Skip to main content

Full text of "Dysentery, Asiatic cholera, and exanthematic typhus"

See other formats 


I  |ii 


I  SORGEX 


Jl^'.  It/     %t 


^lES.CHOLI: 


:-|:ViNCEN 


COL,ANDRE\-^ 


!        i 


THE  LIBRARY 

OF 

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 


ivi3555JB 


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. 


160  DYSENTERY,  CHOLERA,  AND  TYPHUS 

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. 


168  DYSENTERY,  CHOLERA,  AND  TYPHUS 

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 


THE   RIVERSIDE    PRESS   LIMITED.   EDINBURGH 


MILITARY 
MEDICAL 
MANUALS 


A  Series  of  handy  and  profusely  illustrated 
manuals  translated  from  the  French  under 
the  general  Editorship  of  the  DIRECTOR- 
GENERAL   of    the   Army   Medical   Service, 

SIR    ALFRED    ICEOGH 

G.C.B*,  LL.D.,  M.D*,  Hon.  F.R.C.S.,  &c* 

Eaeh  translation  has  been  made  by  a  practised 
hand,  and  is  edited  by  a  specialist  in  the  branch 
of  surgery   or   medicine  covered  by  the  volume. 

It  was  felt  to  be  a  matter  of  urgent  necessity  to  place  in 
the  hands  of  the  medical  profession  a  record  of  the  new  work 
and  new  discoveries  which  the  war  has  produced,  and  to 
provide  for  everyday  use  a  series  of  brief  and  handy  mono- 
graphs of  a  practical  nature. 

The  present  series  is  the  result  of  this  aim.  Each  mono- 
graph covers  one  of  the  manv  questions  at  present  of  surpassing 
interest  to  the  medical  world,  written  by  a  specialist  who  has 
himself  been  in  close  touch  with  the  progress  which  he  records 
in  the  medicine  and  surgery  of  the  war. 

Each  volume  of  the  series  is  complete  in  itself,  while  the 
whole  will  form  a  comprehensive  picture  of  the  medicine  and 
surgery  of  the  Great  War. 

LONDON : 

UNIVERSITY  OF  LONDON  PRESS 

18,  WARWICK  SQUARE,  LONDON,  EX.  4 

PARIS  : 
MASSON    ET    Cie.,  120,  Boulevard  St.  Germain. 


UNIVERSITT    OF    LONDON    PRESS 

Extract  from 

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, 


UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18.    WARWICK    SQUARE,    LONDON,  E.C.  4 


UNIVERSITY    OF    LONDON    PRESS 


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. 


UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18.    WARWICK    SQUARE.    LONDON.   E.G.  4 


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. 


UNIVERSITY    OF    LONDON    PRESS.    LTD. 

18.    WARWICK    SQUARE.    LONDON,    E.G.  4 


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. 

UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18.  WARWICK  SQUARE.   LONDON,   E.C.  4 


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." 


UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18.   WARWICK  SQUARE.   LONDON.   E.G.  4 


MILITARY  MEDICAL  MANUALS 


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. 


UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18,  WARWICK  SQUARE,   LONDON.  E.G.  4 

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. 


UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18,  WARWICK  SQUARE,  LONDON.   E.G.  4 


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. 

UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18,   WARWICK   SQUARE,   LONDON,   E.G.  4    ■ 


MILITARY    MEDICAL  MANUALS 


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. 


UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18,   WARWICK   SQUARE.   LONDON,    E.G.  4 


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. 


UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18.   WARWICK  SQUARE.    LONDON.  E.G.  4 


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. 

— — ^ —  / 

UNIVERSITY    OF    LONDON    PRESS.    LTD. 

18.   WARWICK   SQUARE.   LONDON,   E.C.  4 
12 


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. 


UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18,    WARWICK    SQUARE.   LONDON.   E.G.  4 


MILITARY   MEDICAL   MANUALS 

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. 

UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18.   WAR'-X'ICK   SQUARE,    LONDON.    E.C.  4 
14 


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. 


UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18.   WARWICK   SQUARE.    LONDON.    E.G.  4 
15 


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." 

UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18.   WARWICK   SQUARE,   LONDON,   E.G.  4 
i6 


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. 

UNIVERSITY    OF    LONDON    PRESS.    LTD. 

18,.  WARWICK  SQUARE.   LONDON.  E.G.  4 
17 


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. 


UNIVERSITY    OF    LONDON    PRESS.    LTD. 

18,  WARWICK  SQUARE,   LONDON.   E.G.  4 
l8 


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. 


UNIVERSITY    OF    LONDON    PRESS.    LTD. 

18.  WARWICK  SQUARE,   LONDON.   E.G.  4 
19 


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. 

UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18,  WARWICK  SQUARE.   LONDON.   E.G.  4 

20 


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. 


UNIVERSITY    OF    LONDON    PRESS.    LTD. 

18.   WARWICK  SQUARE.  LONDON.   E.G.  4 
21 


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. 


UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18,   WARWICK   SQUARE,   LONDON.   E.G.  4 


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. 


UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18.   WARWICK   SQUARE.   LONDON.   E.G.  4 


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. 


UNIVERSITY    OF    LONDON    PRESS,    LTD. 

18.    WARWICK    SQUARE,    LONDON,    E.G. 4 

PRINTED  IN  GREAT  BRITAIN  BY  R.  CI^AY  AND  SONS,  LTD., 
BRUNSWICK  STREET,  STAMFORD  STREET,  S.E.  I,  AND  BUNGAY,  SUFFOLK.