greatly above that of the rest of the metropolis. One of these companies changed its source of supply to Thames Ditton, in the beginning of 1852; and immediately the relative predominance of the mortality of the districts it supplied was diminished. In July, 1855, the other company also changed its source of supply to near Hampton: and in that very quarter the mortality of that part of London situated in the county of Surrey fell for the first time below that of the rest of the metropolis, and has remained so ever since. He had not the means of ascertaining all the diseases which were diminished by the improvement in the water-supply; but he found from the weekly returns of the RegistrarGeneral, that the mortality of diarrhoea and typhus was greatly lessened. The author recommended iron tanks, of uniform size, charged with some deodorizing substance, as a substitute for water closets; the tanks when full, to be replaced by empty ones. The water-supply of towns should be from springs or deep wells at a distance. The shallow pump-wells in towns should be closed for domestic use; and in country places where pump-water must be used, the wells should not be sunk near the houses. The part of the Thames which at present most concerned the public health was that near Hampton and Thames Ditton; that part situated in London being never in a better condition, in a sanitary point of view, as hardly anybody ever used the water, except a portion of the population on board ship. The question of diverting the sewage of London from the river he considered to be one of taste, and he would not attempt to decide whether it would be worth the cost. (B) ACUTE DISEASES. ART. 6.-Contributions to the Etiology of Continued Fever; or, an investigation of various causes which influence the prevalence and mortality of its different forms. By CHARLES MURCHISON, M. D., L. R. C. P., Assistant-Physician to King's College Hospital and to the London Fever Hospital. (Proceedings of Royal Med. and Chir. Society, vol. ii. No. 1, 1858.) The subject of this paper is an investigation into the various causes which influence the prevalence and mortality of the different forms of continued fever. The materials consist principally of an analysis of 6628 cases of continued fever which had been admitted into the London Fever Hospital in the ten years during which the distinctions had been recorded between typhus, typhoid, relapsing fever and febricula. The results thus arrived at are compared with the statistical data which the author had obtained from many of the principal hospitals in England, Scotland, and Ireland, and from various published records. The subject is discussed under the following heads. A. Prevalence of continued fever. I. The various epidemics of continued fever which have prevailed in Great Britain and Ireland during the present century. II. Which are the forms of continued fever of which these great epidemics have been composed? III. The influence of months and seasons of the year on the prevalence of the different forms of continued fever. IV. The influence of sex. V. The influence of age, as shown by a calculation of the mean age of each of the different forms of fever, and by ascertaining the number of cases in each quinquennial period of life. VI. The influence of occupation and station in life on the prevalence of the different forms of fever. VII. The localities of London in which each form of fever is most prevalent, as shown by the localities from which the 6628 cases admitted into the London Fever Hospital had been derived. VIII. Overcrowding, with deficient ventilation, and destitution as causes of fever. IX. Putrid emanations from decomposing organic matter in drains, cesspools, churchyards, &c., and organic impurities in drinking-water. X. The contagiousness of the different forms of fever. XI. The influence of recency of residence in large towns as a predisposing cause of fever. B. Mortality from continued fever. I. The rate of mortality from fever in the London Fever Hospital, as compared with that of eleven other hospitals. II. The rate of mortality in the different forms of fever. III. The influence of months and seasons of the year on the mortality of the different forms of fever. IV. The influence of sex. V. The influence of age. VI. The influence of station in life. VII. The influence of recency of residence in large towns. The paper terminated with the following conclusions: 1. Typhus and relapsing fever occur at irregular intervals, and often simultaneously, as wide-spread epidemics. They then gradually disappear, and both of them, but especially the latter, may be absent for years from those places where, during the epidemics, they are usually the most prevalent. 2. Typhoid fever does not occur in such wide-spread epidemics. In certain places it is never absent, and its prevalence varies but little from year to year. When outbreaks of it occur in other situations, these are always of the most local and circumscribed character.. 3. Typhus and relapsing fever are quite independent of the season of the year; whereas typhoid fever is almost invariably most prevalent during the autumn, and it has been observed to be especially prevalent in seasons remarkable for their high temperature. 4. Sex has no influence over the prevalence of continued fever, nor over that of any of its forms. 5. Typhoid fever is pre-eminently a disease of childhood and adolescence, at which periods of life we know that there is a marked proneness to enteric affections. Less than one seventh of the cases of typhoid fever are above thirty years of age. Typhus and relapsing fever exhibit no such predilection for youth. Of typhus, one-half, and of relapsing fever, one-third, of the cases are above thirty. 6. Typhus and relapsing fever are the appanage of poverty and destitution, and seldom or never occur amongst the wealthy, except from direct contagion. Typhoid fever attacks both poor and rich without distinction. 7. In large cities, typhus and relapsing fever are for the most part limited to those localities remarkable for the overcrowding of their inhabitants; and in country districts they are seldom or never met with, except when directly imported. Typhoid, on the other hand, occurs alike in the centre and suburbs of cities, in the crowded hovels of the poor, and in the spacious mansions of the rich, and also in isolated houses and hamlets in the country, without any traceable sources of contagion. 8. When fever breaks out in a house or locality, it seldom or never happens that some of the cases are typhus and others typhoid; but typhus and relapsing fever occur not unfrequently together. 9. Cases of what has been called "febricula" may coexist along with any of the three other forms, but especially with typhus and relapsing fever. Most of them are either mild varieties of some of these, or dependent upon some derangement of digestion, or other non-specific causes. 10. Overcrowding and destitution appear to be the essential causes of typhus and relapsing fever, and to be capable of generating them de novo; while there is no evidence that they have any such influence over the production of typhoid fever. 11. There are many circumstances which tend to the belief that the emanations from decaying organic matter, or organic impurities in drinking water, or both of these causes combined, are capable of generating typhoid fever; but there is no authenticated evidence whatever to prove that such causes can give rise to typhus or relapsing fever. 12. There are some grounds for believing that a combination of the causes mentioned in the last two paragraphs may occasionally, although very rarely, generate a disease intermediate in its character between typhus and typhoid, or may (to speak perhaps more correctly) cause typhoid fever to assume some of the characters of typhus; but such cases cannot be used as an argument in favor of the identity of the poisons of the two diseases, for, first, instances are not wanting of two of the exanthemata coexisting in the same individual; and, secondly, if a known poison generates one train of symptoms, and a second poison another, a combination of the two poisons will generate a combination of the two trains of symptoms, without its being warrantable to conclude that the poisons in the first two instances were identical. 13. Typhus is eminently contagious. Typhoid fever is also contagious, but in a more limited degree, and possibly through a different medium. Again, typhus has in no instance been proved to communicate typhoid, nor typhoid to communicate typhus. An attack of either confers an immunity from future attacks of itself, but not of the other. 14. Recency of residence increases the liability to typhoid; scarcely, if at all, that to typhus. 15. The great majority of the cases of relapsing fever have been Irish, and of these a large proportion had but recently arrived in London. There seems reason for believing that fever imported from Ireland as "relapsing" may gradually pass into typhus. 16. Relapsing fever offers a marked contrast to typhus and typhoid in the small mortality which it occasions. 17. In comparing the mortality from continued fever at different times and places, it is essential to take into consideration the form of fever which has prevailed. If this be not done, the comparison is valueless. 18. The small mortality from continued fever constantly observed in Ireland, along with other circumstances, renders it probable that in that country a fever more or less allied to the relapsing, or to febricula, is more common than in Britain. 19. Season of the year has no influence over the mortality of any of the forms of fever. 20. In all of the fevers there is not much difference in the mortality of the two sexes. 21. Typhus is least fatal between the ages of ten and twenty, the mortality at that period of life being under five per cent. Above twenty, the mortality increases with the age, until of those above fifty considerably more than onehalf die. The mortality from relapsing fever appears to be influenced by age in a similar manner. In typhoid fever, on the other hand, in no period of life is the mortality under 12 per cent.; and although, as in typhus, the rate of mortality increases with the age, it does so in a less degree. 22. The mortality from typhus is greater amongst the very poor than amongst those in better circumstances. Typhoid fever is equally mortal in all classes. 23. Recency of residence increases the mortality from, as well as the liability to, typhoid fever, but has no such influence over typhus. 24. Typhus and relapsing fever are strongly assimilated in the causes which give rise to them, if the specific poison of the two be not actually the same. Typhoid fever, on the contrary, appears to be a perfectly distinct affection, dependent upon totally different causes. 25. The facts which have been adduced in reference to the mode of origin of the different forms of fever deserve the serious attention of those intrusted with the care of the public health, for it is manifest, that should they be confirmed by subsequent observation, they must have an important bearing on the subject of hygiene. ART. 7.-On the Eruption of Scarlatina. By Prof. TROUSSEAU. (Gaz. des Hôpitaux, No. 86, 1857; and Med. Times and Gaz., April 17, 1858.) The eruption appears in some patients four or five hours after the fever of invasion has set in, and does so very rarely after the first day. The cases in which the eruption is said to appear only on the third day must be quite exceptional, and are mostly to be explained by the defective examination of the practitioner and friends. It is generally on the face that we seek for the first manifestation of an eruption, and it is there we find it in rubeola or variola; but in scarlatina we should search for the earliest traces on the trunk, the belly, and bend of the thigh. It may be found there thirty-six hours before it exhibits itself upon the face and neck, and hence a cause of error in the date of its appearance. The duration of the eruption is very uncertain, bearing, in this respect, no analogy to that of variola and rubeola. Commencing on the first day, it may still be very vivid on the twelfth or fourteenth, although generally it becomes paler towards the eighth or ninth. In simple cases it lasts five or six days only. It is by no means so uniform and constant in character as represented in books. When severe and confluent it has the appearance of a tincture applied to the whole surface, but in the more simple cases it consists in a multitude of minute, round, red points, completely separated from each other, and differing entirely from the spots in measles. The peculiar red rash of scarlatina is also accompanied by a miliary eruption, which, even when not visible to the naked eye, feels to the touch like shagreen. It consists in minute vesicles, which in thirty-six or forty-eight hours become filled with a lactescent fluid, and is very seldom absent in confluent scarlatina. If we examine a scarlatina eruption with a magnifying glass, we may be easily convinced it is not of one uniform color as in erysipelas, but consists in elevations that resemble an excessively close eczema. It is the tongue, however, which presents the most specific appearance in scarlatina, and is, perhaps, as special as is the eruption in variola. The first day there is nothing peculiar about it, but the next, if the patient has been sick, it is of a deep green or yellow color, the point and edges being of an excessively bright red. When there has been no vomiting, it is of a milky white at its posterior part. Towards the third day the redness still further increases, and from the fourth to the fifth all the pasty appearance disappears. The tongue, now of a scarlet red, is swollen, painful, covered with projecting papillæ, and peels by friction. Towards the seventh or eighth day it becomes smoother but preserves its redness. By the ninth day the epithelium becomes evidently reproduced, but the tongue scarcely recovers its normal appearance before the twelfth day. M. Trousseau protests against the doctrine usually laid down, that, when the eruption is vivid and comes out well, the patient runs less risk of suffering from the various morbid phenomena. On the contrary, he declares it to be a law in scarlatina as in variola that the gravity of the case is in direct proportion to the intensity of the eruption. In distinct variola life is in as little danger as in scarlatina with slight eruption; and the issue of a confluent variola is surrounded by as many perils as is that of a confluent scarlatina, in which the entire skin is of a vivid red. The more intense the eruption, the more serious are the symptoms, and the more guarded should be the prognosis. ART. 8.-On Amyloid Degeneration of the Liver in Yellow Fever. (American Journal of Medical Science, Oct., 1857.) The existence of an amyloid substance was demonstrated by Virchow and Bennett to be the peculiar anatomical alteration of the liver, in many cases designated as waxy or fatty; and Professor Jackson some time since suggested that the peculiar appearance of the liver in yellow fever, supposed to be fatty degeneration, might possibly be owing to a similar modification. Professor Jones, of Savannah, has since then examined several of these livers, and found that they contained a substance which gave reactions similar in all respects to cellulose, and presented under the microscope an appearance like the granules of starch. Dr. Jones also endeavored to make gun-cotton from the yellow fever liver, but without success. M. Pelouze has, however, since shown that the glucogenic matter of the liver can, under the influence of fuming nitric acid, be transformed into xyloidine like starch. M. Claude Bernard had already shown that sugar is not an immediate product of the liver derived from any element of the blood; but that it is constantly preceded by the creation of a special matter, capable of generating sugar by a sort of secondary fermentation. This glucogenic or sugar-forming matter, obtained separately, possesses all the characters of hydrated starch. Assuming as correct the discovery of Bernard, the mechanism or process of the anatomical modification of the liver in yellow fever becomes apparent. The yellow-fever poison, introduced into the blood, vitiates its characters, properties, relations, and modes of action in the organism. All its functions are at first perverted, and ultimately, if the dose be powerful, are suspended or destroyed. The fermentative power of the blood being more or less impaired, and finally destroyed, the transformation of the amyloid substance into sugar is imperfect, or is not accomplished; the secretion of bile is at the same time arrested, and in consequence the amyloid element of the liver assumes an undue proportion in its structural composition. The peculiar character of the liver in yellow fever was first distinctly announced by M. Louis, as observed by him at Gibraltar. It has usually been supposed to be a form of fatty degeneration, though no regular and sustained chemical analysis, that I am aware of, ever demonstrated the fact. ART. 9.-Epidemic Fever characterized by mild Erythematic Pharyngitis. By Dr. ROCHESTER. (Buffalo Med. Journal, May, 1857; and North American Med. Chir. Review, March, 1858.) During the months of January, February, and March, 1857, there prevailed in the city of Buffalo and its vicinity a form of fever accompanied by mild pharyngitis, having a career of from three to five days, and generally, if not invariably, ending in convalescence. In a report made to the Buffalo Medical Association by Dr. Rochester, the results of an analysis of twenty-three recorded cases coming under his own observation were given, and the question of the identity of the disease with scarlatina discussed. From the results of the analysis, the following deductions were drawn by the reporter: "The disease was an epidemic fever, characterized by mild erythematic inflammation of the fauces as a constant local complication. Its character as essentially a fever is established by the febrile movement being in so marked a degree out of proportion to the local affection-in other words, evidently not being symptomatic of the latter-and by its running a definite although a brief career. It is a fever of from three to seven days' duration. Its epidemic character is sufficiently apparent. It has prevailed more or less extensively in the city for about two months, reaching its acme gradually, declining gradually, and at length disappearing, affecting both sexes and different ages without notable discrimination. As an epidemic fever, its symptomatic features were very uniform. The erythematous affection of the fauces constitutes the only positive character, aside from the brief duration of the febrile career. The other symptoms uniformly present were only those incident to febrile movement; and the symptoms observed in a few cases-viz., the convulsions in one case, the retraction of the head in one case, &c.-were only incidental events, not intrinsic elements of the disease. The small patches of white exudation observed in some of the cases do not suffice to establish any relation of the local affection to that called diphtheritic by Bretonneau and others. The occurrence of several cases repeatedly in the same family does not suffice to prove that the disease was propagated by contagion, since this fact is explicable on the supposition of the patients being equally exposed to an epidemic influence, |