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