THE RELATION BETWEEN ENTERIC AND SCARLET

FEVERS.

SOUND hygienic practice depends so much on accurate notions of the etiology of infectious diseases, and this in its turn depends so essentially on a sound pathology, that any contribution to the pathology of these epidemic diseases cannot fail to have the greatest interest for the student of hygiene. Accordingly we have turned with some eagerness to a paper published in the last volume of the "Medico-Chirurgical Transactions" (vol. xxxvii. 2nd series), by Dr. John Harley, on "The Pathology of Scarlatina and the relations between Enteric Fever and Scarlet Fever." In this paper Dr. Harley again raises a question which he broached a few years ago, and from the analysis of the morbid appearances found in twenty-eight cases of scarlet fever he comes to the conclusion that "the pathology of scarlatina is precisely that of the first stage of enteric fever," and he proposes to term the latter disease " Abdominal Scarlatina" (p. 138).

Dr. Harley's paper is an excellent illustration of the confusion that exists in the minds of some sensible physicians between pathology and morbid anatomy. To anyone who has experience of the pathology, in the true sense, of scarlatina and enteric fever, what can be more startling than the following passage ?—

"If we now take the pathological conditions into one general view, it will appear that febris lymphatica is the appropriate scientific definition of scarlatina; that death is very likely to occur during the first week of the disease from the formation of fibrinous clots in the heart and great vessels; that the condition of the biliary function is such as to lead to an outbreak of diarrhoea; that mesenteritis and enteritis, sometimes general, but usually confined to the solitary and agminated glands, exist from the third day and onwards during an attack of scarlet fever, both being at their acme during the height of the fever, i.e. from the third to the seventh day; that the enteritis is usually latent, but ready to declare its presence upon slight provocation; and that this inflammatory condition of the mesen

teric and intestinal glands may persist to the sixty-ninth day. From this view one general conclusion as to the connection of scarlet fever and enteric fever is inevitable, viz. that the pathological changes accompanying an attack of scarlatina include all those of the first stage of enteric fever, and are so far identical with them. And it follows, therefore, that the transition from the former to the latter is nothing more than a natural pathological sequence, readily determined by any cause which may increase the intestinal irritation."

Dr. Harley had evidently been thinking exclusively of the anatomy of disease when he wrote this passage. Even in respect of anatomy, when one comes to analyse his cases, it is seen that the fact of something being wrong with the same part of the body is regarded by Dr. Harley as evidence of pathological unity. Yet, what would he himself say if one confounded, for instance, tuberculous ulcers of Peyer's glands with the ulcers of enteric fever; or if, what is scarcely less extraordinary than the above statement, one should say that a disease affecting anyhow the breast and the lymphatics connected therewith was, of necessity, some stage of cancer? When, however, it is considered that the identity of two things that present certain anatomical similarities wants to be considered by the light of etiology and of phenomena during life, there is still more curious confusion in Dr. Harley's argument. There is throughout the paper no evidence that the contagion of scarlet fever can produce enteric fever, or vice versa, and apparently no thought that such evidence is of moment. There is no consideration as to incubation time of the two diseases; and there is no recognition of the huge points of dissimilarity between the clinical phenomena of the two. In fact, the only reason adduced for the identity of the two things, apart from some slight similarity in the post-mortem appearances of certain cases of scarlet fever to those of certain cases of enteric fever, rests on the circumstance that sometimes enteric fever and scarlet fever occur in the same person, the one disease either soon before or at the same time as the other. And why should they not? The notion of "mutual exclusion" of epidemic diseases must be given up by anyone who examines the statistics of the two diseases from the obvious arithmetical standpoint. At any rate, no such notion

is present to Dr. Harley. And in the absence of any such "mutual exclusion," it must occasionally happen that the same person will be the subject of two diseases at the same time, or within the same short period. Suppose a number of susceptible persons to be exposed, in the same twelvemonth, once to the contagion of scarlet fever, and once to the contagion of enteric fever; the chances are against the two things occurring together. But there will of necessity be a certain minority of cases where the phenomena of the two diseases will concur. To say that this concurrence means that the two diseases are identical is surely untenable. Not scarlet fever and enteric fever only, but enteric fever and small-pox, typhus and scarlet fever, small-pox and enteric fever, and any other combination that can be proposed, must be expected occasionally to occur at the same time in the same person. We know they do so. But on that account, we do not affirm that enteric fever is small-pox, or that typhus is scarlet fever, or that small-pox is enteric fever. Dr. Harley gives us no help to reckon what was the simple likelihood of concurrence in each of his cases. They are for the most part cases of one disease following on another, and they are derived from fever-hospital practice; where the opportunity of a second disease being contracted has actually been present during the sojourn of a patient admitted for a first disease. Or else they are cases where, as Dr. Harley himself observes, the poison of scarlet fever was affecting the whole family of the sufferer. Why should the fact of the patient having been thus exposed to the poison of scarlet fever keep him safe from the poison of enteric fever if he comes into relation with it? or, conversely, why should he be proof against the scarlet fever poison because he chances to have got the poison of enteric fever? There would appear to be no reason; and one's judgment on this part of Dr. Harley's argument must of necessity be at least suspended until one knows what have been the chances of accidental concurrence. Towards this, as we have said, Dr. Harley gives us no help. For all that can be seen to the contrary, there were special causes of enteric fever operating on his scarlet fever convalescents, and others besides them may have been affected at the same time by these causes. Indeed, if we are not mistaken, something of this kind did actually

occur some few years ago in the hospital from which Dr. Harley gets his experience. We believe that enteric fever, propagated by a faulty and infected local sewer, did affect the scarlet fever patients, but that it also affected other people; and, moreover, that on the removal of the sewer cause, the cessation of the enteric fever (among scarlet fever patients as well as among others) instantly followed.

From his own point of view, in fine, it is clear that Dr. Harley has not done justice to his thesis, when he omits to consider whether scarlet fever and enteric fever have any difference in incubation times; whether the throat symptoms of scarlet fever have or have not anything special in them; and whether the definite tendency to albuminuria on the eighteenth day in scarlet fever can fairly be compared with the occasional and irregular albuminuria of certain cases of enteric fever. The essential defect of his paper consists in his having regarded every anatomical similarity, however small, as indicating unity, while he has ignored far broader differences, anatomical, etiological, and symptomatic; treating these, apparently, as matters not worthy of consideration.

Assistant Medical Officer and Pathologist, West Riding Asylum.

My only reason for placing the following notes on record is, that they may assist to establish the reputation of guarana as a remedy for sick-headache. Those who, up to the present time, have used the drug for this troublesome disease, have not been by any means unanimous in their opinion regarding its efficacy. Although the number of cases of sick-headache which I have treated is comparatively small, the results have been so uniformly successful, that to my mind the drug has a claim to much more extensive use.

Having become convinced of the decided influence of guarana in the cases for which it is usually prescribed, I tried it experimentally in a few cases of epileptic excitement. Work on other subjects has prevented me continuing these investigations far enough to obtain anything like conclusive results. It is therefore my intention to continue this class of observations, and, if the results should prove of sufficient value, to publish them. In the meantime I shall content myself with giving a few of

NO. LXIII.

M