Janu-vby 1,

1877.]

L /

ENTERIC FEVER IN INDIA.?BY T.

ENTERIC FEVEIl IN INDIA.

By T. IIuxton, M.B., Surgeon, A M. D. In this communication I purpose giving rough notes of

a

of Enteric Fever

gy, and nomenclature. The case sele ted, though not

fully detailed, presents many worthy of remark; not so much from its own intrinHie value, but as a fair type of many others, and illustrative of several points to whii-h I shall hereafter refer. Private J. H., in India 7 months, about 23 years of age:

features

Peshuwur. Previous

history

who handed it

over

of case to

me

kindly given on

17th

me

October.

by

Dr.

Joynt,

Admitted

on

" 27th September 1874, with fever which at first seemed in" termittent," but afterwards became remittent." On 4th

October tongue dry, and coated with a brown fur; stomach " diarrhoea and intense headache." irritable ; 5th.?Remission of fever in morning ; considerable diarrhoea, was taking quinine, sulphuric acid, and opium ; night; sleeping badly, 9th.?Diarrhoea continuing, for which opium enemata were given. 12th.?Remarks that " typhoid" state has set in. 14*A.?Lungs became affected, bronchial rales anteriorly and posteriorly. 17th.?I took over charge of this case, and found patient very low, with quick compressible pulse; dry brown tongue ; eordes on lips and raouth ; great thirst; flushed over malar bones ; diarrhoea frequent, motions like yellow ochre, process unaccompanied by pain or straining ; no haemorrhage from bowels ; lungs congested with solidified patches here and there ; no rusty sputa; no albumen in urine, but very high-coloured;

for which he restless at

spots over chest and abdomen; temperature from 102? to 103?. The case in my opinion decidedly enteric, not Treatment?Acidulated remittent as previously returned.

roseolar

drinks, sponging surface of body with cold water, cold douches to head. Quinine in effervescence, with potaBS bicarb and citric acid ; nourishing, bland fluid diet. 19*4.?Yesterday and to-day the roseolar spots marked on 17th remain; tenderness on pressure over abdomen ; on the whole in o very low (what some would call a typhoid) state. A tepid bath to commence with, to be brought down in temperature till a sensation of cold was experienced was ordered, but it was found impracticable ; the patient, was accordingly wrapped up in a cold wet sheet, and cold douches afterwards applied to head and spine ; temperature high, ranging 102? to 103? at 4 P.M. co.

M.B.

pernture fulling?8 A.M. 101?, rising nt 12 neon to 103?, when ha u bath, bringing temperature down to 102?, again rising in evening to 103? at 9 P.M. The baths commence at 9S? Far., and are brought down to 70?. 22nd.?Restless and sleepless in spite of cold douches and 30 grs. chloral; tongue like parchment, trembling and difficult to protrude; pulse very wiry ; lung tissue almost blocked up ; respirations very short, hurried and seemingly oppressive, afraid had

(us taken at the bed-side in a hurried way when work was pressing) with remarks, more especially connected with diagnosis and nomenclature of the affection. Having studied the disease for the past five years in this country, although not troubled with the cacoethes scribendi, I feel it my duty to circulate the conclusions I have formed on the subject, and hone that they in their turn may provoke healthy discussion, help to clear up some points, and bring to light others unknown to me regarding its diagnosis, patholocase

IiUXTON,

to 104? at 9 p ii.; to take aintuon carb gra 5, tinet cinchon 15.

in

2>0th.?No improvement; short quick breathing, with low muttering delirium; tongue like brown parchment ; sordes on raouth and lips very bud; tendernes# over, and marked convexity of abdomen ; diarrhoea stopped ; lungs engorged ; takes no notice of any one; tossing about, getting no sieep ; continue treatment with cold sheets, and with chloral hydrate and potassium bromide to promote sleep ; iemperatur9 at 8 A.M. 102?, 4 P.M. 1039, 9 P.M. 104? 21st.?Bowels free, of dark brown colour, as if mixed with disintegrated blood, but no marked hemorrhage; continue cold iheets, and give fluid nourishment every | hour; tem-

he will choke; ordered 20 grs. sulphate of zinc as an emetic, which not taking effect was followed by a dessert spoonful of mustard in hot water with success; temperature de-

creasing at 9 p.m. after bath to 100?. (N.B.?The decimals of temperature chart were somehow omitted.) 23rd.?Dyspnoea relieved, but he is still in a low muttering delirious state ; temperature falling?12 noon 101'3?, 2-40 P.M. before bath 102?, 3 P.M., after bath 99 3?. 24th.?Lung clearer, moist crepitation in some places, turpentine stupes being applied to encourage resolution of lung tissue; temperature 12 noon 100"2?, 3 pm. after hath 100'2?, again rising at 9 P.M. to 1031?; pulse very compressible, and heart's action languid. ? Tiuct digitalis 5 every 1? hour till 20 minims be taken, and lots of concentrated fluid nourishment to be given. 25th.?Improving ; recognized me for the first time for some days; articulates intelligibly; expression more clear; flush continuing over malar bones ; tongue more moist, and begins to clean at edges; pulse slower and stronger; temperature 12 noon 102?, 2 P.M. after bath lOO'l0, 9pm. after bath 99*1?. Tinct. digitalis >n. 5; tiuct. cinchon co. 10; acid nitro-

hydrochloric

dil. m 10?ter in die.

No other medicine.

26th.?Tongue and head symptoms improving ; no diarrhoea fur some days ; lungs clearing ; crepitation here and there. 28th.?Temperature 10 A M. 1002?, rising at 7 P M to 103 2*; brought down by douche to 102 6?. In spite of precautions, bed-sorei have occurred.

30th.?-Temperature continuing from 102? to J02'6* ; expresses intelligibly ; bed-sores not so troublesome, pressure having been relieved by plasters, and an air bed placed under him; a common feature of convalescence makes its appearance?wanting something solid to eat, which of course, I did not give him, as the diarrhoea would have recurred almost to a certainty ; to take quinine grs. 3, acidi nitro-hydrochlorici himself quite

dil. v\ 15?ter in die. November 2nd.?Convalescent;

diarrhoea action

or

being

pain

in

bowels;

dressed with

craving

bed-sores

carbolic oil.

for solid food ;

taking

on

5th.?No solid food yet given ; tongue white and ing lost its irritable appearance ; bowels inclined to Ferri et quin. cit. grs. 2?ter in die.

a

no

healthv

furred,

hav-

bo costive.

17th.?Took solid food, as evening temperature has been normal for some time, and tongue has completely lost its irritable appearance ; still very tottering on his limbs and spare of flesh. 30*A.?Had a few slight attacks of ague, which is very prevalent, and on one occasion retention of urine, which was relieved by the catheter, otherwise continued free from diarrhoea, and picked up flesh and strength till date of his discharge on January 19th, 1875. Remarks.?I propose to consider the subject under twelve heads:? 1.?The primary diagnosis of ague. This probably would not happen, if the case is seen at once, i. e., if proper thermoare registered, and there is time for doing Peshawur, where ague is so prevalent, this is a very pardonable mistake in the odmission-room, and ono very likely to happen during autumnal epidemics of ague, when time does not permit one to register the temperature of

metrical observations

so.

In

a

district like

the many who report themselves sick.

THE INDTAN MEDICAL GAZETTE.

4 "

hand, a shivering or chill at the onset is somecomplained of by the patient. The usually recognized temperature chart of the first four days of enteric varies more in this country than at homo, a fact to be explained by the On the other

times

influence of the greater range of external temperature; the patient failing to report himself sick at the onset of the disease,

insidiously, and he is accustomed to be seedy occasionally, thinking he will manage to come up for a dose of medicine without coming into hospital; complications of hepatitis and splenitis being more marked than at home. as

it often

comes

on

2.?The secondary diagnosis of Remittent Fever.? The remittent nature of the disease was discovered, and the diagnosis changed accordingly. The thermometer registers a remittent fecale in Enteric Fever, and in this sense it might be classed as Remittent Fever. Remissions are marked in early morning

a

This diurnal range to a in premonitory stage of phthisis before physical symptoms are pronounced. Now comes the question?From the acknowledged remittent character

gradually increasing more

towards

evening. health,

limited extent occurs in

or

of Enteric Fever, is it not very probable that many cases of are returned as remittent ? During the first week of Enteric Fever, the liver and spleen are generally congested and this fever

enlarged, the

more

conditions

we

read of

as

associations of remittent,

characteristic rash and tenderness of

abdomen not

yet hating developed.

why mistakes in diagnosis and nomenclature are frequently made; and the consideration whether Indian fevers over twelve days' duration, and variously described as simple continued, sun, heat, bilious, gastric, and even Remittent Fevers, which, if continued over ten or twelve days, and are said to have taken on the typhoid type, are not in the majority of cases enteric ? The remittent character of disease, the patient failing to report himself sick at onset when valuable thermoinetrical observations might be registered, no regular habit of using the thermometer, the case being overlooked in crowded admission rooms during autumnal epidemics of ague, the insidious nature of the attack, expecting to find some of the more typical symptoms of the disease at its onset, might be mentioned as the probable causes why the true nature of the disease at first is not recognized; and though afterwards suspected, the primary diagnosis is adhered to throughout. No marked haemorrhage from the bowels may take place, roseolar spots may not be recognized, or may be mistaken for petechia or flea bites, diarrhoea may at first be so slight as to escape the notice of even the patient, and when detected, the stools may not be much altered or offensive. Even twice a day with stools more loose than usual, though not watery in consistence, or bowels very sensitive to irritants or purgatives, accompanied with other threatening symptoms, should arouse grave suspicion, for perforation of the bowel has been known to occur in very mild attacks with very slight diarrhoea, and 110 haemorrh3.?Some

reasons

?

age.

"

The old nomenclature typhoid" has fertile source of confusion, having

most

probably been the been applied to a particular and distinct form

stage of disease, as well as to a of fever. Some medical officers who have been accustomed to speak of remittent taking on a typhoid type, etc., cling to these terms with, a wonderfully conservative feeling, worthy of a better cause. Individually, I mm mention an attack in April

Lucknow, where the disease was very common : lean recall to memory the insidious nature of the attack, feeling out of sorts, no appetite, disinclined for mental or bodily exercjse for some days, and which would not respond to the call qf tonics, stimulants or diet. My case was returned as 1873 when at

simple

continued fever, but my numerous and kind medical nomenclature, I believe, as doctors

brethren differed in their are

sometimes said to do.

From my

owu

recollection I had

1877.

[January 1,

enlargement. of liver and spleen, and slight diarrhoea about or 5th day, a decided remission every morning when I felt fairly well, but in the afternoon was fir. only for the horizontal position on a charpoy : after some 14 days on the sick list, then being able to go for a drive in the morning, I left for Nynee Tal, 4t.li

and well do

I remember the low

weak

state

I

was

in

at

Cawnpore, the hemorrhagic stools I passed there after the jolting in that slow coach railway carriage between Lucknow and Cawnpore : nor can I forget the yellow ochre coloured dejecta on mother earth when ascending the hill from Kaledon?ee to Nynee Tal, noted by anxious eyes in the clear and unmistakable light of a tropical sun. This diarrhoea time in the hills, and medicine was aggravated for some seemed to have little effect on it, but thanks to my friend, Surgeon-Major Inkson, it was soon subdued by a well selected dietary of milk and oatmeal porridge, but returned for some time on the slightest departure therefrom. Can there be any doubt I had ulceration of the bowels ? In further support, of my argument I quote 17 fatal cases of fever which occurred in 1870 in 17th Regiment, during the first year's service in India 6th

from

parently

December, at a period when apnecessary always to examine the small The analysis of cases are taken from the hospital

April it

intestines.

was

to

24th

not

records. Of the 17 cases (a) 7 were returned as simple continued fever in which no mention is made iu the P. M. report of the state of the lower third of ileum. Tne true nature of the disease be determined, but. I learn that enteric was suspected.

cannot

now-a-days from simple continued fever. as simple continued fever, 5 had ulceration of both lower third of ileum and large intestine, I had ulceration of lower one-third of ileum alone, and 2 of large intestine, (c) Two only returned as enteric, in which there were well marked ulcers about Peyer's patches. Surely these support the question?Are not. many cases of enteric returned as other fevers? I might mention the case of a young friend, who, poor Individuals seldom die

(b)

In 8

cases

returned

fellow, succumbed from

"

I first

to

the disease, and who

remittent fever and saw

him,

he had

was

haemorrhage from been ailing some

said to be the liver three

suffering when

weeks,

waa

very weak and reduced ; abdomen was convex, dull on percussion ; pain and gurgling over right iliac region, clearly pointing to distension from fluid, and that fluid, sanious, as soon was proved when it passed into stool per rectum. history of the case, and the general symptoms, there little doubt, that the case was enteric, in which opinion

afterwards From the could be

two others, who also ingly agreed. One

saw more

the

case

in consultation, unhesitat-

I shall quote which I saw in Dr. Thomson of Attock, in June

case

consultation with my friend, 1874; the disease was first returned diagnosis was changed to enteric

as

remittent,

from

the

but the

patient's

general look, tongue, and temperature, and he died the following day of hyperpyrexia, but during life he had no diurrhcea, and he presented no symptom of specific bowel lesion. This post-mortem revealed in addition to the enlarged, congested liver and spleen generally associated with remittent fever, congestion and ulceration of both solitary and a^minated Peyer's glands from tiie stage of infarction almost to penetration by ulceration. From pur improved methods of treating hyperpyrexia, death seldom takes place at this sta?e of the disease (about 5th day after reporting himself sick), and we have fewer opportunities of observing its pathology. In this case, though having diagnosed enteric during life, the appearances presented by liver and spleen were such I was as taught were almost pathognomonic of remittent, and they made me doubt wnether the diagnosis was correct; but I was not disappointed, for the ulceration of Peyer's patches in every stage of the process was most marked. 4.?Post-mortem evidence is in many cases the first indication of bowel lesion. For instance:?

January 1,

ENTERIC FEVER IN INDIA.?BY T. RUXTON, M.B.

1877.]

The eight cases previously mentioned and returned as continued fever, out of which si* had congestion and ulceration in the lower third of the ileum. A man in 1872 came to hospital suffering from pneumo-

(a) simple

enteric.

(J) nia, and died, who a short time before death complained of a sharp pain in abdomen and expired suddenly, and who had never previously complained about bis abdomen, but whose post-mortem revealed, in addition to the pneumonic hepatization of lung tissue, intense congestion and two circular ulcers in the lower third of the ileum, one of which had perforated the coats of the intestine causing death. Does this most interesting and satisfactory P. M. help to throw any light on these fatal epidemics of pneumonia which occur in jails* and among natives, but among whom 'post-mortem examinations are often difficult to obtain ? Could the original disease, enteric, be so insidious in character that the patient would not require to come to hospital for advice till thoroughly prostrated by the in-no-way uncommon complication of septic pneumonia? (c) A private in l-17th Regiment admitted into hospital, who died shortly after from hyperpyrexia, whose disease was thought to be heat-apoplexy, but at whose post-mortem ulceration in the ileum, never before suspected, was found. The two last cases show the insidious character of the disease, and prove the necessity for carefully conducted post-mortem

30th

examinations. 5.?Has the disease

generally

known

as

hill-diarrhoea

ever

any connection with the diarrhoea of enteric fever ? In some cases it has, more especially in those, coming from the plains, who tell you they have had a low sort of fever, not ague, for the past ten days or so, and could not manage to shake it off in the

plains,

and

were

sent to the hills for

Hill-diarrhoea, though of disease and is liver and

a

some cases

a

generally

chronic

a

change.

convenient term, is only a symptom associated with derangement of the

mucous

affection of the

bowels,

accompanied with pyrexia of over affirm, with disease of Peyer's glands.

when

venture to

and also in ten

days,

Our

I

means

of communication with hill stations, for I cannot call them sanitaria, is now so quick that medical leave to the hills is to all those suffering from fever of a continued mention my own case in 1873 with which I am most familiar. I was then told I had hill-diarrhoea at Mynee Tal, but as I had been suffering from the same complaint in the

generally given type. I might

plains, theterm, though inappropriate, was ready and convenient. I have

seen

several similar

cases

among sick officers in the hills

complaint yielded to treatment by bland, soothing, semifluid diet, but whose convalescence was much more protracted than if suffering from simple diarrhoea. Does this argument help to explain in some cases the source of enteric fever in hill whose

stations, and its

from the etranations of those diarrhoea, the latter being

propagation

I will make

extracts from the said work in

few

a

support of this position.

European, aged 34, admitted relaxed, irritability of sto-

Case 31.?Remittent fever. bowels

August 1839,

were

mach, abdomen full and tender on pressure, died 6 A. September 2nd; post-mortem revealed vascularity of mudous

membrane of the duodenum ; mucous coat of colon

tinged yellow; some red patches here and there ; no mention of Peyers's patches, but gut filled with yellow feculence? this latter probably corresponding to yellow pea soup or ochre coloured stools?no marked ulceration having taken place, the case proved fatal in 3 days. Case 36.?Admitted 23rd, died 28th June 1833; European ; post-mortem revealed ulceration of Peyer's patches ; inucoua coat note

In a foot of caecum and colon of dark gray colour. he mentions that the mucous lining of the large intestine

indicated

an

undue

of irritants.

use

admitted

fever,

os ileum. Post-mortem?ilueous coat of end of ileum of dark red colour, the patches of Peyer's glands red, turgid, and prominent, and several of them in different stages of ulceration ; close

of

to

the ileo-colic valve

an

ulcerated

the admixture of bile in the of stomach

developing

uneasiness, and

dependent

a

ejected gradually

itself

run

freely

down the hill sides and khuds and

sorts

propagate enteric fever,

need not go far in of the disease. we

hill sanitaria for the cause 6-?Is enteric fever a new disease in

India,

our

or

more or

He also warns

against

He writes of remittent fever then

adynamic

less this is the

tending to become continued, character, taking on a typhoid type. Doubtsame disease; and does not enteric, with its

in

*

Peyer's patches?the pathognomonic

Carefulpo?t-mortem?

Editor.

are

always

made

on

of

but at the

septic

the whole remittent and

same

more

feature of

prisoners who die in iails

time

a

to ulceration material into the system,

course

probably

adynamic symptoms? For probably

in

writers some years back, as Professor Morehead's for example, who, in 1856, distinctly stated that Jenner's typhoid is unknown in India. We, however, find many cases of remittent fever ?with lesion of

of bowels

its

so-called

only a

;

less florid at tip and e !gcs, action of the mucous membrane. use of purgatives in these cases.

tongue

the past 38 years enteric has existed in India, and for a much longer period, though not recognized.

expressive nomenclature, the result of improved means of diagnosis and more perfect pathology ? Not a new disease in my opinion, if we carefully analyse the works of the older

rupee ;

matters, and irritability with distinct epigastric

probably

contaminate water in their downward progress, as doubtless they often do, they may then be innocuous ? If mal-odours of

a

ulceration

inflammatory

on

explain

then

no

" sometimes dened state of mucous membrane of stomach and in others the gastric will be the chief of intestinal canal complication. In writing of bilious remittent, he mentions

disinfect all hill-diarrhooa stools, and

may

the size of

It is needless for me to quote further, many other cases might be cited ; bui in these more attention seems to have been paid daring life to the head than to abdominal symptoms. In remarks on gastric irritability he mentions a deep red-

fever, running and absorption

though they

patch,

dark red colour of the mucous coat of caecum ; rest of large intestine healthy.

thermometrical range,

even

patho-

Bowels

European.

continued

some

no

2nd, died 5th Septemrelaxed; epigastric uneasiness; evacuations, bilious, &c.; post-mortem revealed great enlargement of liver with adhesions, without, much change of texture; "at end of ileum isolated glands were prominent." Case 43.?Remittent fever with adynamic symptoms. European, only 2 months in Bombay, admitted 6th, died 15th February 1840. Hands were tremulous; tongue coated and dry in centre, florid at tip j *ordes about mouth; thirst; more or less diarrhoea. On one occasion pain between right ribs and crest Case 39.? Remittent

ber 1839.

looked upon as a common occurrence on coming to the hills ? If such be the case, is it not a matter of great importance to

to have fever with

Iu this case

in head or liver.

logical changes

remittent

supposed

M., the

7.?Does enteric fever in India differ from that at home, and a malarious country might it be termed entero-malarial ? Disease does not materially differ in this country; the inter-

mittent and remittent characters at onset may in some cases be more marked, and more especially in a malarial district, occasional doses of

where The

by

term

some

cations

American should

multiplicity

quinine will be found beneficial. or typho-malariul as proposed writers, are both objectionable; all complitreated as such, thus avoiding needless

entero-malarial, be

of nomenclature.

8.?The nature of the rash,?when does it appear and is it The rash consists of small roundish roseolar spots,

symmetrical? about

a

line iu diameter, from 2

or

3 to almost countless

numbers,

THE INDIAN MEDICAL GAZETTE.

[January 1,

1877.

sense of touch perceptibly elevated above level of skin, disappearing on pressure, never present at onset of disease, commencing from 7th to 10th day or even later, most marked on abdomen and, chest, sometimes extending to extremities, after second week are seldom wanting, and appear in successive crops. I have entered into this subject more fully, as many do not seem to know the general time the spots appear, expect them at the onset of the disease, and forget their fugitive character. They probably develop about the same time as the tdceration of the bowel. They are to be distinguished from petechise, by the latter being of a more violet livid colour, their not disappearing on pressure, projection above the skin being not so marked, and they may 'be present at onset of disease,

12.?Does enteric fever in a mild form exist in India ? I incline to the belief that it does ; that in many of our milder forms of fever there is congestion of Peyer's patches, which is

in the later stages. Blue spots are said to occur in mild cases of enteric, but I have never satisfied myself of their presence.

diagnosis and pathology of this

to

but

more

common

9.?Is enteric fever and have these fatal

among the natives of India, of low pneumonia any connection

common

cases

with enteric fever, the septic pneumonia being ouly a complication ? Through the courtesy of some medical brethren of the Indian service, I have had some opportunity of judging for myself, and venture to say that the disease is more common than is generally recognized ; and that these fatal epidemics of low pneumonia, unaccompanied by rusty sputa, with fever of an adynamic type, are epidemics of enteric Do not fever with septic pneumonia as a complication. these cases often prove fatal by diarrhoea ? Spots are not bo easily seen as in their more fair-skinned brethren, nor can post-mortem examinations be so easily obtained to perfect our diagnosis and pathology. 10.?What causes the disease ? We have not to look far in this country for the unwholesome food

supposed general causes of this disease, i. e., or drink, decomposing animal and probably also vegetable matter, mal-odouri of sorts and putrid emanations likely to favour its development into an epidemic Marsh miasm may also act as the exciting cause in form. those predisposed. Young soldiers coming to India, and young men from country to town are favourite subjects for its development, those generally attacked being from 15 to 30 years of age, elderly people enjoying comparative immunity' Exposure to the sun may act on some constitutions and so predispose to the disease, causing pyrexia and probably congestion of Peyer's glands as well as that of the liver and spleen. 11.?Is the disease contagious ? If so, there is the greatest importance to be attached to an early diagnosis. Strong arguments on both sides might be advanced. For contagion, the disease being brought from a contaminated district, the nurse or near relations in the house becoming affected, and disease spreading from house to house, assuming an epidemic form. Against contagion, the many isolated cases that occur without any known communication from an infected district, the case not imparting disease to others, &c. On the whole, in spite of the arguments against contngion there are many in its favour, and it is wise, I think, to recognize it as contngious, and take every precaution in disinfecting stools, &c. Many may be brought in contact with germs of disease, but the soil or suitable for the seed, whether from age may not be ready, or other cause unknown; while others do not escape so lightly. Contagion on the whole is a quaestio vexata, and in many cases difficult to separate from the circumstance of individuals being placed under the same insanitary conditions, the susceptibility or otherwise of imbibing the poison ; the amount imbibed probably having some connection with the period of incubation and the variety of the symptoms. The fever may at prostrate one man, while another may be able to knock about till a pneumonia seizes him.

once

modified

by rest, treatment, &c., and which the end of first week, and in

tion about

spots

are

place

in

seen; that in the all, and that the

septicaemia

more severe

cases

ends in resoluthese

adynamic symptoms

derived from the ulcerated

sores

cases

no

ulceration takes are

due to

in the intestine.

In conclusion, my remarks having already occupied more space than I originally intended, I offer my thanks to those who have ft llowed me throughout this rambling paper, and hope they have found it of sufficient interest to repay perusal, and that it may stir up Changla

Gali,

near

some

further most

Mtjbree.

investigation into interesting disease.

the

Enteric Fever in India.

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