ENTERIC FEVER IN INDIA. By J. RIORDAN, M.B., M.CH., Roy. Univ., Ireland,
Surgeon,
Medical
Staff.
In continuation of ray paper in this subject in the July number of the Gazette. I now offer a resume of cases which have since been under observation, from which a few general deductions are drawn, and in addition, a few figures will be given with a view of supporting the climatic or malarial origin of the disease as opposed to the specific theory. To prevent miscouception it may be well to glance en passant at the American It is hard to see term " typo-malarial fever." what is gained by this double-barreled appellation except that it affords a refuge for the indolent?it is merely hiding our ignorance behind a high sounding name, and still further confusing a problem already surrounded by difficulties. It this is an acute specific fever having an infectious (microbic), or spontaneous (sewer or faecal) origin, it does not require a new name because of its course being modified by miuor and accidental accessories. I write from Secuudrabad which has long enjoyed an unenviable sanitary notoriety, ami has of late years shown a high enteric mortality ; and where therefore ample opportunities are afforded of seeing every phase of the disease. The following cases are taken from case-books written in the ordinary course of duty and without any idea of being disinterred for record. The main features of each case have been noted, and although not always as complete as would be desirable, it may be generally accepted that where a symptom or state of an organ is not given no serious deviation from health existed. It only remains to be added that, although it would be better to give the charts of each case, I am compelled, for obvious reasons, to furuish a short verbal description instead. Case I.?Diagnosis, simple continued fever. Pte. PI. D. Ill two or three days before reporting sick. Admitted June 8th. Complained of severe occipital and lumbar pain, vomiting, diarrhoea, stools loose of a brownish colour, flushed face, suffused conjunctivas, dilated pupils, tongue furred oil dorsum, red and irritable at edges, tenderness and gurgling iu iliac fossa, discomfort in epigastrium, spleen enlarged ami tender. In hospital 16 days. Chart?101'4? and 102-8? with remissions first two days, 100? or under for three days, after which it became Motions 6, 4, 2. normal. P. 100, R. 20. Case II.?S. 0. F. Pte. W. H. Exposed to a severe storm oil sentry-go during the night of 15th June, detained on the 17th, admitted on the 18th, with severe diarrhoea, at first dark brown and loose, later becoming light yellow, nausea and vomiting. Liver enlarged downwards and tender, spleeu normal, acute pain and occasionally gurgling in iliac fossa, tongue 47
THE INDIAN MEDICAL GAZETTE.
s62
coated with a yellowish-brown fur, red at edges, dilated pupils, free action of skin. Rose spots not present. Fifty-six days in hospital. Chart?Pyrexia severe and irregular, but of a continued type for seven days, averaging 102?. Somewhat remittent for another week, and aguish for a third, after which it remained practically normal. It reached 104?, or near it on four occasions. Diarrhoea lasted 32 days. P. and R. recorded 100 and 24, but only averaged 80
thickly
and 20. Case III.?S. C.F. Drummer T. M. Admitted 17th June, after exposure to same storm as Case II, with ill-defined symptoms. The following noted :?Flushed face, tongue furred along dorsum, rather irritable at edges. Tenderness and persistent gurgling in iliac fossa, enlargement of liver. Three doubtful rose spots observed on the 8th day. This man had a wellmarked malarial cachexia, and was in hospital for remittent fever three months before. Chart? Fever of a mild continued type for 10 days with an average morning remission of 2 degrees and only once above 102?, mild ague for four or five days longer. Before he left hospital and 11 days after temperature became normal, he had a P. and 11. similar attack again lasting 14 days. In hospital No diarrhoea. normal as a rule. 49 days. Case IV.?S. C. F. Pte. A. D. Admitted 10th June. The only signs in this case were enlargement of spleen with general febrile symptoms inducing marked anaemia and debility, so that he remained 36 days in hospital. Chart?Moderate ague for five days, irregular continued fever for 4, once marking 103?, normal for 2, again mild continued with remissions for six days, marking 102?, afterwards normal. Pulse, respirations and bowels, very little disturbed. Case V.?S. C. F. Pte. I. W. Admitted 21st June. Flushed face, dilated pupils, large flabby tongue covered with dark brown fur, gurgling and tenderness in iliac fossa, enlargement of the spleen, pronounced diarrhoea for three days and irregular tendency for a week afterwards. Chart?101? on admission ascending by steps to 103? in five days with one degree morning remission. Intermittent fever for eight days afterTen days after the temperature became wards. normal, a remittent fever once rising to 103'6 and lasting six days, set in and retarded convalescence. Pulse frequently above 100, once 120. Respirations 24 when pyrexia was marked. In
hospital
42
days.
Case VI.?S. C. F. Pte. I. H. Admitted 25th J line. Complained of pains all over, but worst in the right lumbur region. Tongue thickly plastered with whitish fur, and red irritable edges. Liver and spleen both considerably enlarged and
painful. General abdominal pain, no tympanites, pain and gurgling in iliac fossa, both persisting for
some
time, diarrhoea lasting
about 10
days.
[Dkc.,
1883.
Chart?103*4? and 102 6? with remissions to 100, for next 3 davs intermittent from 101?, after it became and remained normal. Pulse 88 to 100. Respirations 18 to 24. He has since been almost constantly under observation for well-marked malarial cachexia, with enlargement a,,d induration of liver and spleen, and what may be considered consequent intestinal glandular affection giving rise to frequent attack of dysenteric diarrhoea. Case VII.?S. C. F. Pte. F. H., Admitted 25th June. An uncomplicated continued fever with general pains and furred tongue noted " to only complete a series of seven cases under treatment at the same time." Chart?Between 100? and 103? for 6 days, evening rises for two P. and R. once noted 100, and 24 usually more. somewhat lower. Bowels regular as a rule. In hospital 16 days. These are the June cases. It will be seen that five were admitted within 8 days when the preliminary monsoon storms prevailed, and although specially noted in only two cases, they were all probably due to that cause. It will be generally conceded that they were one and all cases of the same disease. Case VIII.?Remittent Fever. Pte. F. S. Admitted 18th July. Said to be suffering for 10 days from febrile symptoms and fromdiarrhcei for three days. He had a sallow complexion, dilated face, pinched pupils. He wandered slightly for some days, alternating with somnolence, diarrhoea slight, stools becoming of a light yellow colour. Thick brown fur on the dorsum of tongue, clean at edges, tremulous. Tympanites, pain and gurgling in iliac fossa, enlargement downwards of the liver, deafness. No rose spots present, skin acted freely. Discharged in 25 days. Chart?Temperature approached 104? for five days, with two to four degrees of remission, normal on the 10th day, with irregular evening rises for five days more. P. and R. 100 and 24 for a few days, about three motions daily for a week. Pte. G. B. Case IX.?Remittent Fever. Admitted 22nd July. Complained of insomnia, weakness and fever, tongue quite clean, but large and somewhat fissured. Tenderness and loud gurgling in iliac fossa, enlarged spleen, enlarged and painful liver, pronounced diarrhoea with loose pale-vellow stools, pulse 100, or thereabouts becoming dicrotic later on, rose spots absent. Thirty-seven days in hospital. Chart? lOW'on admission, going up by steps to 104*4? five days later with r< missions from one to three degrees. Normal on the 8th morning, but irregular ague for three weeks thereafter. The bowels did not become regular, until all fever disappeared. Respirations 18 to 24. Admitted Case X.? S. C. F. Pte. G. P. 21st July. Complained of pain from left nipple downwards, face dull and muddy with suffused
Deo., 1888.]
RIORDAN ON ENTERIC FEVER. P. ami R. 96 and 24
36^
highest
noted.
Motions 4 after-
conjunctivae,tongue furred brownish-white,gurg-and 6 first two days, moderately regular ling and pain in iliuc fossa, diarrhoea with verywards. Discharged in 36 days. loose
yellowish brown motions, spleen enlarged Case XV.?Enteric Fever. Pte. J. S. Adand tender. Heart's action weak but regular.mitted 26th August, but complained for a couple Thirtv-oue days in hospital. Chart? Readied of days before of severe pain in head, back and 104? the evening of admission, gradual declineepigastrium, tongue moderately clean, red at to 100? four days later, followed by irregularedges, diarrhoea severe and persistent, dejecta of aguish pyrexia for ten days more marking 103?,a pale brown loose character. Tenderness and 102?, &e. Pulse reached 100. Respirations 28,gurgling in iliac fossa, and enlargement of the Motions 10. 10, 5, 2 on admission. average 22. spleen, a few doubtful rose spots observed, and Case XI.?S. C. F. Pte. T. W. Admitted subsequently obscured by a red papular rash. 28th July, but suffered from malaise two daysLater deafness and a dry brown tongue superbefore. Pupils dilated, tongue slightly furredvened, the bowels were moved involuntarily, with red edges, gurgling and tenderness in iliacand he had incontinence of urine. About the fossa, some tympanites and enlargement of the14th day pulmonic symptoms set in and soon spleen. He complained later of being "stuffedovershadowed the enteric, with severe cough, up" in the chest, but no physical signs noted viscid broncho-pneumonic sputa, rales, &c. therefor. Discharged in 21 days. Chart?Well Still in hospital but convalescent from Sepmarked, continued fever for six days up to 103?,tember 25th. Chart?Severe continued fever lower. After this for eight from 102? to 104? for 18 days, after which it average a degree days, as a rule, below 100?. Respirations 18 togradually declined for another week. Pulse Pulse 88 to 100. Motions 4, 8, 1, 5. 24. and respirations averaged 100 and 24. Motions Admitted from 6 to 2 for 18 days. Case XII.?Ague. Pte. E. G. 2nd August with high fever, tongue furred olive F. Pte. F. Gr. C. Case XVI.?S. In tinted, face congested, gurgl'm?r but no tender- hospital from 25th June with venereal disease. ness in ili.-ic fossa, and enlargement of the spleen. About 1st August developed aguish symptoms Chart.?Over 104? for first two days with marked with diarrhoea. August 4th face congested, remissions, intermissions of two decrees for three pupils dilated, skin dry and hot, occasionally days longer when all symptoms subsided. In sweating, tongue strawberry, tending to become hospital 17 days. Pulse 90 to 100. Respirations dry, tenderness in iliac fossa, brown, watery 20 to 28. Bowels confined at first. These are stools, rose spots in crops, no tympanites, spleen the July cases. They .are on all fours with the normal. Discharged in 30 days. Chart?Ague June cases except that some of them exhibited for four days, continued fever of irregular ty pe more marked remittent characters. for 12 days, three times 104? or above, followCase XIII.?Enteric Fever. Pte. R. ed by ague for four days. Diarrhoea, secondary, Admitted 5th August, being his 3rd day of only set in when the fever was at its height and disease, with severe fever 104 8? on admission was then moderate. P. and R. also at this time averaging over 102? for 8 days. Diarrhoea recorded 100 and 24. at first; stools dark brown, loose, offensive, and Case XVII?S. C. F. Pte. J. C. Admitted sometimes involuntary. Face dull and heavy, 22nd August, ailing two or three days before. somnolent, tenderness, and gurgling in iliac Dirty brown tongue with red irritable edges, fossa, and tympanites. Tongue furred yellowish pain and gurgling in iliac fossa, spleen enlarged brown, red at edges. Liver and spleen normal. to margin of ribs, bowels confined. A number From 9th to 19tii day more or less ague. I" of small irregularly shaped spots crowned with a hospital 42 days. Chart?-Temperature already pellucid vesicle observed in chest aud abdomen. noted. Pulse 90 to 100. Respirations 20 to 26. Thirty-two days in hospital. Chart?Continued Motions 8, 7, 5, after which he was constipated. fever from 101-4? to 104*4? for four days. ReCase XIV.?Enteric Fever. Pte. T. W. mittent type from 99? to 102? for four davs? and Admitted 17th August, but with history of finally irregular ague for 10 days. P. aud malaise since sun exposure at athletic sports R. 100 and 22. average 80 and 20. .about a fortnight previously culminating the Case XV11I.?Remittent Fever. Pte.H. W. day before in fever and diarrhoea. Face dull Admitted 28t,h August. Out of sorts for a week and heavy, suffused conjunctivae, tongue thinly previously, slight diarrhoea, loose brown dejecta, furred, red edges, gurgling in iliac fossa, no ten- spleen somewhat enlarged, liver normal, gurgderness or tympanites. Rose spots in crops ling but no pain in iliac fossa, suffused conjuncapparently were noted, but no account of the tivas, clean tongue. Two rose-coloured spots tree action of the skiu, it was difficult to follow observed. In hospital 32 days. Chart?Fever their history. Enlargement of the spleen and i distinctly remittent for 12 days from 99? to insomnia. Chart?Continued but somewhat irre- 104?, irregular ague for 8 days. Pulse and gular fever for 8 days, twice reaching 103'2?, respirations averaged 88 and 22. Looseness for then of a remittent type for four days, after 9 days, two to four motions-daily. which au irregular ague lasted a fortnight longer.
j
THE INDIAN MEDICAL GAZETTE.
364
Admitted Case XIX.?S. C. F. Pte. H. M. 25th August. Suffused eyes, face congested, insomnia, abdominal and lumbar pain, enlarged spleen, Taches bleantres, but no rose spots, no gurgling or tenderness, tongue furred, red at edges, bowels confined. Discharged in 12 days.
Chart?Irregular pyrexia (once going
up to normal afterwards. P. and K. 110 and 24, average 88 and 20. Case XX.?S. c. F. Pte. H. C. Admitted 28th August with dull heavy face, dry, brown tongue, gurgling and pain in iliac fossa, enlarged and indurated liver and spleen, bowels fairly regular, rose spots in crops. Is now (September 30th) awaiting discharge. Chart? Remittent of rather mild type for ten days, (once 104?), mild but irregular intermittent for Pulse and respirations averaged 8 days after. 80 and 20 respectively. Case XXL?Enteric Fever. Pte. ,T. J. Admitted 9th September, but feeling ill three or Great weakness and severe four days before. " pain in back and head, so that he was nearly daft." Insomnia, suffused conjunctiva), pupils normal, tongue furred, brownish yellow, some diarrhoea, pale-brown dejecta, abdomen tympanitic, gurgling and tenderness in iliac fossa, spleen normal, liver tender. Is now (SeptemChart?Four rises ber 30) awaiting discharge. on four alternate days to 103? descending in the intervening days to normal, where after the 7th day it rested. Pulse and respirations reached 104 and 28 respectively, but soon subsided. Motions 4,1, 3 ou admission, afterwards regular. These are the August and September cases. It will be observed that they differ only in name from those already given. Let us now proceed to fatal cases. Two deaths only have occurred in my practice during 1888, and one was out of the enteric season. The notes of two other fatal cases are taken from the case books of my colleagues, and I owe them acknowledgment of this generous permission, for while opposed to my views on this subject, I have been allowed to choose the two most instructive cases. Case XXII.?Enteric Fever (frcjnn February 23rd). Pte. J. M. Admitted for venereal on February 4. Ten days later diarrhoea of a mild type set in with loss of appetite, furred tongue. Ou the 20th tenderness, but no gurgling in iliac fossa and enlargement of spleen noted. On the 23rd sordes and tympanites with flushed cheeks and dilated pupils. He became unconscious with restlessness and carphology during the night. .Next day, the stools were fluid and yellow-ochrey. He regained consciousness, and went on favourably? sordes and flushed face disappearing?till the morning of the 27th, when lie suddenly expired. P. M. A conical clot of ante-mortem formation found extending from right into
104?) for
a
week, it
was
appendix
[Dec.,
Lower 10 feet
ventricle.
of
ileum
ulcerated. Sixteen Peyer's and tary ulcers, no perforation. Two
cent and some old
94, spleen
20
rose to
on
102?
solitary
1888.
extensively
few solithree reulcers in colon. Liver a
or
Chart?Temperature
ounces.
evening of 16th, normal till 19th, when it again rose to 102?, the
the evening of also on the 20th and 21st. Evening of 22nd only one degree of fever, but, at, 8-30 p.m. And the a special observation recorded 101?. same on the 23rd. On the 24th and 25th it reached 103? without descending to normal at any hour. These, it will be seen, were the first, days of continued fever. On the 26th the
as
tendency
was
downwards,
Pulse,
102"4?.
as a
5 P.M. 100?, 8 rule, under 100, but,
P.M. once
112. Respirations 20 to 24. Motion 9 to 2, average of 5 daily, from February 16th, and sometimes involuntary. Cose XXI11.?Enteric Fever. Pte. S. A. Admitted September 1st, on the 2nd day of his disease. Fever remittent in type for three' days, from 102? to 104?, during which no suspicious symptom was noted ; bowels regular and tongue typically clean. On the 4th gurgling, but no On the tenderness in iliac fossa detected. night of the 4th diarrhoea set in. and on the 5th the following: clean tongue, brilliant eyes, lie was loquacious, but not delirious, weak thready pulse, general muscular tremor, tenderness but no gurgling in iliac fossa, marked tympanites, enlargement of spleen, insomnia, six to eight rose-coloured spots, small, not raised, and disappearing on pressure. Skin acted freely from time to time. He died three hours afterwards. P. M. Brain, pink blush on surface vessels engorged, small quantity of pinkish fluid in the left lateral ventricle. No clot in heart or large vessels. Lower 7 feet of ileum extensively ulcerated, 12 Peyer's and 20 solitary crlands affected. The ulcers were of a bunched appearance, a Peyer's patch consisting of two or three such bunches separated by inflamed but intact mucous membrane, and composed There was no perof stained necrosed tissues. foration, but inflammation in several places extended through to the peritoneum. Ascending colon thickened of a greyish colour, liver bright red, on section 68 oz., spleen 19 oz. Chart?From 102*4? to 101? every morning, 104? steadily every evening. Pulse and respirations about 96 and 22, steady. Case XXIV.? (Extracted by permission). Remittent fever, but its enteric nature all along suspected. Sergeant J. L. arrived from Bangalore on the 6th June. Admitted 23rd June. Complained of headache and lassitude. Fever
marking
of
an
intermittent,
or
more
usually remittent,
type, becoming more acute and irregular at the end of the third week. Except a moist furred tongue and pale rather loose motions averaging slightly more than one daily for this time;
365
RIORDAN ON ENTERIC FEVER.
Duo., 18SS.J
suspicions symptoms were observed for 24 days. When haemorrhage* from the bowels set in, quickly followed by some diarrhoea, tympanites, pain in iliac fossa, tongue dry and brown, red at edges. He became collapsed on the 2nd day, and died. P.. M. Coats of ileum no
thickened
at
lower
after definite symptoms set in, while all those that recovered exhibited the same severe symptoms for a much longer time, or were just as likely, clinically, to develope them as the more prolonged fatal cases.
I have prepared a few Six acclimatisation and age.
figures, bearing
on
especially portion. Peyer's patches and a large number of solitary Well-marked protection is afforded by accliglands ulcerated, and .deeply necrosed with matisation ; so well marked that Government eroded edges. Perforation in one. Spleen has expended large sums to meet suggestions enlarged. based on this hypothesis. The annexed table c5
of a battalion stationed Case XXV.?(Extracted by permission). gives the enteric history Pte. W. O. First admitted 8th July for remit- here for the past three years. It is their first Tem- Indian station. tent fever, but suspected to be enteric. but of a continued type perature was irregular, tor 8 days when it became intermittent. NorEnteric cases. Deaths. Y ear. Strength. mal every morning, but recording 103? to 105?
in the evening for 16 days longer. Three The weeks later he was discharged quite well. following also noted : moderate diarrhoea f. of all the cases that were treated at the South ^Station Hospital, Secu.nderabad, during 188G-87 and 1888 up to 1st October:?
Age
exerts
48
366
THE INDIAN MEDICAL GAZETTE.
Enteric Fever, Casks.
Deaths. Strength.
pku
MILLK.
Dicaths l'KK MILLK.
Year.
1886 1887 1888
1.136
636
...
1,149
576
...
1,417
621
...
j-20-5
17-4
5-94
6-55
(9 months)
Diagnosis.?The impression which iutimate observation of these cases leaves behind is that they are varying instances of the same disease. Is this enteric to the exclusion of malaria? or is it not rather alone due to the effects of climate (including air, water, soil, heat) ? A word about treatment. Quinine was largely used in all cases; generally one dose of 10 or 15 grains during the morning remission. when the Antipyrin temperature went up to Lead and opium rarely 103? in the afternoon. failed to check diarrhoea. Dietetically they were all treated alike, solids?bread and even eggs? being rigidly excluded. The following conclusions
are
drawn
From mild ague to the most severe euteric so called, every variety of fever with every combination of symptoms has been repeatedly under observation, and the most acute diagnostic skill fails to differentiate the recognised diseases. It is impossible to say that ague may not 2. develope into deadly typhoid (Cases 4, 16 and 22), or the severest enteric revert at any time to a simple ague. By this latter is uot meant the final intermittent of this, equally with undoubted, enteric but the sudden, early, and unexpected collapse of symptoms and fever, as iu Cases 1, 5, 6, 12, and 19. 3. Intestinal lesions are present, it is believed, iu all cases of continued fever at this station. 4. Many cases have a distinct history of excited being by exposure (chill or sun), and the enteric season is well defined just before, during, and immediately after the rains, in other words when susceptibility to chill is at its highest. Without again entering into the question of etiology, without enquiring iuto the immunity of womeu, children and natives, without noticing the evil repute of some cantonments compared with others similarly circumstanced in a sanitary sense, I venture to think that these cases and these figures suggest reasonable doubts as to the specific nature of this disease. May I therefore appeal to my brethren either to hold an opeu opinion for some time louger or to prove or disprove my arguments ? The ulcers 1.
18*8.
in Peyer's and the solitary may not be identical with the lesions universally known as typhoid?their presence or absence in no way affects the theory above set out. Tiie character of these changes is, however, a most important branch of the subject and calls for early and thorough investigation, and I readily admit that my case is incomplete until this is done. or
Cases
other
[Dec.,
glands
changes
may
or
Shcundicrabad, *) September 1888. /
30th
Surgeon,
Medical
Staff.
In continuation of ray paper in this subject in the July number of the Gazette. I now offer a resume of cases which have since been under observation, from which a few general deductions are drawn, and in addition, a few figures will be given with a view of supporting the climatic or malarial origin of the disease as opposed to the specific theory. To prevent miscouception it may be well to glance en passant at the American It is hard to see term " typo-malarial fever." what is gained by this double-barreled appellation except that it affords a refuge for the indolent?it is merely hiding our ignorance behind a high sounding name, and still further confusing a problem already surrounded by difficulties. It this is an acute specific fever having an infectious (microbic), or spontaneous (sewer or faecal) origin, it does not require a new name because of its course being modified by miuor and accidental accessories. I write from Secuudrabad which has long enjoyed an unenviable sanitary notoriety, ami has of late years shown a high enteric mortality ; and where therefore ample opportunities are afforded of seeing every phase of the disease. The following cases are taken from case-books written in the ordinary course of duty and without any idea of being disinterred for record. The main features of each case have been noted, and although not always as complete as would be desirable, it may be generally accepted that where a symptom or state of an organ is not given no serious deviation from health existed. It only remains to be added that, although it would be better to give the charts of each case, I am compelled, for obvious reasons, to furuish a short verbal description instead. Case I.?Diagnosis, simple continued fever. Pte. PI. D. Ill two or three days before reporting sick. Admitted June 8th. Complained of severe occipital and lumbar pain, vomiting, diarrhoea, stools loose of a brownish colour, flushed face, suffused conjunctivas, dilated pupils, tongue furred oil dorsum, red and irritable at edges, tenderness and gurgling iu iliac fossa, discomfort in epigastrium, spleen enlarged ami tender. In hospital 16 days. Chart?101'4? and 102-8? with remissions first two days, 100? or under for three days, after which it became Motions 6, 4, 2. normal. P. 100, R. 20. Case II.?S. 0. F. Pte. W. H. Exposed to a severe storm oil sentry-go during the night of 15th June, detained on the 17th, admitted on the 18th, with severe diarrhoea, at first dark brown and loose, later becoming light yellow, nausea and vomiting. Liver enlarged downwards and tender, spleeu normal, acute pain and occasionally gurgling in iliac fossa, tongue 47
THE INDIAN MEDICAL GAZETTE.
s62
coated with a yellowish-brown fur, red at edges, dilated pupils, free action of skin. Rose spots not present. Fifty-six days in hospital. Chart?Pyrexia severe and irregular, but of a continued type for seven days, averaging 102?. Somewhat remittent for another week, and aguish for a third, after which it remained practically normal. It reached 104?, or near it on four occasions. Diarrhoea lasted 32 days. P. and R. recorded 100 and 24, but only averaged 80
thickly
and 20. Case III.?S. C.F. Drummer T. M. Admitted 17th June, after exposure to same storm as Case II, with ill-defined symptoms. The following noted :?Flushed face, tongue furred along dorsum, rather irritable at edges. Tenderness and persistent gurgling in iliac fossa, enlargement of liver. Three doubtful rose spots observed on the 8th day. This man had a wellmarked malarial cachexia, and was in hospital for remittent fever three months before. Chart? Fever of a mild continued type for 10 days with an average morning remission of 2 degrees and only once above 102?, mild ague for four or five days longer. Before he left hospital and 11 days after temperature became normal, he had a P. and 11. similar attack again lasting 14 days. In hospital No diarrhoea. normal as a rule. 49 days. Case IV.?S. C. F. Pte. A. D. Admitted 10th June. The only signs in this case were enlargement of spleen with general febrile symptoms inducing marked anaemia and debility, so that he remained 36 days in hospital. Chart?Moderate ague for five days, irregular continued fever for 4, once marking 103?, normal for 2, again mild continued with remissions for six days, marking 102?, afterwards normal. Pulse, respirations and bowels, very little disturbed. Case V.?S. C. F. Pte. I. W. Admitted 21st June. Flushed face, dilated pupils, large flabby tongue covered with dark brown fur, gurgling and tenderness in iliac fossa, enlargement of the spleen, pronounced diarrhoea for three days and irregular tendency for a week afterwards. Chart?101? on admission ascending by steps to 103? in five days with one degree morning remission. Intermittent fever for eight days afterTen days after the temperature became wards. normal, a remittent fever once rising to 103'6 and lasting six days, set in and retarded convalescence. Pulse frequently above 100, once 120. Respirations 24 when pyrexia was marked. In
hospital
42
days.
Case VI.?S. C. F. Pte. I. H. Admitted 25th J line. Complained of pains all over, but worst in the right lumbur region. Tongue thickly plastered with whitish fur, and red irritable edges. Liver and spleen both considerably enlarged and
painful. General abdominal pain, no tympanites, pain and gurgling in iliac fossa, both persisting for
some
time, diarrhoea lasting
about 10
days.
[Dkc.,
1883.
Chart?103*4? and 102 6? with remissions to 100, for next 3 davs intermittent from 101?, after it became and remained normal. Pulse 88 to 100. Respirations 18 to 24. He has since been almost constantly under observation for well-marked malarial cachexia, with enlargement a,,d induration of liver and spleen, and what may be considered consequent intestinal glandular affection giving rise to frequent attack of dysenteric diarrhoea. Case VII.?S. C. F. Pte. F. H., Admitted 25th June. An uncomplicated continued fever with general pains and furred tongue noted " to only complete a series of seven cases under treatment at the same time." Chart?Between 100? and 103? for 6 days, evening rises for two P. and R. once noted 100, and 24 usually more. somewhat lower. Bowels regular as a rule. In hospital 16 days. These are the June cases. It will be seen that five were admitted within 8 days when the preliminary monsoon storms prevailed, and although specially noted in only two cases, they were all probably due to that cause. It will be generally conceded that they were one and all cases of the same disease. Case VIII.?Remittent Fever. Pte. F. S. Admitted 18th July. Said to be suffering for 10 days from febrile symptoms and fromdiarrhcei for three days. He had a sallow complexion, dilated face, pinched pupils. He wandered slightly for some days, alternating with somnolence, diarrhoea slight, stools becoming of a light yellow colour. Thick brown fur on the dorsum of tongue, clean at edges, tremulous. Tympanites, pain and gurgling in iliac fossa, enlargement downwards of the liver, deafness. No rose spots present, skin acted freely. Discharged in 25 days. Chart?Temperature approached 104? for five days, with two to four degrees of remission, normal on the 10th day, with irregular evening rises for five days more. P. and R. 100 and 24 for a few days, about three motions daily for a week. Pte. G. B. Case IX.?Remittent Fever. Admitted 22nd July. Complained of insomnia, weakness and fever, tongue quite clean, but large and somewhat fissured. Tenderness and loud gurgling in iliac fossa, enlarged spleen, enlarged and painful liver, pronounced diarrhoea with loose pale-vellow stools, pulse 100, or thereabouts becoming dicrotic later on, rose spots absent. Thirty-seven days in hospital. Chart? lOW'on admission, going up by steps to 104*4? five days later with r< missions from one to three degrees. Normal on the 8th morning, but irregular ague for three weeks thereafter. The bowels did not become regular, until all fever disappeared. Respirations 18 to 24. Admitted Case X.? S. C. F. Pte. G. P. 21st July. Complained of pain from left nipple downwards, face dull and muddy with suffused
Deo., 1888.]
RIORDAN ON ENTERIC FEVER. P. ami R. 96 and 24
36^
highest
noted.
Motions 4 after-
conjunctivae,tongue furred brownish-white,gurg-and 6 first two days, moderately regular ling and pain in iliuc fossa, diarrhoea with verywards. Discharged in 36 days. loose
yellowish brown motions, spleen enlarged Case XV.?Enteric Fever. Pte. J. S. Adand tender. Heart's action weak but regular.mitted 26th August, but complained for a couple Thirtv-oue days in hospital. Chart? Readied of days before of severe pain in head, back and 104? the evening of admission, gradual declineepigastrium, tongue moderately clean, red at to 100? four days later, followed by irregularedges, diarrhoea severe and persistent, dejecta of aguish pyrexia for ten days more marking 103?,a pale brown loose character. Tenderness and 102?, &e. Pulse reached 100. Respirations 28,gurgling in iliac fossa, and enlargement of the Motions 10. 10, 5, 2 on admission. average 22. spleen, a few doubtful rose spots observed, and Case XI.?S. C. F. Pte. T. W. Admitted subsequently obscured by a red papular rash. 28th July, but suffered from malaise two daysLater deafness and a dry brown tongue superbefore. Pupils dilated, tongue slightly furredvened, the bowels were moved involuntarily, with red edges, gurgling and tenderness in iliacand he had incontinence of urine. About the fossa, some tympanites and enlargement of the14th day pulmonic symptoms set in and soon spleen. He complained later of being "stuffedovershadowed the enteric, with severe cough, up" in the chest, but no physical signs noted viscid broncho-pneumonic sputa, rales, &c. therefor. Discharged in 21 days. Chart?Well Still in hospital but convalescent from Sepmarked, continued fever for six days up to 103?,tember 25th. Chart?Severe continued fever lower. After this for eight from 102? to 104? for 18 days, after which it average a degree days, as a rule, below 100?. Respirations 18 togradually declined for another week. Pulse Pulse 88 to 100. Motions 4, 8, 1, 5. 24. and respirations averaged 100 and 24. Motions Admitted from 6 to 2 for 18 days. Case XII.?Ague. Pte. E. G. 2nd August with high fever, tongue furred olive F. Pte. F. Gr. C. Case XVI.?S. In tinted, face congested, gurgl'm?r but no tender- hospital from 25th June with venereal disease. ness in ili.-ic fossa, and enlargement of the spleen. About 1st August developed aguish symptoms Chart.?Over 104? for first two days with marked with diarrhoea. August 4th face congested, remissions, intermissions of two decrees for three pupils dilated, skin dry and hot, occasionally days longer when all symptoms subsided. In sweating, tongue strawberry, tending to become hospital 17 days. Pulse 90 to 100. Respirations dry, tenderness in iliac fossa, brown, watery 20 to 28. Bowels confined at first. These are stools, rose spots in crops, no tympanites, spleen the July cases. They .are on all fours with the normal. Discharged in 30 days. Chart?Ague June cases except that some of them exhibited for four days, continued fever of irregular ty pe more marked remittent characters. for 12 days, three times 104? or above, followCase XIII.?Enteric Fever. Pte. R. ed by ague for four days. Diarrhoea, secondary, Admitted 5th August, being his 3rd day of only set in when the fever was at its height and disease, with severe fever 104 8? on admission was then moderate. P. and R. also at this time averaging over 102? for 8 days. Diarrhoea recorded 100 and 24. at first; stools dark brown, loose, offensive, and Case XVII?S. C. F. Pte. J. C. Admitted sometimes involuntary. Face dull and heavy, 22nd August, ailing two or three days before. somnolent, tenderness, and gurgling in iliac Dirty brown tongue with red irritable edges, fossa, and tympanites. Tongue furred yellowish pain and gurgling in iliac fossa, spleen enlarged brown, red at edges. Liver and spleen normal. to margin of ribs, bowels confined. A number From 9th to 19tii day more or less ague. I" of small irregularly shaped spots crowned with a hospital 42 days. Chart?-Temperature already pellucid vesicle observed in chest aud abdomen. noted. Pulse 90 to 100. Respirations 20 to 26. Thirty-two days in hospital. Chart?Continued Motions 8, 7, 5, after which he was constipated. fever from 101-4? to 104*4? for four days. ReCase XIV.?Enteric Fever. Pte. T. W. mittent type from 99? to 102? for four davs? and Admitted 17th August, but with history of finally irregular ague for 10 days. P. aud malaise since sun exposure at athletic sports R. 100 and 22. average 80 and 20. .about a fortnight previously culminating the Case XV11I.?Remittent Fever. Pte.H. W. day before in fever and diarrhoea. Face dull Admitted 28t,h August. Out of sorts for a week and heavy, suffused conjunctivae, tongue thinly previously, slight diarrhoea, loose brown dejecta, furred, red edges, gurgling in iliac fossa, no ten- spleen somewhat enlarged, liver normal, gurgderness or tympanites. Rose spots in crops ling but no pain in iliac fossa, suffused conjuncapparently were noted, but no account of the tivas, clean tongue. Two rose-coloured spots tree action of the skiu, it was difficult to follow observed. In hospital 32 days. Chart?Fever their history. Enlargement of the spleen and i distinctly remittent for 12 days from 99? to insomnia. Chart?Continued but somewhat irre- 104?, irregular ague for 8 days. Pulse and gular fever for 8 days, twice reaching 103'2?, respirations averaged 88 and 22. Looseness for then of a remittent type for four days, after 9 days, two to four motions-daily. which au irregular ague lasted a fortnight longer.
j
THE INDIAN MEDICAL GAZETTE.
364
Admitted Case XIX.?S. C. F. Pte. H. M. 25th August. Suffused eyes, face congested, insomnia, abdominal and lumbar pain, enlarged spleen, Taches bleantres, but no rose spots, no gurgling or tenderness, tongue furred, red at edges, bowels confined. Discharged in 12 days.
Chart?Irregular pyrexia (once going
up to normal afterwards. P. and K. 110 and 24, average 88 and 20. Case XX.?S. c. F. Pte. H. C. Admitted 28th August with dull heavy face, dry, brown tongue, gurgling and pain in iliac fossa, enlarged and indurated liver and spleen, bowels fairly regular, rose spots in crops. Is now (September 30th) awaiting discharge. Chart? Remittent of rather mild type for ten days, (once 104?), mild but irregular intermittent for Pulse and respirations averaged 8 days after. 80 and 20 respectively. Case XXL?Enteric Fever. Pte. ,T. J. Admitted 9th September, but feeling ill three or Great weakness and severe four days before. " pain in back and head, so that he was nearly daft." Insomnia, suffused conjunctiva), pupils normal, tongue furred, brownish yellow, some diarrhoea, pale-brown dejecta, abdomen tympanitic, gurgling and tenderness in iliac fossa, spleen normal, liver tender. Is now (SeptemChart?Four rises ber 30) awaiting discharge. on four alternate days to 103? descending in the intervening days to normal, where after the 7th day it rested. Pulse and respirations reached 104 and 28 respectively, but soon subsided. Motions 4,1, 3 ou admission, afterwards regular. These are the August and September cases. It will be observed that they differ only in name from those already given. Let us now proceed to fatal cases. Two deaths only have occurred in my practice during 1888, and one was out of the enteric season. The notes of two other fatal cases are taken from the case books of my colleagues, and I owe them acknowledgment of this generous permission, for while opposed to my views on this subject, I have been allowed to choose the two most instructive cases. Case XXII.?Enteric Fever (frcjnn February 23rd). Pte. J. M. Admitted for venereal on February 4. Ten days later diarrhoea of a mild type set in with loss of appetite, furred tongue. Ou the 20th tenderness, but no gurgling in iliac fossa and enlargement of spleen noted. On the 23rd sordes and tympanites with flushed cheeks and dilated pupils. He became unconscious with restlessness and carphology during the night. .Next day, the stools were fluid and yellow-ochrey. He regained consciousness, and went on favourably? sordes and flushed face disappearing?till the morning of the 27th, when lie suddenly expired. P. M. A conical clot of ante-mortem formation found extending from right into
104?) for
a
week, it
was
appendix
[Dec.,
Lower 10 feet
ventricle.
of
ileum
ulcerated. Sixteen Peyer's and tary ulcers, no perforation. Two
cent and some old
94, spleen
20
rose to
on
102?
solitary
1888.
extensively
few solithree reulcers in colon. Liver a
or
Chart?Temperature
ounces.
evening of 16th, normal till 19th, when it again rose to 102?, the
the evening of also on the 20th and 21st. Evening of 22nd only one degree of fever, but, at, 8-30 p.m. And the a special observation recorded 101?. same on the 23rd. On the 24th and 25th it reached 103? without descending to normal at any hour. These, it will be seen, were the first, days of continued fever. On the 26th the
as
tendency
was
downwards,
Pulse,
102"4?.
as a
5 P.M. 100?, 8 rule, under 100, but,
P.M. once
112. Respirations 20 to 24. Motion 9 to 2, average of 5 daily, from February 16th, and sometimes involuntary. Cose XXI11.?Enteric Fever. Pte. S. A. Admitted September 1st, on the 2nd day of his disease. Fever remittent in type for three' days, from 102? to 104?, during which no suspicious symptom was noted ; bowels regular and tongue typically clean. On the 4th gurgling, but no On the tenderness in iliac fossa detected. night of the 4th diarrhoea set in. and on the 5th the following: clean tongue, brilliant eyes, lie was loquacious, but not delirious, weak thready pulse, general muscular tremor, tenderness but no gurgling in iliac fossa, marked tympanites, enlargement of spleen, insomnia, six to eight rose-coloured spots, small, not raised, and disappearing on pressure. Skin acted freely from time to time. He died three hours afterwards. P. M. Brain, pink blush on surface vessels engorged, small quantity of pinkish fluid in the left lateral ventricle. No clot in heart or large vessels. Lower 7 feet of ileum extensively ulcerated, 12 Peyer's and 20 solitary crlands affected. The ulcers were of a bunched appearance, a Peyer's patch consisting of two or three such bunches separated by inflamed but intact mucous membrane, and composed There was no perof stained necrosed tissues. foration, but inflammation in several places extended through to the peritoneum. Ascending colon thickened of a greyish colour, liver bright red, on section 68 oz., spleen 19 oz. Chart?From 102*4? to 101? every morning, 104? steadily every evening. Pulse and respirations about 96 and 22, steady. Case XXIV.? (Extracted by permission). Remittent fever, but its enteric nature all along suspected. Sergeant J. L. arrived from Bangalore on the 6th June. Admitted 23rd June. Complained of headache and lassitude. Fever
marking
of
an
intermittent,
or
more
usually remittent,
type, becoming more acute and irregular at the end of the third week. Except a moist furred tongue and pale rather loose motions averaging slightly more than one daily for this time;
365
RIORDAN ON ENTERIC FEVER.
Duo., 18SS.J
suspicions symptoms were observed for 24 days. When haemorrhage* from the bowels set in, quickly followed by some diarrhoea, tympanites, pain in iliac fossa, tongue dry and brown, red at edges. He became collapsed on the 2nd day, and died. P.. M. Coats of ileum no
thickened
at
lower
after definite symptoms set in, while all those that recovered exhibited the same severe symptoms for a much longer time, or were just as likely, clinically, to develope them as the more prolonged fatal cases.
I have prepared a few Six acclimatisation and age.
figures, bearing
on
especially portion. Peyer's patches and a large number of solitary Well-marked protection is afforded by accliglands ulcerated, and .deeply necrosed with matisation ; so well marked that Government eroded edges. Perforation in one. Spleen has expended large sums to meet suggestions enlarged. based on this hypothesis. The annexed table c5
of a battalion stationed Case XXV.?(Extracted by permission). gives the enteric history Pte. W. O. First admitted 8th July for remit- here for the past three years. It is their first Tem- Indian station. tent fever, but suspected to be enteric. but of a continued type perature was irregular, tor 8 days when it became intermittent. NorEnteric cases. Deaths. Y ear. Strength. mal every morning, but recording 103? to 105?
in the evening for 16 days longer. Three The weeks later he was discharged quite well. following also noted : moderate diarrhoea f. of all the cases that were treated at the South ^Station Hospital, Secu.nderabad, during 188G-87 and 1888 up to 1st October:?
Age
exerts
48
366
THE INDIAN MEDICAL GAZETTE.
Enteric Fever, Casks.
Deaths. Strength.
pku
MILLK.
Dicaths l'KK MILLK.
Year.
1886 1887 1888
1.136
636
...
1,149
576
...
1,417
621
...
j-20-5
17-4
5-94
6-55
(9 months)
Diagnosis.?The impression which iutimate observation of these cases leaves behind is that they are varying instances of the same disease. Is this enteric to the exclusion of malaria? or is it not rather alone due to the effects of climate (including air, water, soil, heat) ? A word about treatment. Quinine was largely used in all cases; generally one dose of 10 or 15 grains during the morning remission. when the Antipyrin temperature went up to Lead and opium rarely 103? in the afternoon. failed to check diarrhoea. Dietetically they were all treated alike, solids?bread and even eggs? being rigidly excluded. The following conclusions
are
drawn
From mild ague to the most severe euteric so called, every variety of fever with every combination of symptoms has been repeatedly under observation, and the most acute diagnostic skill fails to differentiate the recognised diseases. It is impossible to say that ague may not 2. develope into deadly typhoid (Cases 4, 16 and 22), or the severest enteric revert at any time to a simple ague. By this latter is uot meant the final intermittent of this, equally with undoubted, enteric but the sudden, early, and unexpected collapse of symptoms and fever, as iu Cases 1, 5, 6, 12, and 19. 3. Intestinal lesions are present, it is believed, iu all cases of continued fever at this station. 4. Many cases have a distinct history of excited being by exposure (chill or sun), and the enteric season is well defined just before, during, and immediately after the rains, in other words when susceptibility to chill is at its highest. Without again entering into the question of etiology, without enquiring iuto the immunity of womeu, children and natives, without noticing the evil repute of some cantonments compared with others similarly circumstanced in a sanitary sense, I venture to think that these cases and these figures suggest reasonable doubts as to the specific nature of this disease. May I therefore appeal to my brethren either to hold an opeu opinion for some time louger or to prove or disprove my arguments ? The ulcers 1.
18*8.
in Peyer's and the solitary may not be identical with the lesions universally known as typhoid?their presence or absence in no way affects the theory above set out. Tiie character of these changes is, however, a most important branch of the subject and calls for early and thorough investigation, and I readily admit that my case is incomplete until this is done. or
Cases
other
[Dec.,
glands
changes
may
or
Shcundicrabad, *) September 1888. /
30th
