index of the view that is now generally held that there is 110 such thing as remittent fever, and that the cases that are so returned, as well as simple continued fever and allied diseases, are only modified forms of enteric fever. The object of this paper is to discuss the subject, contra, to support the existence of a malarial disease analogous to euteric, and to try and banish the latter from the nomenclature of Indian diseases. The conditions which favour the growth of enteric poison are so foreign to the circumstances under which the British soldier lives in India ; its de novo generation is so frequent, while its epidemic existence is almost unknown ; it is so changed in its characters that it is recognised not by its symptoms, but by its post mortem * appearances. Surgeon-Major Macartney fordown of features mally lays eight separate distinction between the true and foreign varieties. Under these circumstances, I say, it is not surprising that sceptics like myself hold that there is little or no enteric fever in India, and that the so-colled enteric fever is really a malarial disease best classified as remittent fever according to the official nomenclature. Enteric fever itself, the sewer and filth disease, the " " pythogenic fever of Murchison, is above all others amenable to improved hygiene, yet all that foresight, vigilauce, zeal, and money can do, fails to check the ravages of this disease, at and opprobium of Indian once the bugbear sanitation. Being a sewer and filth disease, why is it so rare among the natives of India? Only one to two per cent, of remittent and euteric combined are returned as enteric in the Calcutta hospitals, and these are possibly Europeans. Why again is it five times more prevalent in India than among home troops, where susceptible age, old barracks, and conservancy arrangements, all-important items of causation, either predisposing or exciting, favour its development? Before trustworthy measures, either for prevention or cure, are undertaken, it is necessary to trace any disease to its source ; until this is done, we are merely groping in the dark. In order to obtain a comprehensive view of Indian enteric from this standpoint, let us consult the memorandum of the Army Sanitary Commission on the report of the Sanitary Commissioner with the Government of India for 1885, from " The facts which the following is taken : 1 show that ,iu sanitary work it is not necessary to separate these fevers (ague, enteric, remittent, continued), and that the causes of them, so far as preventive measures are coucerned, should be discussed and remedied together." AcThis dictum is either right or wrong. cepting the specific theory, if right, there should ?
ENTERIC FEVER IN INDIA. BY J. RIORDAN, M. B., M. Ch., ROY. UNIV., IREL., Surgeon, M. S.
The increase of enteric shewn in recent statistics, is
fever
in
India,
probably only
an
*
?
British 31c(lieuI Journal, 8tli October 1887.
?'
July, 1888.]
ENTERIC FEVER IN INDIA.
be no enteric fever in those parts of England from which ague lias disappeared ; if wrong, the whole sanitary fabric comes to naught. The dilemma disappears if this so-called enteric is due to miliaria. The Sanitary Commissioner and the reviewing Commission being unable to take cognizance of change of opinion regarding the diagnosis of this disease, attribute the increase of enteric fever to the greater proportion of young soldiers of late years. But they " are not satisfied, for they add, Its special character was great severity in specific localiti es, and it is clear that unless its prevalence in these cases can be shown to depend directly on the proportion of young soldiers, who were barracked at the more severely affected stations, the predisposing causes of this fever must "be sought elsewhere." And this Sanitary Court of Appeal does not hesitate about the causes, for it adds, " considering the facts regarding enteric fever as a whole, and apart from strictly professional questions of diagnosis and etiology, the evidence in the present and preceding reports appeal's to connect the disease with those prevailing malarial conditions which influence the nature and amount of fever at intertropical stations generally, and we know from statistics that wherever enteric fever shows itself at the stations, the whole surrounding population suffers year after year from miasmatic fevers." The Commission feels that it can hardly question the diagnosis of medical officers, but it goes 011 to enquire into the well-known factors of etiology thus : " In the first place there is no evidence that fatal fever cases are due to
single cause, personal transference, sewer emanations, foul air of badly managed latrines,
any
or of filth deposits, insanitary conditions of civil population,impure well water,diseased milk; all attempts to show that enteric fever has been due to these, have failed to include the known facts." The meaning of those passages is very clear. Now with regard to the symptoms. As above referred to, Surgeon Major Macartney gives eight features of contrast, and Surgeon Bigg,* a sceptic as to the specific nature of the disease, gives seven. Most physicians would be disposed to question the diagnosis, say, of ulcer of the stomach, or cancer of the lung with such numerous points of distinction arising from such disturbing influences. But it may be desirable to point out some of the principal. 1st:-?-The pea-soupy stools, so characteristic of true enteric fever, are entirely absent in this Indian variety, and in place thereof we have either constipation or the well-known yellow-ochrey or mustard dejections. No attempt has been made to explain this important deviation from rule. 2nil.? The rose spots, it is true, may be modified out -
*
Idem,
22nd October 1887.
"
201
the cutaneous eruptions so in this country, hut in the absence of cuticular affections, lenticular spots are admittedly conspicuous by their absence. 3rd.?The departure from the typical temperature chart. It is not surprising that such should occur if we include nearly all the malarial diseases under this head as we are invited to do. But " enteric fever when we are also told that usually occurs in young soldiers who have only lately arrived in the country and who have not previously suffered from malarial fever (Harrison Youuge),* we expect at least a considerable proportion of typical charts and characteristic cases generally. 4th.?The impairment of the mental faculties so frequently observed as a sequel has not been observed in this country, bth.?The average duration of fatal cases is about 21 days in England. No such Indian statistics are available as far as I know. The reader must judge whether he has not found that the majority of deaths occurs before the tenth day as my limited experience leads me to think. With regard to treatment I will confine myself to two remarks, diet and the use of quinine. With respect to the former it is stated by Sur" as geon Younge that long as the belief in remittent fever continues, a large proportion of enteric fever cases will be improperly dieted," and again, (e had this case been diagnosed as enteric fever, the patient's life would undoubtedly have been saved." And this while it is laid down by authorities 011 remitteut fever that severe and sometimes fatal intestinal ulcerations occur. Is not improper dieting as reprehensible in the one case as In the other? Is it only in dealing with enteric that care is to be exercised in prescribing regimen ? I could not refrain when reading this article of Surgeou Younge's from mentally congratulating the large number of enteric fever patients treated by him in 1883, on escaping from the lethal consequences of being diagnosed remittent fever. The want of controlling power of quinine in this malarial disease has been commented on. Quinine fails even in some cases of simple ague, quinine is frequently used in enteric fever, at home; quinine somewhat loses its efficacy from being too frequently prescribed in this country, but it is to the complications and accompanying organic changes which exist in this disease and which will be noticed later on that its loss of specificity must be chiefly of all
recognitiou by
common
i8SS.
ENTERIC FEVER IN INDIA. BY J. RIORDAN, M. B., M. Ch., ROY. UNIV., IREL., Surgeon, M. S.
The increase of enteric shewn in recent statistics, is
fever
in
India,
probably only
an
*
?
British 31c(lieuI Journal, 8tli October 1887.
?'
July, 1888.]
ENTERIC FEVER IN INDIA.
be no enteric fever in those parts of England from which ague lias disappeared ; if wrong, the whole sanitary fabric comes to naught. The dilemma disappears if this so-called enteric is due to miliaria. The Sanitary Commissioner and the reviewing Commission being unable to take cognizance of change of opinion regarding the diagnosis of this disease, attribute the increase of enteric fever to the greater proportion of young soldiers of late years. But they " are not satisfied, for they add, Its special character was great severity in specific localiti es, and it is clear that unless its prevalence in these cases can be shown to depend directly on the proportion of young soldiers, who were barracked at the more severely affected stations, the predisposing causes of this fever must "be sought elsewhere." And this Sanitary Court of Appeal does not hesitate about the causes, for it adds, " considering the facts regarding enteric fever as a whole, and apart from strictly professional questions of diagnosis and etiology, the evidence in the present and preceding reports appeal's to connect the disease with those prevailing malarial conditions which influence the nature and amount of fever at intertropical stations generally, and we know from statistics that wherever enteric fever shows itself at the stations, the whole surrounding population suffers year after year from miasmatic fevers." The Commission feels that it can hardly question the diagnosis of medical officers, but it goes 011 to enquire into the well-known factors of etiology thus : " In the first place there is no evidence that fatal fever cases are due to
single cause, personal transference, sewer emanations, foul air of badly managed latrines,
any
or of filth deposits, insanitary conditions of civil population,impure well water,diseased milk; all attempts to show that enteric fever has been due to these, have failed to include the known facts." The meaning of those passages is very clear. Now with regard to the symptoms. As above referred to, Surgeon Major Macartney gives eight features of contrast, and Surgeon Bigg,* a sceptic as to the specific nature of the disease, gives seven. Most physicians would be disposed to question the diagnosis, say, of ulcer of the stomach, or cancer of the lung with such numerous points of distinction arising from such disturbing influences. But it may be desirable to point out some of the principal. 1st:-?-The pea-soupy stools, so characteristic of true enteric fever, are entirely absent in this Indian variety, and in place thereof we have either constipation or the well-known yellow-ochrey or mustard dejections. No attempt has been made to explain this important deviation from rule. 2nil.? The rose spots, it is true, may be modified out -
*
Idem,
22nd October 1887.
"
201
the cutaneous eruptions so in this country, hut in the absence of cuticular affections, lenticular spots are admittedly conspicuous by their absence. 3rd.?The departure from the typical temperature chart. It is not surprising that such should occur if we include nearly all the malarial diseases under this head as we are invited to do. But " enteric fever when we are also told that usually occurs in young soldiers who have only lately arrived in the country and who have not previously suffered from malarial fever (Harrison Youuge),* we expect at least a considerable proportion of typical charts and characteristic cases generally. 4th.?The impairment of the mental faculties so frequently observed as a sequel has not been observed in this country, bth.?The average duration of fatal cases is about 21 days in England. No such Indian statistics are available as far as I know. The reader must judge whether he has not found that the majority of deaths occurs before the tenth day as my limited experience leads me to think. With regard to treatment I will confine myself to two remarks, diet and the use of quinine. With respect to the former it is stated by Sur" as geon Younge that long as the belief in remittent fever continues, a large proportion of enteric fever cases will be improperly dieted," and again, (e had this case been diagnosed as enteric fever, the patient's life would undoubtedly have been saved." And this while it is laid down by authorities 011 remitteut fever that severe and sometimes fatal intestinal ulcerations occur. Is not improper dieting as reprehensible in the one case as In the other? Is it only in dealing with enteric that care is to be exercised in prescribing regimen ? I could not refrain when reading this article of Surgeou Younge's from mentally congratulating the large number of enteric fever patients treated by him in 1883, on escaping from the lethal consequences of being diagnosed remittent fever. The want of controlling power of quinine in this malarial disease has been commented on. Quinine fails even in some cases of simple ague, quinine is frequently used in enteric fever, at home; quinine somewhat loses its efficacy from being too frequently prescribed in this country, but it is to the complications and accompanying organic changes which exist in this disease and which will be noticed later on that its loss of specificity must be chiefly of all
recognitiou by
common
i8SS.
