Medical Officers of the Army of India.
51
many cases of malignant remittent fevers, however, very extensive changes occur
in the walls of the intestine, particularly in those which present choleraic fea-
t u r e s . I m a y h e r e r e f e r t o t h e r e s u l t o f e x a m i n a t i o n o f t h e t i s s u e s o f s u c h a c a s e ,
which came under my observation in the winter of 1892. Pieces of the liver
and intestine from a fatal case of acute malignant remittent fever in Peshawar,
during the severe outbreak of so-called Peshawar fever in 1892, were kindly given
to me by Surgeon-Captain Evans. In this case the mucous membrane was found
in an advanced state of superficial necrosis, with enormous cellular infiltration of
its deeper layers, which were intensely congested and full of punctiform hæmor-
rhages, and the vessels were loaded with melaniferous leucocytes. The ne-
crosis and great cellular infiltration of the superficial layers is shewn in Plate III.,
fig. 1, a p h o t o - m i c r o g r a p h o f a s e c t i o n s t a i n e d i n h æ m a t o x y l i n , a n d m a g n i f i e d
35 diameters. The liver capillaries in this case were injected with melaniferous
phagocytes ( Pl. II., fig. F., drawing with Zeiss A. A. and No.4 ocular ), leaving
no doubt as to the malarial character of the fever. Sections of the intestine,
stained by Weigert's method with methyl violet, showed the whole of the necro-
tic mucous membrane, down to its deepest layers, to be densely studded with a
large curved bacillus, the appearances of which are well shown in Pl. III,, 2
and 3, photomicrographs with magnifications of 500 and 1,000 diameters,
respectively, It appears to be not improbable that such malignant forms of
choleraiform remittent fever, which occur almost always as severe epidemic out-
breaks, and which have so often decimated regiments particularly in Peshawar,
may be due to a specific bacterial infection of the intestinal mucous membrane
superadded on the primary malarial attack. It is quite conceivable that the
interference to the circulation through the mucous membrane, caused by the
parasitic blocking of the vessels, might render the tissues particularly vulnerable
to the attacks of a schizomycete organism which would otherwise not be patho-
genic. The matter appears to be at least worthy of investigation, if such an
outbreak again occur as that which wrought havoc with the British troops
in Peshawar in 1892. It is difficult to understand on any other hypothesis why
certain outbreaks should be characterised by cases which go on for days,
terminating finally in death from coma with complete blocking of the cerebral
capillaries, the intestine remaining fairly normal while in others, so many cases
should terminate fatally within from a few hours to two or three days, with
complete necrosis of the intestinal epithelium, before the parasite-laden red-cell
embolism becomes anywhere very marked.
I have to thank Dr. Woodhead, Director of the Laboratory of the Con-
joint Colleges of Physicians and Surgeons in London, for his kindly granting me
permission to work at these tissues of Peshawar fever in the Laboratory, and
also for enabling me to have the accompanying photo-micrographs made.
7. The red bone marrow —Contained parasites in all stages both of the
H 2