ENTERIC FEVER IN BENGAL. Hannah, M.D., and Thomas O'Farrell, M.A., M.D., Assistant Surgeons, 63rd Regiment. The subject of this paper was suggested by a study of the statistical returns of fevers in the Bengal Presidency from 1864 to 1868 inclusive, as given in the Army Medical Reports of those years. It will be seen by the accompanying table, that, in the
By
J. B.
year 1864, the number of cases of enteric fever throughout the Year
1867
1865
Strength
39,936
1868
32,909
37,631
Disease.
Febris remitters
Febris phoides Febris tinua
...
ty-
1,643
1,014
911
13
14
16
3,997
3,308
2,647
1,993
62
1,314 70
con-
2,662
23
3,254
whole of the Bengal Presidency, with a strength of European soldiers amounting to 39,936, was only nine : a trifling increase or two in each year has taken place up to the year sixtywhen there is a sudden rise from sixteen in 1867 to 70 admissions in 1868, forty of which proved fatal. As the disease does not appear to have been epidemic in any locality, it is but
of one
eight,
October 2,
ENTERIC FEVER IN BENGAL?BY J. B. HANNAH.
1871.]
reasonable to suppose either that this form of fever is
on
the
increase, or?what is more probable?that in former years it was frequently confounded with, and returned under the head of, continued or remittent fever. Enteric or typhoid fever is said and generally acknowledged to be due to a specific poison, fostered and disseminated by the presence in the atmosphere of decomposing animal and vegetable matter, and is usually to be found in its greatest intensity, where a faulty hygienic
condition and defective removal of excreta exist. In India, owing to the nature of the climate, the want of sanitary arrangements so common in large bazars and native cities, the badly-selected sites and faulty drainage of many old cantonments, the frequency with which in former times barracks were overcrowded, the carelessness exhibited in disposing of human excreta?probably thus causing contamination of drinking water by a foul surface drainage,?would lead one
to expect that this disease would have been of more frequent occurrence, both formerly and even at the present time. The immunity, however, which the British soldier seems to is very remarkable when we enjoy in India from enteric
fever, consider that during the greater period of his service, he is of an age when all the intestinal glands are in their highest state of activity. It is most important to determine beyond a doubt whether this immunity is not more apparent than real, and that typhoid fever may exist to a greater extent than is recognized or shewn by returns. The inspection of the above table points to this conclusion on the following grounds :? Firstly.?That we find the mortality as high as 57*1 per cent., or only surpassed in severity by malignant cholera. Now as a large proportion of typhoid fever cases recover (about one death in five cases), it is only reasonable to suppose that the whole 70 cases must have been of a severe and well-marked character, no inconsiderable number of latent have been classified under other heads.
and that cases
Secondly.?Though
or
less
marked
sanitary arrangements of cities and immensely improved within the last few 1868, with a far smaller number of Eurothe
cantonments have been
years, yet we find in pean troops, that there is an enormous increase of enteric fever ?thus leading one to infer either that careful conservancy or good sanitation have little influence in preventing the development and spread of the disease, or that formerly in the milder cases it has not been fully recognized and returned as such. That there is considerable difficulty in arriving at a correct between enteric fever and some of the severe varie-
diagnosis
ties of the paroxysmal and continued fevers of this country, there is no doubt. A remittent fever may be so severe as to have no appreciable remission, and to distinguish the exacerbations and remissions of some cases from the well-known periodicity of
typhoid,
is
by
no means
an
diseases may be characterized
easy task. At the outset, both similar symptoms :?there is heat of skin, with looseness of
by
languor, feebleness, head-ache, bowels, and perhaps vomiting; as the disease progresses, delirium, brown tongue, and abdominal gurgling may be met with in both forms. True, there are two apparently diagnostic signs in typhoid, namely, "rose spots" and "yellow diarrhoea," the
but when we remember that the spots may be so few as almost to and that Europeans (especialescape detection even in England, ly in illness) in this country are liable to such a variety of of insect bites, &c., the difficulty is considerably
eruptions?marks
increased ; and again, that typhoid fever may prove fatal withThe out any diarrhoea is a well-known fact (Skoda, Aitken). circumstances that lesions of the intestines are said not to be uncommon in many cases diagnosed during life as remittents, and that enlarged spleen is a peculiarity of enteric fever, tend this difficulty even after death. to
exaggerate
"When
tremely
consider the immense tract of country, and the exvaried character of climate and soils occupied by the we
207
European troops, it is not to be wondered that great confusion exists as to the causation and course of Indian fevers. The bad habit formerly so common of naming them after the localities in which they occurred, has certainly not assisted in elucidating
their character.
determining of the precise character of these fevers is plainly of the greatest practical importance, not only to the physician as a guide to treatment, but more especially to those who have charge of the health of large communities as in the case of our armies and jails. It must be remembered that neither true remittent nor simple continued fever is contagious, or likely to spread by human intercourse, and consequently that there is no necessity for using chemical agents to destroy discharges But, on the other hand, or disinfect the bed or body line. enteric fever is held by no less an authority than Dr. William Budd to be communicable by its evacuations and by human intercourse, and chemical agents are useful and necessary both for the purpose of checking its spread and preventing its The
recurrence.
Notwithstanding the apparent rarity of the disease as shown by the Medical Department blue books, we wish to prove from the appended cases, that enteric fever has affected this regiment
at least, to no inconsiderable extent,~ since its arrival in the
country.
On the 8th November, 1870, the 63rd Regiment landed in Bombay, and proceeded by rail to Deolalie ; although composed of a large number of growing boys under twenty years of age, and of inferior physique, they were in a good state of health, and had been so during the voyage. Having remained a short time at Deolalie, the regiment was despatched by rail to Barrackur, en route to Hazareebaugh. At the former place, they were detained for some days, receiving over camp equipage, carriage, &c. The vicinity of the camp was in a very unsanitary condition on account of the large number of native followers, who had been detained there for more than a week; the drinking water, too, was very impure. Shortly afterwards, a woman was admitted into the camp hospital, with fever of a severe continued type, accompanied by vomiting, which was followed by diarrhoea. There was tenderness and gurgling in the right iliac region, with a dry brown tongue and restless delirium; haemorrhage from the bowels took place several times, and the stools were of a typhoid character. No eruption was observed. The peculiar diarrhoea continued for a considerable period, and her convalescence was very protracted.
Knowing India, this
how unusual enteric fever is considered to be in was returned, though with doubt, as a case of
remittent.
days afterwards, another woman was brought under treatfor pyrexia, and was soon admitted into hospital. She became extremely prostrated, with coll extremities and hot trunk, feeble pulse, sordes on the teeth and brown tongue. In this instance there was severe diarrhoea, which, like the last, had the Six
ment
distinctive characters of typhoid. Dull heavy delirium was There was gurgling and pain in the right iliac region, and at times considerable tympanites. She was in an extremely precarious condition, and about the 23rd day of the
present throughout.
disease, had a severe relapse. She was discharged 38 days after admission, doing well, though extremely feeble. This was also returned
as
remittent fever.
The next
case
was
one
of great
interest,
as
there
was
an
for post-mortem examination. was admitted 20th December, after two Private B , aged 19, days' pyrexia; he had rigors and loss of appetite, with a white furred tongue; no diarrhoea. On the 21st, he was considerably worse; had severe fever since the 20th, without remission; he
opportunity
pain in the head, with great thirst. On the 22nd, day of the disease, was still suffering from great fever, bowels constipated; towards evening, slight delirium set in
complained or
the fifth
of
THE INDIAN MEDICAL GAZETTE.
208 ?with dulness of
expression. On the 23rd, or sixth day, there was vomiting early in the morning, accompanied by diarrhoea, not, however, of a severe character; there was sordes on the lips and teeth ; towards evening subsultus tendinum was noted ; he gradually sank and died at 1 a.m. on the 24th December.
violent
Post-mortem.?Brain.?Membranes and substance very much
congested, veins of the choroid plexus filled with blood, venous system throughout greatly distended. Thorax.?Heart healthy, a large fibrinous clot in the pulmonary artery. Lungs.?Great congestion of the lung substance both anteriorly and posteriorly. Abdomen.?Stomach.?Slightly congested towards the cardiac end.
Liver.?Enlarged, friable, and very much congested. Kidneys.?Both congested and enlarged. Spleen.?Intensely congested, normal in size, and presented a peculiar marbled appearance. Glands of the mesentery very much enlarged, some about the size of a pigeon's egg; they were filled with friable fatty-like matter. a
Intestines.?At the commencement of the jejunum, there were number of small miliary white deposits, apparently in the
These little nodules increased in size and number towards the end of the ileum, where they became as large None of these showed signs of ulceration, until the as a pea.
solitary glands.
coecum
was
searched, where several well-defined ulcers
were seen.
Peyer's patches showed an immense amount of deposit, each patch being raised above the surface the i~0-th of an inch. Small vascular points of commencing ulceration were distinctly visible. In the large intestine, the glandular structures were equally enlarged, and the nodules were so closely packed as to become almost confluent ; this state extended to the anus; ulceration of this deposit The mucous membrane was intensely conwas more advanced. gested, and also showed an appearance of commencing ulceration. In this case, death had taken place in the stage of infarction" of the intestinal solitary lenticular glands, and the agminated glands of Peyer, and, without doubt, it was a case of intensely The whole of the mesenteric glands were severe typhoid fever. enormously enlarged at the coecum; several of the engorged intestinal glands had progressed towards ulceration. Had the man lived a litttle longer, there seems reason to believe that
[October 2,
died in the 6th week of the fever, the post-mortem examinaverifying the diagnosis formed during life. Private N aged 18, was admitted on the 16th December; he had been suffering from diarrhoea and fever for some two or three days previously; he was, on admission, in a highly feverish state with furred tougue, but the diarrhoea had ceased; he gradually got worse. On the 23rd, he was very weak, and suffering from considerable irritation of the throat: on the day but one following, he had cough, griping pains in the abdomen, bilious vomiting and diarrhoea. 27th.?He is dull, and had heavy sordes on the lips and gums, abodominal tenderness, with characteristic enteric diarrhoea. 28th.?No change for the better; diarrhoea continues; his breath has a cadaverous odour; tongue very brown and dry, man
tion
no
,
rose
spots visible.
29tli.?Delirium all
spots and
night; a distinct eruption of rose-coloured belly and chest; these were raised above the surface disappeai-ed on pressure: they were unmistakeably of the on
the
enteric character. 31s
By
J. B.
year 1864, the number of cases of enteric fever throughout the Year
1867
1865
Strength
39,936
1868
32,909
37,631
Disease.
Febris remitters
Febris phoides Febris tinua
...
ty-
1,643
1,014
911
13
14
16
3,997
3,308
2,647
1,993
62
1,314 70
con-
2,662
23
3,254
whole of the Bengal Presidency, with a strength of European soldiers amounting to 39,936, was only nine : a trifling increase or two in each year has taken place up to the year sixtywhen there is a sudden rise from sixteen in 1867 to 70 admissions in 1868, forty of which proved fatal. As the disease does not appear to have been epidemic in any locality, it is but
of one
eight,
October 2,
ENTERIC FEVER IN BENGAL?BY J. B. HANNAH.
1871.]
reasonable to suppose either that this form of fever is
on
the
increase, or?what is more probable?that in former years it was frequently confounded with, and returned under the head of, continued or remittent fever. Enteric or typhoid fever is said and generally acknowledged to be due to a specific poison, fostered and disseminated by the presence in the atmosphere of decomposing animal and vegetable matter, and is usually to be found in its greatest intensity, where a faulty hygienic
condition and defective removal of excreta exist. In India, owing to the nature of the climate, the want of sanitary arrangements so common in large bazars and native cities, the badly-selected sites and faulty drainage of many old cantonments, the frequency with which in former times barracks were overcrowded, the carelessness exhibited in disposing of human excreta?probably thus causing contamination of drinking water by a foul surface drainage,?would lead one
to expect that this disease would have been of more frequent occurrence, both formerly and even at the present time. The immunity, however, which the British soldier seems to is very remarkable when we enjoy in India from enteric
fever, consider that during the greater period of his service, he is of an age when all the intestinal glands are in their highest state of activity. It is most important to determine beyond a doubt whether this immunity is not more apparent than real, and that typhoid fever may exist to a greater extent than is recognized or shewn by returns. The inspection of the above table points to this conclusion on the following grounds :? Firstly.?That we find the mortality as high as 57*1 per cent., or only surpassed in severity by malignant cholera. Now as a large proportion of typhoid fever cases recover (about one death in five cases), it is only reasonable to suppose that the whole 70 cases must have been of a severe and well-marked character, no inconsiderable number of latent have been classified under other heads.
and that cases
Secondly.?Though
or
less
marked
sanitary arrangements of cities and immensely improved within the last few 1868, with a far smaller number of Eurothe
cantonments have been
years, yet we find in pean troops, that there is an enormous increase of enteric fever ?thus leading one to infer either that careful conservancy or good sanitation have little influence in preventing the development and spread of the disease, or that formerly in the milder cases it has not been fully recognized and returned as such. That there is considerable difficulty in arriving at a correct between enteric fever and some of the severe varie-
diagnosis
ties of the paroxysmal and continued fevers of this country, there is no doubt. A remittent fever may be so severe as to have no appreciable remission, and to distinguish the exacerbations and remissions of some cases from the well-known periodicity of
typhoid,
is
by
no means
an
diseases may be characterized
easy task. At the outset, both similar symptoms :?there is heat of skin, with looseness of
by
languor, feebleness, head-ache, bowels, and perhaps vomiting; as the disease progresses, delirium, brown tongue, and abdominal gurgling may be met with in both forms. True, there are two apparently diagnostic signs in typhoid, namely, "rose spots" and "yellow diarrhoea," the
but when we remember that the spots may be so few as almost to and that Europeans (especialescape detection even in England, ly in illness) in this country are liable to such a variety of of insect bites, &c., the difficulty is considerably
eruptions?marks
increased ; and again, that typhoid fever may prove fatal withThe out any diarrhoea is a well-known fact (Skoda, Aitken). circumstances that lesions of the intestines are said not to be uncommon in many cases diagnosed during life as remittents, and that enlarged spleen is a peculiarity of enteric fever, tend this difficulty even after death. to
exaggerate
"When
tremely
consider the immense tract of country, and the exvaried character of climate and soils occupied by the we
207
European troops, it is not to be wondered that great confusion exists as to the causation and course of Indian fevers. The bad habit formerly so common of naming them after the localities in which they occurred, has certainly not assisted in elucidating
their character.
determining of the precise character of these fevers is plainly of the greatest practical importance, not only to the physician as a guide to treatment, but more especially to those who have charge of the health of large communities as in the case of our armies and jails. It must be remembered that neither true remittent nor simple continued fever is contagious, or likely to spread by human intercourse, and consequently that there is no necessity for using chemical agents to destroy discharges But, on the other hand, or disinfect the bed or body line. enteric fever is held by no less an authority than Dr. William Budd to be communicable by its evacuations and by human intercourse, and chemical agents are useful and necessary both for the purpose of checking its spread and preventing its The
recurrence.
Notwithstanding the apparent rarity of the disease as shown by the Medical Department blue books, we wish to prove from the appended cases, that enteric fever has affected this regiment
at least, to no inconsiderable extent,~ since its arrival in the
country.
On the 8th November, 1870, the 63rd Regiment landed in Bombay, and proceeded by rail to Deolalie ; although composed of a large number of growing boys under twenty years of age, and of inferior physique, they were in a good state of health, and had been so during the voyage. Having remained a short time at Deolalie, the regiment was despatched by rail to Barrackur, en route to Hazareebaugh. At the former place, they were detained for some days, receiving over camp equipage, carriage, &c. The vicinity of the camp was in a very unsanitary condition on account of the large number of native followers, who had been detained there for more than a week; the drinking water, too, was very impure. Shortly afterwards, a woman was admitted into the camp hospital, with fever of a severe continued type, accompanied by vomiting, which was followed by diarrhoea. There was tenderness and gurgling in the right iliac region, with a dry brown tongue and restless delirium; haemorrhage from the bowels took place several times, and the stools were of a typhoid character. No eruption was observed. The peculiar diarrhoea continued for a considerable period, and her convalescence was very protracted.
Knowing India, this
how unusual enteric fever is considered to be in was returned, though with doubt, as a case of
remittent.
days afterwards, another woman was brought under treatfor pyrexia, and was soon admitted into hospital. She became extremely prostrated, with coll extremities and hot trunk, feeble pulse, sordes on the teeth and brown tongue. In this instance there was severe diarrhoea, which, like the last, had the Six
ment
distinctive characters of typhoid. Dull heavy delirium was There was gurgling and pain in the right iliac region, and at times considerable tympanites. She was in an extremely precarious condition, and about the 23rd day of the
present throughout.
disease, had a severe relapse. She was discharged 38 days after admission, doing well, though extremely feeble. This was also returned
as
remittent fever.
The next
case
was
one
of great
interest,
as
there
was
an
for post-mortem examination. was admitted 20th December, after two Private B , aged 19, days' pyrexia; he had rigors and loss of appetite, with a white furred tongue; no diarrhoea. On the 21st, he was considerably worse; had severe fever since the 20th, without remission; he
opportunity
pain in the head, with great thirst. On the 22nd, day of the disease, was still suffering from great fever, bowels constipated; towards evening, slight delirium set in
complained or
the fifth
of
THE INDIAN MEDICAL GAZETTE.
208 ?with dulness of
expression. On the 23rd, or sixth day, there was vomiting early in the morning, accompanied by diarrhoea, not, however, of a severe character; there was sordes on the lips and teeth ; towards evening subsultus tendinum was noted ; he gradually sank and died at 1 a.m. on the 24th December.
violent
Post-mortem.?Brain.?Membranes and substance very much
congested, veins of the choroid plexus filled with blood, venous system throughout greatly distended. Thorax.?Heart healthy, a large fibrinous clot in the pulmonary artery. Lungs.?Great congestion of the lung substance both anteriorly and posteriorly. Abdomen.?Stomach.?Slightly congested towards the cardiac end.
Liver.?Enlarged, friable, and very much congested. Kidneys.?Both congested and enlarged. Spleen.?Intensely congested, normal in size, and presented a peculiar marbled appearance. Glands of the mesentery very much enlarged, some about the size of a pigeon's egg; they were filled with friable fatty-like matter. a
Intestines.?At the commencement of the jejunum, there were number of small miliary white deposits, apparently in the
These little nodules increased in size and number towards the end of the ileum, where they became as large None of these showed signs of ulceration, until the as a pea.
solitary glands.
coecum
was
searched, where several well-defined ulcers
were seen.
Peyer's patches showed an immense amount of deposit, each patch being raised above the surface the i~0-th of an inch. Small vascular points of commencing ulceration were distinctly visible. In the large intestine, the glandular structures were equally enlarged, and the nodules were so closely packed as to become almost confluent ; this state extended to the anus; ulceration of this deposit The mucous membrane was intensely conwas more advanced. gested, and also showed an appearance of commencing ulceration. In this case, death had taken place in the stage of infarction" of the intestinal solitary lenticular glands, and the agminated glands of Peyer, and, without doubt, it was a case of intensely The whole of the mesenteric glands were severe typhoid fever. enormously enlarged at the coecum; several of the engorged intestinal glands had progressed towards ulceration. Had the man lived a litttle longer, there seems reason to believe that
[October 2,
died in the 6th week of the fever, the post-mortem examinaverifying the diagnosis formed during life. Private N aged 18, was admitted on the 16th December; he had been suffering from diarrhoea and fever for some two or three days previously; he was, on admission, in a highly feverish state with furred tougue, but the diarrhoea had ceased; he gradually got worse. On the 23rd, he was very weak, and suffering from considerable irritation of the throat: on the day but one following, he had cough, griping pains in the abdomen, bilious vomiting and diarrhoea. 27th.?He is dull, and had heavy sordes on the lips and gums, abodominal tenderness, with characteristic enteric diarrhoea. 28th.?No change for the better; diarrhoea continues; his breath has a cadaverous odour; tongue very brown and dry, man
tion
no
,
rose
spots visible.
29tli.?Delirium all
spots and
night; a distinct eruption of rose-coloured belly and chest; these were raised above the surface disappeai-ed on pressure: they were unmistakeably of the on
the
enteric character. 31s
