To those who say that Climate is nothing, the paraeverything, it may suffice to point out that it takes two to make the disease, the host and the parasite ; that these two are engaged in a life-and-death struggle, that even a slight advantage or disadvantage on one side may decide the result and that the Indian climate site


Jitdian Jftorlicnl (Snzottc. JULY, 1899.

is In


perpetual scourge of Europeans in India, who especially of the young Europeans

This and

form the British Army and a considerable proits great portion of the Civil population, is, as in one discussed importance demands, elaborately the of the many admirable scientific articles in with last report of the Sanitary Commissioner the Government of India. In this particular article, which extends to of precise sixty pages, with six additional pages references






the Surgeon-General Harvey critically reviews and researches most recent European and Indian this theories on the causation and spread of these results to the special and



conditions of the Indian climate, he records some new observations lately made in this country

and indicates the gaps in existing information. This work, therefore, not onty focusses for us the scattered publications of the most modern


observers, but it is also in itself bution to the advancement of this disastrous disease.


distinct contriknowledge of


The whole of Surgeon-General Harvey's helpof every ful article merits the most careful study we can Here in India. medical


onlj7 give a few extracts from it. set in After showing the reaction which has enteric fever against the extreme opinion that detailis exclusively a water-borne disease, and that view the of in evidence support ing the this the great bulk of the ordinary form of fever is,


the contrary, derived from the soil, Harvey notes that:

Surgeon-General "

When outbreaks






be clue to some combinaextent of country, they may climatic and conditions, with here tion of polluted soil contamination of the secondary incidental and there simultaneous accidental fouling of water, rather than to is to the A specifically polluted soil water-supplies. of threat danger a constant inhabitants of the place as well as through the many through the water-supply, its particles can reach the other channels by which polluted interior of the body, while the non-specifically for it is a less dangerous, soil is only one degree and ready for favourable nutrient medium prepared arrive. shall it the enteric microbe whenever

certainly the



; to the

European constitution.

native of India, if transported to England, is depressed by the cold, has his lungs irritated and is much more apt to fall a victim to tubercle than in his own country. Many experienced medical officers are impressed by the occurrence of cases which seem to show that over-exertion in the heat renders a man an easier victim, and that with respect to enteric fever liability too much exercise is more dangerous than too little. same



"Though the presence of the enteric bacillus has been but seldom reported in the intestine or gall-bladder of men not suffering or recovering from enteric fever, there are those who believe that it is often present, and would be more often found if looked for oftener and with adequate means.

According to them, men very generally carry about in their bodies the enteric bacillus, which remains quietly waiting its opportunity. That a man escapes is due either to permanent insusceptibility or to temporary insusceptibility or to the absence of the bacillus. According to them again, a man may get enteric fever in one of two Either some indiscreways. tion of diet or exercise, or a lowering climatic influence, diminishes his power of resistance and enables the

bacillus, become


resting peacefully





active invader of the same ; or Mdiile he is in a susceptible condition, bacilli from the stools of another case gain access to his body through water, food, etc. "Experiments on animals by Remlinger and by Chantemesse appear to their authors to have had more satisfactory results than those of previous observers. " Osier seems now to have adopted the opinion of Sanarelli, quoted on page 25 of the report for 1894, that enteric fever is no more 'primarily an intestinal than smallpox is primarily a cutaneous disease. On the other hand Sidney Martin is of the old opinion that the disease probably begins at the intestine and not at the blood. "Block on two occasions cultivated the enteric bacillus from a hypodermic-syringeful of the patient's blood, and after death the bacillus was found in the liver, spleen, kidneys, and in a piece of retained placenta,?along with other microbes. Takaki and Werner succeeded in finding the bacillus in blood taken from the roseola. "Cases of enteric fever without intestinal lesions have been mentioned in former reports. Osier now divides cases of enteric fever as follows :?firstly, ordinary cases with intestinal lesions ; secondly, septicoemic cases, an

general infection without special local manifestations, the diagnosis being made by means of Widal's reaction and by means of cultivations of the bacillus from the organs ; thirdly, cases with localisations other than intestinal,?pulmonary, splenic, renal, cerebrospinal ; fourthly, cases of mixed infections. This division meets with the approval of the Lancet reviewer. Chiari

and Kraus report a number of cases in which the presence of Widal's reaction during life caused the organs to be searched for the bacillus, though there were no intsa-



tinal lesions.


In some, the bacillus mesenteric


found in the

glands, spleen, kidneys,



camps, had come to the conclusion that flies the chief agents in the spread of the disease. Very interesting and important, though not bearing directly on enteric fever, are the investigations of Amedeo Berlese. His experiments prove conclusively the great part taken by insects, especially ants, and several


urine ; while in others, though 110 bacilli were found, the fluids of the body continued to give Widal's reaction 'postmortem. Others also have reported cases. Their ex' perience seems to indicate that pure septiccemic enteric


fever is relatively frequent.' Durham, 011 the other hand, is of opinion that to the bacillus of Gaertner, and not to that of Eberth, belong the similar cases of ' septicemic enteric fever' which lie had seen described as occurring in France, in which death occurred before typical typhoid lesions developed. Some of the observers who have brought forward the cases without intestinal lesions point out that if the bacillus is to be found at all in a body it will likely be found in the

fly, not only in the distribution (as was already but also in the preservation and multiplication known), of alcoholic ferments. Insects, far more than the atmospheric air, contribute to the dissemination of yeasts, which they convey rather internally than externally. There is, moreover, reason for believing that during the cold season some yeasts are chiefly preserved, and per-



and that in the gall-bladder it may remain more or less inactive for long periods after health is re-established,

during which the intestine,

at any moment it may be excreted into and so perhaps make a healthy man a source of infection to others. The bacillus is even said to have been found in the gall-bladder in one case in which there was no history of previous enteric fever. Horton Smith reports that it was found in the faeces of convalescents 12 days after defervescence by Brieger, and 41 days after by Lazarus, and that he himself found it in urine 22 days after. It has also been found in

abscesses years after. "The spread of enteric fever through the air around the patient is generally doubted ; but Dr. Budd strong-

ly maintained that such communication was not only possible but frequent, and Dr. Corfield believes that he was right. There are others who believe in the direct infectiousness of enteric fever, especially in the crowded dwellings of the poor ; but it may be considered doubtful whether the disease would, even under such circumstances, be conveyed without the agency of dirty fingers

and other uncleanlinesses. "The idea that flies convey infection is probably a very old one. Of late years many medical officers have referred to the matter in reports on outbreaks of enteric fever or cholera ; and many of the cook-house3 for British soldiers in India are protected with wire gauze for the very purpose of shielding food from the visits of flies, which may have come from latrines or other unclean resting-places. the neatest bac-

teriological investigations




subject was one in which flies were allowed to alight upon a culture of bacillus prodigiosus, this bacillus being chosen because of the striking red colour its cultivations display, and then given opportunity to walk over the surface sliced sterilised potato. The results were, as might have been expected, positive and conclusive. Various other experiments also, all with positive results, have been made with flies and other insects as







power enteric, cholera, cholera nostras, tubercle, and anthrax bacilli, and the staphylococcus. The microbes in an active condition

also found in the excrement deposited broadcast the flies. Lately a report, couched in somewhat superlative terms, has been published in the Lancet to the effect that an American scientific conimission,appointed to examine into the causation of enteric fever in the were


kinds of

within the organs of insects. Under the ordinary conditions in which Milk reaches and is kept by the consumer the enteric bacillus is capable of maintaining its existence in it, but without multiplication; in fact, it undergoes diminution, the rapidity of which depends on the number of rival microbes present. It can also exist in sterilised milk

haps increased, "

curdled by the bacillus lactis, and also in sour milk, so that it may possibly find its way into curd-cheese. It is said to survive for 48 hours in butter-milk. An epidemic in Hamburg, which chiefly affected women and children, was considered to be due to those properties of the bacillus. In bad and dangerous milk a bacillus, which is either the colon bacillus or a near relation of it, has been found. "The general

among those best qualified to that the only possible way in which present, judge is, Sewer Qas and evil-smelling air can contribute to the causation of enteric fever is by lowering the general



health and resisting power of men. "Heat remains the best disinfectant agent for the prevention of the disease?cooking of all food, boiling of water and milk, cremation of stools ; and these measures have been practised to a considerable extent in India. All authorities seem agreed that pathological stools should be burned, and certainly so in times of epidemics. But as it is not always possible to know that a stool is pathological and pathogenic, and as the burning of all night-soil is out of the question, the greatest attention should be paid to the proper disposal of the dejecta by superficial burial. Those concerned should lay to heart the words of Poore,

heading author


quoted in the present paragraph under the Soil,' and also the following of the same


In order to prevent contamination of the water, it is best to burn the stools. But in the country it would be best to put the excreta near the top of a recently-tilled, humus. Merely digging' a trench, filling it with excreta, and covering it firmly with soil preserves the foeces, and does not lead to their disintegra'

simply tion.'

to be those of burial of the For should be fever enteric destroyed. the rest of the night-soil, which will always contain there is difficulty of getting some dangerous stools, sufficient land 011 the hill-sides \ and the best plan is to in wire-tramways down the hillconvey the night-soil be as as far thought desirable, or till a suitable side may trenching ground is reached. This system is working well at Murree, Gharial, Kuldunnah, and Lower Topa. "

At hill stations also all stools known




out the " 16. As usual, many medical officers point in India ; and influence of youth and of recent arrival of enteric fever subsesome call attention to the increase anew regiment or of station a in quent to the arrival The medical officer at of fresh drafts from England. to say that newcomers to Ahmednagar goes so far as that station are as such more liable to the disease,

it be not their first term of residence the men appear to have already contracted Three there. as in infection before they landed in India. In 1897, former years, some cases were held to have originated to inland stations, and the en route from even




medical officer of Mhow calls for more stringent at the protect fresh arrivals at Bombay, at Deolali, train. Again, medical the in while and rest-camps, of hillofficers frequently noted, especially in the case contracted been have must disease the that


stations, on before arrival, either from impurities encountered the in previous cause a existing the mai'ch, or from was treated station, so that the station where the disease contracted. was it was not always the station in which Peshawar at treated cases of the eleven For



originated on field service. or doubtful patients acknowledged having drunk foul when out water in native villages, by the roadside, the bazar, in shooting, when bathing in a dirty stream, are









in cantonment.

it Bangalore, Deesa, Subathu, and Amritsar from barracks, that men employed away

telegraph signallers





At Jhansi,

was as

noticed military



were liable exercise camps, or at training and musketry, or from and from exposure, whether fatigue to attack, While water. unclean having had opportunity to drink to have held were and fatigue in some cases heat illness was been predisposing influences, in others from a chill or dated from a chill due to a wetting, officer at Mhow medical The following over-heating. had rendered a considered that insufficient clothing The water-supply certain body of men more vulnerable. at Umballa, liable to contamination was considered

AhmedDagshai, Subathu, Poonamallee, Mandalay, and Sitabaldi ; nagar, Mhow, Nasirabad, Hyderabad, thrown while in Fort Lahore, examination having had to a recourse was the well-water, suspicion upon Calcutta, Attock, fresh source of supply. Apparently, Rangoon, Kamandrug, Madras, Bangalore, Wellington, and Taragarh are Nasirabad, Purandhur, Thayetmyo, a double waterstill exposed to the danger involved in mentions Nasirabad of officer medical the and supply ; water the of drunk to having that men had confessed notified by and and gardening, reserved for washing which the " Not for drinking," a water in



been reenteric bacillus had several times presence of the of Lucknow, the in drinking-water ported. Besides this, Muttra, Agra, Subathu, Meean Fatehgarh, Meerut, Mhow, and Deesa the bacillus, Meer, Amritsar, Cherat, or in every was found, mostly, of it, or a near relation officers repoit that medical Two case, by Mr. Hankin. the enteric bacillus in the same bacteriologist discovered had been boiled and passed specimens of water that the Mr. Hankin found through a Pasteur filter. the On and Dagshai. bacillus in milk from Fatehgarh


other hand, the result of the examination of water from Sitapur, Kanikhet, Chakratta, Jhansi, Dagshai, Solon, and Ahmednagar was negative. At Quetta the ai-rangements for the supply of water to the kitchens and to the

soda-water factories was considered such as to risk contamination of the water, and the bacillus coli is said to have been found in a specimen of soda water. In the beginning of 1898 Surgeon-Major Davies, on special duty, found a bacillus of the colon group in the water of the Mhow supply. Where pakhals and mussacks continue to be used, it appears, at least on paper, that

systematic efforts

are made to secure their constant the most difficult cases being those where the use of leather vessels coincides with a double watersupply, and necessitates the provision of two sets of mussaclcs and pakhals. In some cases it appears that dislike of boiled water, or of water treated with permanga-


nate of potash, was the cause of men resorting to forbidden sources, and anyone with a taste for water must sympathise with these men. The combined result of six stations was that 65 cases occurred among total abstainers, and 121 in non-abstainers, or 35 and 65 per cent., respectively. But, as their average annual strengths cannot be obtained, no conclusion can be drawn as to the relative liability of those two classes. An outbreak in Umballa was attributed to water drawn by a bhisti, to save himself trouble, from a well close to some old filth pits. At Indore a patient stated that he had drunk a quantity of soda water in a brothel about a week before the onset of his illness ; at Hyderabad a soldier had drunk lemonade in the bazar ten days before admission ; while at Chakrata a man who contracted the disease had drunk out of the bottle of a comrade in hospital suffering from enteric fever, the

contaminated his Cherat was traced to the adulteration of milk with the water of a dirty tank, this water containing the enteric bacillus. The butter and milk were believed by a committee to have

supposition being that the latter had bottle in using it. An outbreak at


the first out-break of the year at Mhow ;


though doubts have been thrown upon the validity of this conclusion, it was found that the dairy arrangeAs usual, some medical ments were very defective. officers point to the comparative immunity of women and children as an argument against the probability of the disease having been carried by the water or milk supplies, or to the scanty numbers and sporadic distribution of cases as an argument against its having been water-borne. The enteric fever of some stations as not epidemic but was described endemic, with and The medical autumn exacerbations. spring regular officers of three or four stations point out that all the attention lavished on the disinfection of the water has

made little difference in the amount of enteric fever, and draw the conclusion that enteric fever is mostly contracted in the bazars, away from the barracks with their sanitary arrangements. Most medical officers are of opinion that much enteric fever is contracted in the in the brothels ; and, in support, and



the medical officer of Fort Allahabad notes that eight out of nine cases occurred in the persons of baclielors> one of them having primary syphilis when admitted for



while, on the other hand, it is said by the medical officer of Nasirabad that no cases Lave been admitted from the married quarters for some years. None of the reports for 1897 mention the effect on the amount of enteric fever of placing the bazar out o^ the fever ;

bounds, though there are nearly a dozen references to the effects of this measure upon the statistics of venereal disease. The danger from the careless and dirty habits of natives allowed to be about barracks, and especially of native cooks, is insisted on by several medical officers. Two of them suggest that the men should be made to cook their own food, and this reform has actually been carried out in the case of Subathu. In some stations elaborate rules have been introduced to secure cleanliness in the kitchens, and measures have been taken to exclude flies. An outbreak of enteric fever in the

hospital at Jhansi was attributed to the surreptitious introduction from outside of bazar-made sweetmeats and butter. At Dagshai the bread was freed from suspicion by examination. The medical officer at Nasirabad thinks there may be something in the fact that enteric fever is most common when there is most dust blowing about. It was discovered by the medical officer at


that the clothing of enteric patients admitted to hospital was stored without being washed, and, in the event of the patient's death, was sold without having been disinfected.







years, that tonsillitis and sorethroat were






enteric fever. Of Bernardmyo, which was first occupied in 1888, it is said that there is no record of the occurrence there of enteric fever; and Darjeeling and Colaba are reported as comparatively The reasons given for immunity in the case immune. the




of Roorkee were a small garrison and no drafts arriving; in the case of Dagshai military prison, the not allowing any natives inside ; in the case of Murree, a good and abundant water-supply and careful sanitary attention ; in the case of is at



Colaba, the fact that the water-supply

liable to contamination. Again, the a diminution of the disease were, at keeping natives away from the barracks ;


given for


at Ranikhet the

great precautions taken

to secure cleanli-

of water and milk ; and at Dalhousie the sanitary measures of recent years. Among the measures considered to have been successful in an outbreak


staying neighbourhood of the unclean water (Umballa) ; boiling and permanganating the water, and inoculation of the supply with micrococcus Ghadiallii (Meean Meer) ; permanganating the water were

removal from the

(Kamptee). The presence of the micrococcus Ghadiallii in the milk used by a regiment at Dagshai did not, however, apparently prevent that corps from suffering severely from enteric fever. That non-commissioned officers at Umballa suffered little was considered possibly due to the fact that only mineral waters were consumed

their messes. Some regiments and batteries have made very complete arrangements for securing cleanliness in their aerated water factories and in their dairies, but, as a rule, the existence of weak points is reported. For the purification of water alum appears to be used only in about half-a-dozen stations, whereas boiling and permanganating with more or less thoroughness




The Larymore boiler, as made to be general. used by the jail department of Bengal, is being introduced at some stations, and has so far met with Incineration of enteric stools is reported approval. from Dagshai, Subatliu, Jutogh, Mooltan, and Gharial ; but it seems that those are not by any means the only stations in which such a procedure is carried out. At Chakrata urine, fa;ces, etc., were boiled. Finally, on account of the difficulty of maintaining biological cleanliness in all things in India, some medical officers, amongst whom is he of Chakrata, desire the prophylactic inoculation of all men coming to the country." seem


One cannot fail to recognise the practical value of such articles for advancing the important problems with which they deal further oil the way towards a satisfactory solution. For

they undoubtedly fresh research


incite more




activity lines.


Enteric Fever in India.

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