among the Natives in the Hospital. I have mislaid some notes of the post- mortem examinations of two or three Native patients which I thought at the time were illustrative of the morbid anatomy of typhoid fever, but they Were cases about which I felt uncertain during life." The subject was first brought before the Medical Society of Nagpur in July 1895, when I read a paper in which a detailed account of five cases which had occurred in the Nagpur Jail was given. There were present on that occasion Colonel Newman, Administrative Medical Officer of the Central Provinces ; Colonel Little, A.M.O., of the Berars; Major Harris, Civil Surgeon, Nagpur; Dr. Agnes Henderson, Captains Faichnie and Hodgins, U.A.M.C. ; five Assistant-Surgeons and fifteen Hospital Assistants. An interesting discussion followed the reading of the paper. I propose first to give this paper and a note of the discussion and then give a short account of some of the cases of special interest which were met with later. At the time of reading the paper in 1895, no cases had been verified by post-mortem examination, but there have unfortunately been frequent opportunities of verification since that time. Paper of 1895.?I remember hearing a medical officer who had had over eighteen years' service in India state that he had never seen a case of OF INDIA. NATIVES IN enteric in a Native aud he did not believe that FEVER ENTERIC it occurred. This was early in 1890. I had By ANDREW BUCHANAN, M.A., M.D., seen one case before this which I thought might MAJOR, I.M.S., have been enteric. In the autumn of 1890, while I was in medical charge of the 16 th Superintendent, Central Jail, Nagpur, C.P. Bengal Cavalry at Jullunder, there were several cases of enteric in the Hospital for British The Editor of the Indian Medical Gazette has to the asked me to write an account of the cases of Troops. A native boy was admitted the Assistant and Hospital enteric fever which I have seen in Natives of Cavalry Hospital, India. Since 1894 there have occurred 25 cases Pati Ram, who had never before seen a case of in the Nagpur Jail. These cases were seen by enteric fever, drew my attention specially to and said he suspected that he had a large number of medical men and by some this lad, medical ladies, and on many occasions at the enteric fever. It was the peculiar appearance of the stools monthly meetings of the Nagpur Clinical Society the subject of enteric fever has been discussed, which led him to suspect enteric. On the sixth and the lesions found post-mortem in the intes- day there was tenderness on pressure in the right tines have, on several occasions, been shown at iliac fossa. On the tenth day some spots were the Society. During the past ten years I have noticed?three on the right arm and three on the made enquiries from a large number of men in left leg. The boy was unusually fair for a Native, the Indian Medical Service as to whether they and the rose-coloured spots were well seen, eshad seen cases of enteric fever in Natives, and pecially when the lad was carried into a good only a very few have seen any cases, so it would light. The spots came out in crops on three successive days, they were carefully marked, and seem that its occurrence is very rare. In Indian Medical Science for 1860 I find it was noticed that each crop almost disappeared about three days after they had been seen. a clinical lecture on enteric fever, which was I shall not give here full details of the case, delivered by Surgeon Goodeve, Professor of I may repeat some remarks which were made but Medical in Medicine at the College, Calcutta, December 1858, and he states" I feel all but in the case book at the time: This case is intercertain that we have had cases of typhoid fever esting in connexion with the question?Does enteric fever occur in Natives ? There can, I think, be no doubt that this is a case of enteric. None of the symptoms commonly noticed in an uncomplicated case have been absent "
except
THE INDIAN MEDICAL GAZETTE.
404
The gradual onset of the illness, the appearance of his tongue and face, dilated pupils and listless countenance; the tenderness in the abdomen, especially in the right iliac fossa, the appearance of the stools, especially in the early stages, slight delirium in the early part of the second week, a remission on the tenth or eleventh day, and the spots coming out in crops?all point to the case being one of enteric. Captain Aldridge, K.A.M..C who had then several cases of enteric under his care in the British hospital, saw the lad on several occasions, and he said that he had no doubt that the case was one of enteric. On the fifteenth and sixteenth days the boy's temperature ran up in the evening, and it was afterwards found out that his friends had given him some chupatties (scons) to eat. On the twent}7-first or twenty-second day the temperature came nearly to normal. For four years subsequent to this I did not see then a good example of any case of enteric, and the ambulatory type was seen in the Nagpur Central Jail. A man was admitted to hospital suffering from what appeared to be ordinary malarial fever. The fever stopped, and the man A few was discharged to the convalescent gang. days laser lie was admitted with symptoms of sudden collapse, tympanitis and fever. He died next day. The post mortem revealed ulceration of the JPeyer's patches in the lower part of the ileum and perforation. During the past few weeks five cases of enteric fever have occurred in Native prisoners in the Nagpur Jail. The symptoms in these five cases will be referred to, and a comparison will be made between the symptoms observed in these cases and those which have been noticed in Europeans. For convenience, the five cases will be referred to as A, B, C, D, E. Age.?The ages of the five patients are 30, 2G, 18,25,20. Roberts has stated that individuals under 30 are twice as liable as those over 30, and that half the cases occur between 15 and 25. From such a limited number of cases, one cannot draw any general inference; but it is interesting to note that the ages of the Natives who were attacked are much the same as the ages of Europeans who are more subject to the disease. Sex.?Of the five cases, four were males and The number of women in the one was a female. Jail is, however, very small as compared with the number of men?roughly 1 to 25. Onset.?The disease came on gradually, as will be seen when the temperature is considered. Tongue.?In some of the cases the upper and was covered with posterior surface of the tongue the and a brownish yellow fur, edges of the one or two the yellow In red. were tongue colour was marked. If a small quantity of finely powdered iodoform were sprinkled over the tongue, it would give an appearance not unlike that which was seen in two cases. In others the tongue did not present anything charac-
tympanitis.
,
[Nov.
1899.
In a lecture delivered recently, of St. George's Hospital, has stated that there is no tongue which is of special diagnostic value in enteric. He describes the special tongue of fever and gives an instance of a boy who had typical enteric but whose tongue was quite clean. The tongues of several other cases in hospital at the same time for malarial fevers were compared with the tongues of these enteric The yellow coating would appear to have cases. been more in some of the enteric cases, but not to such an extent as to be of any value from a diagnostic point of view. In one case (C) the tongue had a uniformly glazed appearance and was not at all like the tongues of A and B. It would appear, then, that there is not at least in all cases anything in the appearance of the tongue which is specially characteristic of the disease. In those cases in which delirium was at all a prominent symptom, the patients were for a few days unable to protrude the tongue beyond the teristic.
Whipham,
lips.
Abdomen.?Tenderness was complained of in all cases, and pressure in the neighbourhood of the umbilicus caused pain. Gurgling was detected on pressure in the iliac fossce in all cases. The gurgling was found perhaps as much in the left iliac fossa as in the right. Abdominal distension.?Sir W. Gull lays stress on this as being one of the most trustworthy facts in making a diagnosis. In these cases it was present, but only to a slight extent. (Ede-ina of abdominal wall.?There was oedema of the abdominal wall in some of the cases; it is not known if this is a symptom usually found. Bowels.?In A there was no diarrhoea in the first ten days. He had one motion daily or one 12th day he had two. every second day. On the
{To
be
continued.)
except
THE INDIAN MEDICAL GAZETTE.
404
The gradual onset of the illness, the appearance of his tongue and face, dilated pupils and listless countenance; the tenderness in the abdomen, especially in the right iliac fossa, the appearance of the stools, especially in the early stages, slight delirium in the early part of the second week, a remission on the tenth or eleventh day, and the spots coming out in crops?all point to the case being one of enteric. Captain Aldridge, K.A.M..C who had then several cases of enteric under his care in the British hospital, saw the lad on several occasions, and he said that he had no doubt that the case was one of enteric. On the fifteenth and sixteenth days the boy's temperature ran up in the evening, and it was afterwards found out that his friends had given him some chupatties (scons) to eat. On the twent}7-first or twenty-second day the temperature came nearly to normal. For four years subsequent to this I did not see then a good example of any case of enteric, and the ambulatory type was seen in the Nagpur Central Jail. A man was admitted to hospital suffering from what appeared to be ordinary malarial fever. The fever stopped, and the man A few was discharged to the convalescent gang. days laser lie was admitted with symptoms of sudden collapse, tympanitis and fever. He died next day. The post mortem revealed ulceration of the JPeyer's patches in the lower part of the ileum and perforation. During the past few weeks five cases of enteric fever have occurred in Native prisoners in the Nagpur Jail. The symptoms in these five cases will be referred to, and a comparison will be made between the symptoms observed in these cases and those which have been noticed in Europeans. For convenience, the five cases will be referred to as A, B, C, D, E. Age.?The ages of the five patients are 30, 2G, 18,25,20. Roberts has stated that individuals under 30 are twice as liable as those over 30, and that half the cases occur between 15 and 25. From such a limited number of cases, one cannot draw any general inference; but it is interesting to note that the ages of the Natives who were attacked are much the same as the ages of Europeans who are more subject to the disease. Sex.?Of the five cases, four were males and The number of women in the one was a female. Jail is, however, very small as compared with the number of men?roughly 1 to 25. Onset.?The disease came on gradually, as will be seen when the temperature is considered. Tongue.?In some of the cases the upper and was covered with posterior surface of the tongue the and a brownish yellow fur, edges of the one or two the yellow In red. were tongue colour was marked. If a small quantity of finely powdered iodoform were sprinkled over the tongue, it would give an appearance not unlike that which was seen in two cases. In others the tongue did not present anything charac-
tympanitis.
,
[Nov.
1899.
In a lecture delivered recently, of St. George's Hospital, has stated that there is no tongue which is of special diagnostic value in enteric. He describes the special tongue of fever and gives an instance of a boy who had typical enteric but whose tongue was quite clean. The tongues of several other cases in hospital at the same time for malarial fevers were compared with the tongues of these enteric The yellow coating would appear to have cases. been more in some of the enteric cases, but not to such an extent as to be of any value from a diagnostic point of view. In one case (C) the tongue had a uniformly glazed appearance and was not at all like the tongues of A and B. It would appear, then, that there is not at least in all cases anything in the appearance of the tongue which is specially characteristic of the disease. In those cases in which delirium was at all a prominent symptom, the patients were for a few days unable to protrude the tongue beyond the teristic.
Whipham,
lips.
Abdomen.?Tenderness was complained of in all cases, and pressure in the neighbourhood of the umbilicus caused pain. Gurgling was detected on pressure in the iliac fossce in all cases. The gurgling was found perhaps as much in the left iliac fossa as in the right. Abdominal distension.?Sir W. Gull lays stress on this as being one of the most trustworthy facts in making a diagnosis. In these cases it was present, but only to a slight extent. (Ede-ina of abdominal wall.?There was oedema of the abdominal wall in some of the cases; it is not known if this is a symptom usually found. Bowels.?In A there was no diarrhoea in the first ten days. He had one motion daily or one 12th day he had two. every second day. On the
{To
be
continued.)
