January 1,
1881.]
NOTES ON ENTERIC FEVER.?BY JOHN C.
NOTES ON ENTERIC FEVER OR ABDO-
that the various causes?if there were in operation in the long
MINAL TYPHUS. on
Enteric Fever in
Afghanistan,
occurring there. By John C. Lucas, F.R.C.S. About this time last year an article on this subject was written by me, and published in this journalat the time of its going to press, the writer was but too sensitive of its manifold
shortcomings and solicitous to amend these ; but the subsequent additions and alterations, then made) were 011I3- in the hands of the Editor when the paper was already in type. Comme il fciut, it is now proposed to supplement in this issue what has appeared in a previous number. It will be remembered that after reviewing briefly the views of some of our more distinguished authorities, and noticing, more specially from the diagnostic hygienic standpoints, the symptoms and after-death
and
apto draw attention to and
pearances, the writer proceeded point out the directions in which, as it appeared to him, our endeavours should be directed and research prosecuted. A point of paramount moment and value, that of contagiousness in the literal and precise application of the term, was one of the points it was intended to embrace. One of our greatest living savants, John Simon, gives us this definition,?" The word 'contagion' is applied in pathology to the property and process by which, in certain sorts of disease, the affected body or part causes a disease like its own to arise in other bodies other parts ; and the Latin word contagium (pi. contagia) is conveniently used to denote in each case the specific material, shown or presumed, in which the infective property ultimately resides." This is the sense in which we understand and have been in the habit of employing the term. This matter of the proneness or otherwise of a person who comes into personal contact with a patient suffering from typhoid taking the disease?apart from imbibition of the contagium vivum from the intestinal discharges?cannot as yet, we think, be considered as settled once for all. We have at the same time a large or
accumulation of published evidence, both pro and con ; and the majority of advocates of the former view rest their belief, as far as we know, upon certain limitations of age as the sine qua non. The most recent testimony in favour of the contagiousness of typoid fever wherewith we are acquainted has been from the pen of a young and rising physician and sanitarian, Dr. Alexander Collie of the Homerton Fever. Hospital in London. He has for some years made the subject his own by special
study tilling
the fertile, though as yet uncultivated, field, and turning it to the best account?which not only will hardly fail to spread his reputation world-wide, but, what we think he will value far more, will aid in lessening human suffering and tending to prolong human life. From these tables it appears," he writes, '? that "
Indian Medical
Gazette, vol. XV., No. 2, pp. 35-40.
tables,
and
on a case
F.R.C.S.
whatever the cause, be it drains, stools recent or decomposed or personal contagion, their effect is determined by the age of persons. For it may lie fairly assumed
ORIGINAL COMMUNICATIONS.
With remarks
LUCAS,
so
operation
that, given or
a
cause,
were
various
period
whether
causes?
covered by the
continuously
not, the extent of effect would
depend
in
upon
the number of persons of the suitable or more liable Thus equal age ; in other words of persons susceptible. causative conditions would in different hospitals have different effects and in the same hospital at different times, varying in proportion to the varying number of the second factor?susceptible persons." He next proceeds to explain his meaning farther, and then says?'' in accordance with the law which the tables indicate, if the age of the persons were over thirty and verging upon forty, the probability of a small number would be great ; whereas, if the age of persons fell short of twenty-five, the probability of a small number would be slight." He gives tabular statistics of admissions, according to age ?in four of the London Hospitals?the Liverpool Street, London Fever, and the
Homerton?and, in discusses, not unsuccessfully, from the data at his own disposal, and also quotes from the published' reports of seven general hospitals, such as Saint Thomas'. He indicates how in these institutions, situated in different parts of the metropolis, the cases of the sisters, nurses, ward-servants, and of patients all varied with age ; and, it could not fail t occur to a reader perusing his articles?indeed, valuable contributions to science?and scanning them, pari passu, the little dependence that can be placed upon bare figures, especially with meagre or insufficient details ;
Stockwell,
the text he
the little faith that he may have had in mathematics
as
applied to our art will be irreversibly shaken, more particularly in regard to the momentous point on which Dr. Coliie justly has lain so much stress. Our knowledge of histological anatomy teaches us the changes which physiologically and normally do take place in the ileum, mesenteric glands, &c., and spleen (Kolliker) with age. We cannot but be strongly of credence, therefore, that this adds no inconsiderable weight to the arguments so ably brought to bear on this question by him. It would be well nigh impossible within the narrow limits of this paper to do adequate justice to this author, whose writings illumine and shed lustre on not only the columns of the journal0 from which the above passages have been extracted, but also those of several of its contemporaries,and his official annual reports. As an instance, it may be noted that an editorial writer of the Lancet~\ in noticing his report^ for 1879 says,? He makes also some important observations npon the element of ago in the question of immunity from the disease, giving tabulated data, with a view of showing that after thirty years of age few susceptible people are ' This element of age is, I be ieve,' he says, to be found. "
*
British Medical Journal, January 17, 1880. f Lancet, June 26, 1880. t How much better it would be for the profession if Indian Official publications were likewise placed oftener than they now are at the disposal of medical journals.
THE INDIAN MEDICAL GAZETTE. the reason of the relative immunity of nurses from enteric fever in certain hospitals, an immunity which might exist always, and be everywhere complete, if due regard were had to the age of those who nurse enteric fever ; yet this immunity would prove nothing against the views which I maintain, that enteric fever is con-
[January 1,
1881.
'
tagious'." To that,
be said
up Dr. Collie's views, so far, it may enteric fever is doubtless contagious in
sum
opinion, but this in inverse ratio to age within the limitations contended by him. That typhoid has prevailed in Afghanistan during the recent campaigns the writer has had sufficient evidence to convince. That the disease has been known to exist in the Punjab, Cashmere, and in Sind is now a tolerably well established fact. This being so, the occurrence of the disease in Afghanistan itself may be attributable to it. The study, amongst other things, of the subject of enteric fever there, offering as it did certain singular advantages, combined no doubt with drawbacks in respect to the elucidation of the still burning question of its origin, tempts me to make a kaleidoscopic gazeupon the cause of a case which came under my care in that country, and to make a few remarks upon the treatment which proved most satisfactory. When the camunfortunate as it has to paign, proved be, first com-
his
menced and troops were proceeding from India to that despicable and worthless land, it struck the writer with considerable force that the accumulated labour of
patient investigation by all the sion in Afghanistan, in what I
members of
our
profes-
virgin soil, would spark if not light to
term
appear to promise to throw some vanish the darkness. If a considerable amount of blood has been shed and lives otherwise sacrificed and lost, and money expended, it would doubtless be some consoleft a legacy, an iota lation to ourselves if science of benefit howsover small. For instance, if in every case of fever with anything like hyperpyrexia?unusual and, indeed, peculiar rise of temperature?accompanied with diarrhoea, the observer, without preconceived notions and without bias, looks for typhoid, makes thermo-
metric observations, examines the evacuations daily, searches for the rash ; this done systematically, and on the case, perchance, terminating fatally, after he had striven his utmost to save and stay life, obtains an autopsy : ascertaining from others, by means of courteous and encouraging notes on the lines of communication, whether they had had anything of the kind, communicating with others again whence the case, the regiment, or anybody belonging to the patient or the the latter corps, as the case may be, came : then asking
We must feel confident that if some such method were followed much good is likely^ or shall we say certain, to be attained, provided, of course, that all worked in a cordial tone and spirit and mutual harmony?bearing in mind that their reciprocal exertions and labours have in view, as the primum mobile, good to suffering humanity. Then, and then alone, we believe, will medical men, to use Lord Bacon's sublime language, to trace it up to its fount.
exert themselves for the general good, and raise their minds above the sordid considerations of cure ; not "
deriving their honours from the necessities of mankind, but
becoming
ministers of the Divine power
and
good-
both in prolonging and restoring the life of man." These learned words hold as good to-day as they did in the more classic days of the cleverest and wisest of mankind. I am of opinion that, unless complete and absolute faith is reposed in Murchison's pythogenic theory, or there is evidence to show that the disease did not exist prior to the arrival of our troops, there are two points to be considered, studied and settled, and thev are?(a) the importation of the virus from India, and (b) infectiousness from virus, sui generis, already extant in certain parts of Afghanistan and Beluchistan. So far as geography teaches us, there is no connection, by rivers, &c., between India and those two countries. ness
Nature had thought it prudent to separate the former from the latter by huge lofty mountains, devoid of life, which act as barriers against morbid (as well as
human)
The so-called "Scientific Frontier" being as if an isthmus of connection along the Khyber and Knrrarn to Northern Afghanistan ; while the barren wilderness, ' known as the Kutchy Plain, or Put,' which extends between Jacobabad and the place called Sibi (whic]t in Fashtu means commonly hell !) would, I think, be about the worst aerial medium for the spread of disease germ. the poison, or Bryden's atmospheric ' wave' which that able statistician again insists upfoes.
on, in
regard
cholera in India, can scarcely hold no water in the Kutchy to hold !). good for cholera according to recognized to
water, (for there is What holds
authorities, including
with equal
Pettenkofer, applies
force to typhoid. I venture, however, to
think
that
we
are
hardly
justified in arriving, per sallum, at a conclusion more particularly when after a little more thought wo easily perceive that our area of investigation is but
in comparison with the actual ground which we should have traversed. The case about to be described is so markedly in point that I trust it Avill not be deemed uninteresting should I attempt? what alone I can within the small and narrow limits here?but a camera obscura sketch. at my disposal Without the specific cause, as fusee, the followers of Btidd (alas! now dead since I last mentioned him in these columns) challenge proof of conflagration ; allow-
infinitesinal over
ing to the fullest extent the combustible nature of putrid fa3cal matter, it is not easy for them to be made Even to believe in the existence of a fons et origo mali. of incubation I am the possible longest period allowing in
a
position
come
to vouch
in direct contact
solemnly with,
or
that my patient had not been near a place where
there had been cases of typhoid; and, to quote the words of a French savant, M. Piedvache, we may say with him,?'' J'emploierai le mot contagion dans sa
signification
la
plu etendue, designant
sans
ce
nom
transmission de la maladie d'un individu sain quelque soit la mode suivant elle s'opere." That the poison of typhoid can be carried long distances between infected and non-infected places few will be prepared toute
to
deny.
While Professor
Tyndall
has shown
in
his
"
Transacwritings, and amongst them in the tions" of the Royal Society of London, that the highest
various
examined them in the field of have failed to reveal the particles of disease
powers with which he has
the
microscope
January 1,
germs.
The
NOTES ON ENTERIC FEVER,?BY JOHN C.
1881.] poison
had iti this
case
various
means
of
being brought to its subject. R Patient, Lieutenant E., of the Sappers and Miners, aged -27, arrived vvitli his company on the 24th of May at a place called Durgie, and lived in an upperstoried mud house forming part of a village deserted by the Afghans on their being pursued for the murder ?
of
Captain Showers. It was believed from what I could gather that they left it in March, and a detachment of one of the regiments of Sind Horse, under the command of same
an European officer, was encamped on the ground in which this company of Sappers after-
wards was, and the latter officer had occupied the same where my patient afterwards lived, and before the former the Agent of the Governor-General for Beluchistan. There is a missing link or two here which I could not ascertain, and that whether there was rooms
among any body belonging to the camps of these two officers ; there was, I may observe, no typhoid in the company of Sappers before. I came to learn that the time when it arrived at Durgai, the camping ground, although it showed signs of previous and recent occupation, was not in a dirty state, but the mud rooms of the village were ; but those in which these officers lived successively, I understood, were least so at the time. No case of severe fever occurred in the company during its stay there ; but there were several diarrhoea and dysentery. On my arrival at cases of Durgie with another company, on noticing the cases of bowel complaints, I visited the spot from which water
typhoid
was
obtained,?from
?
flowing
stream
to condemn it.
over
a
gravt-1
On the 30th May left Durgai Temporarily and rode part of Lieutenant the way towards the Harnai side of the valley for some ten or twelve miles to see a brother officer off on the I gleaned that on cantering latter leaving for England. back he dismounted and drank water from a stream. I know the country about there, which is irrigated, and sewage appeared to be utilized largely as manure there ; and I also remembered that on marching through it there were several cases of gastro-intestinal symptoms, He went to but none of typhoid, and not even since. Chappar on the morning of the 19th June, but had been in the habit of going there and returning to Durgai close by, but had never been beyond Chappar. On the evening of the 22nd June I was sent for, and found him lying in bed, his face was somewhat flushed, and he complained of an agonizing headache and feebng out of sorts. The weather then, I may note, had been very hot and trying, especially under canvas, and we were all enduring considerable hardships. I desired him to walk out of his tent and have a cold douche, which he did in my presence. This gave him instantaneous relief, enabling him to take part in the evening conversation, but he retired early under advice. His temperature was taken regularly from the evening following, in which it was 99? F. Now, I date the commencement of the ailment from the 22nd, and the period of incubation must have been prior to that. We know that the period of this is generally from twelve to fourteen days, and that cases are on record where it
bed?and
saw
reasons
LUCAS,
F.R.C.S.
had been on the one hand twenty four days and on the other a few hours only. 1 came to hear after some days that there was then a case of typhoid at a neighbouring place called Kutch Amadun, in the person of an officer, and I had also been led to understand from intelligent and reliable sources that pythogenic compounds were rife at that place, and had been so for some time. I
applied to the medical officer there for information regarding his case, and the hygienic environments of his station or rather encampment. In an interview with him he very kindly placed at my disposal certain facts, which I am afraid would demand much space to describe here. But the bearing of it, in short, was that he was inclined to believe that it was at Gwal, on the road to Quetta, and not at Kutch Amadun that the case imbibed the virus, and took the infection, although the diseaso showed itself after arrival at the latter place, the intervening time being within the period of incubation. At Gwal his sanitary recommendations?which certainly, I think, and thought at the time, were deserving of the highest attention?were not acted upon. He had altogether eight cases (including that of that officer, and had two other officers subsequently^, and of these, he informed me, three died : in one of the latter ha made a post mortem examination and verified the usual lesions of typhoid. It is matter for regret that scicnti fic advice from the teachings of Professor Parkes or his pupil and successor in the chair of Hygiene should be thrown away ; but it was gratifying to learn that although the surroundings of Kutch were not sans reproche, some measures appear to have been adopted which certainly tended to minimize the evil effects We cannot be too careful in these matters of prevention, and it behoves officers in command to make it their utmost concern to pay heed to the recommendations of their medical officers. For the health of a regiment the medical officer in charge is primarily responsible. The distance between Chappar and Kutch is thirteen miles, and there was necessarily constant intercommunication between the two places by means of commissariat stores, sepoys going and returning as escorts for these; and the wind, moreover, had been from the west, which Kutch is to Chappar. That with the presence of a case at Kutch another could occur at Chappar was quite within the bounds of possibility: but why the contagium vivum should have operated on this officer, and not on any one of those men and officers who had ?
water and probably eaten food infected?I could not answer. But the onus probandi rested with Kutch to trace the importation of the typhoid poison to Quetta, or elsewhere. It will be seen that in the absence of knowledge of those cases of typhoid at Kutch Amadun, I might have erred in thinking the case at Chappar as of spontaneous origin. Still with that knowledge, we are hardly justified, I think, a fortiori, to infer that the one bears a causal relation to the other, for it is by no means impossible, though not certain, that they all might have had a common or even diverse fons et origo. been to
Kutch, drank
?
possibly
An adverse
these
cases
critic may, however, have declared that not those of typhoid, but a fever
were
only
THE INDIAN MEDICAL GAZETTE.
4
A. of Gordon?"Endemic and clirnatorial." This is easier said than proved, whereas a description of the salient features which I would have wished to have transcribed along with what is of the greatest importance and value
and aid in differential diagnosis, the temperature chart would have supplied positive evidence. These along with other papers and some valuables were lost in the move consequent upon the sad affair at Maiwand. I am extremely sorry for the loss of these papers, as in them were not only records of the temperature taken several times during the day and night, and also those before and after the cold bath and affusion, which treatment was
it
religiously persevered in,and
no one
appreciated
than the patient himself ; and I firmly believe that, had his temperature not been brought and kept down by this plan, the case would have terminated fatally. Only that part of the chart I have where the markings during the early part of the convalescence showed sub-normal indications in the mornings, and normal, or slightly above it, in the evenings, and when gradually they stood less sub-normal and more sit the normal point. The plan of treatment adopted was to give a large dose of quinine early in the morning; this dose varied with more
the period of the disease and according to circumstances from forty grains as the largest to twenty as the smallest, it was followed between 5 and 6-30 A. m. by doses of five grains every half hour, so that in this way I saturated the patient's system well with quinine before the time for hyperpyrexia approached ; and whenever
the temperature rose above 101? F. the cold bath and affusion were employed ; during the second and third weeks the bath was given from sixteen to four times in the four and twenty hours. The diet was carefully regulated, solid food was entirely withheld until after the fifth week, plenty of nutritious soups, broths, and milk and tinned being available), champagne constantly sucked through an Indian-rubber tube, port wine given in the early morning with eggflip. In fact the vital powers were well sustained. At the commencement of the diarrhoea no astringents were
(only goat's
diluted
was
administered when there were only two or three motions a day, but when more than half a dozen, carbolic acid with hydrate of chloral. Soothing by narcotism of the nervous system, I consider, is indicated, except where there is a tendency to coma and cerebral disturbance. Anodynes such as chloral and opium are most valuable remedies. The effeut of opium is most wonderful even with coma vigil. But, I may say, our chief aim in the therapy of typhoid, as I concern, is antipyresis, and the great source of danger is the hyperpyrexia. If we can control this we aro pretty certain of the issue of the case : and even with recovery, the convalescence is mental and bodily energy is soon restored, emaciation and loss of tissue being comparatively less. 1 would again urge, before concluding, that in doubtful cases, although a guarded diagnosis and prognosis be fortiter may be tendered, we, at the same time, should in re to adopt prompt preventive measures, as much
rapid, steady,
indeed
as
the
case
allow of and as much of true enteric fever,
surroundings
in reality were Jlurree, October 1880.
the
one
as
if
[Januatiy
1, 1881.
1881.]
NOTES ON ENTERIC FEVER.?BY JOHN C.
NOTES ON ENTERIC FEVER OR ABDO-
that the various causes?if there were in operation in the long
MINAL TYPHUS. on
Enteric Fever in
Afghanistan,
occurring there. By John C. Lucas, F.R.C.S. About this time last year an article on this subject was written by me, and published in this journalat the time of its going to press, the writer was but too sensitive of its manifold
shortcomings and solicitous to amend these ; but the subsequent additions and alterations, then made) were 011I3- in the hands of the Editor when the paper was already in type. Comme il fciut, it is now proposed to supplement in this issue what has appeared in a previous number. It will be remembered that after reviewing briefly the views of some of our more distinguished authorities, and noticing, more specially from the diagnostic hygienic standpoints, the symptoms and after-death
and
apto draw attention to and
pearances, the writer proceeded point out the directions in which, as it appeared to him, our endeavours should be directed and research prosecuted. A point of paramount moment and value, that of contagiousness in the literal and precise application of the term, was one of the points it was intended to embrace. One of our greatest living savants, John Simon, gives us this definition,?" The word 'contagion' is applied in pathology to the property and process by which, in certain sorts of disease, the affected body or part causes a disease like its own to arise in other bodies other parts ; and the Latin word contagium (pi. contagia) is conveniently used to denote in each case the specific material, shown or presumed, in which the infective property ultimately resides." This is the sense in which we understand and have been in the habit of employing the term. This matter of the proneness or otherwise of a person who comes into personal contact with a patient suffering from typhoid taking the disease?apart from imbibition of the contagium vivum from the intestinal discharges?cannot as yet, we think, be considered as settled once for all. We have at the same time a large or
accumulation of published evidence, both pro and con ; and the majority of advocates of the former view rest their belief, as far as we know, upon certain limitations of age as the sine qua non. The most recent testimony in favour of the contagiousness of typoid fever wherewith we are acquainted has been from the pen of a young and rising physician and sanitarian, Dr. Alexander Collie of the Homerton Fever. Hospital in London. He has for some years made the subject his own by special
study tilling
the fertile, though as yet uncultivated, field, and turning it to the best account?which not only will hardly fail to spread his reputation world-wide, but, what we think he will value far more, will aid in lessening human suffering and tending to prolong human life. From these tables it appears," he writes, '? that "
Indian Medical
Gazette, vol. XV., No. 2, pp. 35-40.
tables,
and
on a case
F.R.C.S.
whatever the cause, be it drains, stools recent or decomposed or personal contagion, their effect is determined by the age of persons. For it may lie fairly assumed
ORIGINAL COMMUNICATIONS.
With remarks
LUCAS,
so
operation
that, given or
a
cause,
were
various
period
whether
causes?
covered by the
continuously
not, the extent of effect would
depend
in
upon
the number of persons of the suitable or more liable Thus equal age ; in other words of persons susceptible. causative conditions would in different hospitals have different effects and in the same hospital at different times, varying in proportion to the varying number of the second factor?susceptible persons." He next proceeds to explain his meaning farther, and then says?'' in accordance with the law which the tables indicate, if the age of the persons were over thirty and verging upon forty, the probability of a small number would be great ; whereas, if the age of persons fell short of twenty-five, the probability of a small number would be slight." He gives tabular statistics of admissions, according to age ?in four of the London Hospitals?the Liverpool Street, London Fever, and the
Homerton?and, in discusses, not unsuccessfully, from the data at his own disposal, and also quotes from the published' reports of seven general hospitals, such as Saint Thomas'. He indicates how in these institutions, situated in different parts of the metropolis, the cases of the sisters, nurses, ward-servants, and of patients all varied with age ; and, it could not fail t occur to a reader perusing his articles?indeed, valuable contributions to science?and scanning them, pari passu, the little dependence that can be placed upon bare figures, especially with meagre or insufficient details ;
Stockwell,
the text he
the little faith that he may have had in mathematics
as
applied to our art will be irreversibly shaken, more particularly in regard to the momentous point on which Dr. Coliie justly has lain so much stress. Our knowledge of histological anatomy teaches us the changes which physiologically and normally do take place in the ileum, mesenteric glands, &c., and spleen (Kolliker) with age. We cannot but be strongly of credence, therefore, that this adds no inconsiderable weight to the arguments so ably brought to bear on this question by him. It would be well nigh impossible within the narrow limits of this paper to do adequate justice to this author, whose writings illumine and shed lustre on not only the columns of the journal0 from which the above passages have been extracted, but also those of several of its contemporaries,and his official annual reports. As an instance, it may be noted that an editorial writer of the Lancet~\ in noticing his report^ for 1879 says,? He makes also some important observations npon the element of ago in the question of immunity from the disease, giving tabulated data, with a view of showing that after thirty years of age few susceptible people are ' This element of age is, I be ieve,' he says, to be found. "
*
British Medical Journal, January 17, 1880. f Lancet, June 26, 1880. t How much better it would be for the profession if Indian Official publications were likewise placed oftener than they now are at the disposal of medical journals.
THE INDIAN MEDICAL GAZETTE. the reason of the relative immunity of nurses from enteric fever in certain hospitals, an immunity which might exist always, and be everywhere complete, if due regard were had to the age of those who nurse enteric fever ; yet this immunity would prove nothing against the views which I maintain, that enteric fever is con-
[January 1,
1881.
'
tagious'." To that,
be said
up Dr. Collie's views, so far, it may enteric fever is doubtless contagious in
sum
opinion, but this in inverse ratio to age within the limitations contended by him. That typhoid has prevailed in Afghanistan during the recent campaigns the writer has had sufficient evidence to convince. That the disease has been known to exist in the Punjab, Cashmere, and in Sind is now a tolerably well established fact. This being so, the occurrence of the disease in Afghanistan itself may be attributable to it. The study, amongst other things, of the subject of enteric fever there, offering as it did certain singular advantages, combined no doubt with drawbacks in respect to the elucidation of the still burning question of its origin, tempts me to make a kaleidoscopic gazeupon the cause of a case which came under my care in that country, and to make a few remarks upon the treatment which proved most satisfactory. When the camunfortunate as it has to paign, proved be, first com-
his
menced and troops were proceeding from India to that despicable and worthless land, it struck the writer with considerable force that the accumulated labour of
patient investigation by all the sion in Afghanistan, in what I
members of
our
profes-
virgin soil, would spark if not light to
term
appear to promise to throw some vanish the darkness. If a considerable amount of blood has been shed and lives otherwise sacrificed and lost, and money expended, it would doubtless be some consoleft a legacy, an iota lation to ourselves if science of benefit howsover small. For instance, if in every case of fever with anything like hyperpyrexia?unusual and, indeed, peculiar rise of temperature?accompanied with diarrhoea, the observer, without preconceived notions and without bias, looks for typhoid, makes thermo-
metric observations, examines the evacuations daily, searches for the rash ; this done systematically, and on the case, perchance, terminating fatally, after he had striven his utmost to save and stay life, obtains an autopsy : ascertaining from others, by means of courteous and encouraging notes on the lines of communication, whether they had had anything of the kind, communicating with others again whence the case, the regiment, or anybody belonging to the patient or the the latter corps, as the case may be, came : then asking
We must feel confident that if some such method were followed much good is likely^ or shall we say certain, to be attained, provided, of course, that all worked in a cordial tone and spirit and mutual harmony?bearing in mind that their reciprocal exertions and labours have in view, as the primum mobile, good to suffering humanity. Then, and then alone, we believe, will medical men, to use Lord Bacon's sublime language, to trace it up to its fount.
exert themselves for the general good, and raise their minds above the sordid considerations of cure ; not "
deriving their honours from the necessities of mankind, but
becoming
ministers of the Divine power
and
good-
both in prolonging and restoring the life of man." These learned words hold as good to-day as they did in the more classic days of the cleverest and wisest of mankind. I am of opinion that, unless complete and absolute faith is reposed in Murchison's pythogenic theory, or there is evidence to show that the disease did not exist prior to the arrival of our troops, there are two points to be considered, studied and settled, and thev are?(a) the importation of the virus from India, and (b) infectiousness from virus, sui generis, already extant in certain parts of Afghanistan and Beluchistan. So far as geography teaches us, there is no connection, by rivers, &c., between India and those two countries. ness
Nature had thought it prudent to separate the former from the latter by huge lofty mountains, devoid of life, which act as barriers against morbid (as well as
human)
The so-called "Scientific Frontier" being as if an isthmus of connection along the Khyber and Knrrarn to Northern Afghanistan ; while the barren wilderness, ' known as the Kutchy Plain, or Put,' which extends between Jacobabad and the place called Sibi (whic]t in Fashtu means commonly hell !) would, I think, be about the worst aerial medium for the spread of disease germ. the poison, or Bryden's atmospheric ' wave' which that able statistician again insists upfoes.
on, in
regard
cholera in India, can scarcely hold no water in the Kutchy to hold !). good for cholera according to recognized to
water, (for there is What holds
authorities, including
with equal
Pettenkofer, applies
force to typhoid. I venture, however, to
think
that
we
are
hardly
justified in arriving, per sallum, at a conclusion more particularly when after a little more thought wo easily perceive that our area of investigation is but
in comparison with the actual ground which we should have traversed. The case about to be described is so markedly in point that I trust it Avill not be deemed uninteresting should I attempt? what alone I can within the small and narrow limits here?but a camera obscura sketch. at my disposal Without the specific cause, as fusee, the followers of Btidd (alas! now dead since I last mentioned him in these columns) challenge proof of conflagration ; allow-
infinitesinal over
ing to the fullest extent the combustible nature of putrid fa3cal matter, it is not easy for them to be made Even to believe in the existence of a fons et origo mali. of incubation I am the possible longest period allowing in
a
position
come
to vouch
in direct contact
solemnly with,
or
that my patient had not been near a place where
there had been cases of typhoid; and, to quote the words of a French savant, M. Piedvache, we may say with him,?'' J'emploierai le mot contagion dans sa
signification
la
plu etendue, designant
sans
ce
nom
transmission de la maladie d'un individu sain quelque soit la mode suivant elle s'opere." That the poison of typhoid can be carried long distances between infected and non-infected places few will be prepared toute
to
deny.
While Professor
Tyndall
has shown
in
his
"
Transacwritings, and amongst them in the tions" of the Royal Society of London, that the highest
various
examined them in the field of have failed to reveal the particles of disease
powers with which he has
the
microscope
January 1,
germs.
The
NOTES ON ENTERIC FEVER,?BY JOHN C.
1881.] poison
had iti this
case
various
means
of
being brought to its subject. R Patient, Lieutenant E., of the Sappers and Miners, aged -27, arrived vvitli his company on the 24th of May at a place called Durgie, and lived in an upperstoried mud house forming part of a village deserted by the Afghans on their being pursued for the murder ?
of
Captain Showers. It was believed from what I could gather that they left it in March, and a detachment of one of the regiments of Sind Horse, under the command of same
an European officer, was encamped on the ground in which this company of Sappers after-
wards was, and the latter officer had occupied the same where my patient afterwards lived, and before the former the Agent of the Governor-General for Beluchistan. There is a missing link or two here which I could not ascertain, and that whether there was rooms
among any body belonging to the camps of these two officers ; there was, I may observe, no typhoid in the company of Sappers before. I came to learn that the time when it arrived at Durgai, the camping ground, although it showed signs of previous and recent occupation, was not in a dirty state, but the mud rooms of the village were ; but those in which these officers lived successively, I understood, were least so at the time. No case of severe fever occurred in the company during its stay there ; but there were several diarrhoea and dysentery. On my arrival at cases of Durgie with another company, on noticing the cases of bowel complaints, I visited the spot from which water
typhoid
was
obtained,?from
?
flowing
stream
to condemn it.
over
a
gravt-1
On the 30th May left Durgai Temporarily and rode part of Lieutenant the way towards the Harnai side of the valley for some ten or twelve miles to see a brother officer off on the I gleaned that on cantering latter leaving for England. back he dismounted and drank water from a stream. I know the country about there, which is irrigated, and sewage appeared to be utilized largely as manure there ; and I also remembered that on marching through it there were several cases of gastro-intestinal symptoms, He went to but none of typhoid, and not even since. Chappar on the morning of the 19th June, but had been in the habit of going there and returning to Durgai close by, but had never been beyond Chappar. On the evening of the 22nd June I was sent for, and found him lying in bed, his face was somewhat flushed, and he complained of an agonizing headache and feebng out of sorts. The weather then, I may note, had been very hot and trying, especially under canvas, and we were all enduring considerable hardships. I desired him to walk out of his tent and have a cold douche, which he did in my presence. This gave him instantaneous relief, enabling him to take part in the evening conversation, but he retired early under advice. His temperature was taken regularly from the evening following, in which it was 99? F. Now, I date the commencement of the ailment from the 22nd, and the period of incubation must have been prior to that. We know that the period of this is generally from twelve to fourteen days, and that cases are on record where it
bed?and
saw
reasons
LUCAS,
F.R.C.S.
had been on the one hand twenty four days and on the other a few hours only. 1 came to hear after some days that there was then a case of typhoid at a neighbouring place called Kutch Amadun, in the person of an officer, and I had also been led to understand from intelligent and reliable sources that pythogenic compounds were rife at that place, and had been so for some time. I
applied to the medical officer there for information regarding his case, and the hygienic environments of his station or rather encampment. In an interview with him he very kindly placed at my disposal certain facts, which I am afraid would demand much space to describe here. But the bearing of it, in short, was that he was inclined to believe that it was at Gwal, on the road to Quetta, and not at Kutch Amadun that the case imbibed the virus, and took the infection, although the diseaso showed itself after arrival at the latter place, the intervening time being within the period of incubation. At Gwal his sanitary recommendations?which certainly, I think, and thought at the time, were deserving of the highest attention?were not acted upon. He had altogether eight cases (including that of that officer, and had two other officers subsequently^, and of these, he informed me, three died : in one of the latter ha made a post mortem examination and verified the usual lesions of typhoid. It is matter for regret that scicnti fic advice from the teachings of Professor Parkes or his pupil and successor in the chair of Hygiene should be thrown away ; but it was gratifying to learn that although the surroundings of Kutch were not sans reproche, some measures appear to have been adopted which certainly tended to minimize the evil effects We cannot be too careful in these matters of prevention, and it behoves officers in command to make it their utmost concern to pay heed to the recommendations of their medical officers. For the health of a regiment the medical officer in charge is primarily responsible. The distance between Chappar and Kutch is thirteen miles, and there was necessarily constant intercommunication between the two places by means of commissariat stores, sepoys going and returning as escorts for these; and the wind, moreover, had been from the west, which Kutch is to Chappar. That with the presence of a case at Kutch another could occur at Chappar was quite within the bounds of possibility: but why the contagium vivum should have operated on this officer, and not on any one of those men and officers who had ?
water and probably eaten food infected?I could not answer. But the onus probandi rested with Kutch to trace the importation of the typhoid poison to Quetta, or elsewhere. It will be seen that in the absence of knowledge of those cases of typhoid at Kutch Amadun, I might have erred in thinking the case at Chappar as of spontaneous origin. Still with that knowledge, we are hardly justified, I think, a fortiori, to infer that the one bears a causal relation to the other, for it is by no means impossible, though not certain, that they all might have had a common or even diverse fons et origo. been to
Kutch, drank
?
possibly
An adverse
these
cases
critic may, however, have declared that not those of typhoid, but a fever
were
only
THE INDIAN MEDICAL GAZETTE.
4
A. of Gordon?"Endemic and clirnatorial." This is easier said than proved, whereas a description of the salient features which I would have wished to have transcribed along with what is of the greatest importance and value
and aid in differential diagnosis, the temperature chart would have supplied positive evidence. These along with other papers and some valuables were lost in the move consequent upon the sad affair at Maiwand. I am extremely sorry for the loss of these papers, as in them were not only records of the temperature taken several times during the day and night, and also those before and after the cold bath and affusion, which treatment was
it
religiously persevered in,and
no one
appreciated
than the patient himself ; and I firmly believe that, had his temperature not been brought and kept down by this plan, the case would have terminated fatally. Only that part of the chart I have where the markings during the early part of the convalescence showed sub-normal indications in the mornings, and normal, or slightly above it, in the evenings, and when gradually they stood less sub-normal and more sit the normal point. The plan of treatment adopted was to give a large dose of quinine early in the morning; this dose varied with more
the period of the disease and according to circumstances from forty grains as the largest to twenty as the smallest, it was followed between 5 and 6-30 A. m. by doses of five grains every half hour, so that in this way I saturated the patient's system well with quinine before the time for hyperpyrexia approached ; and whenever
the temperature rose above 101? F. the cold bath and affusion were employed ; during the second and third weeks the bath was given from sixteen to four times in the four and twenty hours. The diet was carefully regulated, solid food was entirely withheld until after the fifth week, plenty of nutritious soups, broths, and milk and tinned being available), champagne constantly sucked through an Indian-rubber tube, port wine given in the early morning with eggflip. In fact the vital powers were well sustained. At the commencement of the diarrhoea no astringents were
(only goat's
diluted
was
administered when there were only two or three motions a day, but when more than half a dozen, carbolic acid with hydrate of chloral. Soothing by narcotism of the nervous system, I consider, is indicated, except where there is a tendency to coma and cerebral disturbance. Anodynes such as chloral and opium are most valuable remedies. The effeut of opium is most wonderful even with coma vigil. But, I may say, our chief aim in the therapy of typhoid, as I concern, is antipyresis, and the great source of danger is the hyperpyrexia. If we can control this we aro pretty certain of the issue of the case : and even with recovery, the convalescence is mental and bodily energy is soon restored, emaciation and loss of tissue being comparatively less. 1 would again urge, before concluding, that in doubtful cases, although a guarded diagnosis and prognosis be fortiter may be tendered, we, at the same time, should in re to adopt prompt preventive measures, as much
rapid, steady,
indeed
as
the
case
allow of and as much of true enteric fever,
surroundings
in reality were Jlurree, October 1880.
the
one
as
if
[Januatiy
1, 1881.
