENTERY 57

Armand Ruffer and Wilmer have mentioned the serious epidemics of bacillary dysentery which occur among pilgrims who have returned from Mecca. It is estimated that in the vilayet of Hedjaz this malady causes 1000 to 15,000 deaths annually.

The epidemics of dysentery observed in our armies at the front during the present war against Germany have, as a rule, revealed the bacillus of the Flexner type, more rarely the Y type (Bonnel, Joltrain, and Taufflieb), but Shiga's bacillus has also been isolated.

Each of these microbes may therefore give rise to epidemic patches, more or less distinct and of greater or less extent, which may run into one another.

German writers (Kruse and Doerr) are wrong in attributing epidemic dysentery to Shiga's type alone (the other bacilli being said to give rise only to sporadic pseudo-dysenteries). This diSerentiation is invalid. Neither can we admit the existence of a dysentery special to children and lunatics, as Kruse would have it. As a matter of fact, we may find Shiga's or Flexner's bacillus indifferently (Auche).

In France there is an important endemic centre in the departments of Brittany, where certain arrondis- sements have formerly suffered as many as 500 deaths. Dysentery is also found in Champagne, and in the Basse Somme and in the eastern division of France.

The official statistics published by the Ministry of the Interior do not give figures relating to the precise frequency of dysentery in France, as the disease is not subject to compulsory notification.

Dysentery in Armies

The sanitary condition of the army is in general in close relation to that of the civil population. The frequency of dysentery in military circles is, therefore, in accordance with the epidemic or endemic conditions of the garrison towns. It is important to note, how- ever, that the soldier is particularly vulnerable. The

58 DYSENTERY, CHOLERA, AND TYPHUS

statistics of the French Army refer, as a rule, to the sum of the various dysenteries : bacillary, amoebic, etc. It may be affirmed, however, that in France, in time of peace, bacillary dysentery is almost the only form to be met with, excepting a few imported cases of amoebic dysentery, the subjects being colonial soldiers. The average frequency of cases hovers about 1 per 1000, rather below this figure than above it. The region of Lyons is that most affected. Then follow the 18th Army Corps (Bordeaux), the 13th (Clermont-Ferrand), the 10th (Rennes), the Military Government of Paris, the 15th Army Corps (Marseilles) and the 20th.

The Tunis and Oran divisions and the troops in Morocco reveal a morbidity and a mortality which are uniformly higher. But to the cases properly referable to regional influences we must add the numerous cases which are explained by the fact that dysenteric soldiers are sent home from Tonkin, Madagascar, Senegal, etc. : countries in which dysentery is endemic.

The two forms of dysentery, bacillary and amoebic, are found to co-exist in the French possessions in North Africa.

The statistical records of the French Army reveal rather a high proportion of cases, which is due to the fact that they represent the total number of cases reported in Tunis and Algeria as well as in France.

Of all armies that of the United States is most subject to dysentery.

In the French Army the severest forms of bacillary dysentery are observed, as a rule, among the troops in Algeria and Tunis. Certain epidemics (Hussein-Dey, 1894) have been extremely formidable, owing to the frequency of hypertoxic forms with hypothermia and a rapidly fatal termination.

At intervals, for that matter, there have been epidemics of equal gravity in France. G. Bertillon has recorded an epidemic which broke out in July, 1915, in a squadron of dragoons, which yielded 12 cases, of which 5 were of an extremely grave character.

EPIDEMIOLOGY OF BACILLARY DYSENTERY 59

Dysentery shares with typhoid fever and the para- typhoid fevers the peculiarity of attacking armies in the field. It is, however, less frequent than these. It is in a way inseparable from the medical history of

Dysentery in the Wobld's Armies Morbidity per 1000 Men

Army	1903	1904	1905	1906	1907
French	2-34	2-27	1-66	2-38	1-08
German			0-17	0 03	0-10	0-30	0 01
United States			37-71	22-49	16-93	14-47
British			0-80	0-60	0-40	0-40	0-50
AiTstrian .			0-50	0-50	0-60	0-50	0-40
Bavarian .			0	0	0	0-06	0-02
Belgian			0 07	0	0	0 03	0 06
Spanish			0-27	012	0-07	0-05	0-10
Italian			0-30	0-50
Dutch			0-10	0
Russian			0-90	0-50	0-70	0-90	0-70
Rumanian .			0-65	0-90	2-90	0-60	0-70

warfare. In 1415 the English Army, which had in- vaded France, became the prey of a terrible epidemic. After the battle of Agincourt it had to be repatriated, having lost three-fourths of its effectives.

Pringle has recorded the epidemic which raged through the English Army in July, 1743, at Dettingen ; half the soldiers were attacked. The War of the Polish Succession, the Austrian War, and the Seven Years' War were marked by epidemics no less deadly in character.

After the battle of Valmy the troops of the Coalition carried dysentery into Champagne. The Prussian Army, reduced to half its effectives, beat a retreat. At the time of the wars of the Revolution and the Empire, Desgenettes remarked that dysentery had very often killed more men than the fire of the enemy. In Egypt Napoleon lost 2468 men from dysentery.

60 DYSENTERY, CHOLERA, AND TYPHUS

It must be added that in those days dysentery was a disease of extreme gravity, such as is unknown in our time.

At the beginning of the conquest of Algeria dysentery caused as many deaths as malaria, and even more (Kelsch).

It was prevalent during the Crimean War. Between May and September, 1855, 9000 cases and 1478 deaths were reported. During the Italian War it was almost as common as typhoid and malaria.

The War of Secession shows how great the intensity of this malady may be on the occasion of great move- ments of troops. There were 238,812 cases of acute and 25,670 of chronic dysentery among the white troops, with 4804 and 3229 deaths respectively. These figures are very much less than the reality, for an enormous number of cases of acute diarrhoea were recorded (1,155,226), in addition to chronic cases (170,488), which altogether caused 30,481 deaths.

We shall see later that diarrhoea is very often only the abnormal or attenuated expression of dysenteric infection.

The German Army was much harassed by dysentery during the war of 1870-1871. There were 35,652 cases and 2380 deaths due to this malady. The troops be- sieging Metz had an enormous proportion of cases.

The Russo-Turkish War afforded another proof of the intensity of this disease in time of war. Cases of diarrhoea were extremely numerous, very few men escaping it. The statistics record, for the army of the Danube, 34,198 cases (57*75 per 1000) of dysentery, and 9543 deaths (16-11 per 1000). The army of the Caucasus, much weaker in numbers, was visited even more severely : 22,084 cases (90 per 1000) and 3552 deaths (15 per 1000).

During the short Bosnian Campaign the deaths from dysentery for a total effective of 198,000 men were 324. During the Tunis Expedition among 20,000 men there were 3954 cases and 83 deaths from the same disease.

EPIDEMIOLOGY OF BACILLARY DYSENTERY 61

At the time of the Chino- Japanese War dysentery- appeared as soon as the Japanese Army disembarked in Korea. Although the season was winter, the hospitals were overflowing with cases of dysentery. There were 12,052 cases among 200,000 men.

The French Expeditionary Corps sent to China at the time of the Allied Expedition in 1900 had 818 cases and 52 deaths. The American troops (1947 men) had 353 cases in two months.

Among the British troops sent to South Africa at the time of the Boer War there were more than 2500 cases of dysentery.

During the Russo-Japanese War the Russians had 6140 cases and the Japanese 6624 cases.

The Morocco Expeditionary Corps had 1080 cases of dysentery (amoebic) in 1912, and 1295 in 1913 (Job).

The war of 1914 has been no exception to the rule. Dysentery made its appearance among the soldiers of the French Army after the battle of the Marne. Since then it has been encountered continually in the various armies at the front, in France, at the Dardanelles, and at Salonika, sometimes appearing in grave and deadly forms, but more often in benign forms which lead to a prompt recovery.

Remlinger has reported this malady among the French troops in the Argonne. He isolated an atypical and not very toxic bacillus. L. Tribondeau and Fichet have published the results of their investigations as regards dysentery at the Dardanelles. The bacillus most frequently isolated was that of Shiga's type (23 times out of 38) ; the Y bacillus was found twice, and the bacillus of Morgan's type 13 times.

In 1915 a serious epidemic of dysentery appeared among the German armies in Galicia. The death-rate amounted to 16 per cent, of those attacked.

During all the epidemics which have appeared in France, in the civil population as well as in the armies, physicians have drawn attention to the frequency, sometimes excessive, of concomitant diarrhoea. At the

62 DYSENTERY, CHOLERA, AND TYPHUS

time of the epidemic which broke out at Vei-sailles in 1902, in the 1st and 5th Regiments of Engineers, a fourth of the patients suffered from simple diarrhoea. It was the same in 1903 in the case of the 3rd Battalion of Chasseurs at Grenoble.

When the agglutinative reaction is sought for in such cases of simple diarrhoea, it is commonly found to be positive. Job, Braun, and Roussel have often verified this fact.

During the present war against Germany all physicians have noted the frequency of these diarrhoeas, which, bacteriologically speaking, may be laid to the account of the dysentery bacillus (Sacquep6e, Burnet, and Weissenbach).

Consequently, in addition to confirmed cases of dysentery, we must reckon with ill-defined or attenu- ated forms. From the epidemiological standpoint these are extremely important, as they lend themselves with great facility to the propagation of the disease by reason of the fact that, being apparently of little im- portance, they do not seem to necessitate any special precautions.

The chronic forms of bacillary dysentery, and the diarrhoea of children, which may also contain the bacillus in great profusion (Flexner and Strong, Vedder and Duval), are subject to the same remarks. Duval and Basset, during an epidemic, examined the stools of forty-two patients suffering from simple diarrhoea, and found the dysentery bacillus in them. Shiga has reported a similar experience.

Of course, all cases of diarrhoea observed in the armies in the field are not due to the dysentery bacillus. Many are' due to infection by the enterococcus of Thiercelin, to the Proteus vulgaris, or to the polymicrobian vegeta- tion which readily attains an unrestrained development in the case of overworked men. But the dysentery bacillus is incontestably responsible for a great number of those cases of common diarrhoea which are always encountered side by side with the classic dysenteries.

CHAPTER II

ETIOLOGY

The Predisposing Causes of Bacillary Dysentery

Bacillary dysentery exists in all countries and all climates, but, as we have already remarked, it is most commonly met with in cold and temperate countries.

When it appears in cold countries it gives rise with moderate frequency to serious epidemic manifestations. Sweden, Norway, the northern regions of Russia, Kam- chatka, and Denmark have all been visited by epidemics, some of these being of great severity.

But the influence of cold climates is by no means absolute. Here is the proof : if we examine the curve of endemicity among the civil population or in the army in temperate climates, we find that it reaches its maximum, more often than not, during the hot season — that is, in the summer, and, above all, in the autumn.

During great wars, and notably during the present war, dysentery has evaded the influence of the hot season and has been prolonged into the winter. During the Crimean War the French trenches were full of men sick of dysentery during the coldest months of the year.

It was the same during the War of Secession. The months of November and December, 1862, were marked by a great recrudescence of dysentery.

Exposure to cold by day, and above all by night, under canvas and in the trenches, abdominal chills, and the effects of rain, which soaks men's clothes (Cambay ), and the fording of rivers, which has the same result, have been invoked as predisposing causes.

Individual predisposing causes deserve mention. All ages are susceptible ; nevertheless children seem to 63

64 DYSENTERY, CHOLERA, AND TYPHUS

be more often attacked in countries where the disease is endemic, as well as young people who have recently arrived in the country. This is often seen to be the case with young soldiers.

Neither are there any races which are refractory to this form of dysentery. It is as prevalent in the nortlaern regions as in the south of Europe. The yellow race is as frequently attacked as the white race, nor does the black race escape.

Domestic animals^ such as the dog, may contract bacillary dysentery, as has been proved by bacterio- logical examinations.

The predisposing influence of extreme fatigue, and of over-exertion, has justly been incriminated. Wars realise these conditions in the highest degree. It is the same with physiological poverty, a defective diet, coarse and indigestible food, the abuse of biscuits, etc. During the Balkan War the Russian doctors laid stress upon these different causes, notably the consumption of de- composing bread, putrefying food- stuffs, and impure water. To these one must add the inhalation of un- wholesome emanations (from latrines, cess-pits, de- composing corpses, etc.), which cause, as in the diarrhoea of the operating theatre, an irritation of the mucous lining of the intestines, a hypersecretion of bile, and an eliminating diarrhoea ; this irritation prepares the ground for specific infection by the dysentery bacillus.

The protective effect of a previous infection is of great importance. It is well established that a first attack of bacillary dysentery confers substantial im- munity, and this explains why, in countries where dysentery is endemic, it more particularly afflicts children, young soldiers, and new-comers, as, for that matter, does typhoid fever. This immunity is highly effectual, for out of 1000 individuals who had previously suffered from bacillary dysentery, only 3 or 4 were susceptible of contracting it again (Shiga), even when the previous attack had been extremely benign. This explains why an epidemic rarely attacks the same

CAUSES OF BACILLARY DYSENTERY 65

population two years in succession. The usual interval between the great epidemics of bacillary dysentery is ten to twenty years in the same locality. During this interval there has been time for a fresh generation of receptive subjects to spring up.

The army, on the other hand, offers a continuous re- ceptivity, because it constitutes a collectivity which in time of peace is renewed every two or three years ; to it every soldier who has recently joined the ranks brings fresh aliment for an infection against which he has not been rendered immune.

The Determining Causes of Bacillary Dysentery

The bacillus of dysentery may show itself in healthy organisms, unaffected by fatigue, or by conditions of diet, or other factors. The different circumstances already enumerated are, therefore, in reality, only accessories of the infecting germ, which is the sole determining cause of the malady.

Having found its way into the alimentary canal, the bacillus proceeds to localise itself by election in the mucous membrane of the large intestine, and also in a portion of the small intestine, where it provokes the lesions which are special to the malady. The sub- cutaneous or intravenous inoculation of the bacillus into rabbits, dogs, and cats, etc., results in symptoms and lesions identical with those observed in man.

The dysentery bacillus lives exclusively in tht intestine of the patient. 1 It is not found elsewhere (if we ex- cept the bile). It exists in the stools in considerable quantities. The stools, therefore, are the essential and exclusive element of dysenteric contagion.

The most usual mode of contagion is by way of the mouth. Strong and Musgrave caused an Indian con- demned to death to swallow a solution of bicarbonate of soda, and then a culture of bacilli two days' old.

^ Rosenthal, however, has isolated the bacillus from the blood of the heart at autopsy.

E

66 DYSENTERY, CHOLERA, AND TYPHUS

After thirty-six hours diarrhoeal and mucous evacua- tions appeared, streaked with blood ; their expulsion was very frequent (as many as 31 stools in twenty- four hours), and there was meteorism, with abdominal pains.

Cases of accidental infection by the absorption of cultures (Flexner) have been reported. Dodge has recorded the case of a laboratory assistant who, at the end of twenty-four hours, was attacked by an acute dysentery, a small quantity of a culture having flown into his eyes while he was handling a broken tube.

It is easy to understand that the frequency of evacuations, and the abundance at all stages, and especially at the outset, of the dysentery bacillus in these evacuations, greatly favour the spread of the contagion by the dysentery patient.

This is why direct contagion is very common. Hence epidemics in the family, the household, or the village may follow the arrival of a single sufferer. The epi- demic spreads like a spot of oil, successively reaching those about the patient, his relatives, the servants, and the neighbours. In country districts especially con- tagion is easily effected, as the inhabitants, being ignorant of the elementary principles of hygiene, unconsciously expose themselves to the danger of contagion.

Transmission is effected directly by the hands (from the hand of the patient to the hand of the receptive subject), the hands being contaminated by the dejecta, through handling bedroom utensils or slop-pails, body- linen, sheets, etc. From this moment many circum- stances may enable the bacillus to obtain access to the mouth of tiae healthy subject.

In hospitals direct contagion often results in attacks on nurses and students who attend upon dysentery patients, and also on adjacent inmates.

Inter-human contagion operates in the same way in camps, during manoeuvres, and, lastly, in time of war, and the transport of the germ is due to the same

CAUSES OF BACILLARY DYSENTERY 67

mechanism, more particularly to dirty hands. The appearance of dysentery in a cook, or a canteen-keeper, or his assistants, is genuinely dangerous in this respect, as direct contagion is then augmented by other modes of contagion, through a great variety of intermediate agencies.

Hence it is that the dysentery bacillus is so readily disseminated by the dejecta of patients, by dead bodies, and by anything that has become contaminated — water, the soil, etc.

The dog, being susceptible to bacillary dysentery, is also able to conmiunicate the disease to man.

Bacillary dysentery is, therefore, one of the most con- tagious of diseases.

Whatever may be the mode of contagion, whether direct or indirect, the point of departure of the bacillus is always to be found in the faecal matter of the patient or the carrier. The dysenteric patient is contagious from the onset of the disease, from the appearance of the very first symptoms, although these may appear harmless : such, for example, as diarrhoea.

The period of incubation in bacillary dysentery is on an average from two to five days, sometimes a week. The bacilli are particularly numerous in the stools during the initial period.

The disease is contagious during the whole of its course, and it very commonly remains contagious dur- ing convalescence also. There are many examples to prove the role of the convalescent in spreading the germ. Moreover, relapses are sometimes observed several weeks after recovery (Shiga). In such cases, therefore, the bacillus had not disappeared. In 1900 a French soldier, convalescent from bacillary dysentery, was the cause, at Vallorbe, by direct or indirect con- tagion, of twelve cases, with four deaths. Bacterio- logical tests enable one to find bacilli in the stools after the patients have recovered from the disease.

Thus there are carriers of bacillary dysentery, capable of disseminating the dysentery bacillus with their

68 DYSENTERY, CHOLERA, AND TYPHUS

excreta, just as there are carriers of typhoid and para -typhoid fever.

Bacteriological researches show that in some subjects the persistence of the bacillus may continue for three or four weeks, for a few months, or even for a year or more. The proportion of these carriers of germs, temporary or otherwise, is 5 to 7 per cent.

It should be noted that with certain of these carriers the persistence of the bacillus is at the same time be- trayed by a chronic diarrhoea of a dysenteric nature (H. Vincent), which may continue for one or two years. These subjects are extremely active propagators of the virus. It is therefore important to pay attention to these refractory diarrhoeas, which do not always com- mence with the clinical signs of dysentery, with its mucous and blood-stained dejecta.

The existence of germ-carriers who have never pre- sented (or do not appear to have presented) symptoms of dysentery, or even of diarrhoea (Duval, Jehle, and Charleton), has been verified. These carriers have accordingly to be ferreted out, and it will readily be understood how dangerous they are when they follow callings which entail the handling of food, such as those of cook, butcher, milkman, pastrycook, waiter, etc.

Children are frequently disseminators of dysentery.

The prolonged persistence of the dysentery bacillus in certain subjects, sick or healthy, explains the main- tenance of the endemic condition in certain countries, and the appearance of unexplained cases in a village, a house, or a family. Carriers of germs, moreover, suffer from time to time from attacks of diarrhoea, with the passage of abundant stools, which maintain the contagion.

There are, therefore, great epidemiological analogies between dysentery and typhoid fever, the para -typhoid fevers, and cholera.

The bacillus occurs in the gall-bladder of some individuals, but not in all (H. Vincent). If an active culture of Flexner's bacillus is injected into the

CAUSES OF BACILLARY DYSENTERY 69

veins of a rabbit, or under the skin, or into the peri- toneum of the guinea-pig, the bacillus is not always found in the gall-bladder, even when the animal pre- sents the characteristic lesions in the intestine. If the animal is killed at various stages (from eighteen hours to ten days) the bacilli may be found in the gall-bladder (on one occasion it was found after twenty-eight hours), but this is very exceptional. The urine never shows it, but it may be isolated from the spleen and the liver. As a rule it is found in the bile only when the bacilli have been injected into the peritoneum.

In man it has been isolated from the mensenteric glands (H. Vincent).

Amako, having made a bacteriological examination of the bile and the splenic secretion of sixteen indi- viduals who had died of dysentery, was unable to isolate the bacillus.

Further, if the bacillus of Shiga or Flexner is cultivated, in sterilised bile, human or animal, this medium is highly unfavourable. The bacillus does not propagate itself, but generally dies out after a few days (H. Vincent).

Although the bacillus has sometimes been isolated from the human gall-bladder at autopsies, there are certain unknown details which have yet to be cleared up. Does the bacillus form colonies exclusively in the gall- bladder, and if so, under what circumstances ? May it not remain and subsist in the intestinal glands, these becoming the point of departure in the attacks of diarrhoea of which we have spoken ?

Indirect Contagion

To the modes of propagation by contact must be added those by indirect transmission, which also plays an important part in the dissemination of the disease.

Transmission by all kinds of intermediate agents is feasible because the dysentery bacillus is able to

70 DYSENTERY, CHOLERA, AND TYPHUS

survive outside the human organism for a varying length of time.

EHminated with the faeces, the bacillus finds its way into the soil, into latrines, into water-supplies, and contaminates linen, food, etc. It is often trans- ported by the patient himself, who, if he is suffering from a benign form of the disease, moves from place to place disseminating the germ. The most recent cases are the most dangerous, especially in compact bodies, such as regiments, schools, factories, etc. It is the earliest stage which corresponds with the most profuse elimination of the bacilli in the stools. When the disease has continued for some days, the bacilli become rarer.

Disseminated in an external medium, the bacilli are not immediately destroyed. Their vitality varies con- siderably. The bacilli of Flexner's type seem best adapted to survival outside the human body. Those of Shiga's type are far more delicate and frail.

In general, the dysentery bacillus survives longer and more readily in cool and damp surroundings. This is exemplified in the following data.

Vitality of dysentery bacilli :

Damp earth, sterilised . .	13 to 34 days
Dry earth ....	6 ,, 15 „
Garden soil (surface)	6 ,, 15 ,
Garden soil at a depth of 12 inches	34 „ 49 ,
Soil from a heath . . . .	20 „ 31 ,
Dry sand (surface) . . . .	3 „ 4 ,
Damp sand at a depth of 12 inches Dried cultures	29 „ 39 ,
5 „ 7 ,
Cultures in bouillon	20 „ 25 ,
Cultures on agar Dejecta buried in the soil .	25 „ 30 ,
30 „ 90 ,
Dejecta on linen (folded up)	. more than 30 ,

Similar investigations have been made in respect to water, exposed to the action of light or in darkness, and under conditions of greater or less contamination.

A culture of Shiga's bacillus was emulsified in water drawn from the River Vanne and sterilised. A

CAUSES OF BACILLARY DYSENTERY 71

successive series of cultures gave the following results (H. Vincent) :—

■j the outset			94,000 bacilli per cc
"ter 8 hours			77,000 „
„ 24 „			30,000
„ 31 „			29,500 ,
„ 48 „			13,000
„ 72 „			2,000
„ 4 days			850
j» 5 ,,			120
.» 6 ,,			2 to 14

This shows that the disappearance in water is suddenly accelerated after the second or third day.

In impure water the vitality of the bacillus does not persist nearly so long. In impure sterilised water the bacillus disappears in ten to twelve days at 14° to 16° C, and in thirteen days at 1° to 4° C. In water drawn from the Vanne, which contained 220 germs per cc, the bacillus persisted for nine to eleven days at a temperature of 15° to 18° C. In very impure water it survives only two to five days at 22° to 28° C.

If these experiments are made with samples of water unequally contaminated by saprophytic organisms, and kept at a temperature of from 2° to 4° C, in order to prevent the excessive multiplication of saprophytes, we find that the bacillus lives only two to four days, and that its disappearance takes place sooner when the water contains a larger number of common bacteria. These latter are antagonistic to the pathogenic bacillus. The Staphylococcus pyogenes, the Micrococcus prodigiosus, the Bacillus coli, the Bacillus' fluorescens liquefaciens, the Proteus vulgaris, the anaerobic microbes living in water, and the germs of putrefaction, are more especi- ally hostile in their action upon the dysentery bacillus. Even the filtrate of these microbes possesses a deterrent action (H. Vincent).

In ice, and in darkness, the bacillus has been found to survive for forty-one to sixty-eight days.

The action of sunlight is very important. The

72 DYSENTERY, CHOLERA, AND TYPHUS '

bacillus behaves differently, accordingly as it exists in a subterranean body of water, sheltered from the rays of the sun, or in the water of a river or a lake, etc., where the rays of the sun can exert their powerful microbicidal action.

In clear water direct sunlight destroys the bacillus in two to two and a half hours. If the emulsion is rich, so that the water is turbid, the bacillus survives for four or five hours.

In the diffused light of the laboratory it dies in eight days, while in darkness it lives for fourteen days.

Cold, humidity, and darkness are therefore important factors of preservation as regards the bacillus of dysentery. Heat, desiccation, and sunlight, together with the vital competition of saprophjrfces, are, on the contrary, the most effectual natural means of its destruction.

All these facts find their application in the epidemi- ology of bacillary dysentery ; they explain the frequency of the malady, and its persistence in cold climates, the real though limited role of water, the preservation of the germ in the soil under certain conditions, etc.

The receptacles of the dysentery bacillus are, as we have said, very numerous. Latrines, privies, etc., often serve as the connecting link between the sick man and the healthy subject, infection occurring through the medium of boots or shoes, which carry the germ into the house, the kitchen, and the dining-room or mess- room, where it lies on the floor. Finally, the hands may pick up the bacillus.

In armies, in time of peace, and above all in time of war, the cesspits are too often rendered unapproach- able by sloughs of filth in which mud and fsecal matter are mingled, and which serve as reservoirs for the germs. After such a microbic foot-bath a man carries the bacillus with him wherever he goes.

Hence we understand why a first case of dysentery may be followed swiftly by an epidemic outbreak, and there are many examples of regiments which have

CAUSES OF BACILLARY DYSENTERY 73

occupied barracks, camps, or cantonments previously inhabited by men afflicted with dysentery, which have in their turn contracted epidemics, sometimes of a formidable nature.

The soil has the power of preserving the bacillus intact, especially in winter and during the rainy season. In 1890 some troops proceeded to install themselves in the camp of Chalons, and dug the emplacements for their tents in ground where old cesspits full of faecal matter were uncovered. Dysentery had prevailed there the year before. These men contracted dysentery ; the rest of the troops were unaffected. Does this explain why, almost every year, at a given date, we see dysentery reappearing with disheartening persistence in certain garrisons — such as Vincennes and Versailles — and in certain camps — such as Chalons ? As we shall see farther on, flies also play a part in this periodic return of epidemics.

In country districts the contamination of the soil may contribute in the same way, in addition to direct contagion, to the maintenance of epidemic or endemic dysentery.

It seems established that, notwithstanding the rather limited vitality of the dried bacillus, the admixture of the bacillus with dust is capable of propagating dysentery by inhalation. In 1894 a battery of artillery was sent to occupy the camp of Hussein-Dey, near Algiers. In the preceding year there had been an epidemic of dysentery in this camp. After a very violent gale, which raised whirlwinds of dust and sand, and which lasted a week, the men complained that every- thing they ate and drank was full of earth and sand. A very serious epidemic followed, affecting 15 per cent, of their effectives. Their drinking-water, vegetables, and other rations were wholesome.

During the war in the Transvaal the English physicians attributed the epidemic state of dysentery not to the water, but to dried faecal matter, and the sandstorms occurring on the veldt. There is no need

74 DYSENTERY, CHOLERA, AND TYPHUS

to demonstrate the danger of spreading faecal matter on the soil, and of allowing vegetable crops or surface waters to become contaminated with it. The cultiva- tion of vegetables in market gardens by means of this barbarous method of manuring exposes large numbers of persons to the danger of infection.

Cases of contagion by means of clothing worn by patients, their underclothing, sheets, shirts, etc., have been reported. The washerwoman's calling exposes her in a special manner to contagion.

In camps and cantonments soiled bedding-straw may be a factor of contamination.

Contaminated food- stuffs also play a by no means negligible part in the transmission of the disease, whether they have been handled by persons suffering from acute or chronic dysentery, or have been in contact with soil impregnated with faecal matter (as may be the case with vegetables and fallen fruits), or have had the germs deposited upon them by flies.

The contamination effected by persons suffering from dysentery, or by carriers of the germ, is usually due to unclean hands, the patient or carrier having neglected to wash them after visiting the closet or privy. The bacillus survives for thirty days on bread, rice, cooked meat, etc.

In addition to direct contagion, it is an undoubted fact that flies {Musca domestical Calliphora vomitoria, Lucilia ccesar), which carry a large number of infectious agents, play a very important part in the propagation of hacillary dyse7itery. In temperate countries it is at the time of their pullulation — ^that is, during the hot season — that the epidemic curve reaches its maximum. Further, it is easy to realise how great must be the influence of flies when one considers their innumer- able flights, from faecal matter, where they gather the bacilli with trunk and legs, to food- stuffs of every kind — meat, vegetables, bread, milk, pastry, cheese, sweets, etc., which they may also infect with their excrement. If we feed flies (M. domestica) under

CAUSES OF BACILLARY DYSENTERY 75

a sterilised bell-glass on a culture of dysentery bacilli the bacilli may be found in their excreta for four days afterwards. Many of the flies succumb (H. Vincent).

Propagating agents of great mobility, flies bring the pathogenic bacilli from the open air and introduce them into dwelling-houses, into kitchens and dining-rooms, and even deposit them on the skin of the face, especially in the case of young children. They have justly been blamed for the epidemics observed in the Indies, and also during the Spanish- American War, the Boer War, the Manchurian Campaign (Kolosky), and the present war, in which their extraordinary frequency, during the hot season, has been observed.

They may also infect milk. The contamination of milk may further be effected by farm servants afflicted with dysentery (Finny), by carriers of the germ, by its mixture with impure water, or by the employ- ment of receptacles which are unclean and specifically contaminated.

It goes without saying that it is only the drinking of unboiled milk which is dangerous, as boiling in- stantly destroys the bacillus. Even dried milk, cream cheese, butter, and cheese may serve as receptacles for bacilli deposited by flies or by human hands, and will preserve them alive for some days.

It was formerly believed that drinking-water was most commonly concerned in the propagation of epidemic dysentery. This, however, does not appear to be the case — at all events, where the dysentery bacillus is concerned. It is undeniably a fact that the bacillus may be introduced into the organism by means of drinking- water, but it is not so frequently introduced in this way as is the bacillus of typhoid. Shiga has recorded a village epidemic due to water, in which 413 cases were observed. On the other hand, however, a large number of bacteriological analyses of water, made at the very outset of various epidemics of dysentery in the Val-de- Grace laboratory, as well as in local laboratories, have

76 DYSENTERY, CHOLERA, AND TYPHUS

only as an exception revealed the pollution of drinking- water.

During the epidemics observed in the camp of Hussein- De}^ in 1894 and the following years, the water, furnished by an artesian well, was extremely pure. On the occasion of the malignant epidemics which occurred in the garrison of Versailles the water, which was bacteriologically examined on the appearance of the first cases, was irreproachable in quality. The short period of incubation obtaining in dysentery con- firms the complete validity of these examinations.

Similarly Faichnie has reported the occurrence of epidemics in the British Army, although the men were drinking only boiled water and tea.

It may be concluded, then, that drinking-water may cause an outbreak of dysentery, but that it is by no means the most important propagating agent of this disease.

An explanation of this fact is that water is not a favourable medium for the preservation of the Shiga- Flexner bacillus, while it is even less favourable to its vegetation. In water contaminated by numerous germs, as are those waters to which the dysenteric bacillus makes its way, together with all the rest of the bacilli found in faecal matter, and the germs of putre- faction, the bacillus can hardly live longer than two or three days. It quickly becomes rare, and then dis- appears. The saprophytic microbes, aerobic or anaerobic, exert a vigorous competitive action, and are inimical to its survival, especially when the temperature of the water is fairly high, and therefore favourable to their multiplication.

Flexner's bacillus is a little more resistant in water than is Shiga's bacillus. Both are very sensitive to light.

Water becomes polluted in a great variety of ways. These are the same as those described in connection with the etiology of typhoid fever, the paratyphoid fevers, and cholera : the direct discharge of faecal

CAUSES OF BACILLARY DYSENTERY 77

matter in sewage ; the action of rain, which washes the soil and bears impurities along with it ; infiltration into the subsoil ; contamination due to neighbouring cesspools ; the use of faecal matter as manure ; the washing of the linen of dysentery patients or carriers, etc.

In cesspools the antagonistic influence of sapro- phytic bacteria considerably diminishes the vitality of the dysentery germ.

Climatic conditions may mitigate this automatic process of purification in the water, the soil and the sub- soil. Cold, while it prevents the development of sapro- phytes, actually helps to preserve the bacillus of dysentery.

This is an interesting fact, and worthy of record, for it partly explains the persistence of dysentery in northern countries.

In lake waters, where the light is able to act on the germs (the luminous rays penetrating to a maximmn depth of five metres), the superficial strata may be purified, but the deeper levels may remain contagious. The same conditions obtain in the waters of the Durance and the Rhone.

The Spread of Epidemics

Bacillary dysentery may exist endemically, giving rise to isolated cases, but it more often occurs in epi- demics. Then, especially in new countries, it gives rise to nimierous cases, occurring rapidly and over a wide area, attacking a large number of victims simul- taneously. Amongst large collections of people, for example in barracks and schools, where human contact is frequent, the spread of epidemics is often alarming. Every day fresh cases appear — of apparently simple diarrhoea, or of typical dysentery. The epidemic lasts a few days or weeks, and ceases, either because the receptive soil has become exhausted, or because effective prophylactic measures have been taken.

78 DYSENTERY, CHOLERA, AND TYPHUS

In country districts, where the rules of hygiene are ignored, where dejecta are scattered everywhere, and where children maintain the epidemic state by con- tracting attenuated or unrecognised forms of the dis- ease, dysentery is sometimes more tenacious, and may continue for several months. In such epidemics the mortality is high.

This is the case in Japan, where dysentery has been prevalent for centuries, often with disastrous effects. Between 1892 and 1896 it caused 50,000 deaths (Shiga). Between 1890 and 1900 there were 875,534 cases, with 26-39 per cent, of deaths.

When dysentery breaks out in a small village it is not long before it attacks all the receptive subjects (5 to 10 per cent, of the inhabitants in Japan). In the following year there are few cases or none. If the first appearance of the epidemic has been slight or moderate, a more violent return is often observed in the following year. In the third year no cases occur, the inhabitants having become immunised.

In towns dysentery attacks more especially the populous quarters and poor families, in which parents and children live in close mutual contact ; here there are the greatest facilities for contaminating one another.

CHAPTER III

EPIDEMIOLOGY OF AMCEBIC DYSENTERY

The existence of pathogenic protozoa in the intestines of a dysentery patient was proved by Losch, who succeeded in reproducing the disease in the dog, by causing the latter to absorb dysenteric dejecta.

The parasites (Amoeba coli, Losch) reproduce them- selves by division and by the formation of cysts, which give rise to several daughter amoebulse.^

Various apparent species of the dysenteric amoeba have been described : Entamoeba histolytica,^ E. tetra- gena, E. tropicalis, E. nipponica, etc. The first is the most frequent. They are very often accompanied by other parasites : Trichomonas intestinalis, Lamblia, etc. (Simonin).^

As has been said, amoebic dysentery is more especi- ally the appanage of hot and tropical countries. Very common in India, Cochin-China, Tonkin, Sumatra, Java, Madagascar, the Sudan, Central Africa, Egypt, Senegal, etc., it is equally prevalent in South America, Brazil, Cuba, and the Philippines. Tonkin, and above all Saigon, is, for the French troops, a dangerous centre of amoebic dysentery. It is not rare in Morocco.

The admirable work of Osier, and of Councilmann and Lafleur, and the important investigations of Gasser in

^ A. coli dysenterice is a more explicit denomination, as is Entamoeba dysenterke. The latter was proposed by Councilmann and Lafleur. [A . coli dysenteriw, according to the rules of nomenclature, is not a per- missible name, however suitable it may be as a descriptive term. — Ed.]

2 Entamoeba histolytica is the name employed in England at present for the pathogenic amoeba. — Ed.

^ A new non-pathogenic amcBba has recently been described by Wenyon and O'Connor and by Dobell and Miss Jepps. It has been called Entamoeba nana — Ed.

79

80 DYSENTERY, CHOLERA, AND TYPHUS

Algeria, of Marchoux in Senegal, and of Harris, etc., have helped to throw light upon the nature and the modes of transmission of this form of dysentery.

For a long time it was supposed that amoebic dysen- tery could not exist in cold or temperate countries, save as a very exceptional malady, or one affecting subjects infected in the colonies or other hot countries. The discovery of the Entamoeba in a certain number of cases occurring in Russia, at Kiev (Massioutine, Kour- lov), in Prague (H. Lava), in France (Landouzy and Debre, Caussade and Joltrain), and in Spain (Fidel Fernandez Martinez), as well as the more recent dis- coveries made during the present war, in the case of European soldiers infected in the trenches (Ravaut and Krolunitsky, Job, Richet, jun., Rist, Rathery, etc.), has demonstrated the fact that this disease should be looked for, and is perhaps more common than is supposed, in temperate climates. Amoebae have also been found in cases of suppurative hepatitis in Russia, Austria, Paris (Caussade and Joltrain), etc.

Having made their way into the alimentary canal [as cysts], the young amoebulse localise themselves in the mucous lining of the large intestine. This is their seat of election. They may also be found in the vermi- form appendix, where they may give rise to appendicitis (Harris) ; further, they frequently occur in the hepatic parenchyma, where, transported by the veins, they form colonies, giving rise to actual local necrosis, the hepatic abscess. Localisations in the lungs, spleen, brain, and articulations are more unusual.

In the intestine the amoebae find their way into the Lieberkiihn follicles, and then — after the destruction of their walls — into the glandular interspaces, the sub- mucous tissue, the lymphatic spaces, the capillary blood-vessels, etc.

The infection may be conveyed by inoculation to the dog and the cat, and the progress of the parasite may then be followed through the elements of the intestinal walls.

The discovery of amoebae in abscesses of the liver,

EPIDEMIOLOGY OF AMOEBIC DYSENTERY 81

and, above all, in their walls (Rogers), has finally established the relations which Kelsch had stated to exist (basing his statement on clinical observation and pathological anatomy) between dysentery and hepatitis.

The multiplication of amoebse in the walls of the large intestine results in the anatomical destruction of the tissues and the formation of extensive ulcerations of the colon. This destruction is facilitated by additional microbic infections.

The point of departure of the amoebic contagion is there- fore to he found, as in hacillary dysentery, in the intestine of the patient, and, practically, in his dejecta. The latter sometimes contain an enormous number of parasites (amoebae or cysts), especially in recent and acute cases. They are, however, also numerous in the chronic forms, and come from, the intestinal ulcerations and their secretions.

It should be added that when dysenteric abscesses of the liver have found an external opening, usually through the right lung and a bronchial fistula, the para- sites exist in the vomicae, and may, though the case is rather exceptional, be transmissible by this secretion. ^

Unlike bacillary dysentery, which almost always follows an acute development, amoebic dysentery habitually becomes chronic when the treatment opposed to it is insufficient. Bacillary dysentery im- munises the infected subject ; amoebic dysentery does not. It follows from this that in patients suffering from chronic amoebic dysentery the excretion of the parasites is a very long process. But this is not all. In soldiers recalled from Tonkin, etc., and returning to France, the faeces may, after (apparent) recovery, still contain A. coli dysenteries [E. histolytica] or its cysts. Sometimes these patients have, or appear to have, entirely recovered ; sometimes, at irregular intervals, they suffer from attacks of diarrhoea. They are true carriers of amoebae or their cysts. There are even some

^ If this were so it would mean that cysts were formed in these situations. There is no proof so far of such an occurrence. — Ed.

82 DYSENTERY, CHOLERA, AND TYPHUS

who suffer from a return of dysentery after a remission of six or eight months, or even a year (H. Vincent). i These carriers are propagating agents of the dysentery amoeba, through the mediimi of their excreta. Cysts may be found in healthy subjects dweUing in infected countries (Mathis, Ravaut and Krolunitsky).

It is easy to understand how amoebic contagion is effected among soldiers fighting at the front or Hving in cantonments. This is the explanation of the fact that cases occur among soldiers who have never been in the colonies.

In times of peace, moreover, numerous examples of amoebic contagion have been observed on board vessels returning to France with convalescents, healthy subjects, and dysentery patients simultaneously. In a barracks occupied by colonial troops, at Toulon, some soldiers living in contact with comrades who had returned from the colonies contracted amoebic dysentery (H. Vincent).

As the pathogenic agent of amoebic dysentery resides exclusively in the faeces, it is accordingly susceptible of being directly transmitted by the latter.

Immediate contagion^ therefore, is the propagating agent of the amoeba. Instances have been published of contagion in hospital orderlies or persons living in contact with patients suffering from amoebic dysentery (Dopter, H. Vincent, Lemoine). Again, the patient may contaminate those surrounding him by touching articles of food with unclean hands. On the other hand, the absence of precaution on the part of those who are tending the dysentery patient may transfer the germ in the same way.

Experimentally, if young kittens, infected by the rec- tum, are placed in a cage together with other healthy ones, the latter may acquire dysentery by contagion. Female cats, suckling their infected young and licking them, will contract dysentery. A post-mortem examin- ation reveals innimierable amoebae in the large intestine.

^ Low has recently described a case of liver abscess occurring twenty years after the original attack of dysentery. — Ed.

EPIDEMIOLOGY OF AMOEBIC DYSENTERY 83

They are sometimes found in the small intestine as well.

The indirect transmission of A. coli dysenterice [E. histolytica] is rendered possible by the fact that the parasite, although rather lacking in vitality, is yet able to survive by living in the encysted state, thereby re- sisting the natural causes of destruction.

In the ordinary state, not encysted, it is killed in thirty-five minutes at 45° C. (Marchoux) by gastric juice, acids, antiseptics, etc. Urine, even when neutralised, destroys amoebae (Harris). Boric acid does not appear to have any appreciable effect, but osmic acid and sublimate instantaneously arrest the amoeboid movements. Experiments made with recent stools of dysentery patients have given the following further results : — Solutions of permanganate of potash act feebly on Entamoebge ; solutions of tartaric acid, citric acid, oxalic acid, and more particularly of tannin, and oxygenated water, kill them rapidly (Harris). Neutral hydrochlorate of quinine [Quinine bihydro- chloride], even in very minute quantities, in a solution of 0-50 gr. to 1 c.c. of water, placed at the edge of the cover-glass, has an overwhelming effect. The amoebae become instantly retracted, forming unrecognisable masses. They are quickly killed by Labarraque's solution (5 or 10 per 1000), less quickly (in one to five minutes) by a solution of methylene blue or by neutral red (H. Vincent).

The amoeba of dysentery, however, resists desiccation, thanks to its property of forming cysts. It is not always destroyed by freezing (Kiinen and Swellengrebel). If kittens are made to swallow fresh dysenteric dejecta they do not contract the disease, but if the dejecta are allowed to dry the parasites have time to become encysted, and the animals acquire the disease. The cysts resist the gastric juice, but in the small intestine their envelope is dissolved by the alkaline secretion of the latter, and on reaching the large intestine they proceed to multiply.

84 DYSENTERY, CHOLERA, AND TYPHUS

This explains why the dysentery amoeba is able with impunity to traverse the stomach, despite the presence of the gastric secretion, to which it is susceptible, as to all acids.

Its transmission by means of food- stuffs, fruits, vege- tables, etc., contaminated by the spreading of manure, is therefore possible. Flies are probably capable of transporting it by means of their legs or their dejecta, and there is room for further investigation in this direction. 1

It has sometimes been suggested that contagion may be effected by means of the seats of closets, or rectal catheters or thermometers which have not been dis- infected.

Another fact of great importance is that the patho- genic amoeba, above all in the encysted state, is capable of survival for at least nine to thirteen days in water, such as well-water, ditch-water, or the water of ponds, where it is able to enjoy a certain amount of obscurity. It has not been observed that it multiplies there, but the fact of its survival explains the frequent transmission of dysentery by means of polluted water. It is possible that the amoeba is able to multiply in muddy places, for when in the human intestine it is able to feed on bacteria as well as on the corpuscles of the blood. ^ The dysentery amoeba is, therefore, enabled to resist a certain number of natural causes of destruction owing to its property of becoming encysted.

One of the best established and most frequent modes of propagation of the amoeba results from the absorp- tion of polluted water. It has been noted that this parasite subsists in water. Long ago Leon Colin in Algeria, H. Blanc in Abyssinia, Lalluyaux d'Ormay in Cochin-China and Barailler in Guadeloupe called atten-

^ Vide Wenyon and O'Connor's recent experiments, and the work of J. G. & D. Thomson in Egypt.— Ed.

* There is no evidence of this. The living amoebae quickly die when they leave the body. So far they have never been cultivated. It is by the cysts that propagation takes place. — Ed.

EPIDEMIOLOGY OF AMOEBIC DYSENTERY 85

tion to the important part played by drinking-water in the etiology of dysentery. In Guadeloupe it was re- marked that while the water of the River Dugommier was productive of dysentery, the water of the tanks and cisterns was not. A. Calmette has noted that the epidemic of dysentery which prevailed in the arrondisse- ment of Loctrang, in Cochin-China, disappeared when water filtered by Chamberland filters was provided. In the Dutch Indies the employment of purified water has yielded equally favourable results.

Serious epidemics of dysentery used formerly to be observed on board warships, which were attributed to the drinking of water drawn from the rivers of the Far East, particularly in Saigon and Hong-Kong.

Amoebic dysentery is thus almost always associated with a defective hygiene or a bad food-supply. It is observed among the poor populations of hot countries, and in soldiers suffering from sea-sickness and im- properly fed, or who do not observe any precautions.

It is a malady of all seasons, but is nevertheless more common in summer. It is, according to Harris, less frequent in children than in adults.

All the epidemiological data which have just been given apply equally to the suppurative hepatitis of hot countries, which is nothing but a hepatic dysentery. The history of hepatic abscess is, indeed, as closely bound up with that of dysentery as is the history of orchitis with that of mumps. The geographical distri- bution of the two diseases is the same,^ and the fre- quency, or even the mere existence of hepatic abscess in a district enables one to affirm the presence of amoebic dysentery. This is why suppurative hepatitis, so often observed in hot or tropical countries, is very exceptional in cold or temperate countries, where bacillary dysentery is, on the contrary, predominant, if not exclusive.

Even before the discovery of Entamoebse in the walls of the abscess (Dock, Osier, etc.), the specific nature of

^ Though this is so, some parts of the tropics show many more cases of liver abscess than others. India for example. — Ed.

86 DYSENTERY, CHOLERA, AND TYPHUS

the latter had been affirmed by Kelsch, and also by Laveran, Netter, and Peyrot, Marchoux succeeded in causing amoebic abscesses by injecting pus from dysen- teric abscesses into the portal vein of a cat.

Amoebic hepatitis is most frequently preceded by a characteristic or ill-defined dysentery. In certain cases, however, the abscess of the liver may precede the dysentery, or may even occur in the absence of any appreciable condition of dysentery. The hepatitis then represents the primary localisation of the amoeba, but its initial penetration by way of the intestine, and thence through the portal radicles, does not appear to be in doubt. ^

We have yet to speak of mixed cases of dysentery — ^that is, cases where the subject is infected simul- taneously by the bacillus of dysentery and the Entamoeba dy sentence [E, histolytica]. The first discovery of these dysenteries, which we shall call amoebo-bacillary dysenteries, was made by Strong, in the Philippines and the United States. Having examined 246 cases of dysentery in the Philippines, he found that 193 were amoebic, 50 were bacillary, and 3 were mixed.

While the present war against Germany has enabled us to verify cases of autochthonous amoebic dysentery in IVance, it has also afforded opportunities of observing cases in which the patient was infected simultaneously with bacillary and amoebic dysentery. In August, 1 91 5, P. Ravaut and Krolunitsky described a mixed epidemic, sometimes attacking men belonging to the colonial or Morocco regiments, and sometimes soldiers of all ages who had never left France, but who had been living in contact with the former, or occupying the same trenches.

Roussel, Brule, Baral, and A. P. Marie have made bacteriological observations similar to those of the above-mentioned writers.

It is as well to be aware of the existence of these

^ Autopsies certainly bear this out, signs of ulceration, old or recent, being present in the large intestine. — Ed.

EPIDEMIOLOGY OF AMGEBIC DYSENTERY 87

amoebo-bacillary cases, although they are not very common as compared with the individual cases of bacillary or amoebic dysentery.

There are also, for that matter, unconnected with the circumstances of warfare, epidemics in which sometimes the dysentery bacillus and sometimes the Amoeba coli dysenterice \E. histolytica] are encountered in members of the same group of people. Strong and Musgrave found that out of 1328 cases of dysentery occurring among the American troops under treatment in No. 1 Reserve Hospital, in Manila, in ten months, 561 were of the amoebic type, while 766 were bacillary.

Nevertheless, the fact remains that cases of mixed dysentery may be observed, and this is a point of great interest from the epidemiological and prophylactic as well as from the therapeutical point of view.

There are other affections which enter into the dysenteric syndrome, but which, by reason of their rarity, have not the great importance of the diseases already discussed.

In their writings on dysentery Councilmann and Lafleur were the first to express the opinion that dysen- tery is not a single disease, but " that there are dysen- teries just as there are broncho-pneumonias." Although very greatly predominant, bacillary dysentery and amoebic dysentery are not, properly speaking, the only forms of dysentery. Balantidium coli (Strong and Musgrave), Chilodon dentatus (Guiart), Schistosoma mansoni, a special spirillum (Le Dantec), and kala-azar parasites (Leishman-Donovan bodies), etc., may give rise to an acute or chronic colitis, which is closely analogous to the classical form of dysentery.

The truth is that the living organism cannot oppose infecting germs by an unlimited number of reactions.

Balantidium coli exists in great profusion in the ulcerations and the walls of the large intestine of the sufferer, as well as in his evacuations. Its vitality out- side the living organism is increased by its power

88 DYSENTERY, CHOLERA, AND TYPHUS

of becoming encysted. The cysts (80/x to lOO/x in diameter) are formed more particularly under the influence of desiccation. This ciliate, when not in the encysted state, is very fragile, and sensitive to acids (even when diluted to a strength of 1 in 1000), to quinine (1 in 1500) (Klimenko), etc. It may live for three days in water.

Common enough in the pig, Balantidium coli is probably transmitted by the latter, or else by the de- jecta of patients suffering from this form of dysentery ; but only when the parasite has assumed the encysted form, which protects it against the action of the gastric juice. The Balantidian form of dysentery is observed more particularly among pork butchers.

Attempts at experimental inoculation of animals have, however, failed (Manson), and such experiments have also failed even with human subjects, despite the existence of cystic bodies (Grassi and Calandruccio).

The existence of Chilodon dentatus has been noted by Guiart in the dejecta of a patient exhibiting a dysenteric syndrome. 1 Billet considers that Trichomonas intes- tinalis ma}^ also produce an analogous disease. He has observed four cases of this kind. Bilharziasis, accord- ing to Manson, is transmitted by the embryo of the Schistosoma, which, having reached the water, finds its way into the body of a fresh-water animal, and through the medium of the latter enters the human host. Drinking-water is thus the infecting agent in Bilharziasis. 2

* As already pointed out, vide page 29, Chilodon dentatus is a free living protozoon and not parasitic. It can be found in ordinary water taps. Its occurrence in Guiart's case must then have been purely accidental, from some water contamination. — Ed.

2 Leiper has recently demonstrated in Egypt that the bilharzial miracidium passes into a mollusc. After having developed in the tissues of the snail, cercaria appear and escape into the water. From there they pass directly through the skin of the human host, and so bring about the infection. Wading or bathing in infected water is very dangerous, and will speedily result in the acquisition of the disease.

Schistosoma japonicum infections are brought about in the same way. — Ed.

CHAPTER IV

PROPHYLAXIS OP BAOILLARY AND AMCEBIC DYSENTERIES

Bacillary dysentery and amoebic dysentery present a large niunber of common etiological factors.

The prophylaxis of the two diseases accordingly comprises rules which are applicable to either. All disorders of intestinal determination may, from this point of view, be classed together, and the prophylactic measures recommended in the case of cholera will equally apply here.

Among the measures which bear upon the favouring causes, the medical officers of the navy and colonial physicians especially recommend the avoidance of chills in the abdomen in those countries where dysentery is prevalent. One should certainly not disdain the influence of " secondary " causes, and supervision should be exercised over the diet, which in times of epidemic ought to be wholesome and simple and free from indigestible material.

The abuse of biscuits, and preserved meats, and the absence of fresh food have been incriminated, in time of war (the Crimean and Balkan wars), as factors which irritate the mucous membranes of the digestive tract and cause indigestion. The diarrhoea known as " trench diarrhoea " may, as a matter of fact, be due to various germs : enterococcus, Proteus vulgaris, etc., as well as the dysentery bacillus.

The general cleanliness of dwelling-houses, barracks,

privies, latrines, etc., and their surroundings, is

evidently a condition favourable to proper hygiene.

In working-class dwellings and poor quarters it should

89

90 DYSENTERY, CHOLERA, AND TYPHUS

be seen that this condition is fulfilled, as well as that of individual cleanliness, and it is important to combat alcoholism and take measures to prevent physiological want and over-exertion, which are predisposing factors of infectious diseases.

Microbic or parasitic prophylaxis ought to include the compulsory notification of cases of bacillary or amoebic dysentery, owing to the gravity of these diseases, the frequency of epidemics, and the excessively contagious nature of the germ.

This is why the isolation of patients attacked by bacillary dysentery must at once be effected. The evolution of this malady is generally brief (although chronic forms exist), which may facilitate this measure.

Further, it is necessary to take precautions in respect to convalescents and subjects who are or may become carriers of the germ. Consequently recourse to the laboratory is an indispensable part of the rational prophylaxis of dysentery. In the army these labora- tories, which in time of peace already existed in each regional division, have rendered great service in the early diagnosis of infectious diseases and in hunting out carriers of bacilli. Similarly, in time of war the laboratory of the army corps or army should be con- sulted as to the exact diagnosis of dysenteries.

Whatever the pathogenic agent may be, the dejecta are certainly the medium of its propagation. It is therefore necessary to disinfect them as soon as emitted, by means of creosol, lysol, or a 5 per cent, solution of copper sulphate, a little hydrochloric acid being added to this last if needful. Sulphate of iron is not an efficient antiseptic.

Latrines, cesspits, and their approaches, in camps in time of war, should be generously sprinkled with chloride of lime, once a day in winter, twice a day in summer. The installation of the water-carriage system of drainage in barracks is a measure of the greatest utility.

Laboratory examinations should be made, not only in

BACILLARY AND AMCEBIC DYSENTERIES 91

those cases of dysentery which are characteristic in their clinical aspect, hut also in ill-defined or attenuated forms of the disease, in cases of benign diarrhoea, and in the sporadic cases which are the forerunners of an epi- demic and which are very often due to the specific agent of the disease. During the course of the epi- demic these merely diarrhoeal forms are no less con- tagious. It is therefore necessary to take the same precautions as to isolation and disinfection where these are concerned, and to give the patients due attention.

Everything that may have been contaminated by the dejecta is dangerous. It is therefore as well to warn the patients themselves of their contagious condition.

The bacteriological analysis of drinking-water should be made immediately upon the appearance of cases of dysentery, whether in town or in country, or in houses where wells are the source of supply. The same measure is obviously to be applied to soldiers, who must be forbidden to visit taverns and public-houses where non-purified water is served.

It must be remembered that amoebic dysentery in particular is very frequently due to the employment of contaminated water or food. Water should, therefore, before use, be sterilised by boiling or filtration, and vegetables and fruits should be cooked.

All the prophylactic measures which have just been mentioned are of particular importance in time of war, when the incessant contamination of the soil, sub-soil, and water supplies, the frequent presence of germ- carriers, and the inactivity obtaining in cantonments, and, above all, in the trenches, result in exposing the soldier to constant contagion. The prophylactic measures taken should accordingly be particularly stringent, for the dysentery which visits armies in the field is often of alarming gravity. The medical officer should pay special attention to the cleanliness of latrines, etc., their rigorous and repeated disinfection,

92 DYSENTERY, CHOLERA, AND TYPHUS

the elimination of dung-hills, the scavenging of roads and water-courses, the filling in of depressions in the soil and the systematic destruction of flies, those dis- astrous carriers of disease germs.

As regards human germ-carriers, we know that the carriers of dysentery bacilli do not retain these microbes very long. Such individuals should be isolated and subjected to intestinal disinfection. Those who are chronic carriers of amoebae may efficaciously be treated by a daily enema of Labarraque's solution (8 or 10 per 1000), preceded by an ordinary enema to produce evacuation (Vincent). ^

Military patients are often dilatory in presenting themselves for examination, fearing to be placed on diet, or hoping to avoid being sent to hospital. In this way the pathogenic bacillus very quickly spreads through the barracks, cantonments, camps, or trenches. It is therefore necessary, directly the first cases make their appearance, to request the men, by means of notices and by word of mouth, to consult the medical officer immediately any suspicious symptoms appear.

The clothing belonging to dysentery patients, and carriers of germs, especially their underclothes (vest, shirt, and pants), with trousers, sheets, etc., should at once be sent to the oven for disinfection.

Healthy subjects, and those who are tending the sick, as well as carriers of germs, should wash their hands frequently, especially when they have to handle articles of food.

The careful washing of the hands before meals should be recommended, in order to prevent the propagation or ingestion of the dysentery bacillus or amoeba. As regards the amoeba, the hands must be washed if they are soiled with earth, mud, filth of any sort, or vegetable

^ The antiseptic enema should be administered warm (98 -4° F. ), drop by drop, very slowly, the subject lying in the right-hand dorso-lateral decubitus.

[Such injections probably never reach the caecum and upper parts of the colon. If the dysenteric ulcers are situated there they can have no effect upon them. — Ed.]

BACILLARY AND AMCEBIC DYSENTERIES 93

refuse ; lastly, and above all, if there Has been any contact with a dysenteric patient.

In civil or military hospitals the various measures relating to the sick and their personal effects are easily taken. It is otherwise in the case of poor families and in country districts, the ignorance of the inhabitants in respect of the rules of prophylaxis being absolute. This explains the prompt diffusion of the bacillus of dysentery. Sanitary or medical officers should visit such districts and give practical advice to all the inhabitants.

As regards permanent camps, we cannot too strongly insist that they should be situated on high ground, on a sloping surface, and that all roads, as well as the ground on which the tents or huts are erected, should be made impermeable. Flagged or tarred surfaces will be found extremely serviceable.

If an initial case of dysentery occurs the patient must be immediately isolated. His effects and his bedding must be disinfected ; the tent should be struck, the canvas disinfected, and all straw bedding burned on the spot. The patient must never be tended on the spot, but must be sent into hospital.

Dejecta are usually received by the soil (cesspits), or by portable tubs. It would be preferable, in perma- nent camps in time of peace, to install water-carriage systems of drainage, or to destroy all dejecta by means of heat, in special destructors such as have been pro- posed for the purpose ; but these measures have not yet been adopted.

Consequently, sites must be avoided which have previously been occupied by soldiers suffering from dysentery. It has been reconmiended (at the camp of Chalons) that infected emplacements should be ploughed up and cultivated.

The latrines and their approaches should be lit at night, and the deposition of dejecta elsewhere than in these places must be strictly prohibited.

Contamination of the soil by the accumulation of

94 DYSENTERY, CHOLERA, AND TYPHUS

excrement is to be avoided. If cesspits are employed they should be as far as possible from kitchens and mess-rooms or tents, as well as from stables or horse- lines ; and they should not be situated in a quarter of the camp from which prevailing winds blow. When the cesspits are filled and their contents covered up after disinfection, their position should be indicated by a sign-post.

Depressions in the soil in the neighbourhood of kitchens, tents, huts, etc., should be filled up with rubble, clinkers, etc. Measures should be taken to prevent the accumulation of stagnant water, kitchen refuse, dung-hills, manure-pits, etc. — in a word, any- thing that may attract flies and harbour pathogenic germs.

Soldiers suffering from dysentery or diarrhoea, and recognised carriers of dysentery bacilli or amoebae, must be strictly forbidden to enter the kitchens and must on no account assist in the preparation of food.

Cooks, butchers, pork butchers, pastry-cooks, dairy- men, etc., who are suffering from dysentery or are carriers of germs, are active and almost always un- recognised propagators of the disease.

In times of epidemics, or in hot countries where amoebic dysentery is prevalent as an endemic disease, it must be remembered that flies often carry the germ. Accordingly, kitchens, dining-rooms, and mess-rooms, etc., should be provided with screens of wire gauze fitted into the windows and over the doorways ; these will exclude the flies. Food must be protected by means of dish-covers or covered with clean napkins.

The destruction of flies may be effected by means of fly papers or catchers (adhesive or poisonous), or fly- traps, or by placing on the tables, at night, plates con- taining ordinary beer, with the addition of ^th part of formalin. This mixture is a perfect fly-killer.

During epidemics the use of raw vegetables (radishes, salads, etc.), and fruits is to be forbidden, as these may have been contaminated by faecal matter, either by the

BACILLARY AND AMCEBIC DYSENTERIES 95

hands of germ-carriers or by flies. In the army the medical officer should supervise the bill of fare of each company.

During the Manchurian War the Japanese derived some advantage from the daily employment of creosote pills as a preventive.

Preventive serotherapy affords protection only for a limited number of days (ten to fifteen at most), and consequently is not a practical measure. It is not to be recommended, especially as regards large bodies of men. It might be employed in families.

Active immunisation by means of cultures derived from dysentery bacilli has not up to the present become a matter of current practice. Shiga made experiments in the vaccination of animals. He mixed dead cultures with an anti-dysenteric serum, and, having sensitised them, injected them into a rabbit ; the latter was then able to receive non-sensitised vaccine, and then the living virus.

Having vaccinated himself, Shiga reported a consider- able degree of painful oedema at the site of the injection, with fever, severe headache, etc., lasting for several days.

Between 1898 and 1900 he vaccinated 10,000 Japanese by means of dead cultures, first sensitised and then not sensitised. The dose first injected was half a platinum loopful of a culture twenty-four hours old, sown on agar. Four days later he injected twice as much, not sensitised. The injection was made into the cellular tissue of the lumbar region.

The only result of this experiment was the diminu- tion of the death-rate, which, among the vaccinated, fell to 0. But the morbidity was little affected.^

Castellani has practised vaccination against bacillary dysentery, mixing anti- dysenteric vaccine with anti-

^ Animals may be more readily vaccinated against the dysentery bacillus than man. In mice immunity is obtainable in 40 to 50 per cent, of cases ; there is first a phase of sensitiveness as regards the virus, and then a phase of immunity, lasting from four to six weeks (Dopter).

96 DYSENTERY, CHOLERA, AND TYPHUS

cholera or anti-typhoid vaccine. This writer considers that anti-dysenteric vaccine should be prepared with several races of bacilli. Cultui'cs made in bouillon yield an extremely painful and troublesome vaccine. He consequently employs cultures on agar or in peptonised water, sterilised by means of carbolic acid.

J. D. Thomson has investigated the same subject at the Lister Institute. Anti-dysenteric vaccine prepared by heating or sensitising was found to be toxic and painful. Heating does not diminish its toxicity, and, according to Thomson, destroys its property of causing the formation of the specific sensitiser. He prefers vaccine sterilised by carbolic acid.

Dean and Adamson have proposed the preparation of a non-toxic heated vaccine, treating it with equal parts of eusol (1 in 500), and a solution of an alkaline hypochlorite ; this eliminates its toxicity by oxidation.

Two injections of the bacilli thus treated are made (100,000,000 at the first injection ; then, ten days later, 800,000,000; and a third injection of 200,000,000 of bacilli which have been exposed to heat).

ASIATIC CHOLERA

o

PART /.—CLINICAL SURVEY CHAPTER I

SYMPTOMATOLOGY

The term cholera denotes a syndrome the principal characteristics of which are an extremely abundant gastro-intestinal flux, accompanied by algidity, vomit- ing, and cramps (Asiatic cholera, Cholera nostras, Stibial cholera. Cholera infantum, Chicken cholera, etc.).

The endemo-epidemic malady whose specific agent is known as the cholera vibrio, or, by reason of its usual form, the "comma bacillus," will alone be considered here.

There is not one single cholera vibrio, but various races of cholera vibrios, which possess characteristics of their own, and these characteristics sometimes present considerable differences.

Their pathogenic action in man is clinically uniform, and gives rise to a series of symptoms which may be divided, schematically, into four periods :

1. The period of incubation.

2. The initial period, or period of invasion.

3. The choleraic period, or attack.

4. The period of reaction.

1. The Period of Incubation. — The Constantinople Conference adopted the opinion that this period does not, in the majority of cases, exceed a few davs. In reality its duration is variable. According to Thoinot, it varies between a minimum of a few hours and a maximum of five or six days ; it may, however, exceed this.

99

100 DYSENTERY, CHOLERA, AND TYPHUS

2. The Initial Period, or Period of Invasion. — Diarrhoea is the dominant symptom of the period of invasion. In temperate countries it is observed in two cases out of three (Guerin) ; in hot countries it is rarer, the disease often commencing at the first onset with the choleraic period.

This diarrhoea, known as premonitory diarrhoea, usually appears at night (Jaccoud).

The stools, faecal, liquid, green, or the colour of cafS au lait, or sometimes simply serous, possess no particular characteristics. More or less abundant and frequent, they are accompanied neither by straining nor tenesmus. The patient suffers from loss of appetite, flatulence, borborygmi, lassitude and intellectual torpor. The tongue is like that of indigestion, and there is a pronounced thirst. Sometimes certain nervous pheno- mena are observed (vertigo, severe headache, palpita- tion, faintness, lassitude, and epigastric pains). These symptoms may persist for a few hours only, or for as long as a week, or more usually they last from twenty- four to seventy-two hours (Thoinot). They then sud- denly give way to the choleraic period, or attack.

3. The Choleraic Period, or Attack. — The attack usually occurs at night. It comprises two phases, which are plainly distinguished from one another :

A. The initial phase of evacuation, the principal symptoms of which are diarrhoea, vomiting, cramps, change of voice, and alteration in the general appear- ance of the sufferer.

B. The algid phase, which gradually sets in during the course of the foregoing phase, and which, when it is established, is characterised by various derangements, affecting more especially the production of heat, the circulation, respiration, phonation, secretion, absorp- tion, etc. — derangements which give rise to the striking and characteristic appearance of the cholera patient.

A. Phase of Evacuation, — Diarrhoea. — " Without diarrhoea there is no cholera " (Thoinot). Yet cases

SYMPTOMATOLOGY 101

have been recorded, very rarely, it is true, of dry cholera — that is, cases in which death occurs with great rapidity, before there has been any evacuation from the intestine.

If the attack has been preceded by the so-called pre- monitory diarrhoea, the stools immediately assume a different aspect.

If, on the other hand, the onset occurs without pre- monitory symptoms, the intestine is emptied of its faecal contents by two or three stools, and the choleraic stools make their appearance.

The typical choleraic stools are serous, liquid, opaline, or greyisjh white, resembling whey. They hold in sus- pension whitish flakes comparable to grains of rice, whence the name of rice-form or rice-water stools by which they are known.

These rice-like grains consist of masses of desquam- ated epithelium, leucocytes, and amorphous debris, resulting from the necrosis of the epithelial cells, and lastly of cholera bacilli, sometinies in enormous numbers.

After centrifugalisation the superincumbent liquid contains a small proportion of albumin.

Sometimes the alvine evacuations are green and bilious, with or without rice-like grains ; more rarely they are red, sanguinolent, and dysenteriform in appear- ance, resembling meat-scrapings (Petit, Lesage). In exceptional cases they may consist of a thick mucus, like a thick white soup, or starch paste. Their odour is stale or' imperceptible ; never faecaloid. Their reaction is alkaline, rarely acid (Nanu). According to Lesage the stools are at first alkaline, but may become neutral and then acid if the disease persists, and especially if algidity is present. They contain 98 to 99 per cent, of water, little or no albumin, mucin, urea, phosphates, sulphates, etc. They are rich in chloride of sodium and indican. When pure sulphuric acid is added to the stools they assume a characteristic red colour, a true nitrous reaction revealing the presence of indol, known as the " cholera red reaction " (Netter).

The evacuations are very nvimerous, occurring every

102 DYSENTERY, CHOLERA, AND TYPHUS

ten or fifteen minutes, sometimes even more frequently, without tenesmus, without effort, involuntarily in serious eases. Although their volume does not exceed forty to fifty centilitres their repetition results in a loss of six to seven litres of liquid in the twenty-four hours (Lorain). The evacuations are less numerous when the cramps become strongly developed ; they even dis- appear completely in serious conditions of algidity.

Vomiting. — Vomiting is less constant and less fre- quent than the diarrhoea which it immediately follows ; it occurs in nine cases out of ten. When it is not pre- sent the patient suffers from nausea and eructations : alimentary at first, the vomit becomes bilious, yellow- ish, or porraceous, with an acid reaction.

Occasionally the vomit is serous, neutral, or alkaline, holding grey clots in suspension, when it rather resembles the rice-water stools. In this case it is known as rice-water vomit. Sometimes easy, profuse, and emitted without effort, in other patients vomiting is, on the contrary, difficult, scanty, painful, and even convulsive. It may be accompanied by obstinate and persistent hiccough, and gastric cramps of varying intensity, which are increased by pressure (Gaillard, Lesage). These are often provoked by the ingestion of hot drinks, which the patient tolerates less readily than cold or iced ones.

By reason of the enormous loss of water which they cause the patient, the diarrhoea and vomiting set up a violent and insatiable thirst : six litres or more of liquid are insufficient to assuage it (Thoinot). For the same reason, the mucous membranes of the mouth and tongue become parched and dry. The abdomen, usually soft and yielding, supports palpation without pain, and this palpation causes, above all in the right iliac fossa, a distinct gurgling, as of large air-bubbles, a true splashing sound (Thoinot). Sometimes, how- ever, the abdomen is painful and retracted. There is a complete absence of appetite, and the urine is scanty ; while anuria is frequent.

SYMPTOMATOLOGY 103

Cramps. — ^The muscular cramps, which are rarely absent, may be observed in patients whose diarrhoea is not profuse, and even before the appearance of the intestinal flux (Barth, Babinski). They may occur in all the muscles, even the diaphragm (Colliard). They appear first in the muscles of the calf, and then extend to the feet and the hands. In very serious cases they may reach the face, the abdomen, and the thorax. They are rarely generalised. They are spontaneous, and provoked by the slightest exciting cause. Babinski has shown that in cases in which spontaneous cramps are rare or lacking (slight cases, during the abatement of the choleraic period) they may always be provoked by the application of a current of electricity frequently interrupted.

The muscles affected are contracted (Quinquand), hard and rigid, forming distinct prominences under the skin. The pain caused by these cramps is usually violent, and is sometimes absolutely unbearable.

From the commencement of the attack the voice undergoes modifications ; its timbre changes, and it grows shrill and hardly audible ; the patient's voice has " broken " ; the face is emaciated and purplish ; the nose is pinched, the eyes sunken, with rings beneath them, and the skin is dry. The temperature, which, at the outset, may have been from 100° to 102° in the rectum and axilla, falls in a little while to 98-4°, 97°, 96°, etc., in the axilla, while it remains stationary in the rectum. The patient's extremities grow colder, and the diarrhoea diminishes or even disappears. The algid or cadaveric phase is now commencing, with the various disorders which accompany it.

B. Algid Phase. — Disorders of Heat Regulation. — After the slight febrile derangement of the initial period hypo- thermia makes its appearance. The algidity is mani- fested more particularly in the region of the extremities ; it is readily appreciable to the touch. Magendie has noted temperatures of 64-4° and 69-8° at the feet ; Lorain has shown that the buccal temperature may fall

104 DYSENTERY, CHOLERA, AND TYPHUS

as low as 77°. The axillary temperature is less reduced ; it is usually between 95° and 98-6°, but has been known to fall to 91*4° (Lorain). The internal temperature bears no relation to the peripheral temperature. Taken in the rectum, it may be subnormal (93-2° Lorain ; 89-6°, Galliard ; 86°, Hayem), normal, or at times even febrile (104°, Manson ; 104-4°, Hayem ; 106-7°, Galliard). As death approaches, in the algid phase, the rise of temperature may rise to 107° or more in the rectum or vagina.

Finally, Lesage has recorded three cases in which the rectal temperature fell from 100-4° to 78-6°, while the axillary temperature rose from 95° to 98-9°.

As will be seen, the dissociation between the peri- pheral and internal temperatures of the cholera patient is subject to no fixed rule.

A survey of the question of temperature from the standpoint of prognosis may furnish us with a few useful indications. A buccal temperature lower than 80-6° is a fatal prognostic. Great differences between the rectal and axillary temperatures, and progressive hypothermia (although this may not be very consider- able, nor very persistent) internal and external, are of evil augury ; while normal or supernormal temperatures are of good augury.

Derangements of the Circulation. — The pulse is rapid, usually exceeding 100 beats per minute (in a fatal case of Laveran's it was 185). It becomes small and thread- like, and may even disappear completely in serious cases : first from the radial, then from the humeral, and lastly from the crural and carotid arteries. The capillary circulation is interrupted ; there is a stasis of the venous system and the arterial system is unduly empty. The heart fails more slowly than the pulse. Its sounds become muffled and remote ; the first sound disappears, while the second may be distinguished for some time longer (Magendie). At the very end of the algid phase the ear can no longer perceive an>i;hing more than a deep, confused murmur sometimes masked

SYMPTOMATOLOGY 105

by a souffle which is attributed to the formation of intracardiac clots (Thoinot).

The blood undergoes profound modifications. Drawn from the veins during life it is black, thick, sticky, re- minding one of currant jelly which has not set properly. Its respiratory capacity is considerably diminished. The serum is scanty, and exudes with difficulty ; its density is increased, its specific gravity varying from 1036 to 1044 and even 1058; its alkalinity is diminished. (Hayem).

There is a relative increase of organic matter, and above all of albuminoids. The chlorides are diminished. The urea is increased, rising as high as 2 grammes '43 per litre, according to Voigt, and to 3 grammes -60 according to Chalvet, instead of the normal maximum of 0 grammes -20. By reducing the mass of the blood to four-fifths of the normal, cholera produces a very great concentration of the blood (Hayem). This is shown by a very considerable polycythemia, the cubic millimetre of blood containing 5,200,000 to 8,000,000 red corpuscles (Hayem). This polycythemia appears early ; it commences from the third hour. Ansemia is rare. Cholera is usually accompanied by an early hyper- leucocytosis, making its appearance from the twelfth hour ; it varies from 13,500 to 60,000 white corpuscles per cubic millimetre, reaching its maximum in the algid phase, and diminishing in the following phase ; or, on the other hand, in fatal cases it does not diminish, but will even continue to increase until death. This hyper- leucocytosis affects the polymorphonuclear leucocytes (64 to 88 per cent., according to L. Rogers). The proportion of eosinophile leucocytes is diminished or remains normal (0*2 to 1*8 per cent., according to L. Rogers).

Derangements of the Respiration and Phonation. — ^The cholera patient suffers from a continual dyspnoea, with precordial anxiety and a feeling as of a bar across the stomach, which is stifling him. This dyspnoea is characterised by an increase of the respiratory rate,

106 DYSENTERY, CHOLERA, AND TYPHUS

which may attain to fifty or sixty per minute, and also by an alteration of the respiratory rhythm. The in- spiration is prolonged, and it is not unusual, after a forced inspiration, to observe a pause, followed by a sudden expiration, accompanied by a plaintive moan.

This dyspnoea does not arise from any pulmonary lesion ; it is due to imperfect and insufficient oxidation of the blood, and perhaps also to bulbar excitation due to the cholera toxin. It may, when it is extreme, cause the rupture of a certain nimiber of pulmonary vesicles, thus causing emphysematous lesions.

The voice of the cholera patient, which is merely " broken " in the phase of evacuation, becomes stifled, and, in the majority of cases, there is complete aphonia in the algid phase.

Disorders of Secretion. — ^During the course of the algid phase of cholera the biliary secretion is diminished (H. Violle) ; the lachrymal and sebaceous secretions are arrested. The lacteal secretion may persist during the attack, as may also the menstrual flow ; but one of the capital symptoms of the algid phase of cholera, and one of the most constant, is anuria : not absolute anuria, but an anuria which is almost absolute. " One may still manage to obtain a few drops of urine, either by waiting, or by searching for the liquid in the bladder with a catheter " (Lorain). As soon as an improvement takes place the urine reappears. However, fatal cases have been recorded in which there was no suppression of the urinary secretion, and other cases in which patients, who for several days had remained anuric, have passed urine a few moments before death (pre-agonal urina- tion).

Disorders of Absorption. — {a) Absorption through the mucous membranes of the digestive organs no longer takes place during the algid phase. Food and drink are vomited intact, or found intact in the stomach at the autopsy. Drugs taken are without effect, for they are not absorbed. Opium, sulphate of quinine, belladonna, strychnine, all active medicines, with well-

SYMPTOMATOLOGY 107

known effects, are incapable of producing any effect whatever, even in large and almost poisonous doses. Iodide of potassium and ferrocyanide of potassium cannot be detected in the urine (Thoinot). Alcohol, however, appears to be absorbed (Vigla).

(b) Cutaneous and Subcutaneous Absorption. — " In- unctions of belladonna in the axilla (the dose being 4 grammes) do not dilate the pupils. Bouchut, deposit- ing by incision, in the subcutaneous tissues of algid cholera patients, 5, 10, or 15 centigrammes of morphia, found the doses unaffected at the autopsy. Isambert, in 1866, injected curare under the skin ; Grubler in- jected sulphate of quinine, and Lailler injected atropine ; they observed no absorption " (Thoinot).

(c) Intravenous Absorption. — ^The absorption of sub- stances injected directly into the circulation takes place in the normal manner.

External Appearances of the Algid Cholera Patient. — The algid cholera patient presents an appearance which is very characteristic. It has been described in masterly fashion by A. Laveran : " The sufferers, exhausted, prostrated, are lying on their backs, their limbs ex- tended, motionless. The eye, sunk in the orbit, owing to the subsidence of the cellulo -adipose cushion, is in- completely covered by the eyelids, for of these the orbicular lid is paralysed (Graefe) ; dark spots, of a blackish, dirty blue, appear on the surface of the sclera, or the eye is reddened by the development of a keratitis. The cyanosis of the eyelids deeply outlines the osseous contour of the orbit ; the nose is peaked ; the cartilagin- ous prominences are seen through the parched skin ; the lips are thinned, adhering to the teeth, or half open ; they are bluish or purple in hue. The cheeks and temples are hollow ; a livid pallor, or a swarthy, blackish tint gives the features an aspect as characteristic as it is appalling, and when, as the disease progresses, the congested, purulent conjunctiva, and the wrinkled cornea, desiccated as that of a corpse, have robbed the glance of all expression ; when this withered eye, sunken

108 DYSENTERY, CHOLERA, AND TYPHUS

in its orbit, shows through half-opened eyeHds, it is per- missible to say that death has beforehand marked the sufferers with his seal."

The skin of the algid cholera patient presents a cyanotic tint, the intensity varying from blackish purple to pale purple. This is sometimes localised at the extremities (hands, feet, nose, ears), sometimes dis- seminated all over the body in the form of spots and mottlings, and sometimes general.

This is the cyanotic or hliie cholera which is observed in young subjects who present no renal or hepatic altera- tion. There is a rarer form known as pallid cholera (Giraud, H. Lespiau, and Guerrier), observed in patients who have passed their fiftieth year, or who present lesions which are principally renal, in the course of which the algid patient remains pallid until the moment of death, the moment at which cyanosis generally makes its appearance.

The skin of the cholera patient, and particularly the skin of the extremities, possesses another very special characteristic : it is withered, wrinkled, covered with a cold sweat, viscous and sticky, and gives the sensation of touching the skin of a batrachian.

Sometimes there are veritable sweats of urea.

More or less rapidly the algid cholera patient grows weaker ; his intelligence becomes lethargic, and he presently falls into a condition of torpor, absolute physical and mental torpor. In severe and sudden cases, and above all in cases of blue cholera, the patients are restless and agitated ; they constantly turn over and over in bed; they are anxious; they moan and complain, and are slightly delirious. Sometimes the delirium is violent, with cries, and hallucinations of sight and hearing.

Convulsions have rarely been observed at the approach of death, which occurs during the asphyxial collapse. In cases of pallid cholera the patient, calm and somnolent, dies in a state of coma.

The duration of the algid phase varies from a few

SYMPTOMATOLOGY 109

hours to three or four days; its average duration is twenty-four hours.

4. The Period of Reaction. — ^If the cholera patient does not succumb during the attack he enters upon a new period, called by medical writers the period of reaction, which leads to recovery or death.

When the cholera patient recovers, so to speak, at the first trial, without complications, the period of reaction is said to be regular ; it is a true normal convalescence.

Such is not always the case, however ; and only too often the period of reaction gives rise to complications to which the patient succumbs.

The evolutionary grouping of these complications enables us to speak of regular reactions, abortive reactions, and typhoidal reactions.

The Regular Reaction. — After an algid phase of no great severity, slowly and steadily the patient returns to health. His heart beats more strongly and regularly, recovering sooner than the pulse, which beats more slowly and strongly ; and the peripheral circulation re- establishes itself. The skin regains its normal colour ; it becomes warm again, first the skin of the forehead, then that of the face, then that of the neck, the breast, and the extremities (Oddo) ; and it is covered with a warm and abundant perspiration. The respiration grows calm and regular ; the voice recovers little by little ; the temperature regains its general equilibrium. Absorption through the mucous membranes of the digestive organs and the skin, suppressed during the algid period, reappears in its normal activity, and we sometimes find that drugs taken during the algid period, which then remained inactive, produce their normal effects as soon as the reaction occurs ; it is easy to conceive what dangers may result from this in the case of toxic drugs administered without precautions in dangerous doses during algidity (Thoinot).

The biliary, lachrymal, lacteal and other secretions

110 DYSENTERY, CHOLERA, AND TYPHUS

reappear. The chief indication of the reaction is the re-estabhshment of the urinary secretion. The urine first emitted is rather scanty, turbid, and more or less albuminous, while it is poor in urea and in chlorides ; it contains bile pigments and indican ; the sediment is composed of the debris of the epithelium of the bladder, epithelial and hyaline casts, white corpuscles, and some- times red corpuscles.

The urine of the second emission is more abundant and more limpid. Very soon a state of polyuria sets in, usually reaching its maximum — ^when as much as eight litres may be passed in the twenty-four hours — between the fourth and ninth days. Lorain, however, has known this polyuria to cease at the end of twenty-four hours, and in other cases to last a month. This polyuria seems to be an energetic means of elimination.

Urea, uric acid, phosphoric acid, and the chlorides quickly increase in quantity, and for a few days exceed the normal. At the same time the urine eliminates waste products from the kidneys and bladder : pus cells, epithelial cells, red corpuscles, casts, crystals of oxalate and urate of lime, etc., etc. The albumin which is constantly present in the first specimens quickly disappears, and as it does so there is often a temporary and unimportant appearance of sugar.

When the reaction proceeds normally it is apyretic, but in certain very rare cases the patient passes very rapidly from algidity to a veritable circulatory pyrexia ; the temperature rises to 100° to 103° ; the pulse is bounding, its frequency attaining 100 to 120 ; the urine is febrile, the tongue like that of indigestion, and headache is present. This condition continues for about forty-eight hours; then all becomes normal again, and recovery follows.

The Abortive Reaction. — ^Aged persons, or subjects enfeebled by some previous cause, physiological or pathological, are more often than not unable to bear the strain of the reaction. The latter sets in, but is insufficient and abortive. The patient remains

SYMPTOMATOLOGY 111

prostrate and somnolent ; the urinary secretion is scanty ; the warmth of the skin does not return in a uniform manner ; the hands are still cold, while the trunk is already burning ; algidity may return, followed by a fresh abortive reaction.

The patient may succumb suddenly, collapse occur- ring after several fruitless attempts at reaction ; or he may pass into a typhoid-like condition.

The Typhoid State. — The typhoid state gives the patient all the appearances of a typhoid patient ; the face is dull and unintelligent ; there is intellectual torpor, and more or less violent delirium ; the tongue is parched ; there is diarrhoea, vomiting, oliguria and severe headache, while the face and the conjunctivae are injected. Only the temperature — ^and herein the condition differs from typhoid — ^remains normal or nearly so (96-8° to 100-4°).

The typhoid state presents many clinical forms, among which we must mention a cerebral form, with its two varieties, the comatose and the ataxo-adynamic, accordingly as stupor or delirium predominates (Oddo), and a gastro-intestinal form, the most frequent, whose chief symptom is an obstinate, bilious, blood-stained diarrhoea, which may cause death between the fifth and eleventh days, by internal haemorrhage, with prostration and hypothermia. When the patient recovers the convalescence is always long, and is often attended by complications.

In the course of the typhoid state, and also, although more rarely, during the normal reaction, one may observe an essentially polymorphous exanthem recall- ing those of smallpox, scarlatina, papular roseola, urticaria, erythema nodosum, miliaria, herpes, purpura, etc. These eruptions most frequently affect the extremities, particularly the forearm and the wrist, but may be generalised. Their duration is variable ; they evolve without fever, or with slight fever only, and are accompanied by no general derangement ; they termin- ate in a more or less abundant desquamation, according

112 DYSENTERY, CHOLERA, AND TYPHUS

to the nature of the case. Their prognostic significa- tion is said to be favourable rather than otherwise.

Accidents and Complications

Many accidents and complications may occur during the various phases of cholera. But it is more particu- larly during the phase of reaction, and during con- valescence, that they are most frequently observed. The most important only need be mentioned.

1. Chronic Diarrhoea. — ^The intestine of the cholera patient remains peculiarly susceptible, and tolerates a solid diet with difficulty. A chronic diarrhoea may graft itself on to the cholera and bring the patient into a condition of marasmus.

2. Gangrene. — Lesions of the circulatory system are indicated by various complications : anaemia, oedema, or myocarditis, which may result in sudden death. The most usual complication is gangrene. During the algid phase one observes gangrene of a strictly local nature, in superficial patches, on the nose, the tongue (Gendrin), the ears, the lips (Tardieu), etc. But during the period of convalescence and reaction one may meet with :

(a) Visceral gangrene — rare, it is true, of the intestine (Bouillaud, Mouchet, Oddo) and the lungs (Mouchet, Penieres).

(b) Cutaneous gangrene, usually subsequent to an irritation of the skin ; applications of leeches, blisters, sinapisms, chloroform ointments, etc. Galliard records two cases of sudden and overwhelming septic gangrene following upon subcutaneous injections of caffeine and ether.

(c) Gangrene of the extremities, usually very serious, due to arterial obliteration, most frequently throm- botic, but sometimes embolic. This form of gangrene usually attacks the foot, but may spread over the whole of the lower limb.

SYMPTOMATOLOGY 118

3. Nervous Accidents. — During convalescence cramps may be observed, localised in the calves, and true paroxysms of tetany. These paroxysms, which are not particularly frequent, are localised in the hands or feet ; they are generally brief and benign, but occasionally severe and prolonged. The return of the paroxysm may be provoked at will by compressing one of the large nervous or vascular trunks of the part affected (Trousseau's symptom). Localised paralysis has also been reported, and deafness. Dementia of a long-continuing character, and temporary monomania, are not unknown.

4. Pulmonary Complications. — Pneumonia and broncho- pneumonia, rare in hot countries, are of frequent occurrence in temperate countries, the latter disease being far more frequent than the former (Kelsch, Dubreuilh, Sinmionds, Oddo).

Broncho-pneumonia is incidental, more particularly to the abortive type of reaction ; its development is insidious and apyretic, the temperature, according to Dubreuilh, varying from 91-4° to 93*3°, while Galliard gives it as 92-5° ; it is always subnormal (Oddo).

Pneumonia, according to Oddo, is more obvious in its development ; in default of shivering, fever, cough, expectoration, and stitch in the side may attract attention.

These complications are extremely serious, and the rapidity of their development is surprising. Termina- tion by suppuration is not infrequent, and gangrene is not very uncommon.

It has been said that during the algid phase the dyspnoea is sometimes so violent that the pulmonary vesicles are distended to the point of bursting. Usually emphysema stops at the level of the lung, but Galliard has recorded a case in which the air invaded the medi- astinal connective tissue, then the subcutaneous cellular tissue of the neck, and finally the supraclavicular region.

5. Jaundice. — This is a rare phenomenon. Most

H

114 DYSENTERY, CHOLERA, AND TYPHUS

frequently a toxic jaundice of no importance is met with, but sometimes it recalls the characteristics of the dangerous forms of jaundice. In such cases we have to deal with an infectious jaundice, caused by the multiplica- tion of the cholera vibrio in the biliary ducts : choleraic angiocholitis and cholecystitis (Galliard, Girode).

6. Secondary Infections. — ^After cholera, as, for that matter, after all infectious maladies, various inflamma- tions and suppurations and other complications may be encountered. These are : otitis, conjunctivitis, kerato- conjunctivitis, parotitis, rhinitis, lymphangitis, ery- sipelas, boils, phlegmon, thrush, pharyngeal diphtheria, ecthyma, oedema of the glottis, etc.

Relapses, Recurrences

Owing to the results of errors in diet, explainable by the generally voracious appetite and the absolutely inextinguishable thirst presented by the convalescent cholera patient, and sometimes also without any appreciable cause, a relapse may occur which re- establishes the entire series of choleraic symptoms. In all epidemics of cholera a few exceptional cases of recurrences are encountered.

Clinical Forms

From the clinical point of view, cholera presents itself under many aspects, varying according to the development of the disease, the age of the patient, and his previous physiological or pathological condition ; lastly, according to the particular epidemic under observation.

A. The evolution of the disease permits of the dis- tinction of several types.

1. Choleraic Diarrhoea, which is the minimum form of the choleraic infection. It is confined to the premoni- tory diarrhoea which sometimes precedes the attack.

SYMPTOMATOLOGY 115

It is difficult to distinguish it, clinically, from simple diarrhoea. Accordingly, in time of epidemic, any case of diarrhoea must be regarded as suspect, and the bacteriological diagnosis of its nature duly established. Choleraic diarrhoea continues for a few days only and ends in recovery.

2. Cholerine represents a higher degree of choleraic intoxication. It commences suddenly in the middle of the night, with diarrhoea, accompanied by vomiting, cramps in the calves, severe headache, and intense thirst. There are signs of algidity ; the pulse grows weak ; the urine becomes scanty. Cholerine may terminate in recovery in a few days, but recurrences are common if the slightest error of diet is committed.

3. Cholera. — ^A great many classifications have been proposed for the purpose of grouping the multiform clinical aspects of cholera. A simple clinical division into the slight form, the severe form, and the foudroyant or sudden and overwhelming form is sufficient.

(a) The Slight Form. — Characterised, apart from the diarrhoea, by the persistence of the radial pulse, and of the urinary secretion, which may be diminished, but is never completely suppressed, and by a barely percep- tible cyanosis and collapse.

(b) The Severe Form. — ^This is marked by the strongly marked symptoms of cholera already described : aphonia, vomiting, diarrhoea, algidity, pulse nearly or quite imperceptible, absolute anuria, and the choleraic habitus. The reaction is most frequently of the typhoidal type.

(c) The Foudroyant Form. — In certain exotic epi- demics the patients die in a few hours, in a few moments, as though shot or struck by lightning. In our country this foudroyant form, which is often observed in the first cases of an epidemic, is less alarming. Death occurs in three to twenty-four hours (Thoinot).

B. Cholera affected by the Age of the Patient. — ^Newly born infants fed at the breast usua,lly escape cholera.

116 DYSENTERY, CHOLERA, AND TYPHUS

In children the progress of the disease is rapid, the evacuations profuse, the vomiting inconstant, while cramps are rare. The child quickly falls into a state of coma and algidity. The period of reaction is particu- larly rich in nervous phenomena (Thoinot).

The aged are often carried off by foudroyant cholera. Adynamia predominates ; the algid phase is abnor- mally prolonged, and when the reaction sets in it is more often than not abortive. Convalescence is often re- tarded by gangrenous or suppurative complications (eschars), pulmonary or intestinal.

C. Cholera as affecting the Physiological Conditions of Woman. — Menstruation may persist during algidity. If the menses are suspended during this period, they may reappear at the moment of reaction.

Pregnant women escape abortion only if attacked by the slight form of cholera (Galliard). In at least fifty per cent, of cases cholera causes abortion, and it kills women who do not miscarry even more frequently than those in whom it causes the expulsion of the foetus (Thoinot).

The expulsion of the foetus occurs during the period of reaction (Lorain). The child is usually still-born, or succumbs shortly after birth. The death of the foetus always precedes that of the mother, whence the futility of a post-mortem Caesarian operation (Galliard). Cholera almost invariably causes the death of women who have recently been delivered.

In wet-nurses the lacteal secretion may fail during the attack, but upon reaction it returns in great abundance. Sometimes it is unaffected, and the breasts may even become gorged with milk, until artificial extraction becomes necessary (Magendie, Oddo, Galliard).

D. Cholera as affected by the Pathological Condition. — Generally speaking, anterior maladies are suspended by cholera ; when the cholera disappears they return, com- pleting their course if acute, and prolonging it if chronic.

Bronchitis, pneumonia, acute articular rheumatism,

SYMPTOMATOLOGY 117

whooping-cough and diabetes cease at the moment of the attack, to reappear after recovery.

The association of cholera and typhoid fever is one of extreme gravity. The case is equally serious when cholera attacks a malarial patient during an access of fever.

In tubercular cases the pulmonary troubles shrink to a minimum, but if the patient survives the attack the tuberculosis becomes exacerbated and quickly carries the patient off (Briquet and Mignot).

Pleuritic effusions, and the serous or subcutaneous effusions of Bright's disease, of cardiac affections, and of cirrhosis are almost instantaneously swept away by the diarrhoeal flux, but the attack is almost invariably fatal to the sufferer.

E. Cholera varies in different Epidemics. — The general physiognomy of the choleraic attack varies from one epidemic to another. In one epidemic diges- tive symptoms predominate ; in another the algid symptoms ; in a third cyanosis is the most prominent manifestation. The same is true of the modes of reaction.

Certain epidemics, such as that of Lisbon, have been marked by the extreme benignity of the cases.

CHAPTER II

DIAGNOSIS

During the course of an epidemic, the rice-water diarrhoea and vomiting, the cramps, cyanosis, the broken voice, anuria, algidity and the pecuhar facial aspect of the cholera patient, constitute a body of symptoms which render diagnosis an easy matter.

But this is not the case at the commencement of an epidemic, or when the cases are sporadic ; the clinical diagnosis of cholera may then present great difficulties, for a certain number of pathological conditions present choleriform symptoms.

Various acute forms of poisoning — ^viz. tartar emetic and arsenic — bear such a resemblance to Asiatic cholera that they have been described as stihial, or antimonial cholera, and arsenical cholera. In these forms of poison- ing vomiting precedes the alvine evacuations, which are never rice-water. In very acute arsenical poisoning the patient experiences a burning sensation in the mouth, and a pricking in the throat, with a pronounced metallic taste. In poisoning by tartar emetic the sufferer experiences a sensation of burning heat in the throat, which extends all the way down the oesophagus as far as the stomach.

In cases of poisoning by poisonous fungi there is rice- water diarrhoea, vomiting, slowing of the pulse, and algidity ; but there are also constant nervous symptoms, myosis, amblyopia, and occasionally strabismus, and paralysis of accommodation. The interrogation of the patient and those about him will direct attention to the cause of the poisoning.

118

DIAGNOSIS 119

Various forms of poisoning due to decomposing food (meat, fish, molluscs, etc.) may give rise to gastro- intestinal S5nnptoms simulating typhoid fever, dysen- tery, or cholera. Diagnosis is sometimes extremely difficult, even when aided by bacteriological investiga- tions.

Further, infections due to the paratyphoid bacilli, and to Gaertner's bacillus in particular, often closely simulate infection by the cholera vibrio.

The pernicious algid access of malarial origin is closely reminiscent of the onset of cholera. But it is preceded by fever, or comes on in the midst of an attack, and the algidity lasts ten or twelve hours at most, never a whole day. The vomit always remains bilious and greenish ; the stools are never rice-water ; the reaction is followed by a sudoral crisis which does not occur in cholera. Quinine is efficacious. Lastly, examination of the blood enables the physician to discover large numbers of malarial parasites.

Certain serious forms of indigestion, certain forms of peritonitis of varying origin, and intestinal obstructions of a medical or surgical order may also make the diag- nostician hesitate.

Lastly, it is necessary to establish the exact nature of the first cases of cholera. In the so-called cholera nostras the evacuations are usually bilious or serous. The disease occurs in summer and autumn. From the parasitical point of view it may be caused either by the cholera vibrio, or by a large number of bacteria, the paratyphoid bacilli, B. coli, etc.

The reader will perceive the importance which attaches to the determination of the causative agent of a choleriform pathological condition. Only laboratory research can give exact information as to the presence or absence of the cholera vibrio.

In the living cholera patient the vibrio is found only in the stools. It has also been discovered in the vomit. Its presence in the blood (Tizzoni and Catacci) and in the sputimi (Mills) should not be admitted unless con-

120 DYSENTERY,. CHOLERA, AND TYPHUS

firmed by further research.^ At the autopsy it is to be sought only in the intestine : in the rice-water liquid and grains, and the exudate which lines the intestinal walls. If it exists it will certainly be found there, and especially in the small intestine.

The bacteriological diagnosis of cholera necessitates several tests : (1) the cholera vibrio must be discovered and isolated ; (2) the vibrio must be identified.

1. Search and Isolation. — ^A rice-like grain is taken, or in default of this a drop of a liquid stool ; it is spread out on a glass slide, and after fixation and staining by Gram's method, followed by a double staining by fuchsine (1 in 5), search is made for the incurved rose-coloured bacillus which presents the morphological characteristics of the cholera vibrio. In recent and typical cases these vibrios may be found in pure cultures ; in other cases they are comparatively rare, in the midst of a varied and very abundant in- testinal flora. Cultures must always be resorted to, together with biological tests in order to identify the suspected germ.

The cholera vibrio being strongly aerobic, it should be sown in wide-mouthed flasks or tubes. The media of culture employed are alkaline, and but slightly nutritive. The simplest medium is peptonised water, prepared according to the following formula : —

Peptone . . . . . .1 gramme

Sodium chloride . . . . . 0 gr. '50

Water . . . . . . 100 cc.

After a few hours in the incubator at a temperature of 37° C. a turbidity is produced in this medium, and a slight film forms on the surface, this consisting of various microbes, but principally of the cholera vibrios. A portion of this film is re-sown in peptonised water in a second tube, and from this a third tube is sown with

^ Greig has recently described cholera vibrios in the lungs and other viscera. They seem to be specially frequent in the pneumonic con- ditions associated with the disease. — Ed.

DIAGNOSIS 121

the germ, at intervals of six hours. After the third transference the microbic film contains a very large quantity of cholera vibrios, but scarcely any other germs.

Metchnikoff obtains the same result, by adding 2 per cent, of gelatine to the usual peptonised water.

Ottolenghi employs ox bile as a concentrating medium; in this the intestinal germs other than the cholera vibrio do not develop, or develop only with difficulty. This is his formula :

Carbonate of sodium, crystals (10 per cent.) . . 3 cc.

Nitrate of potassium . . . . . 0 gr. "10

Fresh ox bile, filtered through filter-paper . . 100 cc.

U. Massi sows the stools in a mixture of 1 centigramme to 1-5 centigrammes of ascitic fluid and 4 centigrammes of sterilised water. In this medium the atypical cholera vibrio is said always to attain its characteristic form.

Whatever the concentrating or enriching medium employed, the physician must always proceed to isolate the cholera vibrio. The best method is to sow a particle of the film obtained from the surface of one of the liquid media already described on Dieudonne's agar.

The following is the method by which this agar is prepared : — A mixture is made of equal portions of de- fibrinated bullock's blood and a normal lye of potassium (56 per 1000) ; it is kept at boiling-point for half-an- hour. Three parts of this mixture are added to seven parts of ordinary agar (3 per 100), neutral to litmus. The resulting mixture is poured into some Petri dishes, which are left for twenty-four hours in the incubator, at a temperature of 37° C. (98-4° F.), or for forty-eight hours at the temperature of the laboratory. The cultivations are made on the surface ; the medium becomes useless five or six days after preparation.

Pilon replaces the potash lye by a solution of sodium carbonate (NagCog), thus obtaining a medium which possesses the advantage that it can be employed immediately.

122 DYSENTERY, CHOLERA, AND TYPHUS

On Dieudonne's medimn the colonies of vibrios are clearly defined about the eighth or tenth hour. The germs of each isolated colony are then identified. This identification necessitates a certain number of cultures on ordinary agar.

2. Identification. — In order that one may conclude that a given vibrio is the true cholera vibrio, the criteria furnished by the following tests should agree.

(a) Microscopic Examination. — By this we determine the morphological characters of the bacillus, its motility and the existence of flagella.

(b) The Appearance of the Cultures on Gelatine. — Stab Cultures. — ^At 20° C, from the twentieth hour, small irregular colonies appear, A small bubble is quickly formed at the surface, this holding an air-bubble. Liquefaction becomes more pronounced ; it progresses funnel-wise, being more marked at the surface than at the bottom of the tube. The air-bubble at the surface continues to exist until the second, third, or fourth day. This is a characteristic culture (but this character is not constant). The liquefaction progressively invades the whole of the culture-tube, always funnel-wise.

On gelatine plates the isolated colonies, at 20° C, after twenty or twenty-four hours, are small, whitish and transparent. At the end of forty-eight hours the gela- tine begins to liquefy round them, a little cup of lique- faction forming. The colonies then show a granular centre, surrounded by a ring, which is also granular, but wavy in outline. Around this ring is a third, which is formed by the zone of liquefaction, which enlarges daily until it invades the whole plate.

(c) Test for the Nitrous-indol Reaction. — ^This reaction is obtained by adding 1 to 2 centigrammes of pure hydrochloric or sulphuric acid to a twenty-four- hour culture in peptonised water, at 37° C. The reaction is more visible if a small quantity of nitrite of potassium is added to the peptonised water (0 gramme •10 per 100).

DIAGNOSIS 128

(d) The Agglutination Test with Experimental Serums. — ^This agglutination is rather inconstant. There are vibrios which are definitely sensitive to agglutination, but there are others which are only slightly agglutin- able. Others again are agglutinable only after being passed through several culture media.

(e) Inoculation. — The intraperitoneal injection of cultures of cholera bacilli rapidly causes the death of guinea-pigs from peritonitis, with the collection of an enormous quantity of motile bacilli in the peritoneal exudate. If the injection is made into the peritoneum of a guinea-pig which has been highly immunised, the vibrios become immobile, spherical, and granular. The same thing is observed if one injects into an ordinary guinea-pig a mixture of culture and active anti- choleraic serum. In vitro Metchnikoff and Bordet have obtained the same results by mixing in sterile test-tubes a diluted anti-choleraic serum, a few drops of fresh serum from a guinea-pig (alexin), and the microbic emulsion.

The majority of these characteristics are somewhat inconstant. The best test for the cholera vibrio is, perhaps, to cause it to be ingested by young rabbits, either by itself or together with microbes which are favourable to its development (Metchnikoff). Of the various laboratory tests employed with a view to diagnosing Asiatic cholera, the sero-diagnosis of Achard and Bensaude and the fixation of the comple- ment may be mentioned here. It does not as yet appear, however, that these tests can advantageously replace the bacteriological examinations of the stool.

CHAPTER III

TREATMENT

We have as yet no real specific treatment for cholera. The experiments in serotherapy made up to the present do not appear to be conclusive. Spiro Livieriato claims, however, to have obtained satis- factory results by this method during the Graeco-Bulgar War of 1915 ; including less frequent vomiting, mitiga- tion of the cramps, improvement of the pulse, and palliation of the dyspnoea, the cyanosis, and the algidity.

Practically the only method of treatment which is of recognised value in cholera is the expectant and symptomatic one (Sir Patrick Manson). The first duty to be discharged is to deal energetically with all cases of diarrhoea occurring during the course of an epidemic. All varieties of diarrhoeal remedies have been employed, with or without results : opium, paregoric elixir, laudanum, with or without the addition of the sub-nitrate and the salicylate of bismuth, lactic acid, calomel (in massive doses of 5 to 20 centigrammes and more every two hours, until the stools change colour), satm'ated chloroform water, a mixture of lime, catechu, and opiimi, etc., etc.

In England and America a remedy known as chloro- dyne is much in favour. It is given in doses of four to twenty drops. It is said to be an excellent preparation, but only in cases of premonitory diarrhoea (Navarre, Soulier).

The English formulae differ as to the composition of this remedy. The product obtained by these formulae sometimes, in course of time, throws down a precipitate, or even turns into a solid mass, which is useless, the

124

TREATMENT 125

remedy being administered in drops. The following formula, given by A. Manslau, gives a stable product which keeps well :

Morphine hydrochloride Chloroform . . , . Alcohol (90 per cent.) . Treacle ....	. 0 gr. -50 . 12 grammes . 12 „ . q.s, to 60 cc
Fluid extract of liquorice	. 3cc.
Atropine sulphate Essence of peppermint Cherry-laurel water	. 0 gr. -05 . 4 drops . 10 cc.

Mix the chloroform, alcohol, and essence of pepper- mint in a 60 -cc. flask. Dissolve the morphine and atropine sulphate in the cherry-laurel water, add half the treacle and the fluid extract of liquorice in a mortar, mix, and make up to 60 cc. with the treacle. Shaken before using.

Various antiseptic medicaments which have been recommended have not responded to the hopes which were founded upon them. Such are salol, iodoform, benzonaphthol, naphthaline, hydrochloric and sulphuric acid " lemonades," creosol, creosote, chlorinated water, creolin, potassium permanganate, etc.

Vomiting may be relieved by means of seltzer water, chloroform water, iced champagne, ice in small frag- ments. Riviere's draught, etc. The patient should retain a horizontal position, and should drink only a little at a time, as copious drinking usually provokes vomiting.

The beverages most readily tolerated are the " lemonades," made with tartaric or citric acid.

Irrigations of the stomach, with boiled water, plain, or containing 5 per cent, lactic acid, and repeated five or six or seven times a day, recommended by Hay em, Delpeuch, and Lesage, are disagreeable to the patient, and serve to calm him only for a short time.

The cramps are relieved by light friction, dry, or moist, with flannel soaked in essence of turpentine or camphorated alcohol; by hypodermic injections of

126 DYSENTERY, CHOLERA, AND TYPHUS

morphia ; or, if these means fail, by brief inhalations of chloroform.

In cases of asphyxia Cuneo (of Toulon) has success- fully employed inhalations of oxygen.

To relieve algidity, hot bricks have been used ; also hot-water bottles, and warm baths (102° to 106° R). These warm baths, of twenty minutes' duration, re- peated every two or three hours, are excellent in cases of average severity. They cause a rise of temperature of 2° to 4°, improve the pulse, moderate or banish the cramps, and favour the secretion of urine (Hayem, Lesage, Siredey, Delpeuch). Senmiola gives vapour baths, by means of special appliances, the patient remaining in bed. Injections of caffeine and ether have also been employed.

The rational treatment, however, is that which consists in restoring to the organism a portion of the liquid which it has lost, thereby restoring to the blood the amount of serum which it requires in order to once more become sufficiently fluid to circulate.

As early as 1830 the Russian peasants had conceived the idea of gorging cholera patients with saline water. In 1832, in Scotland, Latta made them drink enormous quantities of saline water. At the same time he gave them enemas of a saline solution, and even injected it into their veins.

At the present time, according to circimistances, one of the following methods of treatment may be employed : —

1. Enteroclysis. — Cantani used to make two litres of lukewarm liquid penetrate as far as possible up the large intestine. Lesage, Tipiakov, and Bourcy have obtained good results with this method.

Bourcy injected from two to six litres of boiled water ; cases of average intensity appeared to him to be greatly improved by this treatment. One per cent, tannin may be added to the liquid.

2. Hyperdermoclysis. — Subcutaneous injections of artificial serum, the dose varying from 300 to 600

TREATMENT 127

grammes, may be employed in eases of mediimi inten- sity, when the circulation is not interrupted.

The injections are made under the skin of the abdomen or the buttock. They may be repeated.

3. Venous Transfusion. — The liquid employed is usually the solution recommended by Hayem :

Sodium chloride (pure) .... 5 grammes

Sodium sulphate . . . , 10 ,,

Water ...... 1000 cc.

The greatest advantage is derived from the employ- ment of serum containing adrenaline.

Other writers employ a solution of 6 parts of sodium chloride in 1000 parts of water, sometimes adding a small quantity of alcohol, but no sulphate of sodium.

Leonard Rogers treated 1000 cases of cholera with only 3*4 per cent, of deaths by intravenous injections of hypertonic saline :

Sodium chloride (pure) . . . .8 grammes

Sodium bicarbonate . . . . 20 ,,

Water ...... 1000 cc.

At the same time he administered potassium per- manganate internally.

Sir Patrick Manson gives the following formula ; —

Sodium chloride . . . . .3*5 grammes

Sodium carbonate . . . . 3*5 ,,

Boiled water . . . . .1 litre

One or two litres of this solution is injected slowly and under slight pressure, at a temperature of 98*4° to 99-4°, into a vein of the arm or leg. The saphenous vein is particularly convenient.

In the most favourable cases intravenous injections positively resuscitate the patient, and cause him straightway to enter upon the period of reaction, re- establishing the circulation, arresting the diarrhoea, and restoring the urinary secretion. Thoinot has described

128 DYSENTERY, CHOLERA, AND TYPHUS

this effect as resembling the galvanisation of a corpse, hut too often the recovery lasts only a few hours. Fresh transfusions may be resorted to, if the algidity retm'ns ; as many as two, four, five, and even twelve injections having been administered to the same patient (Lesage). At the present time this method is in current employ- ment, and is not reserved only for cases in extremis.

In Hay em's hands it has yielded 30 per cent, of recoveries ; in Galliard's, 29 per cent. It has therefore stood the test of experience, and, according to Hayem himself, " transfusion should be regarded as a regular method of treatment, not as an exceptional method."

During the period of reaction, if the diarrhoea per- sists, opium and bismuth may be employed. Under these circumstances one may mject into the rectum, ac- cording to Sir Patrick Manson, the following solution :— -

Tannin . . , . . .30 grammes

Gum arable . . . . . 30 ,,

Warm water . . . . .1 litre

Constipation should be treated by means of enemas, never by purgatives.

If the urinary secretion is not rapidly re-established large hot poultices must be applied to the limibar region, or dry-cupping may be employed ; gentle diuretics should be used with great precaution, and not the active ones, which are unsafe. In convalescents the diet should for some time be of the simplest : milk and water, barley-water or rice-water, thin soups, vegetable soups, meat -juice, etc.

, PART //.—EPIDEMIOLOGY AND PROPHYLAXIS OF CHOLERA

CHAPTER I

HISTORICAL

It was only in 1830 that cholera made its appearance in Europe. But from time immemorial, before it over- flowed its accustomed limits, cholera had prevailed, in the epidemic or endemic state, in the valleys of the Ganges, the Brahmaputra, the Nerbudda, and the Tapty. The entire coast of the Bay of Bengal, Malabar, Sumatra, and Cambodia have been the classical homes of cholera. The arrival in these regions of European conquerors, colonists and manufacturers merely increased the spread of epidemics, by bringing them fresh aliment. The conquest of India was marked by murderous losses ; soldiers, camp-followers, etc., falling by thousands in a few hours (Graves).

It was in and after the year 1818 that cholera spread beyond its original home, gaining firstly other Asiatic countries, then the Philippines, Mauritius, and the lie du Bourbon. Persia, Arabia, and Syria were soon to become the intermediate countries across which the scourge was to spread, in a manner that was almost periodic, as far as Russia, whence it found its way into the other countries of Europe. From 1830 to 1869 it seemed as though cholera, before overflowing the continent of Europe in formidable incursions, was drawing fresh energies from India. From that year the disease has become naturalised in Europe, and was responsible for terrible episodes, such as those which marked the Crimean War, when the mortality was so I 129

130 DYSENTERY, CHOLERA, AND TYPHUS

high among the French soldiers and sailors (Fauvel, Scrive). Sometimes it has been possible to trace the manner in which the disease has been transported by- Arabs or Egyptians travelling from infected countries, but in reality the disease has become autocthonous, and if it no longer displays the powers of extension which it manifested during the last century, it none the less remains a terrible scourge unless a rigorous prophylaxis is applied.

To give an example of the disastrous severity of cholera, we may recall the epidemic which in October, 1859, attacked the two army divisions of General Martim- prey, who was operating in the province of Oran. In a few days more than 3000 men succumbed to cholera.

The menace of cholera, moreover, is always existent ; and the military relations which are being established between the East and the West have been and may again become the reason of a fresh appearance of the disease. There are few countries which have escaped cholera : the Faroe Islands, the north of Russia, and Siberia, a few islands in the Pacific Ocean, Terra del Fuego, the island of Nossi-Be in 1870, etc. This im- munity is due to the geographical conditions of these regions, which isolate them and protect them against travellers and the importation of the germ.

European outbreaks have happily become highly irregular and far less extensive. At the present time cholera attacks the army and the fleet, and it also makes its appearance on board ship. Witness the epidemics on board the steamers Remo and Andrea Doria, sailing from Genoa to South America. The second of these caused 114 deaths among 1357 emigrants.

In India the average annual death-rate from cholera between 1877 and 1886 was 298,000 ; between 1901 and 1910 it was 380,000, with a maximum of 710,000 in 1906. The average mortality is from 56 per cent, of those attacked (Madras) to 77-8 per cent. (Bombay) (Pottevin).

The Dutch East Indies are not free from the disease.

HISTORICAL 131

Between the 1st January and the 26th September 1914, 1919 cases and 1030 deaths were recorded.

In Germany the deaths from cholera, which were 114,683 in 1866 and 27,790 in 1875, fell to 866 in 1892, 83 in 1905, and 14 in 1910.

During the Balkan War the third Bulgarian Army, held in check before the trenches of Tchataldja, suffered much from cholera. By the 18th November there had been 17,000 cases and 900 deaths ; by the 30th November these figures had risen to 29,626 and 1849 respectively. The number of cases increased more particularly after the men took to drinking river water in which the corpses of Turkish soldiers were drifting. The civil population also was attacked.

In the Turkish Army, during the same period, cholera appeared all the more readily in that it was prevalent before mobilisation among the civil population of Con- stantinople and the surrounding district, in Syria, etc.

During the present war the French and British armies have had no cases of cholera up to date. There have been very severe and very quickly-developing cases of acute gastro-enteritis, sometimes fatal, but these were found to be due to paratyphoid infections.

On the other hand, the Austrian Army and civil population have been very severely visited by cholera. Between the 23rd September and the 5th December 1914, the official figures for Austria were 3468 cases and 898 deaths. In Vienna, during the same period, there were 386 cases and 39 deaths.

Carinthia, Carniola, and, above all, Galicia have been the scene of numerous outbreaks. During September, October, and part of November, 1914, Galicia numbered 3039 cases and 1164 deaths. In Hungary, during the same period, there were 3605 cases.

A few cases were noted in Silesia among the civil population and the prisoners (277 cases, 33 deaths) between the 23rd September and the 7th November 1914. Bulgaria and Greece were also invaded by the disease.

132 DYSENTERY, CHOLERA, AND TYPHUS

In Turkey 32 cases and 17 deaths were reported in Constantinople during the early months of 1914 ; at Adrianople there were 110 eases and 94 deaths among the troops between the 28th February and the 19th May. In the garrison of Rodosto there were 15 cases ; in that of Trebizond 14 cases and 12 deaths in January, 1914.

We see, therefore, that the importation of cholera into belligerent nations which it has hitherto respected is within the range of possibility.

CHAPTER II

ETIOLOGY OF CHOLERA. FAVOURING FACTORS

Caused by a special pathogenic bacillus, the cholera vibrio, cholera is nevertheless not unaffected by favour- ing conditions, some of which are individual, while others are foreign, or extrinsic.

The comparative protection afforded by childhood is explained by the fact that children at the breast are usually safe from alimentary contagion.

Nevertheless, children of ten months may contract the disease, while, on the other hand, the aged are by no means exempt from it.

It is between the ages of twenty and thirty years, and above all in the male sex, that cholera is most frequent.

No race is safe from its attacks. The black race appears to be even more susceptible than others, and the mortality from cholera is very much higher among them.

No doubt certain individual cases of immunity exist, but they are rare. The effect of agglomerations, wars, and pilgrimages has been invoked ; but these factors are operative only because they multiply human con- tacts— ^that is, the chances of contamination — and favour the transfer of the bacillus.

Alimentary conditions, such as the employment of raw fruits and vegetables, and indigestible foods, have long been regarded as the adjuvants of infection. Possibly they act simply and solely by transport- ing the bacillus. But alcoholism, acute or chronic, seems to play a more considerable part, for it in- 133

134 DYSENTERY, CHOLERA, AND TYPHUS

volves an insufficiency of the digestive and hepatic secretions.

At the time of the Budapest epidemic of 1892-1895, 22- 4 per cent, of those attacked were alcoholics ; while during the Russian epidemic of 1908, 65 per cent, of those struck down were tainted with alcoholism. This explains why, during an endemic period, we often observe the greatest number of patients on a Monday.

The employment even of pure water in too large quantities may lead to a dilution of the digestive juices, and thereby favour infection.

Excessive fatigue has often been incriminated, not without reason. Its evil effects have often enough been exemplified during military expeditions. , Chronic diseases, tuberculosis, and, above all, in- flammation of the intestines, appear to be predisposing factors.

Among the extrinsic factors hot weather and the summer are most frequently incriminated.

It is certainly a fact that the majority of epidemics are observed during this season. However, epidemics are on record which attained their fastigium in the spring, or even in winter. Such was the Paris epidemic of 1832 (which occurred in winter), that of Berghem (also a winter epidemic), and the Russian epidemic of 1830, when the disease persisted in Moscow during a temperature of 4° F. below zero. The Lisbon epi- demic broke out in December, 1893, and the Russian epidemic of 1908 also commenced in winter.

Nevertheless, heat and thundery weather favour cholera, no doubt because of the great consumption of water which they involve.

The following table, borrowed from Bertillon, indi- cates the duration and the season of various epidemics, as well as the number of victims claimed from the population of Paris.

Cholera becomes localised by election in moist, hot regions, such as the deltas of great rivers (the Ganges, the Nile). In such regions its reign is prolonged, while

ETIOLOGY OF CHOLERA

135

in high-lying districts and elevated tablelands it is less persistent. It is observed principally among uncleanly populations, in towns and villages where hygiene is un- known, where dejecta are left lying on the ground, in native quarters, in the soks and suburbs, while the wealthy quarters are frequently spared. The epidemic of Havre, in 1892, attacked the old quarters rather than the rest of the town.

In 1893 the poverty-stricken population of the lies Mol^nes and Trielen suffered an enormous mortality.

Year of Epidemic	Date of the first Death Recorded	Date of the last Death Recorded	Duration of Epidemic in months	Seasons during which the Epidemic was most Violent	Number of Deaths attri- buted to Cholera	Deaths from Cholera per 100,000 in- habitants in each Epidemic
1832 .	Mar. 26	Sept. 30	6 months	rSpring \ \ Summer j	18,402	2345
1833 .	Jan.	Dec.	12 „	Autumn	505	64
1849 .	Mar. 9	Oct. 31	8		Spring	19,615	861
1854 .	Jan. 1	Dec. 29	12		Summer	8591	732 *
1865 .	Sept. 1	Dec. 31	4		Autumn	6357	354
1866 .	July 1	Oct. 31	4 ,		Summer	5218	289
1873 .	Sept. 4	Nov. 10	2		Autumn	855	46
1884 .	Nov. 3	Dec. 31	2		Autumn	986	44
1892 .	Aug.	Dec.	5 ,		Summer	713	29

In the hamlet of Trielen there were fourteen deaths in six days.

The Budapest epidemic of 1892-1893 manifested itself almost entirely in the dirty and overcrowded houses of the working classes, and among domestic servants out of employment. The epidemic of Les Pouilles, in 1910, presented the same peculiarity (Pottevin).

There are certain cases of individual immunity, revealed by the failure to absorb cultures of the cholera vibrio (Metchnikoff), and owing to this fact certain subjects may escape attack although their dejecta contain vibrios.

136 DYSENTERY, CHOLERA, AND TYPHUS

The Determining Causes of Cholera

Cholera results from the toxi-infection caused by the cholera vibrio. This infection is localised in the ali- mentary canal. The germ is most commonly absorbed by way of the mouth and the digestive organs. Having entered the body by the mouth, in one of the ways which will be explained later on, the bacillus reaches the stomach, where the acid secretion is prejudicial to it, but various circumstances, such as the ingestion of the microbe when fasting, or when commencing a meal, or the absorption of a large quantity of contaminated cold water, which flows quickly into the duodenum, and thence into the small intestine, may protect the vibrio from the effects of the acid gastric juice. Having reached the small intestine, the secretion of which is alkaline, and which contains the peptones favourable to its culture, it there multiplies profusely, provoking, at this point, the premonitory diarrhoea.

Such is the first stage of the infection, and to this stage the infection may be confined. More com- monly the bacilli sow themselves on the surface of the epithelial layer, and then in its cellular support, and there they cause first desquamation and then necrosis, owing to the toxins secreted. In the dejecta, frag- ments of the mucous lining, detached and dead, are discovered.

The invasion then spreads along the whole extent of the small intestine. The toxins liberated by the bacilli, and those which result from the death or dis- integration of the bacilli destroyed, are absorbed by the large absorbent surface offered by the ill-protected or desquamated intestinal lining. Then it is that the characteristic signs of the choleraic intoxication make their appearance, the most important, for the epidemiologist, being the diarrhoea and vomiting, which are usually profuse.

The dejecta and the vomit contain the vibrio, often in prodigious quantities. They are, therefore, the

ETIOLOGY OF CHOLERA 137

essential intermediaries of contagion. The first place, however, must be awarded to the alvine evacuations.

These, indeed, often consist of an almost pure culture of the vibrio, mingled with epithelial fragments which give the stools their rice-water appearance, the bacilli swaiming in them. Through the breach afforded by the sub-mucous tissue, deprived of its epithelial coating by desquamation, profuse quantities of serous liquid flow, in which the bacilli vegetate. The multiplicity of the stools, their fluidity, and the involuntary emission of evacuations permit of the easy diffusion of these pro- ducts, which are extremely rich in bacilli. Deposited everywhere, on underclothing, body linen, sheets, the soil, etc., the dejecta carry with them the patho- genic agent. This already explains the excessive con- tagiousness of cholera.

The bacillus, then, is transmitted principally by means of the choleraic stools: these are the chief source of infection. We shall presently see that cholera carriers are equally contagious, and through the same mediimi.

The cholera vibrio also exists in the vomit so fre- quently emitted during the development of a case of cholera, but it is much less abundant there. It is said to have been found in the sputum (Mills), ^ but not in the urine. It does not exist in the blood, intestine, or spleen of the foetus taken from women who have died of cholera.

The elimination of bacilli goes on during the whole course of the disease, and sometimes even long after recovery.

The spread of the vibrio to the kinsfolk of the sufferer, and those about him, is therefore effected with the greatest facility. For this reason, especially in former years, the mortality among orderlies, nurses, and physicians during epidemics has been enormous. One single sufferer may infect numbers of persons : a village, a town, a continent even. On the 5th July 1854, a ship

^ Greig's work loc. cit. supports this. — Ed.

138 DYSENTERY, CHOLERA, AND TYPHUS

having landed a cholera patient at the Piraeus, the epidemic invaded the whole of Greece. It will be understood how the disease may be transmitted by- caravans and shiploads of Mussulman pilgrims return- ing from Mecca, attacking, on their return, the in- habitants of the countries from which they set out.

This again explains how the great epidemics which ravaged Europe during the nineteenth century spread from India to Russia by way of Persia, Afghanistan^ and Arabia, or to Egypt, Turkey, and the ports of the Mediterranean, by means of vessels bringing passengers from the East. Cholera is transported by man, and spreads along the routes followed by man. Countries which have succeeded in isolating themselves entirely have escaped the scourge.

The transmission of the vibrio is effected, not only by admitted cholera patients, but also by persons suffering from " cholerine " or summer diarrhoea (Kelsch). All observers have noted this important fact. Moreover, the experimental absorption of cultures may give rise to these slight forms of diarrhoea (Ferran, Macrae, etc.).

These cases of diarrhoea due to a vibrio, mere cases of indisposition, are extremely dangerous in respect of contagion, for they are not always made the object of special precautions, and, on the other hand, they are able to move about and to travel, thereby spreading the microbe wherever they go.

It has frequently been observed that the great epi- demics have been preceded by an unwonted outbreak of cases of diarrhoea or cholerine. Such was the case at the time of the Russian epidemic of 1907-1908. As early as June, 1908, Jacovlev, in Petrograd, noted the increased number of cases of intestinal affections, and of the deaths due to them. Moreover, at this period the bacillus was isolated from the stools of a patient who had recovered.

To sum up : the vibrio is propagated by the patients attacked by the characteristic forms of cholera ; it is also propagated by those who are suffering from abnormal or

ETIOLOGY OF CHOLERA 139

prolonged forms of the same disease ; further, it is transported by those who present only the morbid symptoms, slight and benign, of simple diarrhoea, bac- teriological examinations nevertheless enabling the diagnostician to isolate the microbe.

But these are not the only sources of contagion. The vibrio may also proceed : 1. From patients who have recovered more or less recently from one or other of the clinical forms of cholera already indicated.

2. From perfectly healthy subjects, who have been in contact with cholera patients, or have absorbed the vibrio, but who nevertheless have presented no morbid symptoms.

Both types constitute what are known as " carriers " of the cholera germ. The latter play a very important part in the propagation of the germ, and they furnish the explanation of the apparent spontaneity of certain epidemics which have affected families, villages, or towns. We ought, therefore, to make a special study of these carriers.

The Carriers of Cholera Vibrios

We have already called attention to a special category of germ-carriers, consisting of persons suffering from slight or insignificant forms of diarrhoea. In practice we must not form any conclusion as to their exist- ence until we have made cultures from their dejecta. Jacovlev, Zabolotny, Zlatogorov, and Kulescha have recorded the presence of the vibrio in subjects who were merely passing liquid stools. In July, 1909, several very grave cases of cholera having appeared in the General Hospital in Calcutta, it was discovered that these cases were due to two natives, who, having the appearance of normal health, but suffering from slight attacks of gastro- enteritis, were carriers of the bacillus.

In patients who have recovered from cholera the vibrio persists in 36 per cent, while the period during

140 DYSENTERY, CHOLERA, AND TYPHUS

which it may be found varies from two days to two months, and sometimes more (Michailov, Komme- laere, Zlatogorov). The confirmation of this possible persistence of the vibrio in the stools — ^though these may be normal — of ex-cholera patients was established by Forrest, in India, by Marcovich, in the Trentino (1910), by Franca, in Madeira (1910), and by Defressine and Cazeneuve, in Marseilles (1912). Somewhat exception- ally the persistence of the microbe may exceed a period of 2 months. It may persist for 69 days (in the epi- demic of Petrograd, 1908-1909), 90 days (Zeidler), or 100 days (Marcovich).

The labours of Russian and Italian physicians have done much to throw light upon this important point. Montefusca, examining the stools of 107 convalescents, found the vibrio persisting in 60 of these subjects for 15 days ; in 40 it persisted for a period varying from 15 to 30 days ; in 2 it persisted for 35 days, and in the rest from 38 to 78 days. Vanda isolated the bacillus for more than 10 days from 30 per cent, of his con- valescents ; for 10 to 20 days from 10 per cent. ; and for 36 to 56 days from 8 per cent. In the case of 24 convalescents who appeared to be rid of the bacillus a slight purgative caused its reappearance in 3 of the 24. The administration of a purgative (15 grammes of magnesium sulphate), recommended by Zirolia, some- times enables the physician to discover that the dis- appearance of the germ is only apparent . On the other hand, an attack of indigestion or an alimentary excess may produce the same result.

Other investigations made in Italy on over 3000 healthy carriers of the bacillus showed that 50 per cent, of the carriers no longer carried the vibrio after five days ; 77 per cent, of the other carriers revealed the germ on the tenth day ; and 95 per cent, on the twentieth day (Pottevin).

Baldoni examined, at Brescia, between the 5th of August and the month of December, 1915, 5200 faeces passed by soldiers under treatment or in quarantine.

ETIOLOGY OF CHOLERA 141

He found that 2-5 per cent, of the latter were carriers.

There is no longer any doubt that certain persons are capable of retaining the vibrio for considerable periods. The designation of " chronic carriers," although it represents a rare eventuality, denotes the existence of these cases. Cases of long-continuing diarrhoea have been noted in which the microbe has persisted for a period of six months (Alain, Vallee and Martineau, Ruffer), a year, and even three years (Crendiropoulo and Panayotatau).

Analysing the researches conducted by the preceding writers, and also by Piras, Debonis, Defressine and Cazeneuve, Necchi and Randone, etc., it follows : (1) that the cholera vibrio may persist after the complete recovery of the patient in about 30 to 33 per cent, of cases ; (2) that this persistence is not, as a rule, very prolonged, but continues at most for thirty or forty days, rarely more ; (3) that the excretion of the vibrio may be irregular, intermittent and interrupted for a few days, and then reappears.

From this last point of view the facts are analogous to those which have been established in respect of carriers of the bacillus of typhoid, but the long persist- ence of the latter bacillus, which may continue during a lifetime, does not obtain in the case of the carrier of the cholera vibrio.

In practice it is always useful, before concluding that the vibrio has disappeared, to make repeated cultiva- tions and previously, on each occasion, to administer a gentle saline purgative.

The existence of healthy carriers — that is, carriers who have never suffered from cholera, even in an obscure or attenuated form — is to-day fully demonstrated. The truth is that there are carriers whose blood contains antibodies, which shows that the choleraic infection must have been serious. Klein, who frequently isolated them, owing to this observation, queried the specific and pathogenic character of the vibrio described by

142 DYSENTERY, CHOLERA, AND TYPHUS

Koch. Persons who, in time of cholera, absorb the vibrio but escape infection, possess, in reahty, only a relative immunity. Their existence has been verified by many writers during epidemics, and in various countries. In Russia Jacovlev found that in 100 instances of isolation, the bacillus was in twenty cases derived from healthy subjects. At the time of the Russian epidemic, during the three months commencing on the 21st December 1908, the stools of 2440 persons who had been in contact with cholera patients were examined. The vibrio was isolated 125 times, or in 5 per cent, of these cases. These carriers fell into three groups :

1. Twenty-five were in the incubation stage of cholera. 1

2. Forty were emitting rather liquid stools, without morbid symptoms.

3. Sixty exhibited normal stools, and presented no sign of disease.

According to more extensive data published by Jacovlev, Zlatogorov, and Kulescha, the examination of 21,962 persons yielded the cholera vibrio 4497 times. Of 9752 persons who had been in contact with cholera patients 571 were carriers of the bacillus.

The proportion of these healthy carriers among those who form the entourage of cholera patients may vary, however, within wide limits. The average proportion is 6 to 7 per cent. (MacLaughlin, Forrest). Such carriers have been found among pilgrims on their return from Mecca (Zonchello). They were also found on the occasion of the epidemic which visited Holland in 1909 ; in the Belgian epidemic (Van der Velde), the Marseilles epidemic of 1912 (Salimbeni and Dopter, Orticoni), the Italian epidemic (Vivaldi), and the epidemics in Madeira (Franca and Stevens), and Tunis (Conor). The

^ Cholera made its appearance one to three days later. We have here the confirmation of the idea that the cholera subject may be con- tagious before the appearance of the first symptoms of cholera (Edm. Sergent, L. Negre, Bregeat and Vivien).

ETIOLOGY OF CHOLERA 143

proportion of carriers may be very high — as high as 14 per cent, (as in the Genoa epidemic of 1911, when of 1525 persons 214 were found to be carriers). On the other hand it may be very low, or the carriers may be non-existent. Crendiropoulo, examining the stools of 34,461 persons in Egypt, isolated the vibrio from only 25 of them. At the time of the Madeira epidemic not one of the seventy-one physicians or nurses was found to be a carrier. It results from this that a thorough prophylaxis may prove to be a perfect protection against infection by the vibrio, whether latent or effective.

It has been queried whether the vibrios thus isolated from the dejecta of healthy carriers have pathogenic properties. Attempts to inoculate animals have some- times proved their low degree of virulence (Piras), and sometimes their activity and toxicity (Debonis, Cinmiino, etc.).

The period during which the germ-carrier eliminates the cholera vibrio is fairly brief, varying from a few days to three weeks.

Between the 4th of December 1908 and the 4th of December 1909 the Service of Hygiene in Petrograd ex- amined the faeces of 9357 subjects who had been isolated as possibly contaminated. Of these 577 were carriers of the vibrio. Between the 4th of December 1909 and the 4th of December 1910, 3173 persons exposed to contagion through their proximity to cholera patients were examined in the same way. The results were :

Adults . . . 2368 . .157 carriers = 6-6 per cent. Children, 1 to 15 years 720 . . 71 „ =9*8 „ Children under 1 year 85 . . 17 ,, =20 ,,

(Pottevin). Children, accordingly, are particularly dangerous.

In connection with the cholera in Hedjaz, it has been noted that the pilgrims, who yield so many cases of the disease, also exhibit instances of healthy carriers. In 1912-1913, 2-8 per cent, of the pilgrims had agglutinable vibrios in their stools.

144 DYSENTERY, CHOLERA, AND TYPHUS

It was in the Egyptian hospitals that the discovery of suspected vibrios was first made with any frequency. In certain cases of ulcerative gangrene of the intestine a vibrio identical with that of cholera was isolated. In 90 post-mortem examinations suspected vibrios were discovered in 36 instances: some of these being extremely virulent, agglutinable, secreting a hsemolysin, etc.

In subjects returning from Mecca and dying of various diseases (such as dysentery), cultures have yielded a vibrio (the vibrio of El Tor) analogous to the cholera vibrio, agglutinable by anti-choleraic serum, and showing Pfeiffer's reaction. Nevertheless, it seems that we ought to regard these bacilli as paracholera vibrios. Castellani has isolated paracholera bacilli in Ceylon.

The important part played by the carriers of bacilli in the extension of epidemics of cholera need not be emphasised. The perennial nature of the disease in certain countries, its persistence, and its periodical or irregular return in others, can only be explained by the persistence of the germ in certain persons who act as reservoirs or depositories. A healthy subject, travelling through a given country, or sojourning in it awhile, may thus become the origin of serious epidemics.

The conditions which thus permit of the conservation and retention of the cholera vibrio, during a variable period, by a certain number of persons who have or have not suffered from an attack of cholera, are the same as those which obtain in the case of carriers of the bacillus of typhoid, or the paratyphoid bacilli. The cultivation of the contents of the gall-bladder on the occasion of autopsies on victims of cholera first enabled Nicati and Rietsch, during the Marseilles epidemic of 1884, to isolate the comma bacillus. This important discovery was veri- fied by Tizzoni and Cattani, and by Doyen, Raptchevski, Sevastianov, Rekovsky, Tanda, etc. The vibrio is not, as a matter of fact, absolutely constant in the gall- bladder ; but its occurrence there is frequent, since

ETIOLOGY OF CHOLERA 145

Brullov found it in 76 per cent, of cases, and Otto Schobl, in the Philippines, in 18 cases out of 39.

Kulescha concluded, after conducting 430 autopsies, that the vibrio is most frequently encountered, first in the intestine, and then in the gall-bladder. As in typhoid infection, the local multiplication of the vibrio determines catarrhal and haemofrhagic lesions of the mucous membrane of the gall-bladder, sometimes amounting to a true cholecystitis. The same microbe may give rise to suppurative angiocholitis, with jaundice (Piras). During the epidemic of Toulon (1911) Def res- sine and Cazeneuve found the vibrio in the pure state in. the bile of three patients who had succumbed to cholera, the cultivations having been made four to eight hours after death.

As regards the bacteriological diagnosis post mortem, therefore, the search for the vibrio in the bile may be of great service ; but it should be undertaken in good time.

Experimentally, Baroni and Ceaparu have discovered the existence of the vibrio in the bile of inoculated rabbits. Job has observed that if the guinea-pig is made to absorb the vibrio it may be found in the blood, in which it remains for a short time, and then in the gall-bladder. He believes that the intestinal phase of cholera is preceded by a septicaemic phase.

Otto Schobl has observed the brief survival of the vibrio in guinea-pigs inoculated in the gall-bladder, the stomach, or the intestine. Intravenous injection is more favourable.

However this may be, the passage of the bile into the intestine explains the presence of the vibrio in the dejecta of carriers.

It is, therefore, through the medium of their excreta that the carriers of vibrios, like those suffering from cholera, disseminate the bacillus and become contagious. The contagiousness of the carrier is inferior to that of the actual cholera patient, because the mmiber of bacilli eliminated by the former is very much smaller.

CHAPTER III

ETIOLOGY OF CHOLERA — continued The Modes of Propagation of the Cholera Vibrio

Issuing from the cholera patient, or from a carrier of the bacilli, the cholera vibrios contained in the dejecta pro- ceed to contaminate linen, chamber utensils, latrines, privies, the soil, water, etc. They may be transferred . by the sufferer or the carrier to those who attend on him or surround him ; the contagion is in that case direct. They may on the other hand be propagated by one of the intermediate agencies mentioned below : the contagion is then indirect.

Innumerable examples testify to the propagation of the cholera bacillus from man to man. Examples of the direct propagation of the vibrio by germ-carriers have also been published. In families and collections of people, persons whose duty it is to prepare food (cooks, etc.), when they are germ-carriers, are particularly dangerous. At the time of the Petrograd epidemic a female cook in a house of retreat who had prepared a dish with gelatine contaminated forty-seven persons thereby. Kulescha has recorded the case of an old lady who, having a terrible dread of cholera,used to have her crockery boiled, and her food sterilised, while she frequently disinfected her hands and employed only boiled water for her bath. None the less she contracted cholera, of which she died. Inquiry proved that she had been contaminated by her bacilli-carrying cook, who lived in a neighbouring house, and had been in contact with cholera patients.

W. Greig records that an epidemic which broke out in the prison at Puri, in India (1912), was due to

146

ETIOLOGY OF CHOLERA 147

the communication of the infection by a vagrant who had previously suffered from cholera. Imprisoned on the 25th July, a few days later he had caused seven- teen cases among the rest of the prisoners and the warders. There were five deaths. His dejecta con- tained numerous vibrios.

There is, therefore, a useful comparison to be drawn between the modes in which cholera is transmitted and those by which typhoid fever and the paratyphoid fevers are transmitted. Cases of infection by contact are in reality cases of infection by means of dirty hands, the hands of the person who transmits the germ and contaminates other persons, or the hands of the person who is infected, and contaminates himself, by neglect- ing to wash his hands.

It is easily understood that direct contagion readily occurs in working-class circles, in country districts, and among the natives of non-European countries, because the general conditions of hygiene and cleanliness are less regarded there.

The original centre of contagion being in faecal matter, we may well ask ourselves what becomes of the vibrio, and how long it can survive — that is, remain con- tagious. We know that according to R. Koch and certain others the vibrio is supposed not to persist longer than twenty-four hours in the dejecta. But investigations made by Mattel and Canalis have shown that in putrefying, and therefore alkaline dejecta, the bacillus may survive for two or three months. Filov found that it persisted from 18 to 101 days ; Rabescha, for 9 months. It is in faecal matter, sheltered from the air and the light, that the vibrio persists longest (Zlato- gorov). Job, having during the winter mingled cholera vibrios with faecal matter, made cultivations every three days in peptonised water, peptonised and saline agar, etc. He found that the bacilli persisted for 4 to 33 days.

Investigations as to the persistence of the vibrio in various media give the following data : — In moist sand,

148 DYSENTERY, CHOLERA, AND TYPHUS

7 days ; in moist garden soil, 33 to 68 days ; in moistened dust, 4 months. Investigations as to its persistence on the surface of a great variety of food- stuffs give the following results : — On barley bread, 1 to 3 days ; on ordinary bread, covered up, 7 days ; on smoked herring, 4 days ; on meat, 8 days ; on fruits and salad, 2 days ; on fresh apples, cut, 4 days, etc. In reality the nature of the substratum matters less than the conditions of dryness or humidity, the action of light and of the oxygen of the air, and the degree of acidity of the medium, which affects the vitality of the bacilli. During the sojourn of varying length which the vibrio makes in the outer world while incorporated in faecal matter, it is, as a rule, imperfectly protected. In reality it offers little resistance ; desic- cation kills it in 3 or 4 days, or at most in 13 to 38 days (Kitasato). Antiseptics and acids kill it quickly.

One may conclude, in consequence (1), that apart from immediate or direct transmission, the cholera vibrio is transmitted by means of indirect or inter- mediate factors of transmission: hy all the extremely various intermediaries on which the alvine evacuations of cholera patients or the dejecta of carriers may be deposited.

2. That its conservation will be the more readily effected as the receptive medium is more humid, and better pro- tected from the microbicidal action of light and the oxygen of the air.

3. That as desiccation has the effect of killing the bacillus, its propagation by means of dust is hardly probable, and would at best be greatly restricted.

4. That contaminated articles of food, especially liquid^ food, are contagious factors of the first order.

The intermediate agents which may serve to propa- gate the cholera vibrio are either living and animated, or inert. Both play a more important part than that of direct contagion in all localities subjected to a thorough personal hygiene. This is why it was said that direct infection, or infection by contact, " played only an insignificant part in the hospitals of Petrograd,"

ETIOLOGY OF CHOLERA 149

although in these hospitals the cholera patients were very insufficiently divided from the other patients. We must therefore award an important place to in- direct contagion.

This is commonly effected by means of flies. During the hot season, at the period of their chief activity, the part played by flies is a considerable one. The vibrio lives in the alimentary canal of the fly. Maddox has verified its presence in Calliphora vomitoria and Eris- talis tenax. Savtchenko, having fed flies upon cultures of the cholera vibrio, found the vibrio in a pure culture in their intestines. Ganon, similarly, verified its presence 20 hours after an infectious meal. Accord- ing to Passek, the vibrio lives 72 hours in the fly's intestine.

Tizzoni and Cattani have isolated the bacillus from flies captured in the rooms of cholera patients. Tiskov and Tsukuki have done the same.

Flies alight upon the vomit or excrement of cholera patients, thus loading themselves with vibrios, which they absorb, or with which they soil their feet and legs. They defaecate very frequently, depositing the specific infection upon all sorts of articles of food — fruits, sweets, cakes, custard, pork, bacon, etc. Lastly, they pollute the face and hands of sleeping children and adults. The bacillus survives for several days on the surface of most articles of food.

The vibrio does not live long on cut fruits whose juice is acid. It survives longer on very ripe fruits, on the melon, the grape (3 to 4 days), and the date. Putrefac- tion and mould, etc., have little effect upon its vitality.

Often enough the flies die within a few days; their dead bodies then may fall upon food and pollute it. This is why the proximity of kitchens, dining-rooms, mess-rooms, tents, larders, slaughter-houses, pork butcheries, butchers' shops, pastry-cooks' shops, etc., to privies, stables, accumulations of dung or organic refuse, or to hospitals, may in seasons of epidemic entail the most serious danger.

150 DYSENTERY, CHOLERA, AND TYPHUS

Flies, moreover, may cover long distances, being transported by carts, carriages, railways, and ships.

The pollution of food may be effected not only by flies, but, as has been said, by cholera patients and by germ-carriers, by the soil, and by water (as in the case of raw fruits and vegetables).

Cases of contagion have been reported which were due to polluted clothing, especially to linen (shirts, sheets, etc.). The calling of washerwoman in a special manner exposes those who follow it to infection by cholera vibrios. Duflocq has published examples of these various modes of contagion. The cholera bacillus multiplies on the surface of a piece of soiled linen which has been folded up. Its period of vitality is from eight to twelve days on damp stuffs, and one to four days on dry fabrics. On damp cloth, protected from the air and the light, it may survive for five weeks (Gamaleia).

Contagion by means of footgear may be compared with the foregoing means of contagion. It occurs on soil which has had dejecta thrown upon it, or in gardens, or ill-kept privies, etc. The germ is thus introduced into the dwelling-house by the boots or shoes, or by wooden shoes or clogs, or by bare feet even in country districts. It thus becomes deposited on the hands, or on the floor, whence it is picked up by flies, or by children at play. This is one of the ways in which the cholera microbe may be introduced into the organism. It must, of course, reach the mouth. This it may do in a great variety of ways.

The infection of the soil may also be effected by means of the bodies of the victims of cholera, which carry with them a stupendous quantity of pathogenic germs. In them the bacillus may survive for twenty- eight days. In India the religious practice of the natives, who place the corpses of those who have died of cholera on the banks of the Ganges, favours the infection of the water of the river.

The same microbe which, mixed with the dejecta of

ETIOLOGY OF CHOLERA 151

cholera patients or germ-carriers, pollutes the surface of the soil may also contaminate vegetables and fruits which have fallen from the trees. According to Rem- linger and Nouri, fish living in contaminated water may preserve the vibrio intact. It may survive within the fish for two to four days (Gran and Shor).

Infection by water holds the first place in the pro- pagation of cholera, as in that of typhoid fever.

The cholera vibrio retains its vitality in water for considerable periods (Nicati and Rietsch, Straus and Dubarry). Investigations undertaken to elucidate this point have yielded results which are not absolutely concordant. According to some the microbe may live for thirty to eighty days in well or river water, while, according to others, it can only live for seven days (Santi Sirena, Dunham, etc.). It is possible that the cholera vibrio not only survives, but even undergoes multipli- cation in still waters, when it is sheltered from the light and when the external temperature is sufficiently high.

Hankin, however, has called attention to the fact that the waters of the Ganges, and of its affluent, the Jumna, possess bactericidal properties in respect of the cholera bacillus. Filtered water in which vibrios had been placed, and which was subjected to bacteriological examination, yielded, at the outset, 7000 to 8000 colonies, but was sterile at the end of three hours. This property disappeared on boiling. To tell the truth, it appears to be exceptional.

The effect of solar light on water, even when diffuse, has a powerful bactericidal effect. Clear water, holding the cholera vibrio in suspension, and exposed to the rays of the sun, is sterilised in three to four hours. In hot countries those waters which are sheltered from the solar rays, such as the water of ponds, and of the Indian tanks, are particularly dangerous. The renewed con- tamination of water by the introduction of dejecta, the washing of the underclothes of cholera patients or germ -carriers, the discharge of contaminated brooks

152 DYSENTERY, CHOLERA, AND TYPHUS

or tributaries into a river, form many causes of the persistence of the infectious germ.

The causes of the contamination of water-supplies by the bacillus of cholera are indeed extremely numerous. The rains favour the direct discharge of dejecta, of putrid liquids, of contaminated manure-pits, into rivers or bodies of standing water. The subsoil layer is exposed to the same infection, through the infiltra- tions which reach it, and which originate either on the surface (owing to the spreading of faecal matter on the soil) or at a deeper level (from cesspits).

The bacilli constantly swept down, in times of epi- demic, by rain-water, sewage, the washing of linen, etc., maintain the noxious condition of water-supplies. In the Ganges the water of the river itself does not im- mediately kill the bacillus. The religious practices of the Hindus, which prescribe baths and ablutions in the sacred river, and the ingestion of the water into which corpses are thrown, are in the highest degree favourable to infection.

The direct proof of the presence of the cholera bacillus in a large number of suspected rivers was obtained long ago. Nicati and Rietsch isolated it on several occasions from the waters of the Old Port of Marseilles. Sanarelli, Metchnikoff, Netter, Vincent, etc., have also verified its presence in different waters. At the time of the epidemic which prevailed in Petro- grad in 1908, 1010 samples of the water of the Neva yielded the vibrio 193 times. In the same water when filtered, which serves as drinking-w^ater, the bacillus was found in 13 per cent, of the specimens analysed; and in 6*1 per cent, of the specimens of ice examined. The investigations undertaken by Zabolotny and his colleagues resulted in the isolation of the vibrio from 549 of 3505 samples of water.

Huylov isolated the vibrio from the water of the Volga. In this water the vibrio persists for 508 days, a fact which can only be explained by its actual multi- plication. River-mud is a receptacle favourable for

ETIOLOGY OF CHOLERA 158

the preservation of the microbe, and the stirring up of the mud has been incriminated as the cause of the contamination of river- waters.

The muddy bottoms of wells are said to possess the same property. Defressine and Cazeneuve have isolated the vibrio from the mud of a river.

Similar discoveries have been made in all countries, notably in Italy. One must suppose that the specific contamination of water, and especially of river-water, is maintained by the dejecta of the carriers of germs.

Epidemiology, as a matter of fact, confirms at every point the etiological role of drinking-water in the pro- pagation of cholera. This role is an important one. At the time of the epidemic which prevailed in France in 1884, Marey, in his well-known report to the Academy of Medicine, demonstrated with remarkable precision the influence of this factor, describing epidemics in certain districts or villages which were attributable to the absorption of contaminated water, the disease spreading through the different villages strung out along the same water-course. A sufferer brought the germ to the hamlet of Val, in the canton of Vignolles. His linen was washed in a wash-house from which the water drained into a little river flowing on to Montfort. At Montfort there was a case of malignant cholera.

At Barr^me the contamination was due to the clothes of a working man suffering from cholera, which were thrown into the River Asse. All the villages down- stream had cases of cholera. At Gap, Prades, Cerb^re, Perpignan, Nantes, etc., the same thing was proved to occur.

The Hamburg epidemic commenced on the 18th August 1892. By the 29th there had already been 3400 cases and 1100 deaths, due to the water of the Elbe, which was unfiltered, but was the only water utilised. The city of Altona, which adjoins Hamburg, was very little affected. In these two communities it happened that one side of a street, belonging to Hamburg,

154 DYSENTERY, CHOLERA, AND TYPHUS

was infected, while the other side, forming part of Altona, was unaffected. In 1913 there were, on certain days, in Hamburg more than 1000 cases a day. In Altona, where filtered Elbe water was consumed, there were only sporadic cases.

The Petrograd epidemic of 1908 was due to drinking- water. There were as many as 400 cases daily (Gamaleia).

The epidemic which prevailed in the outskirts of Paris in 1892 afforded another demonstration of the influence of drinking-water. Neuilly, Suresnes, Saint- Denis, which were supplied with water drawn from the Seine below Paris, suffered severely. At Saint -Denis those inhabitants who employed the water from an artesian well were unaffected (Netter).

The contamination of river and lake water is certainly effected by sewage and the washing of clothes. But boatmen, bargees, etc., play a very important part in infecting such waters ; for they are frequently in- fected by drinking them, and they themselves discharge great quantities of germs into the water if they are sick of cholera or carriers of the vibrio.

The presence of a certain amount of marine salt is by no means prejudicial to the preservation of the vibrio in water. Quite the contrary, the salt favours its multiplication, which is a point of great interest, and explains the persistence of the bacillus in the estuaries of rivers. At Archangel the water of the Dvina has been found to be thus contaminated. We know, on the other hand, that peptonised and saline agar is one of the best media for the isolation of the vibrio. According to Parini, sea-water does not kill the microbe. He mentions the case of two men who, at a time when no epidemic existed, contracted cholera as the result of falling into the polluted water of a harbour, when they swallowed a certain amount of water. Sanarelli, Carapelli (at Palermo), etc., have insisted on the comparatively frequent occurrence of vibrios resembling the cholera vibrio in river waters,

ETIOLOGY OF CHOLERA 155

apart from the existence of any case of cholera. There is no doubt as to the animal or human origin of these microbes. It is, nevertheless, curious that the exist- ence of these microbes is not accompanied by a simul- taneous choleraic infection. Zlatogorov has recorded the case of a Russian student who, having accidentally absorbed a bacillus isolated from the Neva, developed a choleriform infection. But on the other hand, E. Sergent and L. N^gre have recorded the immunity of a town whose fluvial waters contained a vibrio which apparently was the authentic cholera vibrio. There are still, therefore, some unknown vibrios.

Gosio has expressed the opinion that earth-worms, which are coprophagic, might contribute to the pro- pagation of the cholera vibrio. He has found the vibrio in the alimentary canal of earth-worms. These vibrios came from a lake from which Carapelle had isolated the cholera bacillus. A month later the bacillus still existed in the intestine of young earth- worms. According to Venuti, earth-worms and molluscs retain the vibrio in their alimentary canals, but it becomes attenuated.

The danger of consuming raw oysters and other shell- fish results from the fact that these molluscs have lived in waters infected by the cholera vibrio, while preserved in the neighbourhood of ports or near the outfall of sewers. Oysters feed on particles of organic matter contained in the water. In this way they retain its impurities ; they act as a kind of filter, conserving the vibrio for twelve to sixteen days (Pinzani). Cases of established contagion, due to oysters (Geddins, Cal- mette, Rouchette, Pottevin, etc.) have been reported in Italy and in France.

Fish living in contaminated waters may introduce the germ into the body if they are eaten raw, or insufficiently cooked, for example, as in Japan.

The transportation of the microbe has also been attri- buted to the bilge-water of ships, which may contain the germ. It has been stated that sea- water is by

156 DYSENTERY, CHOLERA, AND TYPHUS

no means hostile to the vibrio. Nicati and Rietsch, having stirred the vibrio into sterihsed water taken from the Old Port of Marseilles, discovered that the microbe survived for eighty-one days. Other observers have noted its persistence for two or three weeks, and even for four months (Piccinini). In 1909 the bacillus was isolated at Gand from the very saline bilge-water of ships hailing from Riga and Petrograd. Water employed as ballast may also contain the vibrio (Jacobsen, of Copenhagen). According to Remlinger, the spray of contaminated sea-water may spread or communicate the cholera vibrio.

It goes without saying that if the drinking-water kept on board ship contains the cholera bacillus, it may become the point of departure of an epidemic among the sailors, and in the ports at which the vessel touches, or in towns or villages situated along the course of a river. The epidemic which prevailed in Toulon in 1911, attacking the crews of the warships there, was attributed to this cause (Defressine and Cazeneuve).

With the exception of milk, the part played by beverages — wine, cider, beer, etc. — is inconsiderable. The cholera vibrio is not robust, and is easily killed in an acid medium, such as wine. It does not survive longer than five minutes in red or white wine, mixed with an equal volume of water. In beer it survives only for a few hours. Vinegar and lemon juice destroy it very quickly. According to Met in, infusions of tea, if contaminated, may transmit the vibrio.

Milk has often been condemned as a source of infection. Its pollution may result either from dilution with polluted water, or to contamination by a milkman ormilkma id who is suffering from cholera or is a germ- carrier, or to the use of unclean receptacles, or, lastly, to flies, living or dead. We have already spoken of the infection of milk by means of flies.

Le Dantec has recorded the details of an epidemic in which nine sailors out of ten contracted cholera after

ETIOLOGY OF CHOLERA 157

drinking milk diluted with water from a pond into which the dejecta of choleraic subjects had been thrown. The vibrio, as a matter of fact, multiplies in milk, above all in boiled milk. The lactic ferment is in- jurious to it and kills it. It readily survives on the surface of butter, in fresh cream, and on cheese.

CHAPTER IV

PROPHYLAXIS OF CHOLERA

Prophylaxis of Favouring Causes. — ^Although the factors which have been described as favouring causes play only an accessory part, their importance must not be disregarded in times of epidemic.

A moderate diet and sobriety are useful precautions. Heavy meals should be avoided, and the excessive use of alcohol. Purgatives may awaken the choleraic infection.

Personal cleanliness, particularly that of the hands, is to be especially recommended. Avoid fatigue, over- exertion, and long marches, especially in the heat of the day, as these factors diminish organic resistance and increase thirst, thereby augmenting the possibilities or the severity of contagion.

Houses, courtyards, and gardens must be kept scrupulously clean, the same applying to barracks. Ventilation, natural lighting, and sunlight are excellent means of disinfection.

Particular attention must be paid to closets, privies, urinals and dung-hills, which ought to be removed, and manure-pits, which must be done away with.

Kitchens are to be inspected, and everything should be destroyed, by fire or burial, which might attract flies and permit of their multiplication : ordure, kitchen refuse, organic matter, etc.

When there is a danger of cholera the general hygiene of towns demands the same measures. The accumula- tion of filth must be avoided ; the flushing of gutters and sewers must be facilitated ; streets, cesspools, etc., must be cleaned. Slaughter-houses, butchers' and

158

PROPHYLAXIS OF CHOLERA 159

pork-butchers' shops, factories, and the working-class quarters should be carefully inspected. Sanitary in- spectors should visit hotels, restaurants, and wine-shops, above all in the neighbourhood of ports and in in- salubrious quarters, and ensure that the special pre- ventive measures which will presently be described are applied.

In the case of barracks, the entire premises should be kept in a condition of scrupulous cleanliness. Scrub- bing and sluicing with plain water, which favours the conservation of the microbe, is to be abandoned in favour of cleaning by means of sawdust impregnated with an antiseptic (carbolic acid, lysol, cresol).

Dung-hills or muck-heaps must be removed from the barracks daily, while dung-pits should be cleaned out and sprinkled with antiseptics. It is useful to appoint fatigue parties to clean the latrines or privies and their approaches several times a day.

Prisons, reformatories, etc., whose cleanliness only too often leaves much to be desired, must not be neglected. In camps, and in time of war, the application of the above measures must be most strictly enforced.

It is also necessary to eliminate from the diet all indigestible and imperfectly cooked foods, salt pork, fresh pork, sausages, meat pies, etc., which might be made from unwholesome meat.

Raw vegetables are to be prohibited : salads, radishes, cucumbers, tomatoes, etc., and even raw fruits. River bathing must be stopped.

Prophylaxis of Cholera on hoard Warships. — The prophylactic rules to be followed are obviously the same on board ship as on land. Respecting vessels on active service, a circular issued by the French Ministry of Marine on the 3rd October 1909 prescribed the following measures : Healthy vessels touching at an infected port will cast anchor at a sufficient distance, will reduce the term of their stay in port, will avoid mooring at quay- sides, and will take the usual precautions with a view to avoiding infection.

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Infected vessels will, in respect of themselves and their sick, take the necessary measures of isolation, dis- infection, etc. On their arrival they are subjected to the medical inspection of crew and passengers, the dis- infection of dirty linen, water-closets, etc., the immedi- ate disembarkation and isolation of the sick, and also of the healthy passengers and sailors. These latter are kept under supervision for five days, and should be vaccinated against cholera.

Microhic Prophylaxis. — Efforts should be made to attack the infectious germ wherever it exists : in the patient, in the carrier, on soiled linen and underclothing, in privies, on the surface of the soil, in and about dwelling-houses, in polluted waters, on food, etc.

The microbic prophylaxis is accordingly extremely complex. Any negligence, or the omission to carry out any of the necessary precautions, will result in the spread of epidemic cases. The vibrio must therefore be followed, step by step, from the patient or the carrier, and we must seek to destroy it in each of the stages through which it passes, either in living or in inert media. For this purpose the aid of the laboratory is absolutely indispensable to the rational prophylaxis of the disease.

As soon as the threat of cholera exists, and, u fortiori, directly the first cases appear, special bacteriological laboratories should be mobilised for the examination of the first suspected cases. They should be amply equipped with the necessary appliances for collecting the dejecta of suspected patients, and with the appli- ances required for the cultivation and incubation and expert examination of cultures.

On the precise diagnosis of the first cases the fate of an epidemic will very often depend. The verification of the reactions of immunity in the blood of the persons affected is not so valuable as the discovery of the vibrio. It is of little use save as a means of retrospective diagnosis.

In the acute forms of cholera, above all when the rice-

PROPHYLAXIS OF CHOLERA 161

like grains are observed, the cultivation of the stools in appropriate media readily yields cultures of the vibrio. This is not true, however, of ill-defined cases, or of slight diarrhoeas ; it is therefore necessary to practise culti- vations of the stools in these latter cases, as in the more authentic cases.

After death the autopsy and the bacteriological examinations should be made as promptly as possible. The vibrio is found in the exudate which covers the mucous membrane of the intestine, mingled with numerous epithelial cells.

It should be remembered that the cholera vibrio comprises a fairly large number of races, which differ in their dimensions — that is, in their length and thickness ; their form (some are rectilinear and rod-like, others ovoidal, almost like cocci) ; and their motility, which may even be lacking.

Cultivations should be made with one to five cubic centimetres of medium, and sometimes with much larger quantities, distributed in a certain number of receptacles containing 50 centigrammes of peptonised water. The examination should be made, at the latest, six to twelve hours later. Simultaneously cultures may be made in a mixture of agar and blood made alkaline with potassium. It must be remembered that B. coli, certain cocci, and B. pyocyaneus are also capable of multiplying on Dieudonne's agar. It is, in general, therefore, preferable to enrich the medium previously, rather than to commence the bacteriological analysis by cultivations made in pepton- ised water, before making discriminative cultivations on a solid medium.

The specific verification of the microbe isolated by agglutination in vitro, the test of injection into the peritoneum of an inmiunised guinea-pig, the indol reaction, and Bordet's reaction, will complete the in- vestigation.

The permanent Committee of the International Bureau of Hygiene, in 1911, confided to M. Pottevin the

162 DYSENTERY, CHOLERA, AND TYPHUS

preparation of a report upon the bacteriological diag- nosis of cholera. Italy, in 1915, published information of the same nature, indicating, at the same time, the means of removing and dispatching suspected matter. The latter (50 centigrammes) is placed in a glass receptacle, as are fragments of soiled linen. After death about six inches of that part of the ileum which lies immediately above the ileo-caecal valve is re- moved, between ligatures. This material is enclosed in receptacles of thick glass, sterilised by boiling, and well stoppered.

Administrative dispositions and sanitary regulations have been adopted by European countries to prevent the introduction of cholera, and to combat its propaga- tion and its sequelae, during the present war. Sweden (Royal ordinance of the 9th of November 1915), Holland (the 15th of November 1915), etc., have decreed the precautions necessary to protect themselves against this disease, which has been prevalent among the Austrian, Turkish, and other troops, while it was im- ported into Italy by Austrian prisoners.

Consequently, a bacteriological diagnosis of the first case or cases should always be established. Without waiting for the result of the expert inquiry, all sick and suspected persons should be isolated, and such isolation should be extended to orderlies and nurses of either sex.

The case must be immediately notified by the physician, and access to such cases should be forbidden to any other persons than the physician.

Isolation premises should be sufficiently removed from other buildings, and must be provided with special closets and a special drainage system.

Nurses and orderlies should be vaccinated against the disease. The sick person's clothes and underclothes should be placed in a sack for disinfection and sent to the oven.

If disinfection cannot be effected immediately clothes should be plunged into a vat containing water to which

PROPHYLAXIS OF CHOLERA 163

Javel's solution has been added, in such proportions that the mixture contains 0-5 centigrammes of chlorine per litre. Linen polluted by alvine evacuations and vomit must be the object of special precautions ; such materials must be handled with tongs or hands protected by rubber gloves. Boiling lye, or even boiling water merely, kills the cholera vibrio instantaneously.

Bedroom utensils, basins, slop-pails, spittoons, etc., are to be disinfected with sulphate of copper (10 per cent.), or with powdered chloride of lime, or Javel's solution, 1 in 50. The dejecta and the vomit of the patient should, if possible, be incinerated after being subjected to the action of the above-mentioned anti- septics. They must not be deposited in the neighbour- hood of wells or water-courses, or in gardens, or on dung-heaps, etc., etc.

Floors, walls, etc., subject to contamination are dis- infected with boiling water and washing soda.

The usual articles used by the patient — bowls, spoons, plates, metallic drinking-cups, etc. — should be placed in a wire basket and plunged into boiling water made alkaline with washing soda.

The patient should be kept scrupulously clean, and disinfected with a solution of cresol or dilute Javel's solution, his hands being frequently washed. Cholera cases should be placed in a special ward and tended by a special staff, the members of which have been vaccin- ated against cholera. Precise instructions as to avoid- ing contagion, as to washing the hands, wearing rubber gloves, and effecting frequent changes of blouses, etc., should be given. Pencils, pen-holders and pins must not be placed in the mouth, and no one must eat or smoke in the cholera ward, but in a separate apartment, after a change of protective clothing and disinfection of the hands.

In country districts the supervision of the patient and those about him, and the application of the above- mentioned measures of hygiene, are only too often im- perfectly carried out. The dispersion of faecal matter

164 DYSENTERY, CHOLERA, AND TYPHUS

over the soil, in back yards, farmyards, roads, gardens, dung-hills, etc., favours the diffusion of the vibrio. It is therefore necessary to leave physicians or qualified assistants in such localities, whose business it will be to ensure that these rules are observed.

The same measures of disinfection are to be applied, in times of epidemic, to the dejecta of any persons suffering from even light forms of diarrhoea.

The stools of patients who have recovered are dealt with in the same manner, as long as the appropriate cultivations reveal the vibrio in them.

Dead bodies should as quickly as possible be wrapped in sheets which are strongly impregnated with cresol, and should at once be placed in water-tight coffins with a large quantity of saw-dust impregnated with cresol.

All doubtful or uncertain cases must be subjected to bacteriological examinations of the stools.

Identical precautions should be taken in the case of ships carrying cholera patients, or suspected persons, or in the case of ships hailing from contaminated ports. The International Conferences of Constantinople, Vienna, and Paris have issued regulations as to the hygienic and administrative measures designed to protect ports of arrival, and to prevent the spread of cholera. To this end, when an epidemic threatens, lazarettos are established in the ports of arrival. The above-named conferences have decreed that passengers and crews should be inspected and placed in quarantine.

Pilgrimages to Mecca are prohibited. Lazarettos are established in Egypt to stop travellers and provide the sick with attention. Similar measures are taken on the frontier and at the railway stations at which travellers coming from contaminated countries arrive.

It should be remarked that the above measures relative to the protection of frontier ports and stations, although of the greatest service, are not nowadays re- garded as indispensable. We cannot guard absolutely against cholera by closing the frontiers. Healthy germ-

PROPHYLAXIS OF CHOLERA 165

carriers, convalescents, and the water of rivers may effect the spread of the disease. So may imported food-stuffs.

Accordingly the quarantine system has been re- placed in the principal ports by the careful medical inspection of passengers, and their medical and ad- ministrative supervision in whatever localities they go to. International prophylaxis has everywhere adopted very similar precautions.

In France the notification of cholera is compulsory. A decree of the 28th of August 1909 requires that a general sanitary supervision shall be exercised in respect of every traveller, package, or other object coming from a contaminated region. Sufferers from cholera are detained in a special hospital. Suspected persons are isolated for a period which must not exceed five days. The other travellers receive a sanitary passport, which they must present to the mayor of the commune within twenty- four hours of their arrival. They are then subjected to a special sanitary supervision for five days, and are visited in their place of domicile, and, if they are found to be infected, or regarded as suspect, they are immedi- ately isolated. In Paris they must notify any change of address to the prefecture of police or the mayor of their arrondissement. All their luggage is officially disin- fected. The importation of soiled linen, clothing, soiled bedding, rags, fruits, and vegetables is prohibited.

It is to be noted that these precautions do not take into account the possibility of contagion due to the carriers of germs, and the danger which these constitute. On the other hand, the period of five days allowed for medical supervision is assuredly too short when it is not completed, as is usually the case, by a bacteriological examination of the dejecta. The incubation 'period of cholera may, as a matter of fact, exceed five days.

To the above-mentioned precautions it is as well to add the special supervision of vagrants, nomads, pedlars, and itinerants. As regards inland navigation, the same medical supervision should be exercised in respect of boatmen, bargees, etc.

166 DYSENTERY, CHOLERA, AND TYPHUS

During epidemics, fairs, public meetings, etc., should be prohibited, as these multiply or prolong the causes of interhuman contagion. Lastly, the practice of vaccination against cholera, on as extensive a scale as possible, should he urgently recommended.

MacLaughlin, in order to facilitate the search for the cholera vibrio in the case of travellers arriving from countries where cholera is suspected, has recommended that they should be dosed with sulphate of magnesia, in the morning, on an empty stomach ; with the excep- tion of children and persons suffering from diarrhoea. Under these conditions he made 2000 examinations in Boston and Providence. This procedure is said to be preferable to the removal of matter from the rectum by means of a plug of cotton wool. The administration of a saline purgative causes the reappearance of the vibrio in the excreta of convalescents or healthy carriers. • •••••••

The prophylaxis relating to contagion by means of intermediate agents, living or inanimate (indirect con- tagion), deals more particularly with articles of food, drinking-water, flies, clothing, underclothing, linen, the soil, and, generally, anything that may have been contaminated by the faecal matter of cholera patients or germ-carriers, and anything that may have been employed as a receptacle of such faecal matter.

Everything that may cause indigestion or diarrhoea, or may introduce the cholera vibrio, must be avoided : green fruits, cucumbers, oysters, shell-fish, high meat or game, etc. The use of purgatives is dangerous.

In times of epidemic cooked foods should be con- sumed— that is, foods disinfected by heat — while those foods which will not bear cooking (cheese, etc.) should be effectually protected from contamination by flies, which is sometimes difficult, and from germ -carriers, which is still more difficult. The employment of safes, dish-covers of wire gauze, napkins, etc., and the mechanical prophylaxis of kitchens, dining-rooms, mess- rooms, hospital wards, etc., against the access of flies.

PROPHYLAXIS OF CHOLERA 167

by means of the fitting of screens of wire gauze or mosquito-netting in doors and windows, will prove of the greatest service.

The disinfection of latrines, privies and their approaches, by means of chloride of lime, protects them from the vibrios and the flies which distribute them.

Flies may be destroyed by means of fly-traps, fly- papers, and powdered pyrethrum, scattered at night over shelves and tables, and by means of saucers containing a little beer, to which a fiftieth part of formalin has been added.

It is needless to insist that in times of epidemic it is necessary to drink no water that has not been carefully purified. Sterilisation by boiling constitutes a perfect guarantee of safety. Extremely susceptible to anti- septics, the cholera vibrio is killed in a few minutes by chlorine, in the proportion of 1 milligramme to 1 litre of water. Hence the value of sterilisation by means of Javel's solution, or the special tabloids of hypochlorite of calcium (Vincent and Gaillard). The Lambert process also affords an excellent means of destroying the cholera vibrio.

The prophylaxis of cholera in barracks, camps, and cantonments, and, lastly, among troops in the field, calls for the same general measures as those which have just been indicated. In time of war, it cannot be denied that this prophylaxis would offer considerable practical difficulties were it not that specific vaccination against cholera affords a real, though not an absolutely com- plete, protection.

An early diagnosis must be made of every case of cholera, and, without waiting for results, the patient or suspected person should inmiediately be isolated, and the premises or quarters involved, together with the latrines, should be immediately disinfected. All benign cases must be made the object of bacteriological ex- amination, and patients must not leave hospital until two bacteriological examinations of the stools have been made, at an interval of a week.

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Ambulance cars should be disinfected (with boiling water and washing soda or JavePs solution, the stretchers and canvas, etc., being washed).

The bacteriological laboratories should also under- take the bacteriological analysis of water supplies.

In France, in time of peace, a special delegate, appointed by the Prefect and approved by the Minister of the Interior, is instructed to place himself in com- munication with the chief officers of the Army Medical Service in the fortresses, hospitals and infirmaries, with a view to taking all prophylactic measures in the inter- ests both of the army and the civil population.

Public water-closets, whether free or otherwise, should be inspected and disinfected. Urban disinfecting stations should be created, while disinfecting appliances and automobile ovens should be placed at the disposal of small towns and country districts.

A public notice might usefully be posted up, indicat- ing the principal ways in which cholera is propagated, the part played by the dejecta of cholera patients and of certain healthy subjects, the part played by water (insisting on the point that it is not the only agent of transmission), and the necessity of notifying the medical or sanitary authorities in cases of suspicious illness, etc. The deposition of faecal matter in famiyards, stables, manure-pits, roads, and lanes must be forbidden. The exportation of clothing, linen, rags, etc., from districts in which cholera is prevalent should also be prohibited, unless these articles have been subjected to disinfection by steam under pressure.

Specific Prophylaxis : Vaccination against Cholera. — Vaccination against cholera constitutes at the present time a really efficacious method of protection against the disease. It was first practised in 1885, by Ferran, in Spain. This physician discovered that guinea-pigs which had escaped death from infection due to the vibrio were protected against a deadly dose of virus. He cultivated the vibrio in bouillon at a temperature of 37° C. and injected living cultures of the microbe.

PROPHYLAXIS OF CHOLERA 169

Haffkine inoculated the vibrio into the peritoneum of the guinea-pig, and, after passing it through several animals, which increased its virulence, he cultivated it in bouillon, in large, well-ventilated flasks, in which it became attenuated. It was this culture which he inoculated as vaccine.

Vaccine sterilised by heating to 56° or 60° C. (130° or 140° F.) has been employed in Russia, Germany, Greece, Italy, Serbia, etc.

Besredka has recommended an anti-cholera vaccine sensitised by the same method as that which he em- ployed for anti-typhoid vaccine.

Vincent has prepared and employed, in France, Serbia, etc., an anti-cholera vaccine sterilised by ether. This vaccine is prepared with five races of vibrios, derived, as far as possible, from the countries in which cholera is prevalent. The vibrio is killed in less than one minute by the action of ether.

These vaccines afford experimental protection against the subcutaneous, or even intra-peritoneal, injection of extremely virulent vibrios.

In man the injection of Ferran's anti-cholera vaccine, which necessitates one or two repetitions of the in- jection, produces an intense local reaction (pain, oedema, redness, fever), and a general reaction (fever, etc.), and sometimes diarrhoea, lasting one to three days.

Haffkine injected under the skin of the flank -^ or ^V of an attenuated culture made on agar. Three to eight days later he injected the same dose of fixed and exalted virus. Later Haffkine employed the latter exclusively.

Powel inoculates in one injection I of a culture on agar of Haffkine' s exalted virus. Sterilisation by heat and antiseptics (carbolic acid), " without destroying the vaccinating property of the Haffkine vaccines, diminishes it considerably " (Salimbeni).

Between April and October, 1885, Ferran adminis- tered 150,000 preventive inoculations to 50,000 people.

170 DYSENTERY, CHOLERA, AND TYPHUS

With remarkable patience and perseverance, Haffkine, between April, 1893, and September, 1895, vaccinated 42,197 persons by means of nearly 70,000 injections. The vaccine was living. The nimiber of subj ects vaccin- ated by his method has been considerably increased since then. The vaccinations have been carefully checked, and their results compared with the morbidity of persons subjected to similar conditions of infection. In each locality one-half only of the inhabitants were vaccinated, the other half serving as a control. The results testified to an efficacy which was not absolute, but was genuinely considerable. The immunity, it was said, might continue for twelve to fourteen months.

Aldo Castellani, in 1909, adopted the employment of living cultures as vaccine, a method which Ch. Nicolle has also employed. For the first injection he recom- mends Wriglxt's dead vaccine.

The employment of vaccine sterilised by heating has been recommended in Germany. Two milligrammes of a culture made on agar (a platinum loopful) is in- jected, diluted with physiological water, and with the addition of carbolic acid. The injection is accompanied by considerable local and general reaction.

For four days there is said to be a negative phase, with predisposition to infection (Testi).

Cawadias has stated that during the epidemic which broke out in the Greek Army at the time of the last Balkan War, his cholera patients included :

82-5 per cent, of non- vaccinated subjects 10-6 ,, of incompletely vaccinated subjects 6*7 ,, of completely vaccinated subjects.

Among the non-vaccinated there were 21 per cent, of deaths ; among the vaccinated patients, 2 per cent.

Arnaud has published similar data.

In Russia an official circular appearing in 1909 recommended vaccination against cholera.

PROPHYLAXIS OF CHOLERA 171

Three injections were made, the first consisting of 0*5 to 1 c.c. ; the others of 2 and 3 c.c. One should avoid vaccinating persons suffering from cholera, persons suffering from febrile complaints, and weak or anaemic persons.

About this time Zverev collected and classified the observations of a large nimiber of hospitals : 28,996 persons were given preventive injections. The number of injections was only 53,162. The reaction caused by the injection was slight in 58 per cent, of these, of medium intensity in 32 per cent, (involving lassitude, vertigo, severe headache, nausea, colic, diarrhoea), and severe in 10 per cent, (involving violent headache, vomiting, frequent diarrhoea, pain, high fever, and incapacity to work for several days).

As regards the immunising effects, only twelve persons contracted cholera. In addition to these, twelve persons fell ill one to three days only after vaccination ; the injections, therefore, had no abortive action on the cholera.

Two suffered from diarrhoea of a choleraic type, 12 and 15 days after an injection, and rapidly recovered. One nurse had cholera 2 months and 5 days after the second injection, and recovered. A woman of forty- four developed cholera 30 days after the second in- jection, and died.

The immunity conferred by vaccination has in general been high.

Kasch Kadarrov has published an essay giving par- ticulars of the vaccination of 16,011 persons by means of 30,078 injections. Of these persons 635^ received one injection (that is, 39-7 per cent.) ; 5251 received two injections (32-8 per cent.) ; and 4408 received three injections (27*5 per cent.).

34-6 of those vaccinated suffered reactions : severe in 13-5 per cent., of medium intensity in 32-4 per cent., and slight in 54-1 per cent.

The fact of immunity was thoroughly established,

172 DYSENTERY, CHOLERA, AND TYPHUS

but only several days after the injections. The dura- tion of the immunity was brief (a few months).

It is estimated that the duration of the immunity conferred by vaccine sterilised by heating is not in general more than six months.

Aaser, of Christiania, made an anti-cholera vaccine (by heating) with a very virulent race of vibrios, and vaccinated thirty-one persons, nearly all of whom exhibited local and general reactions.

In the Val-de-Grace laboratory an anti-cholera vaccine is prepared with ether. This vaccine is poly- valent— that is, it is prepared with five races of vibrio, obtained from countries actually infected (Galicia, India, etc.). This vaccine has been injected into several thousands of soldiers in France, Serbia, etc., and gives rise to no local or general reaction. It causes neither swelling, nor pain, nor fever, and may be in- jected, as it is so readily tolerated, into any individual, without any counter-indication save incipient cholera. Two injections are given at five days' interval : one of 2 c.c. and the other of 2-5 c.c.

The Serbian troops were vaccinated by means of two vaccines, one prepared by means of heating and one with ether. The result was an excellent degree of protection.

The same vaccines were employed in the Italian Army, cholera having been imported by the Austrian prisoners ; but the disease was very quickly suppressed.

In the German Army vaccination against cholera has been practised systematically beginning a few months after the commencement of the war.

We possess certain data as to the vaccination of the Austrian troops in Cracow, where cholera was preval- ent. The mortality among the non- vaccinated was 50 per cent. ; among the vaccinated, Q'5 per cent. The vaccinated subjects developed a fairly large number of slight forms of cholera. Vaccination effected during incubation or even in the initial stage of cholera does not appear to have produced any evil effects.

PROPHYLAXIS OF CHOLERA 173

Moreschi and Marcora have recommended intra- venous vaccination, in preference to subcutaneous vaccination. The dose injected is 0-1 to 0-3 of an ordinary platinum loopful, instead of six loopfuls (nine milhards of vibrios) injected under the skin.

EXANTHEMATIC TYPHUS

PART /.—CLINICAL SURVEY CHAPTER I

SYMPTOMATOLOGY

Typhus/ an acute infectious malady, without special anatomo -pathological lesions, the specific agent of which is not yet known, is characterised by a con- tinuous fever, lasting, on an average, a fortnight, and by morbid symptoms which are chiefly nervous and respiratory. One of its symptoms, and the most con- stant, is the appearance, during the first days of the disease, of a characteristic exanthem.

The clinical development of typhus consists of four periods :

1. The period of incubation.

2. The period of invasion.

3. The period of eruption.

4. The period of termination.

1. Period of Incubation. — ^The duration of the period of incubation varies from 5 to 21 days. According to Jeanneret-Minkine it averages 8 days ; according to V. Bue, 10 days ; according to A. Netter, 11 days. Marsh and Netter have reported cases where in- vasion followed almost inmiediately upon infection. In general, this period is not marked by any indication which particularly draws attention to it. Toward the end, however, one may note certain digestive dis- orders (a condition of nausea and anorexia), headache, lassitude and vertigo, while the disposition of the

^ Synonyms : Exanthematic typhus ^ typhus petechialis, *• spotted typhus," '* camp typhus," etc.

M 177

178 DYSENTERY, CHOLERA, AND TYPHUS

patient seems changed. The temperature is 99*5° F. ; the pulse eighty beats to the minute. On the follow- ing day the headache is more violent, the anorexia more complete. The temperature rises to 100-2°. The patient already wears a jaded expression, which bears no relation at all to his condition. He complains, often enough, of sharp pains in the limbs, pains in the spine, headache, and vertigo, with buzzing or humming in the ears, during the days which immediately precede the first appearance of the symptoms.

2. The Period of Invasion. — Sometimes after two or three days of these prodromes, but oftener quite suddenly, the patient is attacked by a violent and peculiar fit of shivering, an excruciating headache, frequent vomiting, and epistaxis, the persistence and profusion of which alarm those who witness it, some- times necessitating plugging (Bue). The temperature rises to 102°, and may reach 104° or 105° ; the pulse is rapid, 100 to 120 beats per minute. The respira- tion is accelerated, and there is cough, with signs of slight bronchitis. The face is congested and the con- junctivce injected, and a muco-purulent discharge is sometimes observed. The eyelids are tumefied. Sometimes, from the commencement, the patient is violently delirious. The tongue is coated. The pharynx is inclined to redness. The epigastric region is painful upon pressure, and the patient is usually con- stipated ; the abdomen is not painful. Diarrhoea is not exceptional, however, and is accompanied by abdominal rumbling and pain provoked by pressure. Combemale has reported cases of choleriform diarrhoea. The urine, scanty, and dark in colour, contains albimiin. The patient is apathetic. His sleep is disturbed, in- terrupted by dismal dreams ; sometimes there is even complete insomnia, the patient being unable to obtain even ten or fifteen minutes' rest. Narcotics are gener- ally powerless to afford relief (H. de Brun).

3. The Period of Eruption. — ^From the fourth or fifth

SYMPTOMATOLOGY 179

day (Netter, Jeanneret-Minkine, Escalier, etc.) the exanthem of typhus appears, an exanthem which is not, however, constant, and which may be lacking in one-tenth or one-twentieth of the cases observed (Netter). It commences on the trunk ; it should be looked for first of all under the armpits, on the shoulders, then in the region of the epigastrium, and on the thorax ; finally, on the limbs and the abdomen, where the erup- tive elements are sometimes very numerous. The eruption presents two different aspects, which differ greatly. At certain points the patient's skin is sprinkled with marblings, due to the appearance, under the epidermis, of very fine, pale, irregular spots. But the eruption which occurs with by far the greater fre- quency consists of spots which present no relief, or very little, yet which are sometimes papular, with rounded but ill-defined contours. These spots are at first rose- coloured or reddish, but they afterwards assume a livid, bluish tint. Their size varies from that of a small pin's head to that of a large lentil. Often isolated, they may, however, be confluent, and their outlines then become irregular and indented.

On their appearance the spots disappear for the moment on pressure, like the rose-coloured, lenticular spots of typhoid, but two or three days later they are surrounded by a very pale bluish-grey halo. If they were raised they now subside. It seems as though the skin had suffered a slight contusion at this point : slight, but sufficient to produce a tiny patch of ecchy- mosis, which no longer disappears under pressure. This petechial aspect may not be presented by all the spots. With moderate frequency (in 10 per cent, only of the cases occurring in an epidemic observed by Jeanneret- Minkine during the present war), the spots undergo a hsemorrhagic transformation ; they are then completely reminiscent of the spots of purpura. They are first observed in the region of the back and the tracts exposed to continuous pressure (Escalier). The typhus spots persist, on an average, for five to ten days. Most

180 DYSENTERY, CHOLERA, AND TYPHUS

of them disappear without leaving any traces, but others reveal their position, sometimes until the end of the convalescent period, by a bluish tinge or a slight pigmentation of the skin.

The eruption of typhus sometimes appears very early, and is also extremely fugitive. It may he confined^ even in fatal cases, to a few spots, lightly marked, which sometimes have to be carefully sought for (H. Vincent). It may even be absent in children under fifteen years of age. The spots may become more visible, or assume their characteristic aspect, after washing the arm with soap, and then tying a ligature round the root of the limb. They should be sought on the palm of the hand, which, according to some writers, is their favourite situation.

Appearing simultaneously with the exanthem, or sometimes even earlier, there is an erythema character- ised by a deep, diffuse redness of the mucous membranes of the mouth, invading the pillars of the soft palate, the uvula and the tonsils (Bue, Petrovich). From the second day, on the mucous membrane of the palate, a certain number of red spots (5 to 15), from 1 to 3 milli- metres in diameter, may sometimes be observed. They very soon disappear. Their outlines are denticulated.

These buccal spots invade the respiratory passages. All sufferers present, from the outset, a dry, fitful cough, which later on is accompanied by expectoration. This is often very profuse, purulent, and fetid.

The appearance of the eruption coincides with an aggravation of the intensity of all the morbid symptoms. The nervous disorders and the delirium are aggravated. The eye is haggard, the face now pale, now flushed. The temperature oscillates between 104° and 106° ; the pulse is small and feeble ; the number of beats, in cases of average severity, being from 110 to 120 per minute. It is at this stage that sudden impulses toward suicide are observed, and extreme agitation, during which the patient seeks to get up and go out ; if he is not watched he will make his escape. In the benign forms

SYMPTOMATOLOGY 181

of the disease the nervous system is not greatly affected by the toxins ; the sick physician will take notes of his own case (Bu^). However, in addition to the spinal pains and gastralgia which are not uncommon, a cutaneous hyperesthesia may be observed, local or general, and sometimes extremely intense.

Toward the eighth day it seems as though the dis- ease were about to reach its termination. The tem- perature falls a couple of degrees, or even four ; but this deceptive remission is of brief duration (twenty- four hours at most). The fever reappears, as severe as before, and is maintained until the fifteenth day.

During this second portion of the critical period nervous disorders are constant, more or less accentuated, and varying infinitely in the case of different patients. Certain sufferers exhibit a calm and gentle delirium ; plunged in a semi-torpor, they mutter incoherently. In others the delirium is definitely systematised, re- volving round a fixed idea.

Lastly, a delirium of action may be observed, which is influenced by terrifying hallucinations. It is very similar to that of delirium tremens (de Brun), and is accompanied by a return of the suicidal impulses.

Convulsive crises have also been observed (R. Job and E. Ballet).

Generally speaking, the deliriimi is not of long dura- tion, although in certain cases it has been known to persist even after defervescence (de Brun). Often enough it disappears after two or three days, to give rise to prostration and stupor. About the ninth day of the disease the patient is inert, lying in the dorsal decubitus, the eyes almost closed, the pupils contracted, the hearing much impaired. The patient is completely indifferent to all that is happening around him ; he does not recognise those about him, and it is very difficult to rouse him from his torpor. Sometimes he is plunged into a sort of coma, which lasts until defervescence or death.

However slight it may be, the prostration of the

182 DYSENTERY, CHOLERA, AND TYPHUS

typhus patient is of a very special kind. Remlinger has recently drawn attention to one of its peculiarities, which he has called the " sign of the tongue." The typhus patient cannot protrude his tongue from his mouth, or can do so only at the cost of extreme effort. Fumey, Godelier, Billot, Maurin, Masse, and H. de Brun had already noted this fact, and also that in certain cases the tongue even seemed to be retracted toward the pharynx. Some writers, moreover, have noted fibrillary movements, and tremors of the tongue, as well as difficulty in speaking. In 1893, referring to the nervous manifestations which he had observed during the Beyrout epidemic, H. de Brun remarked: " The tongue seems as if fixed to the floor of the mouth ; it is heavy and sticky, and is moved with difficulty ; speech is slow and often tremulous. . . . When the tongue is protruded from the mouth it is animated by incessant vermicular movements ; it is always moving, and cannot be kept motionless in one position ; the commissures of the lips also are twitching, owing to the trembling of the levator muscles, and the whole jaw may jerk so violently that I have sometimes found it impossible to take the buccal temperature. In forms of medium or slight intensity the speech is con- spicuously tremulous, and this symptom may persist so long after defervescence that it has enabled me to form a retrospective diagnosis six weeks after recovery."

Congested, broad, and more voluminous than in the normal condition, the tongue is covered with a mucous coating which is at first white, then yellow, then brown or black, thick, and covered with cracks. The edges and the tip are a bright red. At other times it is small, dry, and withered, as though baked and shrivelled. The lips and teeth are dry, black, and fuliginous.

Tremors are not localised only to the tongue, lips, and jaw; they may also be observed in the hands and forearms, the oscillations here resembling alcoholic tremor (de Brun).

SYMPTOMATOLOGY 188

Subsultus tendinum is more constant and more accentuated than in typhoid fever.

The cutaneous, abdominal, and cremasteric reflexes are fairly constantly suspended (Potel).

The abdomen is flat, or slightly distended ; con- stipation is persistent, or else one or two diarrhoeal stools may be observed. There is often relaxation of the sphincters, evacuation and urination being in- voluntary. Sometimes also there is an actual retention of urine which necessitates the use of the catheter.

The urine, rather more abundant than at the outset, very frequently contains albumin, with or without any increase of urea. The albuminuria noted in 50 per cent, of patients usually disappears about the fifteenth day. The skin is hot, sometimes moist. The pulse rarely exceeds 115 to the minute ; it is small, feeble, compressible, and often intermittent (Netter). The spleen is slightly enlarged. The emaciation is extreme. The vasor-motor sign of supra-renal insufficiency is pretty constantly observed (Bue). Combemale in four cases has noted a development on the face, of a greyish, crystalline efflorescence; two of these cases died in a few hours.

4. The Period of Termination. — Death occurs in 15 to 50 per cent, of the cases, the period of its occurrence varying ; but it most frequently supervenes during the second week, on the eleventh, twelfth, or thirteenth day (Jeanneret-Minkine). It is most commonly due to a sudden cardiac syncope.

In favourable cases a critical improvement occurs on the fourteenth or fifteenth day. Very rarely defer- vescence is sudden, occurring in a few hours. More commonly the temperature falls slowly, defervescence assuming the form of lysis. In three, four, or five days it becomes normal, or even subnormal. At the same time the pulse suddenly falls to 80, and is sometimes even abnormally slow, while maintaining the normal qualities of rhythm and tension.

184 DYSENTERY, CHOLERA, AND TYPHUS

The skin scales off in fine, small, squamous flakes, which, as they approach desquamation, give the skin a greyish- white, metallic lustre (Escalier). The nervous symptoms are progressively abated, and in a few days have disappeared. Sometimes, after a peaceful sleep, of several hours, the patient awakes transformed. He recognises those about him ; he is no longer delirious, but his deafness usually remains and is more or less marked, while the haggard expression persists for some weeks.

The tongue grows moist and clean ; the appetite returns and is insatiable ; there is frequently a sudoral, polyuric, or diarrhoeal crisis.

Muscular impotence is very marked, and emacia- tion extreme. The convalescence is always long, the strength returning slowly, and the patient is very quickly fatigued. For about a month the convalescent experiences a sensation of physical depression and general exhaustion, an exaggerated need of food and very prolonged sleep.

Recurrence is rare, but possible.

Complications

The complications which may make their appearance during convalescence are numerous.

Among these we must give the first place to myocar- ditis, which is, if not of invariable occurrence, yet extremely frequent, and is betrayed by the acceleration and enfeeblement of the cardiac pulsations, the very marked deadening of the heart sounds, the diminution of arterial pressure, and the failure and irregularity of the pulse. A careful examination of the heart should be made every day, in order to provide against the sometimes fatal complications which accompany cardiac insufficiency.

Broncho-pulmonary complications are also frequent. Simple bronchitis, capillary bronchitis, pneumonia, or broncho-pneumonia may be encountered. The patient may complain neither of a stitch in the side, nor of

SYMPTOMATOLOGY 185

a cough, nor of expectoration ; but only show an acceleration of the respiratory movements, with a slightly purplish, cyanosed coloration of the face. Vomicce have been recorded (Combemale), pulmonary gangrene, and purulent pleurisy.

Laryngo-typhus may be observed, as well as ulcera- tions of the vocal cords, and laryngeal perichondritis with oedema of the glottis.

Sacral, trochanteric and malleolar bed-sores are not uncommon.

Gangrene of the mouth, the scrotum, the labium majus, the extremities, and the lower limbs, principally through arterial obliteration, is fairly common ; it may vary considerably in extent, sometimes necessitating numerous operations.

Periostitis and peripheral neuritis (Job and Ballet, Bu6) are also observed with some frequency, as are lymphatic suppurations, phlegmons, adenitis, and erysipelas (Delearde and d'Halluin), etc.

Suppurative otitis media and suppurative parotitis are frequently observed, as is also phlegmasia alba dolens. Certain patients suffer from a considerable oedema of the lower limbs long after recovery from typhus, and this sometimes coincides with oedema of the eyelids, most frequently without albuminuria. Lastly, Delearde and d'Halluin and Bue have noted the exceptional gravity of bucco-pharyngeal diphtheria when it develops during the developing period of typhus, or during convalescence, and the frequency of various tubercular manifestations which may sooner or later appear.

Clinical Forms

A certain number of clinical forms of typhus have been described, which are differentiated by the pre- dominance of certain symptoms, or the rapidity with which the disease develops. We shall briefly re- capitulate these forms.

186 DYSENTERY, CHOLERA, AND TYPHUS

Inflammatory Typhus. — ^A form which occurs in young and vigorous subjects, and persons belonging to the wealthier classes ; it is characterised by a high temperature, violent headache, and acute delirium, in the course of which attempts at suicide are not uncommon.

Ataxic Typhus, Adynamic and Ataxo - Adynamic Typhus. — These forms are sufficiently characterised by the symptoms which serve to indicate them ; they are usually serious.

Typhus siderans ( Jaccoud), in which death may ensue in two or three days, sometimes in a few hours. This form is observed in alcoholics (Baudens).

A slight form of typhus, of very brief duration, is also described by Hildebrand as typhus levissimus ; it is not accompanied by eruptions. In this case the initial period may pass unperceived unless it was known that an epidemic of typhus existed. It is generally sudden, with shivering, headache, vertigo, lassitude, and insomnia. The tongue is coated, the skin hot, the spleen slightly enlarged, and a little bronchitis may be present. These symptoms increase for four or five days ; then the disease quickly terminates. The patient breaks into profuse sweats, and frequently exhibits labial herpes. These cases have been described by Netter as ephemeral fever. There are also abortive forms, with violent onset, which suddenly abate after three or four days. The patient frequently suffers from facial herpes.

Lastly, Jacquot has described a series of symptoms : malaise, slight fever, loss of appetite, nausea, headache, and intellectual debility, which may be exhibited for several weeks by subjects exposed to contagion, but who, apparently, have not contracted typhus. Jacquot describes this condition as " typhisation in small doses. ^^ Combemale noted similar clinical phenomena during the Lille epidemic. They are due to attenuated forms of the infection.

CHAPTER II

DIAGNOSIS

At the beginning of an epidemic, or when isolated eases of typhus are occurring, the diagnosis is not easy. It is always uncertain before the appearance of the eruption (Murchison).

The sudden onset, the high temperature, rising to 104° or 105°, the rapid pulse, of 100 to 120 per minute from the first days of the disease, the early appearance of the nervous symptoms (on the second or third day), the presence of constipation without intestinal phenomena, the profuse and frequent epistaxis, the phenomena of congestion, the injection of the con- junctivae, the state of the mucous membranes, and upper air passages, and the almost constant vomiting are assuredly not to be disdained as elements of diag- nosis. They do not, however, acquire their full validity until the appearance of the exanthem, with all its characteristics : its sudden commencement (on the second to the fifth day), its petechial character, the abundance and the general distribution (except on the face) of the eruptive elements, and the successive trans- formation of these elements, which persist for some length of time. Lastly, the verification of the exan- them, the " sign of the tongue," the nervous pheno- mena, and, above all, the tremor and the loss of memory are very diagnostic.

The physician, in pursuance of Netter's advice, may derive great assistance from the following factors :

1. The existence of transmitted cases among the members of the medical staff (physicians, orderlies, nurses, etc.). 187

188 DYSENTERY, CHOLERA, AND TYPHUS

2. The social position of the first sufferers (vagrants, destitute persons, prisoners, etc.).

3. The not infrequently advanced age of the patients.

4. The predominance of the disease in cold weather. The diagnosis is usually facilitated by such factors

as the knowledge that an epidemic exists ; the well- established fact that the patient comes from a house where there have been cases of typhus ; that he has been in direct or indirect contact with persons suffering from typhus. But even in such cases as this it is neces- sary to establish a precise differential diagnosis.

Typhoid fever is, of all diseases, the one which presents the closest clinical analogies to typhus. Here, how- ever, the commencement is usually much less sudden ; the injection of the conjunctivae, so peculiar to typhus, is absent in typhoid fever. The eruption appears later, and is less abundant. However, the rose-coloured spots may become generalised, may attain large dimensions and, especially in time of war, may be purpuric or haemorrhagic in character. In typhoid fever diarrhoea is more frequent than constipation ; in typhus the con- verse is true. In typhus the temperature rises to 104° or 105° at the outset, and remains at that level for five or six days, without any notable remission. During the present war the general signs and symptoms of torpor have sometimes been so marked during the course of typhoid fever and paratyphoid fever that one might have believed them cases of typhus. In such cases the sero-diagnosis of non-vaccinated subjects, or the culti- vation of the blood, during life, and of the bile, after death, make it possible to establish a diagnosis. In Serbia, during the present war, Petrovich observed instances in which typhus made its appearance in typhoid wards. On the second day the patients exhibited photophobia and turgescence of the face, while a dark, diffuse redness, with roseate spots, covered the throat ; the tongue was coated and was red at the edges and the tip. On washing the arms and the trunk with soap it was possible to verify the

DIAGNOSIS 189

commencement of the exanthem. The heart sounds were already weakened.

Relapsing fever begins in a much more sudden and dramatic manner than typhus ; there is violent shiver- ing, nausea, bilious vomiting; a temperature of 104°, 106°, or even 107°, and more from the outset ; there is enlargement of liver and spleen, the latter being painful upon percussion. These phenomena suddenly dis- appear at the end of four, five or six days. The tem- perature falls to normal and the patient may think he has recovered. But after the lapse of about a week a fresh attack develops, in every way resembling the first. There is no exanthem, or at most a limited roseola may be observed, but this is exceptional. Moreover, during the whole course of the attack an examination of the blood reveals the specific spirochaete.

Malarial fever of the continuous type is not usually observed during the same season as typhus in countries where malaria and typhus are endemic. Typhus is more common in the winter and spring, malarial fever in the simxmer and autumn. The hypertrophy and the con- sistency of the spleen, the absence of an exanthem, and stupor, combined with the knowledge that malaria is prevalent, and finally, the examination of the blood, and the discovery of the malarial parasite, will establish the diagnosis, and the efficacy of treatment by quinine will subsequently confirm this.

The eruption of typhus has caused the disease to be confused with measles, especially in children. The prodromic period of measles is highly characteristic, with its coryza, its epiphora, and its sneezing. The eruption, which appears about the fourth day, involves the face, which typhus respects. In measles the tem- perature falls as soon as the exanthem appears ; the spleen is normal.

Cerebrospinal meningitis has also been confused with typhus. In meningitis there is photophobia, and a dread of noise, while in the typhus patient there is usually deafness, and the senses are dulled. The face

190 DYSENTERY, CHOLERA, AND TYPHUS

of the sufferer from meningitis expresses suffering and anxiety ; that of the typhus patient stupor and in- difference. In meningitis there is stiffness of the nape of the neck, and Kernig's sign is present ; there is no exanthem.i

Influenza may give rise to exanthemata like that of scarlatina, or measles, or papular eruptions (Van Swieten, Comby, Perrenot), with redness of the pharynx and a typhoid aspect, which may give rise to confusion at the beginning of epidemics. The onset of influenza is even more sudden than the onset of the sudden form of typhus. The temperature, which at first rises to 104° or 106°, remains only for a short time at that level. Sometimes it drops suddenly, after two or three days, and does not again rise; sometimes, after a sudden and very marked fall, lasting twelve to twenty-four hours, it rises as high as before the fall, forming a de- pression in the thermal curve like an inverted steeple (J. Teissier's "V of influenza ") ; sometimes it falls by lysis. Apart from the behaviour of the temperature, the oculo-nasal catarrh, the arthralgia, the neuralgic character of the headache, which is often supra-orbital, and the frequent perspirations, will enable the physician to form a diagnosis.

Apical pneumonia is sometimes accompanied by typhoid-like phenomena, though, for several days, despite careful examination, it may be impossible to discover local indications. The commencement is, as a rule, easily specified ; the dyspnoea, the dryness of the tongue, the redness of the cheek-bones, the presence of herpetic vesicles, the absence of petechias, and, lastly, the examination of the lungs, will assist the physician to establish his diagnosis.

The spotted fever of the Rocky Mountains presents remarkable points of resemblance to typhus : it com- mences with violent shivering ; the temperature rises to 104° or 106° by the second day, and between the

^ In certain cases purpuric spots appear in cerebro-spinal fever, whence the name spotted fever. — Ed.

DIAGNOSIS 191

second and fifth days an eruption appears, exactly like that of typhus ; rose-coloured spots which become generalised and are transformed into petechise, but which first appear on the wrists and ankles ; not until later do they reach the thorax and the abdomen. Moreover, there is constipation, enlargement of the spleen, delirium, a sub-icteric tinge of the skin and the conjunctivae, scanty and albuminous urine and oedema. This disease prevails more particularly in iSpring and summer. Wilson and Chowning claimed that it was due to a piroplasma, which was rare in the peripheral circulation, but, on the other hand, abundant in the visceral circulation. Their discovery has not been confirmed by the researches of StileS and Ricketts.^ Quinine in large doses is said to possess a curative action in Rocky Mountain spotted fever (Anderson).

Finally, it must be remembered that there are cases in which diagnosis is rendered extraordinarily difficult by the association and overlapping of two quite differ- ent maladies, these giving a type of "mixed malady " (Kelsch, Remlinger), which does not in any way re- semble either of them. Among these mixed maladies we should specially mention the association of typhus with recurrent fever, with typhoid fever, with dysentery, and with scurvy. Exceptional in time of peace, these morbid associations are not rare in time of war. It is important to be forewarned of their existence.

^ It is now generally accepted that Rocky Mountain spotted fever is a variety of typhus. The disease is spread by ticks. — Ed.

CHAPTER III

TREATMENT

A PATIENT definitely attacked by typhus, or merely suspected of typhus, should immediately be isolated in a spacious, well-ventilated room. Bodily cleanliness should be Scrupulously attended to. Diet should consist of liquids : milk, beef -tea, lemonade, with the addition of wine, and diuretic beverages in abundance. Alcoholic drinks and preparations should be re- served for patients whose hearts are weak. The very numerous systems of treatment which have been recommended have not always given the excellent results which were expected of them. Among these we may refer to the blood-letting treatment (Clutter- buck and Armstrong), the stimulant treatment (Alison, Graves and Stockes), the hydrotherapic treatment (Currie), the quinine treatment (Dundas), the emetic treatment (Rasori), etc.

The best treatment is the symptomatic one. High temperatures and intense cerebral phenomena are beneficially influenced by lotions (Petrovski), and warm, or, better, cold baths.

The headache which is so troublesome during the first few days may be combated with preparations contain- ing opium, with aspirin, or with cryogenin. The latter, according to Marini (of Aleppo), has the further advan- tage, in cases of typhus, of lowering the temperature, regulating the pulse, and procuring for the sufferer a sort of euphoria.

Constipation, if it is present, should be treated by emollient or slightly purgative enemas, or by laxatives. No attempt is to be made to establish diarrhosa. The

192

TREATMENT 193

respiratory organs, the heart, and the urinary secretion must be closely watched, and complications treated by the usual means. In cases of cardiac collapse during typhus, Jeanneret-Minkine recommends massive in- jections of ethero-camphorated oil.

Bouyges claims to have obtained good results by intravenous injections of electrargol and colloidal gold. This last drug excites powerful reactions, and must not be employed when there is myocarditis.

Gaston has reported good results from intravenous injections of citrated and iodised serum.

Legrain and Raynaud (Algiers) have treated typhus patients by Subcutaneous injections of the serum of convalescents. The temperature has fallen very quickly, has remained low for thirty to thirty-five hours, the pulse has improved, the general condition has been ameliorated, and the patients have recovered.

During the present war Escluse and Liber have attempted to treat typhus by means of intravenous injections of the blood of convalescents, coagulation being retarded by citrate of sodium. By this method they claim to have obtained recoveries in cases which were despaired of. The injections should be made from the fourth to the tenth day at latest. The blood should be drawn from a robust convalescent whose defervescence dates back only eight or ten days. Thirty c.c. may be injected with impunity during the twenty -four hours, in three instalments. The recovery of the patient may depend upon perseverance in the treatment.

Finally, Charles Nicolleand Ludovic Blaizot have been able to produce a condition of hyper-immunisation in the ass and the horse, by administering repeated inoculations of emulsions of the spleen or supra-renal capsules of guinea-pigs infected with typhus. The serum of these animals is said to possess actual preventive power, and an undeniable curative power. Non-toxic to man, it has been administered in thirty- eight cases, and thirty-Seven times with success.

194 DYSENTERY, CHOLERA, AND TYPHUS

MM. Nicolle and Blaizot give the treatment as follows : —

1. There is much to be gained by commencing the serotherapeutic treatment at the very commencement of the disease, immediately the diagnosis is admitted, or even suspected merely.

2. The inoculations should be repeated daily until defervescence, or, at all events, until a real and pro- found improvement of the general condition is obtained, foreshadowing an imminent convalescence.

3. The proper doses of the serum are 10 c.c. to 20 c.c. daily, administered hypodermically.

4. The serotherapeutic treatment should be com- pleted by a medical treatment designed to favour the elimination of the microbic toxins and the residues of the defensive reaction of the organism. This medical treatment consists of abundant diuretic beverages, tepid baths (82° to 90°), stimulants, and cardiac tonics ; lastly, in serious cases in which the intoxication is pro- found, it may be needful to inject 500 to 800 grammes of artificial serum.

PART //.—EPIDEMIOLOGY AND PROPHYLAXIS OF TYPHUS

CHAPTER I

MEDICAL HISTORY AND GEOGRAPHY

Typhus is probably as old as man himself. We find descriptions which answer to this disease in the Hebrew scriptures and in the medical works of the Arabs. In the narrative of the terrible plague which ravaged Greece, and of which Thucydides was the historian, one recognises typhus. The first study of this terrible malady is due to Frascator. There was no lack of material for observation, for Italy was decimated by typhus between 1505 and 1530. Lautrec's army, infested by the disease, left 30,000 dead before Naples.

Since then there has not been a single war unaccom- panied by typhus. Physicians learned to distinguish typhus {Pesticula), or Typhus petechialis, from plague, which was then common. All the wars of the sixteenth, seventeenth, and eighteenth centuries were, with- out exception, the occasions of a return of typhus. The armies of Charles V., before Metz, were ravaged by this disease. During the wars of the Revolution it was constantly active. The French, besieging the Austrians before Mantua in 1806, were as severely visited as the latter, and carried the germ back to France with them. At the same period 14,000 deaths were reported in Genoa. In France Montpellier, Marseilles, Toulon and Grenoble were infested by typhus.

After the battles of Austerlitz and Jena the 195

196 DYSENTERY, CHOLERA, AND TYPHUS

ambulances and hospitals were encumbered with typhus patients. The German prisoners brought the sickness to France. During the retreat from Russia the un- happy French troops, exhausted and covered with rags, died by the thousand along the road- side at Wilna. In the latter city, where 30,000 men had taken refuge, 25,000 succumbed ; 8000 of the inhabitants also perished by typhus, the poorer inhabitants being principally affected. In Dantzig 36,000 Frenchmen were besieged ; 13,000 died of typhus. There were 10,000 deaths among the civil population. At Torgau 14,000 men out of 26,000 succimibed. At Mayence also 20,000 soldiers died of typhus.

These frightful hecatombs amply justify the name which at this period was given to the disease — ''army typhus," "camp typhus." It seems probable that typhoid, which presents clinical analogies to typhus, and which is the peculiar scourge of armies in the field, has shared with true typhus the responsibility for these terrible onslaughts.

Although typhus has not again broken out with such terrible violence, it has not, however, entirely disappeared.

After 1815 typhus persisted in convict establish- ments, hulks, and prisons, and also amid the poor and wretched populations of certain countries. It per- sisted in the East, in Russia, Prussia, Poland, Silesia, and Ireland. Between 1846 and 1848, according to Murchison, there were 300,000 deaths from typhus in Ireland. The Crimean War reawakened it. At first a few cases appeared among the Russians ; then it spread rapidly; 12,000 cases and 6000 deaths were reported to have occurred in their ranks. The French Army was attacked in turn. The soldiers, crowded together in dug-outs and the trenches, exhausted, subjected to superhimaan exertions, and deprived of the most elementary hygienic attention, were struck down in the proportion of one in ten (F. Jacquot). More than 17,000 succumbed. On their return the

MEDICAL HISTORY AND GEOGRAPHY 197

armies infected the populations of Marseilles, Toulon, Porquerolles, and Avignon.

It is said that there were a few eases of typhus in the French Army in 1870, after the battle of Mans, and at Mayenne (Morisset), but this fact is not satisfactorily proved.

On the other hand, during the Balkan War the Army of the Danube had 32,451 cases (54-8 per 1000), and 10,031 deaths (17-02 per 1000). The Army of the Caucasus had 15,660 cases, with 6506 deaths.

The disease showed a few cases at the outset of the war, then spread rapidly, especially when the cold weather set in and the men were packed together in cattle-sheds.

The proportion of cases in the Army of the Caucasus was as follows : —

November, 1877

December ,,

January, 1878

February

March

April

May

June

4-69 per 1000

19-65 „

43-85 „

46-90 „

38-13 „

22-65 „

12-38 „

608 „

Erzeroum and Khorassan were the centres most severel}^ infected. Certain regiments were almost annihilated. A company of the 74th Regiment, on entering Kara-Kilisse, was made up thus : First came a lieutenant, on a stretcher, paralytic, with sores. Beside him came his sub-lieutenant. These two officers, and eight men carrying the stretchers, represented all that was left of the company. " The rest," said Koslov laconically, "were in the hospitals or the tomb."

Typhus was again encountered by the belligerent armies during the Balkan Campaign of 1912.

There was no outbreak of typhus during the Manchurian War.

During the present war against Germany no case of typhus has so far been observed in the French Army.

198 DYSENTERY, CHOLERA, AND TYPHUS

Bacteriological investigations have shown, in certain suspected cases, that these were really malignant and hypertoxic forms of typhoid fever, the typhoid bacillus being isolated from the blood, or, after death, from the spleen and the gall-bladder.

The civil population has been equally free from it. The disease has, however, been raging in the German, Austrian, and Russian armies, and among the in- habitants of those countries as well.

In the prisoner's camps in Germany, as a result of a deplorable hygiene and the abandonment of the sick, large numbers of cases and deaths have occurred among soldiers of the Allied armies.

In Germany, at the present time, a hundred cases are reported monthly among the civil population. The German Army has not been spared, and many physicians also have succumbed to the disease.

During the first year of the war there were in Austria- Hungary, according to Jeanneret-Minkine, about 1500 cases of typhus monthly.

Serbia, during the present war, has of all countries been most cruelly scourged by typhus. Soldiers and inhabitants have succumbed in enoiinous numbers. It is estimated that typhus has claimed at least 135,000 victims, and 160 physicians have perished while attending to the sick. In one American ambulance eleven nurses out of fourteen were attacked.

The origin of this terrible epidemic was due to the 70,000 Austrian prisoners interned in Serbia, who brought the disease with them. It spread in every direction, and almost every house was stricken. It is estimated that one person out of every five was attacked. The mortality in the hospitals was 19 to 65 per cent. In Belgrade there were 7000 cases in less than six months. The towns of Valjevo, Nish, Monastir, and Uskub were most seriously affected.

It must not, therefore, he supposed that this infectious disease is extinct in these regions.

Apart from war-time, it has been and is still prevalent.

MEDICAL HISTORY AND GEOGRAPHY 199

although by no means frequent, among the civil populations. In 1868 the natives of Algeria, being in a state of famine, had to be collected in relief stations, where the disease was not slow to make its appear- ance. It was then for the first time that cases of typhus were observed among Europeans who had been in contact with the starving Arabs, who were them- selves, however, exempt from typhus, at all events in appearance.

A few sporadic cases are fairly often reported in Volhynia, Austria, and Holland.

Ireland and Norway are also subject to outbreaks. In Spain, Castellvi reported that he had, in 1909, observed 545 cases of typhus in Madrid. It Italy, in 1888, an epidemic caused 2099 deaths.

In France, in 1870-1871, 551 cases and 121 deaths were reported at Riantec, near Lorient. The epidemic continued for fourteen months.

At Rouisan in 1877 there were 165 cases ; in the lies Molenes in 1878, 282 cases and 12 deaths ; in the tie Tudy, in 1891, 80 cases.

In 1892-1893 scattered cases of typhus appeared, first in Amiens, in a night shelter for vagrants and tramps, then in Abbeville, Pontoise, Beauvais, Evreux, Mayenne, Saint-Denis, Paris, Dieppe, Lille, Havre, and Bordeaux (among the workers of the port and in the Nanterre prison).

In all 684 cases were reported. About 100 physicians, nuns, and assistants were infected in the north of France.

Between 1903 and 1912 (inclusive) there* were 209 cases of typhus in France.

In Russia a serious epidemic was reported in Petro- grad during the winter of 1864-1865 (causing nearly 12,000 deaths). Between 1905 and 1911 there were 665,865 cases and 54,533 deaths from typhus (Pottevin).

In England, between 1899 and 1913, there were only 390 deaths. In Ireland, during the same period, there were 1043 deaths. In 1914 there were 37.

200 DYSENTERY, CHOLERA, AND TYPHUS

In Sweden, since the epidemic of 1875, which caused 1918 cases, typhus has become much less frequent.

In Germany, the very serious epidemics which occurred among the French armies in 1813 appeared among the inhabitants- also : 18,000 cases and 3024 deaths were recorded in Bavaria, between November, 1813, and June, 1814. In the kingdom of Prussia alone the epidemic caused 200,000 deaths in 1813.

There were epidemics in Prussia in 1867-1869, and in Berlin ; in Koenigsberg in 1880-1882 (672 cases and 97 deaths). Silesia remained the most virulent centre of the disease. In 1868-1869 there were 1333 cases in that province ; in 1878-1879, 600 cases. Between 1877 and 1910, 14,655 persons infected with typhus were treated in the German hospitals (Pottevin). Cases were reported in Silesia (district of Oppeln) in

1912, 1913, and 1914.

Austria and, above all, Galicia and Poland have been particularly infested by typhus. Between 1904 and 1913 (inclusive) Galicia was responsible for 24,107 cases of typhus, and 2282 deaths.

The Bukovina, Bohemia, and Bosnia -Herzegovina are not exempt. The disease reappeared at the commencement of the war of 1914, among the Austrian troops and in most of the provinces. The Austrian prisoners, as has been stated, carried it into Serbia.

In Rumania typhus is very rare. However, during the first three months of the war there were forty cases in Bukarest. There is typhus in Bulgaria. It was prevalent among the troops during the war of 1912-

1913, above all at Chataldja and Adrianople, and at Philipopolis, in Macedonia, in July, 1914.

In 1914, fifty-one cases and thirty-one deaths were recorded at Salonika. Fresh cases made their appear- ance in 1915.

Turkey, in which country there is a lack of exact statistical information, is the accustomed home of typhus epidemics. Cases have been observed in Con- stantinople, Smyrna, Trebizond, Adalia, Konieh, and

MEDICAL HISTORY AND GEOGRAPHY 201

Karpout, and at Gallipoli, in 1914-1915 both in the army and among the civil population of the country. ^

In Persia, Ispahan, Hamadan, etc., were visited during the year 1914 by an epidemic of typhus.

In the north of Africa, notably in Algeria, Tunis and Morocco, typhus prevails in a mildly sporadic condition, with occasional epidemic outbreaks, in the native douars. Its propagation is facilitated by the customs of the country ; the sick man, supported under the . arms, walks about the streets to combat the fever, and in the midst of an epidemic typhus patients in the eruptive stage have been seen moving about the streets of Tlemcen (Dauthuile). The Arabs and vagrants, in return for a trifling payment, sleep packed together in the Moorish cafes and fondouks, where they infect one another.

Cases of typhus affecting Europeans have been reported from Western Morocco also, and rigorous prophylactic measures had to be taken to eradicate the disease.

Egypt yearly furnishes a large number of cases. In 1914 there were 9350 cases and 2634 deaths. During the first six months of 1915 there were 14,505 cases and 3398 deaths. The disease attacks the natives more particularly.

In Central America, in Mexico, typhus is known by the name of fabardillo. Between 1904 and 1913 there were 56,719 cases and 14,758 deaths.

In the United States typhus is endemic (Nathan Brill), introduced, or maintained by immigrants.

CHAPTER II

ETIOLOGY OP TYPHUS

Predisposing Causes

Typhus does not appear to spare any race or races. All (Latin, Slav, Anglo-Saxon, Indian, Chinese, etc.) pay it tribute. The Arabs and Turks, however, are its chosen victims.

The malady is more benign in children and adoles- cents. Its gravity increases conisderably after the age of thirty or forty.

The mortality in children is 5 per cent. ; in adults it is 8 to 20 per cent., and often more. It increases with age.

According to Murchison the mortality per 100 patients is :

Over 30 years . . . .35 per cent.

„ 40 „ . . . .45 „

,, 50 ,, . . . . 53 ,,

„ 60 „ . . . .67 „

During the Russo-Turkish War the mortality among assistant surgeons, orderlies, and the men of the supply trains was at its maximum between twenty-five to forty years of age.

The two sexes are not attacked with equal frequency, women being more frequently attacked than men (Rochard).

Typhus is a malady of cold or temperate countries. It is most frequently observed during the cold season, as was seen during the Russo-Turkish War. According to Brill, the severe form is prevalent more especially in winter ; the attenuated form in summer. In Mexico

202

ETIOLOGY OF TYPHUS 203

typhus does not exist in cities where the temperature is high, such as Vera-Cruz.

At the time of the Serbian epidemic the disease was checked in summer.

Typhus has been intensely prevalent in Serbia during the present war, from the end of December, 1914, to July, 1915. The first cases made their appearance in September, chiefly among the patients in the typhoid wards, in the hospital for contagious diseases at Valjevo. It was during the retreat to, Albania, however, that it attained its greatest severity. The epidemic was " the most serious that Europe has ever experienced " (Petrovich). In March there was no longer the least little hamlet untouched by the scourge. The mass of favouring causes which are most commonly incriminated were all united in the case of this unhappy people.

Crowding results in the readier propagation of the germ and its agents of transmission. This explains why typhus spread so rapidly through the prisoner's camps in Germany during the present war.

Famine and physiological want have always been incriminated as the adjuvants of typhus. Hence the name of " famine fever," " famine typhus," which the old physicians gave the malady. Still, it is im- portant to note that these depressing conditions go hand in hand with the lack of personal hygiene and the hygiene of clothes, individual uncleanliness, and infection by means of vermin, which play such an important part.

Anaemia, fatigue, privation, and cachexia, moreover, give the clinical development of typhus a special and particularly serious character, which has been observed in all those epidemics which have been associated with famine. Under these circumstances the bastard non -febrile forms are equally nimierous, and because their exact nature is habitually misunderstood they contribute to maintain the frequency of epidemic cases.

in Algeria, above all, in the region contiguous to

204 DYSENTERY, CHOLERA, AND TYPHUS

Morocco, typhus maintains itself in the numerous encampments in which the natives of Morocco live in promiscuity, without hygienic precautions. A serious epidemic broke out in the province of Oran, in 1906, on the occasion of the important construction works of the railway to Lalla-Mamia.

The harvest in the Algerian Tel had attracted also numbers of natives from Tafilalet or Marakeesh, where the disease was prevalent. A number of physicians died. Driven by famine, the cachectic natives of Morocco, arriving in great numbers, brought the malady into the workshops, into the houses of the railway workers and the agricultural labourers, and infected the beggars and the indigent (Surgeon-Major Duthuile).

Whichever races or countries are infected, typhus furnishes a body of predisposing causes the nature of which is fairly uniform. It persists more especially among poor and uncleanly populations. When it attacks the civilised inhabitants it does so, in a way, accidentally. It dies out on the spot instead of giving rise to a true epidemic state.

In famine- stricken countries, on the other hand, and also in armies, its appearance may be terribly serious, on account of its progressive extension.

This was exemplified in the case of the prisoners interned in the German camps in 1915. Their nourishment was extremely bad in quality, extremely insufficient, and only partially assimilable. As a result the prisoners fell into a positive state of inanition (Davy and Brown, Leonetti). They received a bath only once a month, or once in two or three months, and, covered with vermin, were packed into small, insanitary huts, which provided six cubic metres of air per head ; the atmosphere was fetid. All these factors predisposed them to infection in the highest degree.

In the camp at Langensalza, in April, 1915, nearly the whole of the 1000 prisoners contracted typhus (Leonetti). It is said that on an average thirty-five men died daily. They were ill-attended, without

ETIOLOGY OF TYPHUS 205

medicines, and their clothing was insufficiently dis- infected. In the camp at Niederzweren typhus also made serious ravages. It was only when the epidemic attacked the civil population and the garrison that precautions were finally taken. At Erfurt there were 600 cases among 20,000 prisoners. In the camp at Gustrow the hygienic conditions were equally deplor- able. The 12,000 prisoners, suffering from cold and hunger, were crowded together on mouldy straw, with a single blanket apiece, which was worn, and often torn.

CHAPTER III

ETIOLOGY OF TYFKVS— continued

Determining Causes

Many bacteriological researches have been undertaken with a view to isolating the pathogenic agent of typhus ; this, however, is still unknown. ^ Cultivation of the blood on the usual media gives negative results. Thoinot and Calmette have described a flagellated parasite ; Bruhl and Dubief a diplococcus ; Gottschlick a protozoon, like an endoglobular piroplasma, or free and motile ; Plotz a -special bacillus, etc.

Ricketts and Wilder have reported the presence in the blood of certain rare bodies, always free, which Gavino and Girard have recognised under the aspect of " bacilliform bodies," 2fi by 1-2/a in diameter, exhibit- ing at the extremities two small masses, rounded, like the weights of dumb-bells ; the significance of these is, however, extremely obscure, and their etiological functions have not yet been demonstrated.

Proescher stained blood-smears for five to ten hours with carbonate of methylene blue (1 per cent.), and carbolic acid (1 per cent.); he then saw very fine diplococci and diplobacilli from 0-2/x to 0-3ja in length, enclosed in the endothelial cells of the blood- vessels.

There is reason to believe that the virus of typhus belongs to the group of invisible or filterable viruses. The ultramicroscope reveals nothing in the patient's blood.

^ Quite recently a spirochsete has been described in Japan in cases of typhus, but this requires confirmation. — Ed.

206

ETIOLOGY OF TYPHUS 207

The inoculation of typhus blood gives rise to the malady. Motshovkovsky, after five fruitless experi- ments upon himself, obtained a positive result the sixth time. Blood was drawn from a young girl suffering from typhus, and on the tenth day presenting numerous petechiae. Motshovkovsky was inoculated with this blood. The incubation period lasted eighteen days, after which time he was attacked by violent shivering, fever (104-9°), delirium, and a comatose state which lasted for fourteen days, accompanied by a petechial eruption, bronchitis, and myocarditis.

In Mexico, where typhus is frequently prevalent, and is known as tabardillo, Otero inoculated four healthy individuals with the blood of typhus patients. In one case the injection of 0-2 c.c. of blood from a tabardillo patient into a man whose physiological condition was poor determined a serious form of typhus after eleven days' incubation.

Yersin and Vassal, in Indo-China, succeeded in in- oculating two coolies with typhus, by means of blood drawn on the second day of the malady. The incuba- tion period lasted fourteen days in one case, twenty-one in the other.

From these experiments we may therefore conclude that the parasite of typhus exists in the blood of the patient.

Exact confirmation of this statement has been obtained by the admirable investigations of Ch. Nicolle, Comte and Conseil, of Tunis.

These experts have established the fact that the higher apes are receptive to the typhus virus, and form the most favourable subjects for inoculation. They inoculated a chimpanzee with the blood of a typhus patient on the third day ; after the lapse of twenty-four hours the ape was suffering from fever, and on the fifth day the eruption appeared on the face, ears, and flanks.

This was not a case of a lesion of a toxic order, for the blood of this ape was itself virulent and inoculable on the fourth day, when it was injected into a Chinese

208 DYSENTERY, CHOLERA, AND TYPHUS

macacque, which developed typhus after an incubation period of thirteen days. It was not inoculable before the fourth day.

To sum up, the injection of a cubic centimetre of the blood of a typhus patient suffices to cause the certain development of typhus in the chimpanzee. The symptoms and the development of the disease recall in- fantile typhus ; the fundamental characteristic is fever. Death may result.

In this way innumerable transfers may be realised. After recovery the apes are immune. The serum of a man or an ape possesses, after recovery, preventive and curative properties as regards the ape, but does not retain them for more than fifteen to twenty-five days.

The blood is virulent two days before the fever com- mences, and while the fever lasts, and for a few days longer (Nicolle, Comte, and Conseil). A temperature of 55° C. applied for fifteen minutes (Gavino and Girard), or even of 50° C. (Nicolle) kills the virus. The incuba- tion period of tjrphus in apes is from four to twenty-eight days ; it averages from five to eight days. The typhus of apes resembles that of man (injection of the con- junctivae, exanthemata, fever, commencing suddenly or progressive, anorexia, prostration, etc.).

In Mexico, Goldberger and Anderson, and then Ricketts and Wilder, shortly after Ch. Nicolle and his collaborators had completed the above experiments, confirmed the inoculability of the typhus virus in the Macacus rhesics, the incubation period being five to twelve days. The animals recovered. The initial inoculation was almost always positive in its results. Ricketts and Wilder employed the serum derived from defibrinated blood subjected to centrifugalisation (Nicolle allowed the blood to coagulate).

Gavino and Girard successfully repeated the whole of the investigations described above upon AtelUs vellerosus.

Diluting the blood of patients and filtering it through a Berkefeld filter, Ricketts and Wilder were unable to

ETIOLOGY OF TYPHUS 209

provoke the disease by inoculation ; but the portion left upon the filter was virulent.

Nicolle succeeded in provoking the disease by the injection of filtered blood once out of six times. Campbell failed.

The usual " laboratory animals " have usually been regarded as refractory to typhus, but Nicolle has demonstrated that the guinea-pig is sensitive to the virus. The infection is revealed by one symptom only, and that an inconstant one — fever, which lasts eight to twelve days, commencing a week after inoculation. During this period the blood is virulent if injected into the monkey or the guinea-pig, even if the animal pro- viding the blood is not suffering from fever. Transfers through alternate monkeys and guinea-pigs can be effected indefinitely.

On separating the various elements of the blood, Nicolle found that the white corpuscles are extremely virulent in infinitesimal doses ; the plasma is less so ; the red corpuscles are inactive.

The typhus virus appears, therefore, to he localised in the leucocytes of the blood.^

The foregoing discoveries already throw an interest- ing light on the etiology of typhus. We are forced to ask ourselves what, considering the contagiousness of typhus, is the medium of contagion in the patient. Is contagion effected by the normal or pathological secretions, by the saliva, the expectorations, the urine, etc. ? It does not seem that this is the case, contrary to the opinion which was formerly current. Netter and Nicolle, in this connection, deny that the expec- torations play any part.

On the other hand, the plainly demonstrated exist- ence of the parasite in the blood would lead us to suppose that the transmission of the virus, as in

^ The blood of typhus patients and of the animals inoculated reveals necrosis of the polyauclear neutrophiles, sometimes to a considerable extent. The nucleus has a mulberry-like appearance, and the proto- plasm shows granulations of a lilac colour (Nicolle).

210 DYSENTERY, CHOLERA, AND TYPHUS

malaria and yellow fever, is effected by an ectoparasite or by the bites of insects.

Nicolle has found that the bite of the mosquito, the tick, the stomoxys, the louse, the flea or the bug, after the insect has sucked the blood of typhus patients, is without effect upon the normal monkey.

In the phosphate mines of Tunisia, where the fleas are very abundant and bite everybody, only the natives suffer from typhus.

Mosquitoes and ticks do not exist in winter, nor in spring, seasons at which typhus is especially prevalent. Lastly in the prisoner's camps in Germany where typhus was prevalent, there were swarms of lice, but no fleas or bugs.

Ricketts and Wilder have also found that neither fleas nor bugs can transmit typhus to the monkey. Nicolle, Conseil and Comte have proved that it is the louse, and particularly Pediculics vestimenti which serves as the agent of inoculation. In more than 800 cases of typhus observed in Tunis in 1908, if of the patients suffered from parasites, or were vagrants exposed to the bites of lice. Their contagiousness disappeared when they had been bathed and given a change of linen. In four cases of typhus the malady had assuredly followed the bites of lice.

Experimentation has, for that matter, verified the truth of this proposition. Lice nourished on the blood of a monkey (Chinese bonnet monkey), and left without food for eight hours, when transferred to another monkey (a macacque) infected it with typhus.

Ricketts and Wilder (the first of these scientists dying of typhus on the occasion of these experiments) also obtained positive infections with body-lice which had been placed on typhus patients, or infected apes, or monkeys, and were then transferred to healthy animals. The same effect was produced by taking the excrement of lice and inoculating it under the skin, or by crushing the lice themselves and inoculating them.

ETIOLOGY OF TYPHUS 211

the lice having sucked the blood of a typhus patient three days earlier. Having collected a thousand young lice, the offspring of 140 adult lice, fed on the blood of a typhus patient, Ricketts and Wilder reared them to the adult state. This generation produced lice which, placed upon a macaque, caused no infection. But afterwards this monkey was refractory to a very powerful inoculation.

According to Nicolle the bite of the louse is pathogenic only from the fourth to the seventh day after an infective meal.

Pediculus vestimenti is thus the intermediate host, as well as the agent of transmission of typhus. When the louse has absorbed the blood of a typhus patient the parasite of typhus infects the louse itself after the lapse of a few days. Possibly this infection causes an actual disease in the louse. At all events, a multiplication of the typhus germ takes place, and after a period of a few days the germ has become inoculable into man. Perhaps it is in the louse itself that we might most fruitfully search for the virus.

It may be concluded, then, that the agent of trans- mission for the virus is the body-louse, after the insect has fed upon a person affected by the disease. The blood of the patient is virulent during the whole course of the malady, and even for some days before the onset, and a few days after recovery.

The infectious germ survives, maintaining its viru- lence, in the alimentary canal of the louse, multiplies there, and undergoes a special development ; it is inoculated by the louse, or by its very profuse excrement deposited on a cutaneous excoriation. Experiments upon monkeys have verified this latter mode of contagion.

The louse is capable of transmitting typhus for a few days only. But it may once more become con- tagious after a fresh infective meal. Finally, its offspring may sometimes transmit the infection (Nicolle).

212 DYSENTERY, CHOLERA, AND TYPHUS

Examples cited by Jeanneret-Minkine show that the bite of the louse may be much more certainly infective than involuntary inoculation with instruments polluted by the blood of the typhus patient. This was exempli- fied by an attendant in a post-mortem room, who re- mained unaffected in spite of excoriations and daily wounds which he did not disinfect. However, this man contracted typhus later, while attending on a patient.

Cases have been cited in which typhus seems to have developed independently of the bites of Pediculus vestimenti. Physicians attending typhus patients, but protected by rubber gloves and hermetic overalls and boots, have nevertheless contracted typhus. This fact, if verified, would seem to prove that the louse is not the only agent of transmission (Larrieu). Still, it appears to be demonstrated that one single bite of an infected louse is capable of provoking typhus. It is easy to understand that this bite might pass unnoticed, especially as the louse bites almost immediately, if hungry.

Of the three species, P. capitis, P. pubis, and P. vestimenti, the latter is by far the most usual agent of transmission. P. capitis, having bitten a typhus patient, retains the virus for at least twenty hours,' and if placed upon a monkey gives it typhus (Anderson and Goldberger). P. vestimenti, in the adult state, attains a length of 3 and even 4 millimetres (Jeanneret- Minkine). It has three pairs of limbs, by means of which it fixes itself upon clothing or moves about. It lodges in the folds and seams of clothing, or upon the surface itself. It lays its eggs on the fibres of cotton or woollen garments, but it can also deposit them on the hairs of the body. From its birth, which takes place in six or seven days, the insect bites the human host. The eggs may also be laid on the covers of mattresses. The best temperature for hatching is 82-4° F. It is retarded by temperatures of 76° or 95° to 104°.

ETIOLOGY OF TYPHUS 213

P. vestimenti lives only upon blood , and dies if deprived of it for two to five days. It does not settle on the skin except while puncturing it for the purpose of obtaining nourishment. Extremely avid of blood, it absorbs excessive quantities of it, even as much as a milli- gramme. This explains the abundance of its dejecta, by means of which infection may occur if the victim scratches himself.

The capacity of multiplication possessed by P. vestimenti is, according to Jeanneret-Minkine, consider- able, for in one month a couple may give birth to more than 2000 descendants. Moreover, among the Arabs one sometimes sees persons whose bodies and garments are entirely covered with these parasites.

When it is hungry the louse is capable of deserting abandoned garments or straw bedding and of going in search of its food. It can therefore make its way, although slowly, toward an adjacent human being. This is certainly what takes place in cantonments and trenches, where men who are not infested may be contaminated by sleeping on straw.

The body-louse does not survive in hot climates. This has been observed in Mexico. At Tampico the louse-infested labourers who come in search of work are rid of their lice in five days, although no measures have been taken to destroy them. The serious epidemic which was lately raging in Serbia was arrested in spring " because at this season the lice had disappeared " (Hirschfeld).

Numerous examples, recorded by the medical history of typhus, testify to the excessive contagiousness of the disease.

The introduction of the germ by a single patient may give rise to a serious epidemic. This was seen on the occasion of the epidemic of 1893. Thoinot and Ribierre have summarised the part played by contagion in respect of the cases which occurred in Paris at this time in an instructive table.

214 DYSENTERY, CHOLERA, AND TYPHUS

Twenty vagrants suffering from typhus (in Paris) infected :

At the poorhouse In asylums, police-stations, At the Palais and lodging-houses de Justice

41 persons under de- 42 vagrants, 3 lodging-house 1 recorder tention, 4 warders keepers, 3 other persons

These typhus patients, nursed in the hospitals, caused 23 cases.

A total of 137 persons infected.

Typhus, as we have seen, is transmissible during the prodromal period. In 1893, at Lille, fifteen persons who had come into contact with a prisoner contracted typhus. Now the prisoner himself did not develop typhus until several days later. Typhus is also trans- missible after recovery. At the same period a female

patient, Mme F , of Amiens, carefully isolated,

having recovered from a benign form of typhus, left hospital and communicated the disease to another woman who called to see her. A few days later she went to Dreux, and introduced the disease there.

The facts already expounded as to the function of the Pediculus give us the explanation of the delayed transmission of the disease by lice which have drawn blood at the end of the febrile period, or even several days later, when the blood was still infective. The louse itself retains the germ of typhus for several days, and this after a definite period of incubation.

It will therefore be understood how typhus may be propagated not only by those who have been in direct contact with the patient, but also by those who have come into contact with his clothes, his body-linen, his bedding, his mattresses, his straw bedding, etc.

It should, however, be remembered that P. vestimenti dies after the lapse of a few days if unable to nourish itself upon blood.

The propagation of typhus has been reported in the case of orderlies who have handled the clothing of typhus patients, those who have charge of the cloak-room in hospitals, and those who repair soldiers' overcoats if

ETIOLOGY OF TYPHUS 215

these have not been disinfected. Contagion may also be effected in railway carriages, public vehicles, prisons, etc., through the medium of lice in search of a human host. However, the cause of infection may remain uncertain. This was the case with an advocate who contracted typhus in 1895, at Lille, in the Palais de Justice, where vagrants and thieves were tried. He died, as did his secretary. It was impossible to discover the source of contagion. ^

The older generation of physicians laid great stress on the transmission of typhus by famishing masses of persons who themselves were apparently unaffected (Perier, Vital, Maurin). Kelsch has confirmed this hypothesis. The episode of the Shea-Gehald, cited by Griesinger, is well known. This vessel sailed from Egypt in November, 1860, arriving at Liverpool on the 16th February following. She carried a native crew, ill-fed, suffering from diarrhoea and sea-sickness, but with no case of typhus among them. Now three persons who visited the vessel on her arrival contracted typhus ; one of them died. Some sailors sent to the hospitals on account of various affections carried typhus thither : 1 physician, 1 student, 2 male nurses, 2 porters and 17 patients were attacked. The sailors, to the number of 340, visited the baths ; 3 bath-house attendants out of 6 contracted typhus, etc.

It seems highly probable that there was typhus among these men, but that it existed in some ill-defined form such as is frequently observed among famine- stricken or ill-nourished persons. Moreover, eleven deaths had occurred during the voyage through the Mediterranean.

These unusual forms of typhus, without fever, but with diarrhoea, loss of strength, and early or sudden death, have been observed during all epidemics, and in particular during the Serbian epidemic of 1915.

* Why not the louse ? Vagrants and thieves are notoriously lousy, and it seems highly probable that the advocate and the secretary were bitten by infected lice introduced by these people. — Ed,

216 DYSENTERY, CHOLERA, AND TYPHUS

Numbers of these cases were variously diagnosed as physiological want, dysentery, etc.

The epidemiological importance of these bastard forms need not be emphasised. A precise inquiry should always be made in order to trace the antecedents of such cases. As we have seen, this is not always easy to establish. It often happens that the first cases are unrecognised. At other times patients or convalescents are sent into neighbouring hospitals, and are discharged too early, and without disinfection. These patients spread typhus wherever they go by means of the lice which they carry with them.

CHAPTER IV

PROPHYLAXIS OF TYPHUS

Although typhus has not hitherto been observed in the French and British armies, and although the civil population has been free from it, we may consider that this infectious disease, which is prevalent in the armies of the east and south-east of Europe, is always a menace to our armies, because of the conditions of life to which the men in the trenches and cantonments at the front are subjected, the multiplicity of human contacts, and the profusion of ectoparasites which afflict our soldiers. It is therefore important thoroughly to understand the prophylactic measures to be opposed to this disease.

The campaign against lice remains the most profitable means of prophylaxis, and that which should be most urgently insisted upon. This point will be specially dealt with later.

Wherever the disease has manifested itself an early notification should be made of every case. The patient should be strictly isolated in a special ward, in a port- able building in winter, or in a tent in summer.

Immediately upon admittance the hair of the head should be cropped, the hair of the body shaved, and both should be burned. The patient should be placed in a bath containing corrosive sublimate, washed, soaped, and scrubbed, and all his parasites destroyed. His clothes should be burned or sent to the oven directly upon his admittance to hospital. If this is not done they should be plunged immediately into boiling water containing washing-soda.

All persons who have been in contact with the patient, and, above all, those who are infested with lice, should be placed under supervision for a period of fifteen days. 217

218 DYSENTERY, CHOLERA, AND TYPHUS

This precaution, therefore, applies to families, ships' crews, or passengers, military units, workshops, Arab douars, prisons, etc. All suspects should undergo a scrupulous insect disinfection, by means of antiseptic baths, soaping, etc. The hair and beard should be cropped or shaved, while clothing, underclothing, boots or shoes, caps, etc., are to be sterilised or destroyed by fire.

The quarters inhabited by the patient, his linen, sheets, mattresses, bedding, etc., must be subjected to disinfection ; the linen and articles to be sent to the stove should be placed in special sacks ; the infected premises should be disinfected w^ith sulphur gas ; articles of no value, such as rubbish, worn clothing, mats, carpets, etc., should be destroyed by fire ; the floor should be washed with a boiling solution of soda (1 per cent.). The persons entrusted with the work of disinfection must wear special clothing and rubber gloves.

On board ship the same precautions should be taken, while passengers and crew are to be subjected to sanitary supervision for fifteen days. Carriers of vermin must be placed under observation for the same period.

In hospitals the nurses or orderlies should be selected from the younger members of the staff ; those who have already had typhus should be chosen, if such are available. They should wear special clothing : blouses closing tightly at the neck and wrists, rubber gloves, trousers fitting closely at the ankles, with well-laced boots, and a head-covering or " helmet " of linen. In the British hospitals in Serbia the staff wore a single garment, a sort of " combination," closed at the neck, buttoning at the shoulders, wdth the ends of the trousers shaped to enclose the feet ; the latter were shod with sandals. Nurses or orderlies must not relax their precautions, experience having frequently shown that after some time they are apt to become forgetful, and so contract the disease.

PROPHYLAXIS OF TYPHUS 219

Blouses, aprons, head-coverings, etc., should be re- moved by the attendants when they leave the ward or go to meals. A change of clothing is advisable each time a fresh patient is admitted.

Instructions as to the means by which typhus is transmitted, and the part played by lice in the spread of contagion, should be issued, and everyone should be reminded of the difficulty of protecting themselves against the bite of the louse, and of all the precautions to be taken to avoid them, particularly on the arrival of patients who have not as yet been disinfected. Nurses, doctors, and attendants should take an antiseptic bath daily (containing cresol or corrosive sublimate).

No specific prophylaxis has so far been discovered.

Anderson, however, has suggested that persons exposed to typhus would act prudently by getting themselves inoculated with attenuated typhus (Brill's disease).

Nicolle attempted to immunise twenty Serbian soldiers and eighteen other persons by injecting half a cubic centimetre of serum from an infected guinea-pig, followed, at an interval of nine days, by one cubic centi- metre. He obtained satisfactory results, which should encourage others to repeat such experiments.

The Campaign against Lice

The transmission of typhus by the pediculi necessi- tates, as its prophylactic consequence, the " disinsecti- fication " or " disinsectisation " of the patient, his entourage, and all those who approach him or have approached him.

Pediculus vestimenti lives more particularly in or on the surface of clothing. The frequency of vermin among soldiers in the field, even among those who take precautions as to cleanliness,^ would constitute a

* According to Peacock, 4 '9 per cent, of the British soldiers have no lice ; 41 "9 per cent, have very few. The rest suffer from them in varying degrees.

220 DYSENTERY, CHOLERA, AND TYPHUS

formidable factor of propagation were the virus to be imported. It is important, therefore, to describe the various means designed to destroy these parasites.

1. For the individual himself numerous means have been recommended : swabbing with petrol, xylol, benzine, essence of aniseed, turpentine, ether, chloro- form, essence of cloves, or of eucalyptus, etc. These volatile liquids, it is to be remembered, are inflammable ; nevertheless, they are really efficacious, especially xylol ; the nits often resist benzine.

Frictions with anisol (methyl-phenyl-ether) may be recommended. A mixture of oil and petrol, less volatile, is equally useful. The mixture :

Naphthol + benzol + NH3 . . \eaual Darts

Benzine .... /equal pans

pulverised on the skin (and clothing) with an ordinary pulveriser effectually destroys lice. This means is recommended in the Italian Army by Guido Izar.

Sachets for personal wear, containing naphthaline and camphor, placed under the armpits or at the waist, are of little use. Sulphur has no effect, and the same is true of powdered pyrethrum.

The British Army makes considerable use of the N.C.I, powder, composed as follows : —

Naphthaline . . . .96 grammes

Creosote . . . . . 2 ,,

Iodoform . . . . . 2 ,,

This powder is applied to the skin, shirts, trousers, etc., and renewed every five days. It does not kill eggs with certainty.

Swellengrebel has recommended anisol, globol (para- dichloro-benzene), which is non -toxic, or lausofane, a cyclo-hexanon base and cyclo-hexanon associated, in powder or alcoholic solution, with which the skin is soaked or covered while the clothing is being disinfected.

The hair of the head and body should be cropped or shaved, and the body should be soaped with soft soap

PROPHYLAXIS OF TYPHUS 221

or cresol soap ; this treatment should be continued for a fortnight. Brumpt recommends washing with three parts of soft soap mixed with one part of glycerine.

The nits of P. pubis are destroyed by a solution of corrosive sublimate (1 in 1000), to which 30 per cent, of acetic acid has been added (Brumpt).

Excellent results are also obtained by swabbing the pubic and axillary regions with strong alcohol, in which 10 per cent, of p. naphthol has been dissolved.

All these local operations should be followed by a bath.

After each bath, disinfected clothing" [should be donned. The process of insect disinfection must be carefully carried out, for an imperfectly cleansed person may in a few days reinfect all his neighbours.

The hair of the head should be cropped very close, and soaked in a mixture of oil and petrol.

2. The destruction of lice on clothing is effected by means of heat, dry or moist, or by anti-parasitical vapours.

Lice are killed in three hours by a temperature of 45° C. (113° F.) ; in one and a half hours by a temperature of 50° C. (122° F. ) ; in twenty or thirty minutes by a tem- perature of 60° C. (140° F.) ; and in ten minutes by a temperature of 80° C. (176° F.).

The nits are more resistant.

Dry heat applied by a hot iron effectually kills lice and eggs on clothing, but the iron must be carefully passed several times along all the seams.

•Boiling destroys the parasites. Ordinary coppers or lye- washing machines of 80 litres capacity are employed, and give excellent results (Voyotte).

Live lice, placed in test-tubes in the midst of clothing, are killed by this process in three or four minutes ; in ten minutes the embryos in the nits are killed (Brumpt).

A note issued by the General Staff, Direction de Varriere,^ dated the 28th August 1916, suggests, as an emergency method of disinfecting clothing, the

^ As distinguished from the medical service in the field.

222 DYSENTERY, CHOLERA, AND TYPHUS

employment of a barrel (as recommended by Surgeon- General Richard) placed above a saucepan or copper which is giving off steam. The bottom of the barrel is perforated to allow the steam to pass through.

The same note recommends the employment of Budan's device, which consists of two coppers or vats, of unequal size, one being placed over the other. The whole is heated by means of wood or coal.

Finally, a supply of steam may be employed (from a boiler or agricultural engine), the exhaust-pipe ending in a barrel containing the articles to be disinfected.

The Bordas process consists in passing steam through a worm contained in an ordinary barrel.

It is as well to use. alkaline water in the coppers in order to increase its bactericidal power.

In Amsterdam the destruction of lice is effected by the vaporisation of ammonia (25 per cent.) in hermetic- ally closed rooms.

In the German Army sulphuret of carbon is regarded as being possessed of great activity.

The employment of silken underclothing has been recommended in place of woollen or cotton articles, as the lice cannot effect a lodgment on silk.

When the articles have been sufficiently baked or steamed, they should be carefully dried before being worn again.

During the operation of disinfecting and drying the clothing and underclothing the carrier of the vermin himself may be shaved, disinfected, soaped, and bathed.

Thanks to these measures, typhus, which has made such serious ravages in Serbia, has been stamped out.

Rumania succeeded in protecting herself against the importation of typhus from Serbia, by means of adopt- ing the same measures on the frontier, and by imposing a rigorous quarantine on immigrants.

It was the same with Greece. Travellers coming from contaminated countries received an inspection card, containing five divisions, on which the tempera- ture was entered for five days. The traveller was

PROPHYLAXIS OF TYPHUS 223

required to visit the physician under penalty of a heavy fine. Useful as it is, this measure is not infallible, for the incubation period of typhus may be much longer, and in infected subjects who are in a low physiological condition typhus may be apyretic.

The treatment of clothing by the vapour obtained by burning sulphur or sulphuret of carbon (CS2, 90 per cent. ; stove alcohol, 5 per cent. ; water, 5 per cent.) destroys the parasites very effectively. The clothes are hung up in a carefully closed room or closet.

The vapour of formol is less reliable.

3. The disinfection of roams, etc., can also be effected by the use of sulphurous acid (50 grammes per cubic metre), the vapour being applied for two or three hours.

The flooring may conceal lice derived from typhus patients, underclothing, healthy subjects, etc. In this case it is best to go over the planks and skirtings with petrol, or to wash them with alkaline boiling water.

The staff entrusted with the insect disinfection of lousy persons and their clothing must take all necessary pre- cautions to avoid infection. They should wear special garments, frequently changed, and rubber gloves to handle the infested clothing. The latter may be collected by means of long tongs of wood or metal for transference to the stove or oven.

These precautions are particularly recommended during epidemics.

INDEX

Abdominal pains of dysentery,

16, 25 Abscess, hepatic, in amoebic

dysentery, 81, 85-86 Absorption, disorders of, in

cholera, 106-107 Amoeba of dysentery, the. See

Entamoeba Amoebic dysentery, 25-30

complications of, 26-28

epidemiology of, 79-88

Europe, in, 82, 86

treatment of, 46-48

Apes, typhus produced in, by

inoculation, 206-207 Armies, dysentery in, 57-64

— cholera in, 130-132

— typhus in, 195-198 Arsenobenzol in dysentery, 47 Association of dysentery with

other diseases, 32

Bacillary dysentery, 18-24

causes of, predisposing,

63-65

causes of, determining, 65-

69

diagnosis of, 31-43

epidemiology of, 55-62

serotherapy in, 95-96

specific treatment of, 45-46

Bacillus of dysentery, the, cul- ture and isolation of, 41-43

propagation of, 65-77

vitality of, in various

media, 70-74 Bacteriological diagnosis of dysentery, 35-36

Bacteriological examination for

cholera vibrios, 167 Bilharzia, 29, 33, 88 Blood in typhus, 209 Blue cholera, 108 Bronchial fistula in hepatic

dysentery, 81

Calomel in dysentery, 49 Carriers of dysentery, 67-68,

81-82 — of cholera, 139-145 Chilodon dentatus, 87-88 Chlorodyne, 124-125 Cholera, Asiatic, 99-173 algidity of, 103-104, 107-

109 causes of, determining,

136-139 causes of, predisposing,

133-135

clinical forms of, 115-116

complications of, 112-114

cramps in, 103

diagnosis of, 118-123

epidemiology of, 129-132

evacuations of, 101-102

prophylaxis of, 158-173

reaction after, 109-112

symptomatology of, 99-

117

vomiting in, 102

women, how affected by,

116 Cholera vibrio, the, 119-123, 133-

157 Choleraic diarrhoea, 114-115 Cholerine, 115 Circulation, the, in cholera, 104-

105

225

226

INDEX

Complications of dysentery, 24

— ot cholera, 112-114 Contagion in dysentery, 65-69

— indirect, 69-77

— in amoebic dysentery, 80-81

— in cholera, 137-157 Crimean War, dysentery in the,

63 Cultivation of the dysentery bacillus, 35-41

— of Entamoeba, 35-40

— of the cholera vibrio, 120- 122

Cysts of Entamoebae, 38-40

D

Diagnosis of cholera, 118-123

— of dysentery, 31-43, 118-123

— of typhus, 187-191 Diarrhoea, premonitory, 100 Diet in dysentery, 44 Disinfection, 92-96, 162, 218-

223

Dysenteries due to various etio- logical agents, 28-30, 53, 87-88

Dysentery. See Amoebic and Bacillary Dysentery

— armies, in, 57-62

— chronic, 50

— clinical forms of, 20-24

— complications of, 24

— diagnosis of, 31-43

— differential characters of the two kinds, 34

— epidemics of, 56-62, 73

— mixed dysenteries, 48

— prophylaxis of, 89-96

— symptomatology of, 15

— treatment of, 44-52

E

Emetike in amoebic dysentery,

46-47 Enemata in dysentery, 50-51 Entamoeba histolytica, 38 Epidemics of dysentery, 55-57 in armies, 57-62

— of cholera, 129-135

— of typhus, 195-201

Etiology of bacillary dysentery, 63-78

— of cholera, 133-157

— of typhus, 202-216

Flies, agents of contagion in

dysentery, 74-75 in cholera, 149-150

Hepatitis, suppurative, 85-86

I

Immunity conferred by attack of bacillary dysentery, 64-66

— by dead cultures, 95

— by cholera vaccine, 168-173 Influenza confused with typhus,

190 Ipecacuanha in dysentery, 48-

49 Irrigation in dysentery, 50-64

Labakbaque's Solution, 51 Lice, agents of transmission of

typhus, 210-216 — campaign against, 217-223

M

Malaria, 189

Meningitis, cerebro-spinal, 189- 190

N Notification of cholera, 166

O Opium in dysentery, 49

P

Pediculis capitis, p. pubis, P., vestimenti, in the transmis- sion of typhus, 212

INDEX

227

Pneumonia, apical, confused

with typhus, 190 Prophylaxis of dysentery, 89-96

— of cholera, 158-173

— of typhus, 217-223

Quinine in chronic dysentery, 52

Recto-sigmoidoscope in dysen- tery, 50

Relapsing fever, 189

River water, cholera vibrios in, 151-164

Rocky Mountain spotted fever, 190-191

S

SAiiiNE purgatives in dysentery, 49

Saprophytic organisms antagon- istic to dysentery bacilli, 71-77

Sea-water, cholera vibrios in, 154-156

Segond's Pills, 49-50

Serotherapy in dysentery, 45-46

— in typhus, 193-194, 208 Sero-diagnosis of dysentery, 33 Spotted fever, Rocky Mountain,

190-191 Stools, dysenteric, 17

— choleraic, 101-102, 136-137 Syndrome of dysentery, 53

Typhus, causes of, determining, 202-216

— causes of, predisposing, 202- 205

' — clinical forms of, 185-186

— complications of, 184-185

— diagnosis of, 187-191

— epidemiology of, 195-201

— eruption of, 178-183

— etiology of, 202-216

— history of, 195-201

— incubation period of, 177

— pathogenic agent of, un- known, 206

— production of, experimental, by inoculation, 206-207

— prophylaxis of, 217-223

— symptomatology of, 186

— treatment of, 192-194

U

Ulcerations in dysentery, dressing of, 50

Vaccination against cholera,

168-173 Vaccine, antidysenteric, 95-96 Vagrants, inspection of, 165 Vibrio, the cholera, 119-123

— agglutination test for, 123

— cultivation of, 161

— search for, 166

— search for and isolation of, 120-122, 166

— propagation of, 133-157

— races of, 161

Tenesmus in dysentery, 16 Transfusion in cholera, 127-128 Treatment of dysentery, 44-52

— of cholera, 124-128

— of typhus, 192-194 Typhoid fever, 188 Typhus, 177-223

W

Water in propagation of dysen- tery, 75-77

of cholera, 151-154, 167

— sterilisation of, 167

Women, physiological condition of, affected by cholera, 116

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the Introduction by the General Editor^

Sir Alfred Keogh.

The special interest and importance, in a surgical sense, of the great European War lies not so much in the fact that examples of every form of gross lesion of organs and limbs have been seen, but is to be found in the enormous mass of clinical material which has been presented to us and in the production of evidence sufficient to eliminate sources of error in determining important conclusions. For the first time also in any campaign the labours of the surgeon and the physician have had the aid of the bacteriologist, the pathologist, the physiologist and indeed of every form of scientific assistance in the solution of their respective problems.

The achievements in the field of discovery of the chemist, the physicist and the biologist have given the military surgeon an advantage in diagnosis and treat- ment which was denied to his predecessors, and we are able to measure the effects of these advantages when we come to appraise the results which have been attained.

But although we may admit the general truth of these statements it would be wrong to assume that modern scientific knowledge was, on the outbreak of the war, immediately useful to those to whom the wounded were to be confided. Fixed principles existed in all the sciences auxiliary to the work of the surgeon, but our scientific resources were not immediately avail- able at the outset of the great campaign ; scientific work bearing on wound problems had not been arranged in a manner adapted to the requirements,

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were not fully foreseen ; for the workers in the various fields were isolated or had isolated themselves pursuing new researches rather than concentrating their power- ful forces upon the one great quest.

However brilliant the triumphs of surgery may be, and that they have been of surpassing splendour no one will be found to deny, experiences of the war have already produced a mass of facts sufficient to suggest the complete remodelling of our methods of education and research.

The series of manuals, which it is my pleasant duty to introduce to English readers, consists of translations of the principal volumes of the " Horizon " Collection which has been appropriately named after the uniform of the French soldier.

The views of great authorities," who derive their knowledge from extensive first-hand practical experience gained in the field cannot fail to serve as a most valuable asset to the less experienced, and must do much to enable them to derive the utmost value from the experience which will, in time, be theirs. The series covers the whole field of war surgery and medicine, and its predominating note is the exhaustive, practical and up-to-date manner in which it is handled. It is marked throughout not only by a wealth of detail, but by clearness of view and logical sequence of thought. Its study will convince the reader that, great as have been the advances in all departments in the services during this war, the pro- gress made in the medical branch may fairly chal- lenge comparison with that in any other, and that not the least among the services rendered by our great Ally, France, to the common cause, is this brilliant contribution to our professional knowledge.

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MILITARY MEDICAL MANUALS

THE TREATMENT OF INFECTED WOUNDS

By A. CARREL and G. DEHELLY. Trans- lated by HERBERT CHILD, Capt. R.A.M.C, with Introduction by Sir ANTHONY A. BOWLBY, K.C.M.G., K.C.V.O., F.R.C.S.,

Surgeon-General Army Medical Service. With 97 illustrations in the text and six plates. Price, 5J. net. Postage 5^. extra.

"Is as fine an example of correlated work on the part of the chemist, the bacteriologist, and the clinician as could well be wished for, and bids fair to become epoch-making in the treatment of septic wounds.

" I am glad to take the opportunity of expressing the ap- preciation of British Surgeons at the Front of the value of what is known to us as Carrel's method. The book itself will be found to convey in the clearest manner the knowledge of those details which have been so carefully elaborated by the patient work of two years' experience, but it is only by scrupulous attention to every detail that the best results will be obtained . . .

"The utility of Carrel's method is not confined to recent wounds, and in the following pages those surgeons who are treating the wounded in Great Britain will find all the necessary in- formation for the treatment of both healthy and suppurating wounds." — From Sir Anthony Boiulbfs Introduction.

This volume is included by arrangement with Messrs. BailHere, Tindall and Cox.

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MILITARY MEDICAL MANUALS

THE PSYCHONEUROSES OF WAR

By Dr. G. ROUSSY, Assistant Professor in the Faculty of Medicine, Paris, and J. LHERMITTE, sometime Laboratory Director in the Faculty of Medicine, Paris. Edited by Colonel WIL- LIAM ALDREN TURNER, C.B., M.D., and Consulting Neurologist to the Forces in Eng- land. Translated by WILFRED B. CHRIS- TOPHERSON. With 13 full-page plates. Price, 6s, net. Postage 5^. extra.

The Psychoneuroses of War being a. book which is addressed to the clinician, the authors have endeavoured, before all else, to present an exact semeiology, and to give their work a didactic character.

After describing the general idea of the psychoneuroses and the methods by which they are produced, the authors survey the various clinical disorders which have been observed dur- ing the War, beginning with elementary motor disturbances and passing on through sensory disorders and disorders of the special senses to disturbances of a purely psychical char- acter. Under the motor system, affections such as paraplegia, the tics and disturbances of locomotion are detailed ; under the sensory system, pains and anaesthesias are passed in re- view ; under disorders of the special senses, deafness and blindness are studied ; then follows a detailed account of the visceral symptoms and finally some types of nervous attacks and lastly the psychical disorders.

A special chapter is given to a consideration of cerebral concussion and a review of the symptoms following the ex- plosion of shells in close proximity to the soldier. The book ends with a survey of the general etiology of the psycho- neuroses of war, the methods of treatment adopted and used successfully by the authors, and finally the points bearing upon the invaliding of the soldier and his discharge from the Army.

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MILITARY MEDICAL MANUALS

THE CLINICAL FORMS OF NERVE LESIONS

By Mme. ATHANASSIO BENISTY, House Physician of the Hospitals of Paris (Salpetriere), with a Preface by Prof. PIERRE MARIE. Edited with a Preface by E. FARQUHAR BUZZARD, M.D., F.R.C.P., Captain R.A.M.C.T., etc. With 8i illustrations in the text, and 7 full-page plates. Price, 6s. net. Postage 5^. extra.

In this volume will be found described some of the most recent acquisitions to our knowledge of the neurology of war. But its principal aim is to initiate the medical man who is not a specialist into the examination of nerve injuries. He will quickly learn how to recognise the nervous territory affected, and the development of the various clinical features ; he will be in a position to pronounce a precise diagnosis, and to foresee the consequences of this or that lesion. In this way his task as military physician will be facilitated.

With this end in view considerable space has been devoted to the illustrations, which are intended to remind the physician of the indispensable anatomical elements, and the most striking clinical pictures. Numerous diagrams in black and white enable him to effect the essential work of localisation. The diagnosis of nervous lesions is thus facilitated.

A second volume will be devoted to the study of the lesiotts themselves, together with their restoration, and all the methods of treatment which are applicable to^ such lesions. This will appear immediately.

Together these volumes will represent a complete epitome of one of the principal departments of " war neurology."

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THE TREATMENT AND REPAIR OF NERVE LESIONS

By Mme. ATHANASSIO BENISTY, House Physician of the Hospitals of Paris, with a- Preface by Professor PIERRE MARIE, Members of the French Academy of Medicine. Edited by E. FARQUHAR BUZZARD, M.D., F.R.C.P., Captain R.A.M.C.T., etc. With 62 illustrations in the text and 4 full-page plates. Price, 6s. net. Postage 5<^. extra.

The other book published by Mme. Athanassio Benisty, which was devoted to the Clinical Features of Injured Nerves^ explained the method of examination, and the indications which enable one to differentiate the injuries of the peripheral nerves. It is a highly practical guide, which initiates in the diagnosis of nervous lesions those physicians who have not hitherto made a special study of these questions. — This second volume is the necessary complement of the first. It explains the nature of the lesions, their mode of repair, their prognosis, and above all their treatment. It provides a series of particularly useful data as to the evolution of nerve- wounds — the opportunities of intervention — and the prognosis of immediate complications or late sequelae.

But it is especially the application of prosthesis which constitutes the principal therapeutical innovation by which our "nerve cases " have benefited. All these methods of treatment ought to be made commonly known, and a large space has been reserved for them in this volume, which will not only furnish an important contribution to the science of neurology, but will enable the medical profession to profit by the knowledge recently acquired in respect of the diagnosis, prognosis, and treatment of nerve-wounds.

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7 B 2

MILITARY MEDICAL MANUALS THE TREATMENT OF FRACTURES

By R. LERICHE, Assistant Professor of the Faculty of Medicine, Lyons. Edited by F. F. BURGHARD, C.B., M.S., F.R.C.S. Formerly Consulting Surgeon to the Forces in France.

Vol. I. FRACTURES INVOLVING JOINTS.

With 97 illustrations from original and specially prepared drawings. Price, 6s, net. Postage 5^. extra.

The author's primary object has been to produce a handbook of surgical therapeutics. But surgical therapeutics does not mean merely the technique of operation. Technique is, and should be, only a part of surgery, especially at the present time. The purely operative surgeon is a very incomplete surgeon in time of peace ; " in time of war he becomes a public disaster ; for opera- tion is only the first act of the first dressing."

For this reason Prof. Leriche has cast this book in the form of a compendium of articular therapeutics, in which is indicated, for each joint, the manner of conducting the treatment in the different stages of the development of the wound. In order to emphasize their different periods he has described for each articulation :

I. The anatomical types of articular wounds and their clinical development. — 2. The indications for immediate treatment at the front. — 3. The technical indications necessary for a good functional result. — 4. Post-operative treatment. — 5. The con- ditions governing evacuation. — 6. The treatment of patients who come under observation at a late period.

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MILITARY MEDICAL MANUALS THE TREATMENT OF FRACTURES

By R. LERICHE, Assistant Professor in the Faculty of Medicine, Lyons. Edited by F. F. BURGHARD, C.B., M.S., F.R.C.S. Formerly Consulting Surgeon to the Forces in France.

Vol.11. FRACTURES OF THE SHAFT. With 156 illustrations from original and specially pre- pared drawings. Price, 6s. net. Postage 5^. extra.

Vol. I. of this work was devoted to Fractures involving Joints ; Vol. II. (which completes the work) treats of Fractures of the Shafts and is conceived in the same spirit — that is, with a view to the production of a work on conservative surgical therapeutics.

The author strives on every page to develop the idea that anatomical conservation must not be confounded with func- tional conservation. The two things are not so closely allied as is supposed. There is no conservative surgery save where the function is conserved. The essential point of the treatment of diaphysial fractures consists in the early operative disin- fection, primary or secondary, by an extensive sub-periosteal removal of fragments, based on exact physiological knowledge, and in conformity with the general method of treating wounds by excision. When this operation has been carefully performed with the aid of the rugine, with the object of separating and retaining the periosteum of all that the surgeon considers should be removed, the fracture must be correctly reduced and the limb immobilized.

For each kind of fracture the author has given various methods of immobilization, and examines in succession : the anatomical peculiarities — the physiological peculiarities — the clinical course — the indications for early treatment — the technical steps of the operations — and the treatment of those who only come under observation at a late period.

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FRACTURES OF THE LOWER JAW

By L. IMBERT, National Correspondent of the Society dc Chirurgie, and PIERRE REAL, Dentist to the Hospitals of Paris. With a Preface by Medical Inspector-General FEVRIER. Edited by J. F. COLYER, F.R.C.S., L.R.C.P., L.D.S. With 97 illustrations in the text and 5 full- page plates. Price, 6s. net. Postage 5^. extra.

Previous to the present war no stomatologist or surgeon possessed any very extensive experience of this subject. Claude Martin, of Lyons, who perhaps gave more attention to it than anyone else, aimed particularly at the restoration of the occlusion of the teeth, even at the risk of obtaining only fibrous union of the jaw. The authors of the present volume take the contrary view, maintaining that consolidation of the fracture is above all the result to be attained. The authors give a clear account of the various displacements met with in gunshot injuries of the jaw and of the methods of treatment adopted, the latter being very fully illustrated.

In this volume the reader will find a hundred original illus- trations, which will enable him to follow, at a glance, the various techniques employed.

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MILITARY MEDICAL MANUALS

FRACTURES OF THE ORBIT AND INJURIES OF THE EYE IN WAR

By FELIX LAGRANGE, Professor in the Faculty of Medicine, Bordeaux. Translated by HERBERT CHILD, Captain R.A.M.C. Edited by J. HERBERT PARSONS, D.Sc, F.R.C.S., Temp. Captain R.A.M.C. With 77 illustrations in the text and 6 full-page plates. Price, 6j. net. Postage 5^. extra.

Grounding his remarks on a considerable number of obser- vations, Professor Lagrange arrives at certain conclusions which at many points contradict or complete what we have hitherto believed concerning the fractures of the orbit : for instance, that traumatisms of the skull caused by fire-arms produce, on the vault of the orbit, neither fractures by irradia- tion nor independent fractures ; that serious lesions of the eye may often occur when the projectile has passed at some distance from it. There are, moreover, between the seat of these lesions (due to concussion or contact) on the one hand, and the course of the projectile on the other hand, constant relations which are veritable clinical /aws^ the exposition of which is a highly original feature in this volume.

The book is thus far more than a mere " document," or a collection of notes, though it may appear both ; it is, on the contrary, an essay in synthesis, a compendium in the true sense of the word.

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MILITARY MEDICAL MANUALS

HYSTERIA OR PITHIATISM, AND REFLEX NERVOUS DISORDERS

By J. BABINSKI, Member of the French Academy of Medicine, and J. FROMENT, Assistant Professor and Physician to the Hospitals of Lyons. Edited with a Preface by E.

FARQUHAR BUZZARD, M.D., F.R.C.P., Captain R.A.M.C.T., etc. With 37 illustra- tions in the text and 8 full-page plates. Price, 6s. net. Postage 5^. extra.

The number of soldiers affected by hysterical disorders is great, and many of them have been immobilized for months in hospital, in the absence of a correct diagnosis and the application of a treatment appropriate to their case. A precise, thoroughly documented work on hysteria, based on the numerous cases observed' during two years of Avar, was therefore a necessity under present conditions. Moreover, it was desirable, after the discussions and the polemics of which this question has been the subject, to inquire whether we ought to return to the old conception, or whether, on the other hand, we might not finally adopt the modern conception which refers hysteria to pithiatism.

This book, then, brings to a focus questions which have been especially debated ; it does not appeal exclusively to the neurologist, but to all those who, confronted by paralysis or post-traumatic contractures, convulsive attacks, or deafness provoked by the bursting of shells, have to grapple with the difficulties of diagnosis and ask themselves what treatment should be instituted. In it will be found all the indications which are necessary to the military physician, summarized as concisely as is possible in a few pages and a few illustrations.

— — ^ — /

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MILITARY MEDICAL MANUALS

WOUNDS OF THE SKULL AND THE BRAIN^ Clinical forms and medico-surgical treatment*

By C. CHATELIN, and T. De MARTEL.

With a Preface by Professor PIERRE MARIE. Edited by F. F. BURGHARD, C.B., M.S., F.R.C.S. Formerly Consulting Surgeon to the Forces in France. With 97 illustrations in the text, and 2 full-size plates. Price, 6s. net. Postage 6d. extra.

Of all the medical works which have appeared during the war, this is certainly one of the most original, both in form and in matter. It is, at all events, one of the most individual.

The authors have preferred to give only the results of their own experience, and if their conclusions are not always in conformity with those generally accepted, this, as Professor Pierre Marie states in his Preface, is because important advances have been made during the last two years; and of this the publication of this volume is the best evidence.

Thanks to the method of radiographing the convolutions after filling the furrows, which has become sufficiently exact to be of real service to the clinician, the authors have been able to work out a complete and novel cerebral pathology, which presented itself in lamentable abundance in the course of their duties, which enabled them to examine and give continued attention to many thousands of cases of head injuries.

Physicians and surgeons will read these pages with profit. They are pages whose substance is quickly grasped, which are devoid of any display of erudition, and which are accompanied by numerous original illustrations.

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LOCALISATION AND EXTRACTION OF PROJECTILES

By Assistant-Professor OMBREDANNE, of the Faculty of Medicine, Paris, and M. LEDOUX- LEBARD, Director of the Laboratory of Radi- ology of the Hospitals of Paris. Edited by A. D, REID, C.M.G., M.R.C.S., L.R.C.P., Major (Temp.) R.A.M.C, with a Preface on Extraction of the Globe of the Eye, by Colonel W. T. LISTER, C.M.G. With 225 illustrations in the text and 30 full-page photographs. Price, 10s. 6d, net. Postage 6d. extra.

Though intentionally elementary in appearance, this com- pendium is in reality a complete treatise concerning the localisation and extraction of projectiles. It appeals to Sfurgeons no less than to radiologists.

It is a summary and statement — and perhaps it is the only summary recently published in French medical literature — of all the progress effected by surgery during the last two and a half years.

MM. Ombredanne and Ledoux-Lebard have not, however, attempted to describe all the methods in use, whether old or new. They have rightly preferred to make a critical selection, and— after an exposition of all the indispensable principles of radiological physics— they examine, in detail, all those methods which are typical, convenient, exact, rapid, or interesting by reason of their originality : the technique of localisation, the compass, and various adjustments and forms of apparatus. A considerable space is devoted to the explanation of the method of extraction by means of intermittent control^ in which the complete superiority of radio-surgical collaboration is demonstrated.

Special attention is drawn to the fact that the numerous illus- trations contained in this volume (225 illustrations in the text and 30 full-page photographs) are entirely original.

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MILITARY MEDICAL MANUALS WOUNDS OF THE ABDOMEN

By G. ABADIE (of Oran), National Corre- spondent of the Soci^te de Chirurgie. With a Preface by Dr. J. L. FAURE. Edited by Sir ARBUTHNOT LANE, Bart., C.B., M.S,,

Colonel (Temp.), Consulting Surgeon to the Forces in England. With 67 illustrations in the text and 4 full-page plates. Price, 6s, net. Postage 5^. extra.

Dr. Abadie, who, thanks to his past surgical experience and various other circumstances, has been enabled, at all the stations of the army service departments, to weigh the value of methods and results, considers the following problems in this volume, dealing with them in the most vigorous manner :

1. How to decide 7i>Aa/ is the best treatment in the case of penetrating wounds of the abdomen.

2. How to instal the material organisation which permits of the application of this treatment ; and how to recognize those conditions which prevent its application.

3. How to decide exactly what to do in each special case ; whether one should perform a radical operation, or a palliative operation, or whether one should resort to medical treatment.

This volume, therefore, considers the penetrating wounds of the abdomen encountered in our armies under the triple aspect of doctrine, organisation^ and technique.

We may add that it contains nearly 70 illustrations, and the reproductions of sketches specially made by the author, or photographs taken by him.

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MILITARY MEDICAL MANUALS

WOUNDS OF THE BLOOD- VESSELS

By L. SENCERT, Assistant Professor in the Faculty of Medicine, Nancy. Edited by F. F. BURGHARD, C.B., M.S., F.R.C.S. Formerly Consulting Surgeon to the Forces in France. With 68 illustrations in the text and 2 full-page plates. Price, 6s. net. Postage ^d. extra.

Hospital practice had long familiarised us with the vascular wounds of civil practice, and the experiments of the Val-de- Grace School of Medicine had shewn us what the wounds of the blood-vessels caused by modern projectiles would be in the next war. But in 19 14 these data lacked the ratification of extensive practice. Two years have elapsed, and we have henceforth soHd foundations on which to establish our treat- ment. This manual gathers up the lessons of these two years, and erects them into a doctrine.

In a first part. Prof. Sencert examines the wounds of the great vessels in general ; in a second part he rapidly surveys the wounds of the vascular trunks in particular, insisting on the problems of operation to which they give rise. " I should like it to be clearly understood," he concludes, " that the surgery of the blood-vessels is only a particular case of the general surgery of wounds received in war. There is only one war surgery : the immediate operative surgery which we have been learning for the last two years.

"This rule is never more imperative than in the case of vascular wounds. Early operation alone prevents deferred and secondary haemorrhage ; early operation alone can prevent the complications which are so peculiarly liable to result from the effusion of blood in the tissues ; early operation alone can obviate subsequent complications. Here, as everywhere, the true and useful surgery is a surgery of prophylaxis."

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MILITARY MEDICAL MANUALS

THE AFTER-EFFECTS OF WOUNDS OF THE BONES AND JOINTS

By AUG. BROCA, Professor of Topographical Anatomy In the Faculty of Medicine, Paris. Translated by J. RENFREW WHITE, M.B., F.R.C.S.jTemp. Captain R.A.M.C, and edited by R. C. ELMSLIE, M.S., F.R.C.S. ; Orthopedic Surgeon to St. Bartholomew's Hospital, and Surgeon to Queen Mary's Auxiliary Hospital, Roehampton ; Major R.A.M.C.T. With 112 illustrations in the text. Price, 6s. net. Postage 5^. extra.

This new work, like all books by the same author, is a vital and personal work, conceived with a didactic intention. At a time when all physicians are dealing, or will shortly have to deal, with the after-effects of wounds received in war, the question of sequelae presents itself, and will present itself more and more.

What has become — and what will become — of all those who, in the hospitals at the front or in tha rear, have hastily re- ceived initial treatment, and what is to be done to complete a treatment often inaugurated under difficult circumstances?

This volume successively passes in review : vicious calluses — prolonged and traumatic osteo-myelitis (infected stumps) — articular and musculo-tendinous complications — and "dis- solving " calluses — terminating by considerations of a practical nature as to discharged cases.

Profusely illustrated under the immediate supervision of Pro- fessor Broca, this volume contains 112 figures, all executed by an original process.

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MILITARY MEDICAL MANUALS

ARTIFICIAL LIMBS

By A. BROCA, Professor in the Faculty of Medicine, Paris, and Dr. DUCROQUET, Surgeon at the Rothschild Hospital. Edited and translated by R. C. ELMSLIE, M.S., F.R.C.S., etc. ; Orthopaedic Surgeon to St. Bartholomew's Hospital, and Surgeon to Queen Mary's Auxi- liary Hospital, Roehampton ; Major R.A.M.C.T. With 2IO illustrations. Price, 6s, Postage 5^. extra.

The authors of this book have sought not to describe this or that piece of apparatus — more or less " new-fangled " — but to explain the anatomical, physiological, practical and technical conditions which an artificial arm or leg should fulfil. It is, if we may so call it, a manual of applied mechanics written by physicians, who have constantly kept in mind the anatomical conditions and the professional requirements of the artificial limb.

Required, during the last two years, to examine and equip with appliances hundreds of mutilated soldiers, the authors have been inspired by this guiding idea, that the functional utilisation of an appliance should take precedence of considerations of external form. To endeavour, for aesthetic reasons, to give all subjects the same leg or the same arm is to risk disappoint- ment. The mutilated soldier may have a "show hand" and an cvery-day hand-implement.

The manufacturer will derive no less profit than the surgeon or the mutilated soldier himself from acquaintance with this compendium, which is a substantial and abundantly illustrated volume. He will find in it a survey and a reasoned criticism of mechanisms which notably display the ingenuity of the makers — from the wooden " peg " of the poor man, together with his " best " leg and foot, to the artificial limb provided with the very latest improvements.

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MILITARY MEDICAL MANUALS

TYPHOID FEVERS AND PARA- TYPHOID FEVERS (Symptomatology, Etiology, Prophylaxis)

By H. VINCENT, Medical Inspector of the Army, Member of the Academy of Medicine, and L. MURATET, Superintendent of the Labora- tories at the Faculty of Medicine of Bordeaux. Second Edition. Translated and Edited by J. D. ROLLESTON, M.D. With tables and tempera- ture charts. Price, 6s. net. Postage 5^. extra.

This volume is divided into two parts, the first dealing with the clinical features and the second with the epidemiology and prophylaxis of typhoid fever and paratyphoid fevers A & B. The relative advantages of a restricted and liberal diet are discussed in the chapter on treatment, which also contains a description of serum therapy and vaccine therapy, and general management of the patient,

A full account is to be found of recent progress in the bac- teriology and epidemiology of these diseases, considerable space being given to the important question of the carrier in the dissemination of infection.

The excessive frequency of typhoid fever in war time is demonstrated by a sketch of its history from the War of Secession of 1 861 -1866 down to the present day.

The concluding chapter is devoted to preventive inoculation, the value of which is proved by the statistics of all countries in which it has been adopted.

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MILITARY MEDICAL MANUALS

DYSENTERIES, CHOLERA, AND EXANTHEMATIC TYPHUS

By H. VINCENT, Medical Inspector of the Army, Member of the Academy of Medicine, and L. MURATET, Director of Studies in the Faculty of Medicine, Bordeaux. With an Introduction by Lt. Col. ANDREW BALFOUR, C.M.G., M.D. Edited by GEORGE C. LOW, M.A., M.D., Temp. Captain LM.S. Price, 65. net. Postage 5^. extra.

This, the second of the volumes which Professor Vincent and Dr. Muratet have written for this Series, was planned, like the first, in the laboratory of Val-de-Grice, and has profited both by the personal experience of the authors and by a mass of recorded data which the latter years of warfare have very greatly enriched. It will be all the more welcome as hitherto there has existed no comprehensive handbook treating these great epidemic diseases from a didactic point of view. The articles scattered through the reviews, or memoirs buried in the large treatises, did not respond to the need which was felt by the military physician, in France as well as in distant expeditions, of a work which should bring to a common focus a number of questions which were, in general,^ very imperfectly understood.

The authors review, in succession, the Clinical details, the Epide- miology, and Prophylaxis of Dysenteries^ Cholera, and Typhus. In the section dealing with Prophylaxis, in particular, will be found practical advice as to the special hygiene possible in the case of large collections of people placed in conditions favourable to the development of these diseases.

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MILITARY MEDICAL MANUALS

ABNORMAL FORMS OF TETANUS

By MM. COURTOIS-SUFFIT, Physician of the Hospitals of Paris, and R. GIROUX, Resident Professor. With a Preface by Professor F. WIDAL. Edited by Surgeon- General Sir DAVID BRUCE, C.B., F.R.S.,LL.D., F.R.C.P., etc., and FREDERICK GOLLA, M.B. Price, 6s, net. Postage 5^. extra.

Of all the infections which threaten our wounded men, tetanus is that which, thanks to serotherapy, we are best able to prevent. But serotherapy, when it is late and insufficient, may, on the other hand, tend to create a special type of attenuated and localised tetanus ; in this form the contractions are as a general rule confined to a single limb. This type, however, does not always remain strictly monoplegic ; and if examples of such cases are rare this is doubtless because physicians are not as yet very well aware of their existence.

We owe to MM. Courtois-Suffit and R. Giroux one of the first and most important observations of this new type ; so that no one was better qualified to define its characteristics. This they have done in a remarkable manner, supporting their remarks by all the documents hitherto published, first expounding the characteristics which individualise the other atypical and partial types of tetanus, which have long been recognized.

The preventive action of anti-tetanic serum should not cause us to disregard its curative action, the value of which is incontest- able. However, a specific remedy, even when a powerful specific, cannot act upon all the complex elements which constitute a disease ; and tetanus presents itself, in the first place, as an affection of the nervous system. To contend with it, therefore, a symptomatic medication should come to the aid of a pathogenic medication. — Professor Widal.

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MILITARY MEDICAL MANUALS

SYPHILIS AND THE ARMY

By G. THIBIERGE, Physician of the Hopital Saint-Louis. Edited by C. F. MARSHALL, F.R.C.S. Price, 6s. net. Postage 5^. extra.

It seemed, with reason, to the editors of this series that room should be found in it for a work dealing with syphilis considered with reference to the army and the present war.

The frequency of this infection in the army, among the workers in munition factories, and in the midst of the civil population where this is in contact with soldiers and mobilized vvorkers, makes it, at the present time, a true epidemic disease, and one of the most widespread of epidemic diseases.

Dr. Thibierge, whose previous labours guarantee his peculiar competence in these difficult and important questions, has, in writing this manual, very notably assisted in this work.

But the treatment of syphilis has, during the last six years, undergone considerable modifications ; the new methods are not yet very familiar to all physicians ; and certain details may no longer be present to their minds. It was therefore opportune to survey the different methods of treatment, to specify their indications, and their occasionally difficult technique, which is always important if complications are to be avoided. It was necessary before all to state precisely and to retrace, for all those who have been unable to follow the recent progress of the therapeutics of venereal diseases, the characters and the diagnostic elements of the manifestations of syphilis.

Of late years, moreover, new methods of examination have entered into syphilitic practice, and these were such as to merit exposition while the old elements of diagnosis were recalled to the memory.

In short, this little volume contains those essentials which will enable the physician to accomplish the enh're medical portion of his anti-syphilitic labours ; it will also provide him with the elements of all the medical and extra-medical advice which he may have to give the civil and military authorities in order to arrive at an effective prophylaxis of this disease.

It is therefore a real practical guide, a vade-mecum of syphili- graphy for the use of civil or military physicians.

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MILITARY MEDICAL MANUALS

WAR OTITIS AND WAR DEAF- NESS* Diagnosis, Treatment, Medical Reports*

By Drs. H. BOURGEOIS, Oto-rhino-laryngolo- gist to the Paris hospitals, and SOURDILLE, former interne of the Paris hospitals. Edited by J. DUNDAS GRANT, M.D., F.R.C.S. (Eng.); Major, R.A.M.C., President, Special Aural Board (under Ministry of Pensions). With many illustrations in the text and full-page plates. Price, 6s. net. Postage 5^. extra.

This work presents the special aspects of inflammatory affections of the ear and deafness, as they occur in active military service. The instructions as to diagnosis and treatment are intended primarily for the regimental medical officer. The sections dealing with medical reports {expertises) on the valuation of degrees of disablement and claims to discharge, gratuity or pension, will be found of the greatest value to the officers of invaliding boards.

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MILITARY MEDICAL MANUALS

MALARIA :

Clinical and Hematological Features.

Principles of Treatment*

By P. ARMAND-DELILLE, P. ABRAMI, G. PAISSEAU and HENRI LEMAIRe! Preface by Prof. LAVERAN, Member of the Institute. Edited by Sir RONALD ROSS, K.C.B., F.R.S., LL.D., D.Sc, Lieut-Col. R.A.M.C. With illustrations and ,a coloured plate. 6s. net. Postage 5^. extra.

This work is based on the writers' observations on malaria in Macedonia during the present war in the French Army of the East. A special interest attaches to these observations, in that a considerable portion of their patients had never had any previous attack. The disease proved to be one of exceptional gravity, owing to the exceptionally large numbers of the Anopheles mosquitoes and the malignant nature of the parasite (Plasmodium falciparum). Fortunately an ample supply of quinine enabled the prophylactic and curative treatment to be better organised than in previous colonial campaigns, with the result that, though the incidence of malaria among the troops was high, the mortality was exceptionally low. Professor Laveran, who vouches for this book, states that it will be found to contain excellent clinical descriptions and judicious advice as to treatment. Chapters on parasitology and the laboratory diagnosis of malaria are included.

Further volumes for this series are under consideration, and future announcement will be made as soon as possible.

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