4
from the other patients by the mere distance of one bed from the other. If by accident the
excretions from the typhoid patient were to find their way into the water or milk or other
uncooked food or drink supplied to the other patients, the outbreak of typhoid fever would
be certain and general, however pure and good might be the surrounding air; but under
less exposure to danger no evil would accrue."
Dr. Harley in Reynold's System of Medicine reviews what he terms—
" the associated pathology of enteric fever, meaning thereby a comparative view of the
development of the particular intestinal lesion in other acute diseases—an investigation of
great importance in the comprehension of the relation of acute diseases generally, but one
of especial value in the elucidation of the nature of enteric fever. Enteric fever is asso-
ciated with the following diseases :—Pneumonia, pleurisy, laryngitis (rare), scarlatina and
diphtheria, erysipilas, myelitis, phthisis, endemic intermittent and remittent fevers,
dysentery, cholera and scurvy. After the foregoing review can we adopt the dogma of
.Chomel—Quand nous trouverons dans les auteurs, soit anciens, soit modernes, des
observations de maladies aigues a la suit desquelles, on aura rencontre de ulcéres a la fin
de 1'intestine gréle, nous aurons le droit de les considerer comme des cas d'affection
typhoide; or, going to the other extreme, shall we deny the existence of enteric
fever as a specific disease and regard the' intestinal lesions merely as the result of an
accidental but severe local complication which may arise in any general, febrile
condition of the body ? If we accept the first proposition we must include tuberculosis
under enteric fever ; if we adopt the second, we may, with about equal reason, deny the
existence of scarlatina as a distinct disease. We can only avoid the dilemma of admitting
that the enteric disease and all its attendant phenomena may occasionally become a part of
some other more general inflammatory condition, and then, I think, it can hardly be denied
that in other cases the disease is due to some poison or poisons introduced from without, in
the elimination of which the digestive organs especially are deranged. In order to include
all the phenomena of enteric fever I find it necessary to divide it into these three varieties :
(1) Simple Inflammatory Enteric Fever, (2) Contagious Enteric Fever, (3) Paludal Enteric
Fever.
'' It may seem paradoxical and unphilosophical to include under one kind contagious and
non-contagious diseases ; but since the question of contagion is still an open one with many,
and neither symptoms nor anatomical lesions mark a distinction, we must be content thus
to classify the disease at present:—
"(1). Simple Inflammatory Enteric Fever.—This variety is non-contagious, due to no
specific cause, and may arise in any inflammatory condition of the body such as
acompanies pneumonia, erysipilas, pyoemia. The common enteritis which constitutes
autumnal diarrhoea if protracted, often lapses into this variety of enteric fever. The
recognition of the intercurrence of enteric inflammation with ulceration of the glands of the
ileum in acute diseases generally is of very great importance. The frequency with which
the intestinal glands become implicated in acute disease is probably due to their exposed
situation, their delicate corpuscular structure, their great vascularity, and the arrangement
of their blood vessels. We shall have little or no difficulty in distinguishing a tubercular
ulcer from any other ; but between the lesions assumed to be characteristic of enteric fever
and those arising from ordinary inflammation, which of course may affect the intestinal
glands in common with every other part and organ of the body, there is, I conceive, no
distinction.
" (2). Contagious Enteric Fever.—Of this variety I can say but little. I am not sure I
have ever seen it, but that it exists, appears to be an indisputable fact. Eight of the
sixty-eight patients referred to below came from houses in which other residents were
affected with the fever. The disease may have been propagated by contagion in some
of these cases; but in two instances, in each of which three members of the same family
were affected, I found, from personal observation, that an endemic cause existed in impure
drinking water. The associations of this variety appear to be with scarlatina and malarial
affections, diphtheria and croup exudations upon the faucial and laryngeal mucous membrane
appear to be more frequent in this variety, and the course of the disease more rapid than
in the third variety.
" (3). Paludal Enteric Fever.—This we believe to be the common form of the disease.
It arises from putrescent animal and vegetable substances. It is non-contagious, and its
course is usually slow. In thus unreservedly recognizing the connection which I cannot
doubt exists between intermittent and enteric fever, it may appear to some that I transgress
the facts which have been adduced to illustrate this view; but I feel sure justice has not
been done to the numerous observations which abound in medical literature and which,
if collected, would together form irresistible evidence of the direct connexion between the
two diseases."
In America the association between remittent and enteric fever is acknow-
ledged :—
" Not only, says Dr. Austin Flint, may the former present typhoid phenomena or the
typhoid state, but the diseases occur not unfrequently in combination. This statement