the full benefit of what we know respecting treatment. It is certainly surprising, considering the way in which the subject has been discussed of late years, to find how ignorant men still are of this most common disease. Out of the 16 cases just referred to, no less than 9 were of typhoid fever, and yet this grave fact was never suspected. Dr. Lyons refers to another case, in which a man was discharged from hospital, after "a short fever" of seven or eight days, and was then in a few days readmitted, and speedily died with extensive ulceration in the ileum. The fact simply being, that the decline of headache and fever-which in mild cases of typhoid often occurs at eighth or tenth days-must have been mistaken for full convalescence, and the unhappy soldier was therefore thrust out of hospital, and was compelled to perform his heavy duties during the height of a disease, which had been made dangerous and fatal by an unpardonable mistake. How many cases of typhoid fever do we see in civil practice, in which life is imperilled, and sometimes destroyed, by the indiscriminate use of purgatives, the disease receiving all sorts of names but the right one, and being treated in all kinds of ways but the proper one? Hæmorrhage or perforation is sometimes the first symptom which startles the practitioner out of his dream of a "bilious seizure," or a "slight bronchitis," or something of that kind. In Dr. Lyons' description of the morbid appearances of typhoid, we notice nothing unusual.

The typhoid fever, although most prevalent during the summer and autumn of 1855, was seen more or less till the complete evacuation of the Crimea. During the winter, however, cases of typhus became more frequent, although in the English army they never became very

numerous.

In the French and Russian armies, however, soon after the capture of Sebastopol, typhus, which had existed all the summer, began to assume an epidemic character, and from this time till May, 1856, it ravaged these armies with a fury unknown since the great epidemies of the imperial wars.

The reason of its spread was almost always attributed by the French and Russians to two causes; viz., a general scorbutic condition of the men, and an immense amount of over-crowding both in the barracks and hospitals. The Russians, retiring from Sebastopol after the 8th of September, were concentrated in the valleys, where they suffered greatly from intermittents, and the hospitals became much

crowded.

"As the result of this over-crowding" (said a Russian physician, M. Alferieff, to the Constantinople Society), "the typhus appeared. At Simpheropol, at Odessa, and at Nicolaïeff, there was also over-crowding, which was evidently the cause of typhus in these different cities. The unfavourable season may have had an influence, but in all cases over-crowding (encombrement) must be recognised, if not as the unique, yet as the essential and most active cause of the epidemic. The description of typhus, as given by Hildenbrand, corresponds perfectly with this disease.. The eruption which

This gentleman, the Professor of Pathology at Kiev, and M. Moering, Professor of Hygiene at Kiev, were sent by the Russian Government at the beginning of the autumn to Odessa, and then to the Crimea, to inspect and report on the health of the troops. After the peace they proceeded to Constantinople to survey the French hospitals.

like the papules of measles, appeared generally on the thorax and abdomen, extended sometimes over the whole of the body, and even to the palms of the hands. . . . . The duration was seven or fourteen days, or longer. The most usual complication, when the disease lasted for any time, was pneumonia, such as is characterized by M. Piorry as hypostatic. But this pneumonia, sometimes lobular, sometimes lobar, was not always limited to the posterior and inferior parts of the organ; it extended sometimes to the summit, it had not any very pronounced symptom, there was scarcely any cough, a slight dyspnoea, the characteristic expectoration was wanting, and without auscultation it would have been most frequently undetected." (pp. 126-127.)

His observations have "led M. Alferieff to reject the opinions of those who admit that the typhus and the typhoid fever are the same disease." (p. 127.)

Further particulars as to this Russian typhus were given by M. Moering, who was charged by the Russian Government to examine the chemistry and the microscopic anatomy of the blood and organs. M. Moering had made about two hundred dissections. The chemical results were negative; he found albumen in the urine towards the end of the disease, but it does not appear that he examined the urine otherwise. The analysis of the blood led to no special result, except that the absence of ammonia was ascertained. The anatomical conditions were hyperæmia of all the organs and of the muscles, during the first week, and increased epithelial formation on all the mucous surfaces. The hyperemia, thus general, "had no special seat of election." In the second week the membranes of the brain were more particularly affected; the arachnoid was opaque; the depending parts of the brain were softened; the posterior parts of the lungs were engorged, while the anterior were a little emphysematous. In the intestine there was increased mucus, and the follicles were even a little swollen. At the end of this period there was often parotitis. In the third and following weeks the lesions were very variable; the lung and the intestine, especially its inferior part, were the organs most affected.

"But the lesion of the intestine was not that of the typhoid fever; it was in fact only a softening of the mucous membrane. Twice only were ulcerations found in the small intestine; but these individuals laboured under tuberculosis, and these ulcerations were evidently due to this general disease, since they had none of the characters of the dothinenteric lesion described by M. Louis." (p. 130).

The amount of mortality caused by this fever in the Russian army is not known, but we have reason to believe it to have been enormous. Although not mentioned by MM. Alferieff and Moering, it was attended by scurvy; and we have it from a competent witness, that at Odessa, at any rate, every scorbutic person attacked with typhus died. It was perhaps fortunate for the English army that the advance so ardently longed for was prevented by the unexpected peace; the Russians, no doubt, more than decimated by disease as they were, would not have resisted the attack of the English troops, who were in the highest state of vigour and endurance; but in the Russian positions the English would have met a foe more deadly and more tenacious. As it was, the repose of the winter, which strengthened the English, exhausted the Russians; and if the elements fought

against us in the previous year, we gained an ally in the following winter, which silently sent more victims to their rest than the most deadly volleys of the red artillery.

Nearly at the same time that the Russians retreated, the French began to suffer. All the hard work during the autumn and winter of 1855-56 fell upon them. They were écheloned in vast masses along the marshy valleys of the Tchernaya, and suffered like the Russians from malarious fevers and from typhus, which spread rapidly in the regiments; their ambulances soon became overcrowded, and were emptied into Constantinople, where they had hospitals capable of holding 14,000 sick. On board the hospital ships the fever always increased; the Constantinople hospitals were soon overcrowded, and the terrible state of things with which we are all familiar, commenced. Despite the organization and the admirable foresight of the French, they were for a time overwhelmed; the fever spread from bed to bed, the intensity of the propagation being in proportion to the overcrowding (Jacquot); a considerable proportion of medical officers and 600 male attendants were attacked in two months; the Sisters of Charity and the priests largely suffered; the culinary and laundry arrangements could not meet the pressure, and finally (at the end of March) the transit of sick from the Crimea to Constantinople was stopped, and the army in the field was for the time compelled to provide for its own sick. The mortality at Constantinople, from November to April, has been variously estimated at from 15,000 to 40,000. The mortality of the fever itself at some of the hospitals was 35 per cent. In these secondary hospitals, in fact, the disease was more general and more fatal than in the Crimean ambulances.

With respect to the distinction between this typhus and the typhoid fever, a fierce discussion was carried on among the French doctors at the Imperial Society. On the one side, M. Cazalas, the principal medical officer of the Hôpital de l'Ecole, represented the indefinite school, and asserted that:

"1. Identical in reality, typhus and typhoid fever differed only in form. "2. The typhus, properly so called, common in the Crimea and in certain hospitals at Constantinople, existed at the Hôpital de l'Ecole only in isolated cases, which did not generally differ from the typhoid fever.

"3. The discases which declared themselves among the convalescents at Constantinople were sometimes gastric fevers, the typhus or typhoid fevers; sometimes a cerebral congestion, a meningitis, an active or passive hydrocephalus; sometimes a remittent or intermittent affection.

“4. These diseases were all complicated with scurvy, and very often with chronic diarrhoea.

"5. These diverse affections seldom ran their course without complication of remittence or intermittence, and those which had the intermittent or remittent character had a great tendency to continuity.

"6. All these affections tended equally to take a typhic or typhoid character. "7. The pathological states resulting from the mélange of all these elements were very complex. The scurvy is, perhaps, always the foundation; and the gastric, intermittent, and typhic elements enter most often into their composition.

"S. These morbid states are for the most part neither typhus nor typhoid fevers; they are the complex accidents in which the typhus has only a

secondary role, and are determined in cachectic or sickly men by the access of fever, or reactions too violent for the organs enfeebled by scurvy or by a miasmatic infection, either animal or vegetable.

"9. These states have only exceptionally a regular course and a constant symptom, stupor with delirium, like typhus; they offer in general the form and the marks of typhoid fever; and at the autopsy the lesion which characterizes this malady." (p. 19.)

We omit six other statements made by M. Cazalas, as the above quotation sufficiently expresses his opinion. We need only observe that he afterwards says, that "the lesion of the typhoid fever is wanting when the invasion has been sudden and the death rapid." (p. 20).

It will be seen, on a critical examination, that two questions are raised by M. Cazalas, although they are not distinctly put. He alleges, first, that any special fever which could be called typhus was uncommon in his hospital, the cases in which were of a very complex nature, since the men had been acted upon by various causes, which profoundly influenced nutrition-viz., scurvy (which implies bad food), miasmatic influences, and fatigue. That cases do occur in which such profound lesions of nutrition give us forms of disease so complex as to render it difficult to refer them to any particular nosological heading, is certain; and it is a mere question of evidence how many patients in any given hospital are affected with such cachectic conditions, and how many with a disease to which a definite name can be given. At the other hospitals of Constantinople, the proportion stated by M. Cazalas was not found to be correct; and there prevailed, as a principal disease, a definite fever with a certain course, and which had characters so marked as to call for a separate and distinguishing name,

M. Cazalas's other proposition is, that this fever, when it did occur, was in reality the ordinary typhoid fever, only it did not present the definite intestinal lesion when its onset was abrupt and its fatal issue rapid.

On the opposite side to M. Cazalas we must place M. Jacquot, the chief of the French hospital at Pera. While this able physician fully recognises the possible coincident occurrence of typhus, of scurvy, of marsh fever, he insists much "on the necessity, to avoid confusion, of disengaging these morbid states from each other." (p. 29.) The great epidemic disease which ravaged their hospitals was not, he insists, a mélange of typhoid states superinduced on other diseases; it attacked sound individuals, it was highly contagious, it had definite symptoms; a special eruption, quite distinct from the typhoid rash, existed, and there was not the intestinal lesions of typhoid fever. By way of exclusion, M. Jacquot proves that it would be neither a meningitis nor an encephalitis, nor a cerebral congestion, nor a marsh fever, nor a typhoid fever, nor a mélange of typhoid states occurring in diverse maladies. With respect especially to dothinenteritis, M. Jacquot asserts that the autopsies made by himself and MM. Hospel, Ganam, Valette, Barudel, Gauderax, Tholozan, and Lallemand, amounting to 160 in number, prove that "the dothinenteric lesion never exists in the typhus." (p. 149.)

M. Jacquot concludes finally;

"1. The reigning epidemic was the contagious typhus of armies.

2. The typhus showed itself,-a, solitary, as when it attacked the persons composing the hospital staff, or in the Crimea the healthy men; b, it attacked convalescents arrived at such a state of reparation that it pursued its ordinary course; c, it attacked persons cachectic, scorbutic, or already affected with other profourd maladies; the affection was then complex; the typhus was profoundly modified in its symptoms and in its march; its distinctive characters were obscured; the anatomical lesions were numerous and diverse; the curative means were multiplied; the prognosis was graver, the diagnosis difficult.

"3. Typhus and typhoid fever are distinct maladies, and they can be distinguished with facility at the bedside by the symptoms, the course, and the commemorative circumstances. The absence of the intestinal lesion of the typhoid fever verifies the diagnosis on the dead body.

4. The Constantinople typhus had no special fatal period, nor any determinate and invariable duration.

In addition to the true typhus, solitary or complex, there existed accidental or typhic states grafted on other affections." (p. 149.)

We need not now prolong this discussion. Few of our readers, we fancy, but will find M. Jacquot's opinions more consonant with their views than those of M. Cazalas. Like M. Jacquot, we found no difficulty, in 1855-56, in at once diagnosing the typhus and typhoid fevers among the English. The distinction, which in this country is one of the most facile clinical problems, was not more difficult in Turkey. It is true, however, that our men did not present the scorbutic and cachectic conditions which among the French masked the new disease, and rendered typhus occasionally difficult of diagnosis. These underlying conditions constitute the great difficulty in the management of disease in times of war. To recognise, appreciate, and. treat them, is no easy task for men who have been accustomed only to the simpler features of disease in times of peace. A full description of these complex states has never yet been given, but we know no greater service that could be rendered to military medicine than a comprehensive modern work on the 'Diseases of the Camp and Army,' if it were written with the honesty and vigour of Pringle, and with the quick intelligence and keen insight of Robert Jackson.

If the French were for the time oppressed, and even overwhelmed by this terrible epidemic, their admirable organization soon began to regain ground; during the months of April and May, the fever rapidly declined, and it is a good example of the excellent method of our allies, that the French troops were conveyed home without any great outbreaks of typhus on board the transports, and without the introduction of the disease into France. To prevent the chance of this latter event, every sanitary precaution was taken, both in embarking the men in the Crimea and at Constantinople, and in landing them. at Marseilles, where large camps and hospitals were formed, in which the men were placed in quarantine. The medical history of the war shows indeed in a striking way the advance of sanitary science since the Imperial wars of the first Napoleon. At that time, each army carried with it the spotted fever, and the ravages of the sword were not the only curse it inflicted on the countries it marched across. In this war the most careful steps were taken to prevent such a catas