polis. Of these, twenty were unmistakably cases of typhoid fever, with a mortality of two, one death from perforation occurring in March, 1903, and another from hyperpyrexia in the same month. The remaining 72 cases appeared to conform to a different type and there was no mortality among them. It is of this type that I now wish to tr at:

1. SEASONAL DISTRIBUTION. Seven of the cases occurred before 1st July, 1903, 65 after. Of the typical typhoids 13 occurred before 1st July, 1903, 7 after.

5. COURSE AND DURATION OF THE FEVER. In only a small proportion of the cases could continuous records of the temperature be kept, viz, those occurring in the town. In a few instances, thermometers were given to those found capable of using them at the outlying farms. In the cases continuously observed the temperature had daily remissions as in typhoid, and ran a continuous course for several weeks, gradually subsiding into an intermission, which, however, lasted only a few days, after which there was a repetition of the original course. Two or three such intermissions were observed consecutively in three cases, but the e was a tendency as time advanced for the fever to run a low continued course, without intermission, and in some there appeared to be no intermission from the outset. The fever was fairly acute during the first few weeks, suggesting typhoid, but later was low, 99 to 100F, in the morning, and 100 to 101F. in the evening.

The duration was quite indefinite. The shortest period cannot be stated, because there is no certainty that any of the cases were seen at the beginning. The longest period was five months (in three cases) from the time of first observation. The usual period was about three months.

6. SYMPTOMS.-In those cases seen early the aspect of the patient during the first few weeks suggested typhoid, the tongue being furred and the face flushed. In some there was abdominal distension and tenderness over the spleen. Enlargement of the spleen was never detected. There were no rose spots. There was no diarrhoea. Constipation was present in a large number of the cases, and diarrhoea occurred only in some as an incident of short duration in the course of the disease. The stools never presented the pea soup appearance characteristic of typhoid. Sweating, not very profuse but continuous, was present in most cases. There were no rigors.

7. COMPLICATIONS.-Pulmonary complications occurred in 18 out of the 72 cases. There was never typical pneumonia. The physical signs were in almost all cases coarse sonorous bronchial rales, and in a few of the more severe, fine rales at the bases.

Orchitis occurred in five cases. In those the date of the commencement of the disease was unknown. All the patients were able to say was that for many weeks they had been suffering from lassitude and inability to work, until finally they had had to take to bed.

8. SEQUELE (occurring late in disease):

By far the most common and characteristic sequele were neuralgic affections. Those occurred in 40 cases out of the 72. In all of those lumbago and sciatica of a very severe and obstinate kind were present, at first rendering all movement impossible, and later rendering the patient lame for weeks cr even months. Pleurodynia was also present in several cases. In one case, not yet recovered, there is paraplegia below the knees with absence of the knee jerks.

Joint affections occurred in five cases. In four of those there was a cold effusion into the ankle joint suggesting tubercular disease. The joint was painful on movement With rest, elevation of the and tender on pressure. limb, hot fomentations and bandaging, the joint became normal in a few days in all the cases. There was no multiple or flitting affection of the joints. In the fifth case there was brawny induration of the skin over the joint as well as gingivitis, clearly a case of scurvy. This yielded quickly to treatment with antiscorbutics.

There were 21 cases with none of the above complications and sequelae.

In every case the patient ultimately became anamic and debilitated, with a dirty muddy complexion, and clammy sweating. In the latter stages patients were seldom aware that their temperature was elevated.

The tongue generally became clean after the first few weeks and the appetite returned long before the termination of the fever.

TREATMENT.-With regard to the effects of drug treatment attempted, little favourable can be said. Quinine, Salicylates, Iodides, and Bromides were tried with no avail, with the exception that the Bromides gave temporary relief from the neuralgia. The general line of treatment adopted was that usual in enteric fever. In other respects the treatment was symptomatic.

THEORIES AS TO THE NATURE OF THE DISEASE.-(1.) That this fever is a distinct specific fever of which the virus has not yet been isolated. The only possible evidence in favour of this theory would be the isolation of a virus from the body of the patient, which would be put through the usual tests. One would naturally first attempt to get cultivations from the spleen in a case which bad proved fatal.

(2). That the disease is identical with one of the known specific fevers, being a modification of the same. By identity is here meant being due to the same virus.

The only fevers which can bear comparison with the one under discussion are (a) Malarial fever, (b) Enteric fever, (c) Malta, Mediterranean, or Undulant fever. (a) Properly speaking, Malarial fever can bear no comparison. The ineffectiveness of Quinine and absence of rigors and quotidian, teitian, or quartan intermissions put it out of Court.

(b) There can be no doubt that in its initiatory stage the disease bears a close resemblance to Enteric fever. In many cases the aspect of the patient is the same. The temperature during the first few weeks runs the same course. Cases with distinct intermissions every few weeks might be supposed to be relapsing enteric. In one case in which there were two successive remissions at intervals of three weeks with no intermissions, I thought it was Enteric fever with overlapping relapses. In this case the fever became continuous for six weeks after the secord remission. It is believed that the termination as well as the occasional intermissions in Enteric fever are due to the development of antitoxins. It is possible that owing to prolonged drought and the absence of moisture in the soil the Bacillus Typhosus becomes attenuated and partially loses its virulence, being still capable of causing fever, but too feeble to excite the effective formation of antitoxins. That the prolongation of the fever may be due to suppuration in the mesenteric glands is possible. That such suppuration should occur in so large a proportion of cases would indicate some modification of the Bacillus Typhosus; but one would expect a higher mortality among cases presenting so serious a complication.

(c) I have purposely left the comparison with Malta or Undulant fever to the last, because here, I believe, the resemblance is very close, perhaps as close as could be expected under altered climatic conditions.

I have had no practical experience of Malta fever, and it is not my intention to burden my hearers with a description of it. That, they will find in Manson's book on Tropical Diseases. On reading Manson's description of Undulant fever, one cannot fail to be struck with the resemblance between it and the fever under discussion at present. Let us compare the characteristic of the two In detail:

TEMPERATURE.-It will be found that the course and duration of the fever are identical in both.

SYMPTOMS.-The aspect of the patient resembles Typhoid at first in both. In both, the tongue becomes clean and the appetite may return long before the termination of the fever. In both, constipation is the rule, diarrhoea the exception. In Undulant fever tenderness and enlargement of the spleen are present in a majority of the cases; in the other, although tenderness. was present in some, enlargement was never detected. No other abdominal symptoms are mentioned by Manson. In Undulant fever, sweating is profuse, and is a prominent symptom. In the fever under discussion, sweating was constant, but not profuse.

COMPLICATIONS.-In both, pulmonary complications of the same character are met with frequently. Orchitis is found occasionally in both.

SEQUELE Neuralgic affections of similar character occur in large proportion of both. In Undulant fever multiple joint affections of a transitory character are mentioned as the most prominent and constant sequel. In the other we find only four cases of single joint affections, not traceable to another cause, among 72 cases.

The anæmia and debility common to both is of course a sequel of prolonged fevers.

SEASONAL DISTRIBUTION. In both we find the majority of the cases occurring during the dry season of the year, in contradistinction to Enteric fever, which occurs during the wet season.

AGE INCIDENCE.-Undulant fever is said to occur most frequently between the ages of 6 and 13 years. In the other, 34 out of 72 cases occurred between the ages of 6 and 20.

MORTALITY.The mortality is very low in both.

From the above comparison of the two fevers it will be seen that the chief differences in the characteristics are the following:-Spleen generally enlarged in Undulant fever; no enlargement detected in the other. Sweating more profuse in Undulant fever. Joint affections frequent and characteristic in Undulant fever; present in only a small proportion of cases of the other. In all other respects they are similar.

The best way of settling the question as to the identity or non-identity of this disease with Enteric fever or with Undulant fever would be by means of the agglutination tests. With that object in view I am now trying to procure some dead cultures of both the Bacillus Typhosus and the Microccocus Melitensis, having failed to find a laboratory in South Africa where those tests could be performed with the living germs, and having no time to devote to their cultivation.

A few words may now be said on the question whether this fever has recently appeared in South Africa, or has been present for an indefinite time in the past. I have had to fall back upon the testimony of non-professional men, never having had an opportunity of discussing the subject with a medical man of long standing in South Africa. The universal testimony of the people in Philippolis District is that although they may have seen a few similar cases in the past, the disease has never been epidemic as during the last six months. The cases

66

with neuralgic affections the Dutch speaking people call zinking koorts," literally, neuralgic fever. The name is an old one, and is also applied to cases of severe Those lumbago and sciatica in which there is no fever. who can speak English say the term means "rheumatic fever." When we remember the looseness with which the term "rheumatic " is used by the public, and even by medical men, we need not be surprised that it is applied to such affections as lumbago and sciatica. Cases of continued fever without neuralgic symptoms the Dutch call "slepende koorts" literally, "continuing fever." This is also an old name. Whether those are old names applied to a new disease, having been formerly used for modifications of enteric, or whether the disease to which they are now applied existed in the past, is difficult to decide owing to the untrustworthy nature of the evidence. Undulant fever is known to exist in India. It is possible that it may have been introduced into South Africa by returned prisoners of war or by British Indian Troops.

A few quotations from Manson on Undulant fever may now be given as specially applicable to the present theme :

"It is highly probable that the same, or a similar fever, occurs in many other parts of the Tropical and Subtropical World, having been confounded hitherto

with Malarial or with Typhoid fever. As a rule the most serious consequences of Malta fever are the debility it entails, the profound anæmia, the rheumatic-like pains, and the neuralgiæ. There is little risk to life: the mortality does not exceed 2 per cent.

"Quinine and, on account of the joint affections, the salicylates, are very generally prescribed. Both are useless, if not injurious. In fact the treatment of Malta fever resolves itself into a treatment of symptoms."

In conclusion, Gentlemen, I crave your indulgence for having inflicted upon you a paper full of facts with which many of you must be already familiar, and of theories, which I trust have not bored you. I regret very much that, owing to the exigencies of a busy practice in a wide district, I have been unable to make sufficien1ly accurate and continuous observation of the cases. The fewness of the cases is also to be regretted, tending, as it does, to render the results of statistical analysis less trustworthy.

The only practical suggestions I have been able to offer are as to the means of identifying the disease. With regard to treatment I have had nothing to offer, but I hope that some present here may have been fortunate. My experience in the treatment of this disease is summed up in the converse of one of Rochefoucauld's Reflections: "The most just comparison of love is that of a fever, and we have no power over either, as to its violence or its duration."

Since the above paper was read, blood smears from six typical cases of the fever described were examined by the Widal test for typhoid at the Grahamstown Bacterio. logical Institute. Dr. Edington has kindly consented to procure some cultures of the Micrococcus Melitensis in order to try the agglutination test for Undulant fever.

One is rather glad to welcome the advent of a man even though he is a layman, who is prepared to do electric and Xray work for the profession. It goes without saying that few private practitioners, if any, can afford to fit themselves out with a complete installation. and if they could, they certainly could not afford the time to work it. And yet, it is highly important that we should have at our command valuable agencies of this kind. Undoubtedly the ideal plan is the devotion of medical men to such work in honest collaboration with their confreres, but we fear that the difficu'ty of getting medical men to take up this speciality with strict ethical propriety, is in this country great, on account of the limited field, which constitutes a standing temptation to appropriation of patients without regard to their own medical attendants. And, even if it is not insuperable, we are pretty certain that it will take a long time to give the Cape Town private practitioner full confidence in specialists in these directions. Under these circumstances, probably the best solution of the difficulty is having the work done by a trained layman, provided only that he works in strict subordination to the profession, simply carrying out their orders and charging for the work he does himself, as a chemist charges for making up a prescription or a nurse for taking care of a patient. We have satisfied ourselves that Mr. Creedon, who has the recommendation of one or two of the most honourable and respected practitioners in Cape Town, is working on these lines. His card appears in the "Nursing Directory" column.

On Varicose Veins.

BY SIR KENDAL FRANKS, C.B., M.D. DUBLIN, F.R.C S.I.,

Surgeon to the Johannesburg Hospital.

Read before the Transvaal Medical Society, July 7th, 1904.

no

The treatment of Varicose Veins by operation requires no apology to-day, and yet, some twenty years attended with ago, surgical interference was attended inconsiderable risk, and was generally deprecated. In Gross System of Surgery," published in 1882, I find the following: "excision and direct exposure of the diseased vessels are too dangerous to be practised, being extremely liable to be followed by phlebitis, erysipelas and pyæmia. My conviction is that no surgeon should ever expose a patient to such risks." To-day we know that veins can be excised or otherwise dealt with, with very little of that awe and reverence which they inspired in the older school. This change has been brought about, like most of the changes in Surgery, by the introduction of the antiseptic method. I remember well the day when one of our leading physicians at home came into the Theatre when I was operating on Varicose Veins, and the look of astonishment in his face. Before leaving the Theatre he observed: "We treated veins with greater respect in my day." It would be a work of supererogation to-day to say a word in favour of operation; the object of this paper is rather to act as a break upon the indiscriminate resort to operative measures without regard to the causes of the varicosity, cr to the age and condition of the patient. Now, causation is the most important point to consider in all cases of varicose veins. They may result when the veins are no longer equal to the pressure of the blood within them. This may follow from two causes, one extrinsic, when from some remote cause an unusual amount of pressure is thrown upon the veins, such as pressure upon the iliac veins, due to overloading of the intestines, or to some abdominal tumour, or as in some forms of heart disease, cirrhosis of the liver, and such other obstructions to the free cause of the blood in the veins. Or the cause may be intrinsic - that is, for some reason or other, the veins have lost their tone and their elasticity, and are no longer capable of resisting the normal pressure from within. It is not easy to account for this loss of tone and elasticity in the veins, which has been attributed by some to an hereditary predisposition, and by Sir James Paget is stated to co-exist with an indolent temperament, or with a debilitated condition of the general health. Others look upon this condition of the veins as the result of a chronic phlebitis, analogous to chronic endarteritis, causing such an alteration in the walls of the vessels themselves that they lose their elasticity and become prone to dilatation. This chronic phlebitis is further supposed to be due to some nervous condition which gives rise to paralysis of the vaso-motor nerves supplying the small vessels which

nourish the walls of the veins. From this results hyperemia of the coats of the veins, ending in chronic phlebitis.

Whatever the agency at work may be, the result is the same the balance between the elasticity of the walls of the vein and the intravenous pressure is lost, and gradual dilatation and distension of the veins occur.

This loss of balance will be felt most, of course, wherever the pressure is greatest; and these situations are those, in the dependent parts of the body, where the column of blood is the longest. The column of blood in the veins is supported by the column of blood in the arteries, but the pressure in the veins will depend on the length of the column of blood it has to support. Nature provides a means of taking off this excessive pressure by supplying the veins with valves, so that under normal circumstances the vein has only to support the column of blood that lies between two pairs of valves. But Nature has also endowed the veins with the power of distending, so as to be able to accommodate an increased quantity of blood, should there arise any temporary obstruction to the outward flow through the heart. Now, when the veins so dilate, the valves within them are drawn apart and so allow of regurgitation. The temporary distension of the veins and insufficiency of the valves is quite a normal process. But, suppose that the obstruction to the onward flow of the blood, due to one of the extrinsic causes, is permanent, or that the condition of the vein walls is such that after distension their elasticity has become so impaired, as to prevent them returning to their usual size, then the valves remain permanently apart, and are no longer capable of supporting the column of blood. This throws an extra strain upon the valves below, and in time they yield; and their process goes on until the whole length of the vein is implicated. Now, in obedience to a general law in the body, that when a part loses its function it gradually wastes, so in the veins we find that the valves, being unable to accomplish their purpose, gradually atrophy, and may ultimately either disappear altogether, or their former existence be only recognised by their fibrous bands on the inside of the vein. Hence it is, as Gay says, that as a rule, veins that become varicose are destitute of valves."

Now when a particular vein has reached this stage, that is, that it has become valveless, the removal of the original cause will not cure the varicosity, nor will it prevent a further extension of the disease. The veins below the original site of lesion have a permanently increased pressure of blood thrown upon them, their valves have a permanently abnormal length of blood column to support, and this alone will eventually cause them to become varicose.

Some doubt has been expressed as to whether the deep veins in the leg-that is, the veins running between the muscles, and those which run within the muscles themselves-that is, the intermuscular and the intramuscular veins-are liable to varise like the superficial veins. I think Verneuil has satisfactorily proved that they are, and that in the majority of cases the subcutaneous and the intermuscular veins are equally affected. But the fact that for many years it was doubtful whether the deep veins ever became varicose, shows that, even when they are, the condition gives rise

to comparatively little inconvenience. This, I believe, is due to the fact that, lying between powerful muscles, which are constantly contracting, they are so squeezed and protected, that even in a varicose state, their function is preserved. But it is quite otherwise with the superficial veins. The skin alone protects them on one side, and can afford them but poor support, and therefore all the evil effects that can follow from varicosity find their fullest development in connection with these subcutaneous varices. As a result of the obstructed circulation in the veins of the leg, we find the circulation in those parts of the skin and subcutaneous tissues from which the venous radicals arise is impeded. The result is, the skin no longer obtains the quantity or the quality of nourishment that it requires, and it becomes discoloured (Eczematous.)

The increased venous pressure causes an abnormal amount of exudation, and the tissues around the veins become infiltrated. The skin of the part becomes brawny and edematous. It is a process of slow starvation. Allow it to remain unrelieved a little longer, and the tissues are eventually starved to death, or in other words, the skin sloughs, and an ulcer is left that well marked sore, with its unhealthy or sloughing surface, and its hard, elevated brawny edges, which is commonly, and I believe very properly, called a Varicose Ulcer. This is a condition with which every practitioner, and every student is painfully familiar. The inconveniences it causes, the incapacitating effect it has upon the man who is afflicted with it, are reasons sufficient to urge us to seek a remedy-and that if possible a permanent one. But the condition itself is not without its dangers. The sloughing process may involve a portion of the vein, and when this separates, the hæmorrhage may be appalling. For not only does the blood come from the distal end, but from the proximal, as the valves which would otherwise have prevented this backward flow, have ceased to exist, or have become ineffectual. We all remember in our hospital experience, how bed after bed was occupied by cases of this kind; and the innumerable varieties of dressings applied to hasten the healing of the ulcer. We remember how successful most of them were, provided that the recumbent position were maintained, and how pleased the patient was, and the dresser too, when the patient left the hospital with his ulcer healed. But we also remember the disappointment, when after a time, sometimes long, sometimes short, the case returned, with his legs as bad as ever. The reason was clear. We were spending our time and our energies in curing the effect, and not in removing the cause. Now to remove the cause of Varicose ulcer, we must deal with the Varicose veins themselves, but we must try to remove the condition which gave rise to them. You, who have seen Varicose Veins excised, or have excised them yourselves, must have been struck by the fact that in some cases the veins are excessively thin walled so thin, indeed, that it seems a wonder that they have not burst long ago, so thin and attenuated that a ligature has to be applied with the greatest care. And, again, in other cases you will have noticed that the veins are extremely thick walled so thick and strong that they look more like arteries than veins. I remember in one case excising a portion of the Saphena vein just above the bend of the knee. It was as thick and