eral Hospital and of the 1,381 cases in the Toronto General Hospital were admitted in the autumn months."

The next question with which we have to deal is the mode of infection. I have already given an outline of the disease and its etiology and now naturally follows the description of the methods by which this extremely active bacillus effects an entrance into the human system.

There are several ways which I shall name in order of their frequency as follows:

1st-Through drinking water.

2d-Through milk supply.

3d-Through sick-room contamination.

4th-Through ice.

The most common of all these sources of infection is the first-that of drinking water, an article so universally used that the chances for the transmission of disease-germs are very great.

Given then a privy-vault, into which dejecta of a typhoid fever patient have been thrown, a well or reservoir or water-shed of the same, in close proximity, so situated as to receive the drainage or overflow from said privy-vault and a sufficiently severe rain-storm to cause an outflow or overflow of said vault, and we have all the conditions present for producing an epidemic of typhoid fever, the enormity of which is almost unlimited.

Thus, to illustrate, I will cite the recent outbreak of typhoid in the city of New Haven, report of which has just been published in the annual report of the State Board of Health of Connecticut for 1901, data of which I am able to present through the courtesy of Dr. C. A. Lindsley, the Secretary. This epidemic occurred in the months of April, May and June, 1901, and consisted of 497 cases. During the early part of April, Dr. F. W. Wright, Health Officer of New Haven, found evidences of an epidemic of typhoid in a certain district of the city,

Here he

and upon inquiry was led to investigate the illness occurring in a certain family which resided along the watershed of Lake Dawson, one of the large reservoirs used in supplying the city with drinking water. found undoubted histories of typhoid fever. investigation showed careless disposition of non-disinfected feces of these patients, not only in the privyvault, but even on the surface of the ground as well.

Further

The city is supplied by several reservoirs, the distributing pipes of which are more or less intimately connected, but by a series of tests and analyses it was quite clearly shown that the water supply used in the infected district was taken from the Dawson reservoir, or in other words about 90% of these cases resided in the district supplied by the Dawson Lake water.

In an epidemic which occurred in Plymouth, Pa., in 1885, over one thousand cases of typhoid developed and nearly one hundred deaths occurred. In this case a single patient infected this mountain stream miles away, and was the cause of this great loss of human life.

Numerous other instances of this kind could be cited if time permitted.

Regarding the second method, viz., through milk supply, I have only to recall the recent epidemic in the city of Stamford to bring to your minds a vivid illustration of the manner in which milk may become infected and produce wholesale disaster among its consumers.

Again, a somewhat peculiar outbreak of the disease occurred in New Milford a few years ago. This is interesting because of the manner in which the infection was transmitted.

A farm hand from an adjoining town who was convalescing from typhoid fever, came to visit his brother in New Milford, who was employed on one of the best milk producing farms in the town. While thus visiting, he offered his services in the capacity of milking a portion of the herd of cows.

Within a short space of time several cases of typhoid fever began to develop and an investigation was ordered. This resulted in attributing the outbreak to the convalescent visitor, whose hands had not been properly sterilized before milking.

The third method, or sick-room contamination, is brought about by the handling of soiled or infected vessels or linen and afterward lack of proper cleanliness or disinfection on the part of the nurse or attendants.

Regarding the fourth and last means mentioned of spreading typhoid infection, viz., through the medium of ice, it may be said that this is, perhaps, the most uncommon way. Although it is well to bear in mind that any given lake, water-shed or stream, subject to typhoid infection, would prove equally as dangerous in proportion to the amount of ice used for family consumption as the water itself.

PATHOLOGY AND DIAGNOSIS OF TYPHOID

FEVER.

R. HERTZBERG, M.D.,

STAMFORD.

Typhoid fever may be regarded as a local disease with well marked and definite general symptoms, due to absorption into the general circulation of the toxines produced by the Eberth bacillus at the site of the lesions. The small intestine composed of its mucous, sub-mucous, muscular and serous coats is the principal seat of the lesions of typhoid fever. The mucous membrane is studded throughout with folds or replicae, which run partly around the lumen of the tube, and are named the "Valvulae Conniventes." These folds serve to increase the area of the intestine, and are beset, as well as the intervening tissue, with finger-like projections called villi. The villi are the radicles of absorption, containing in their centre the chyle-vessel or lacteal which ends in a blind pouch at the extremity. Surrounding this lacteal are numerous unstriped muscular fibres, the afferent artery, the efferent vein and nerve fibers the whole being held together by adenoid and connective tissue. The mucosa proper is composed of the true secreting glands of Lieberkühn, whose mouths open between the bases of the villi. These glands furnish the intestinal secretion. Between the glands of Lieberkühn we find dense aggregations of lymphoid tissue, named respectively the solitary glands and the agminated glands. The first named are isolated lymph nodes, the second a collection of the solitary.

Peyer's patches are large oval groups of closely aggregated lymph follicles, held together by diffuse adenoid tissue. These patches vary in size and number and

are usually limited to the lower two-thirds of the small intestine, reaching their highest development in the ileum.

What concerns us most about these glands is the fact that they are not limited to the mucosa proper, but encroach upon the sub-mucosa, sometimes to such an extent that the muscular layers of the intestine are stretched only thinly over them. Typhoid ulceration having destroyed these patches, we have practically nothing left of our intestine but the serous coat, and a much thinned and perhaps ulcerating muscular layer, and it can be readily seen that but little force is required to cause a rupture of these the remaining structures. We may well ask ourselves the question, "Why have we so many lymph follicles situated along this tract?"

The answer is plain. Lymph glands all over the body act as sentinels which guard the systemic circulation against the introduction of infectious material. In the intestine, bacteria, and digestive and putrefactive processes are continually in operation, and it is to prevent the deleterious products of intestinal activity from reaching the general circulation that the lymph glands are so thickly placed in this part of the economy. The digestive product is taken up by the lacteals and emptied into these nodes which filter it and destroy all deleterious substances. If the infecting agent overcomes the resistance of these glands, death of tissue, ulceration and general infection follow.

After the infecting agent has passed the stomach, and it is often destroyed here, it reaches the small intestines, the contents of the bowel being alkaline in reaction, multiplication begins, absorption into the lymph nodes follows and the disease enters upon its course unless the lymph nodes are able to overcome the germs. Infection of the lymph nodes is characterized first by cell infiltration, followed by a marked dilation of the capillary blood-vessels. These after a time become compressed