NOTES ON ENTERIC FEVER.

By P. E. Hogg, M.D., Surg eon-Major, A.MD. 1873, a battery of Horse Artillery, fresh from home, suffered severely at Meerut, where the sub-soil level from 14 feet in September 1869, rose in 1870 to 13 feet; in 1871-1872 to In

12; in 1873 to 11 ; and in 1874 to 9 feet 6 inches: the proxthe Ganges canal, and certain questions connected with and irrigation were blamed by some, yet denied by others. In 1872, cholera appearing at its usual date, August

imity of drainage

was complicated with fever and dengue. On a march Futtyghur to Meerut, a detachment of the 85th contracted enteric at Khoorja, on a camping ground near a crowded feverstricken village ; the well water was near the surface, the sub-soil saturated, undrained, and the extensive neighbouring j heels at times resembled arms of the sea. Between December 1874 and the middle of January 1875,

20th,

from

about When March

19 cases of undoubted enteric occurred with 4 deaths. encamped at Khoorja, whilst returning from Agra in 1876, personal enquiries and observations led to the con-

clusion that the fever was typho-malarial. With one exception, all the affected men of the 85th were over 25 years of age, all had been four years in the country, two never out of it?quite

contrary to accepted experience, for it is the young unseasoned, weakly, scrofulous new arrivals, who as a rule at particular stations, under certain conditions, meteorological amongst others, start enteric, which is apt to cling to regiments until the poison is starved out, through want of victims. In addition to climate there are to be considered, irrespective of the water theory, connected with barracks, food, bedding, clothing abdominal belts), bodily cleanliness, drills, fatigue, recreation; and, although the disease is started by faulty conservancy, by fseoal exhalations, it requires a suitable soil for birth, progress, and extension. Very little is known about matters

(helmets,

or how far the silting up of the beds of rivers, the construction of barriers to the flow of water, as railway embankments, and irrigation by means of canals, affect the health of the inhabitants. Seasoned sojourners exposed to typho-malarial

malaria,

influences escape enteric, yet every year are debilitated by ague. No month in certain years would appear clear of enteric, but the

September, and low from November days in August 1873, were notable, because almost every station, over several enormous areas in India, returned cases. The fatal age is 22, and the worst subjects often are light-haired, pink-faced, fragile lads, who in the hot weather suffer more seriously than in the cold. Sportsmen, exposing themselves to the sun, or wading through malarious jheels appear very susceptible. Whether the disease be imported or start afresh, the results are the same, just as one case recovers, another crops up ; but fortunately in the opinion of many, the deaths have been reduced to a minimum by the cold bath or wet admissions onwards

:

are

highest

in

about the last ten

sheet treatment.

The water level at Meerut in 1875 stood, I believe, the same in 1874, but cases of fever were singularly few, a mild visitation of cholera appearing instead. For years, the existence as

typhoid fever in India has been denied, until closer clinical, thermometrical, and pathological observations silenced the sceptics. Every year susceptible young men come to India, and some drafts suffer, whilst others escape ; but the great point is to deal very gently with new comers, who, strangers to the climate, are easily enervated by heat. The water nt Meerut has always been considered excellent, and the M^cnaLads who go to the mara filters are constantly looked after. hills directly on arrival in India, may, on return to the plains the next year, develop enteric ; or they may suffer mildly at the hills- At one of the Lawrence Asylum schools in the Himalayas, 5 children died of enteric in 1875. In the plains, a case of enteric, after long struggling, diverted into fatal cholera. In a military epidemic in Germany, the

of

November 1,

NOTES ON ENTERIC FEYEE.?BY F. E. HOGG, M.D.

1876.]

violence and continuance of exercise and drill, followed by exposure and chill, were blamed as the cause of fever. "When Louis Philippe went to St. Cloud, 1,200 soldiers were packed into a space for 400, and enteric followed. Horses, dogs, and, I die of this fever. llussell Reynolds' and

believe, In

cats

exhaustive

Aitken's works will be found In England, predisposing influences include foul sub-soil,

articles

on

the

subject generally.

certain causes or or around

houses, arising from dirt, want of drainage, long occupation; old houses with plaster floors, and walls saturated with impurities, over-crowded, unventilated;

under floors,

open latrines, cess-pits, dung-heaps near habitations ; sewer air from faulty engineering ; water contaminated with putrescing The Sanitary Commissioner for Madras, reported in matter.

1876, that typhoid fever at the Hill station,

Ootacamund,

6,000

feet above the sea, depended on the absence of a healthy plan and construction, of proper arrangement of houses, of efficient drainage and cleansing, so that the ground has become sodden with filth, and on the pollution of water sources. One attack of enteric, as a rule, confers immunity for the future, so that native adults, having graduated in infancy, are safe; but the belief is gaining ground, that a large number of native children die of enteric. There are many expensive difficulties connected with the earth system of conservancy, aud it has been suggested that it would be cheaper to lay down pipe-sewers to remove both solid and liquid excreta outside stations, to places where

sewage farming might be conducted. Many believe also in the idea of cheap, temporary barracks of mud and straw, periodically to be destroyed, and the situation changed. The enormous ex-

pense of sanitary storms, cyclones,

improvements ; the uncertainty connected with earthquakes ; the periodic epidemics; excessive or Bcantv rainfall, drought or inundations, caprice of river courses; native poverty and prejudices must ever be remembered. Considerable apathy and disregard of danger exist even amongst educated Europeans, on the subject of conservancy. "Weary, dreary work is it for medical men to be eternally urging that the earth system be carried out in its full integrity, and only to find warnings and remonstrances disregarded. What with the free use of tar and earth about latrines, there ought to be a perfect freedom from all effluvium. A good quarter-

with a sufficient and an efficient staff would be At some place, the natives would defile the ground until the hand of the Prophet, or other religious symbols, were painted on the adjoining walls. The ground may be reticulated with old cess-pools, or materials may soak through the soil from master

invaluable.

cess-pits, or from being merely thrown on the ground, and thus obtain access into wells. Every body knows the native pollution of drinking water, and neither boiling nor filtration of the latter can guarantee safety. Iu the 23rd volume of perfectly

the Medical Annals is an exhaustive report by Dr. Clarke on typhoid fever at Jutog in 1866, when 17 out of 67 boys were attacked and recovered. The disease at all Hill stations is far easier to treat than in the burning plaitis down below. Jutog,

comprising a small plateau or terrace long and a quarter of a mile bro;id, about three miles distant from Simla, nad been occupied by GoorKhas uutil the mutiny, and for about four years by Bishop Cotton's school for boys of European and mixed parentage. The rocks mostly consist of impure lime-stone and metamorphic schists; the water supply is excellent, from springs bursting 7,000

three

feet above sea level, quarters of a mile

out of the precipitous hill side, there is a small bazar at a reasonable distance; the food is fair; the vessels regularly tinned ; the ground is freely intersected with deep and precipitous water courses, which were dammed up in three places, so as to form small fringed with trees, and one with much

ponds

; the boy's were somewhat

under-growth

parents, blankets, quilts,

boys

were

clothing

and

bedding, supplied by

the

deficient in shirts and sheets; the mattresses might have been cleaner, and the

indifferently

shod.

291

Drs. Clarke and Cuningham blamed deficiency of space, area and ventilation?each boy had 49 superficial and 524 cubic feet. Most of the cases came from a dormitory near and over a neglected latrine ; the earth system was not then adopted. Evidently prolonged exposure to sewer air, was the chief cause of sickness. The ages ranged from 5 to 24 (the adult, a master), the average being 14 ; those who had been there three years escaped; Europeans and Eurasians suffered alike; fever lasted from 14 to 45 days, average 29; 15 boys had diarrhoea, 10 developed Bpots, 7 were delirious, 4 had epistaxis ; abdominal pain was rare; sordes uncommon ; the pulse, as a rule, feeble, jerky, had Treatment included fever mixture, James' a double beat. powder; but whilst quinine and chlorate of potash proved useless, acetate of lead, turpentine, castor oil, and simple medicines Some of the healthy boys were useful, aided by simple diet.

sent into Simla shewed fever, in one instance after 7 weeks' incubation; other boys sent to distant homes remained well. The epidemic lasted from July to November. From 1869, until a present date, Jutog has been occupied by Mountain Battery of relieved. The health has continued excel-

Artillery, periodically lent, and in 1874 Dr. Simons shewed me over the place, and was happy in having no history of enteric to tell. His Battery went from Jutog to Delhi, eventually to Khyra Gully, and there curiously enough a man aged 25, of five years' service, nearly all in India, suffered and recovered from enteric?the only case, and the only light thrown on it, was that of faulty conservancy, Mr. Grant Duff writes, that it will require soon remedied. India can be raised to many millions of money outlay before the level of civilized countries. Such being the case, we must make up our minds to expect typhoid, and to study its prevention and treatment. Very many recover, yet not a few remain deaf, foolish, debilitated, wasted. Relapses are very common, convalescence is tediously protracted, and no immunity from ague follows. Perhaps for a couple of years, a man continues cowed, stolid, taciturn, rheumatic, neuralgic, nervous, unable to exercise authority or judgment. Twitching of the face, swelling of the legs, a tendency to constipation or tape-worm may follow. "Without in the least doubting the sub-soil level, the drinking water, or the milk theory, these questions will not now be discussed at length, but it may be mentioned that typhoid has suddenly subsided where the well has remained polluted, and typhoid has returned to places considered secure by the drinking water having been changed or purified. Pettenkofer, who mentions that water is never accused of causing small-pox or scarlet fever, dwells on the fact that inhabitants drink one and the same water, and yet only some suffer from typhoid, whilst others escape. The observations at Munich for 16 years, go to prove that the most violent epidemics coincide with the lowest level in the soil water.

It must ever be

re-

membered, that typhoid loves to fasten on the scrofulous young whose glandular system is so sensitive. Many years ago, Dr. Allan Webb believed that consumption in India remained latent or unrecognized, because those affected died of diarrhoea, or dysentery, before time had been allowed for the growth of tubercle in the lungs, in such quantity as to impair their functions and lead to their ultimate disintegration and disorganization. Dr. Ewart considers that the tubercular growth, once commenced in the lungs in tropical countries, is seldom positively and successfully arrested; and that the longevity of strumous and phthisical persons, is not promoted by residence in any part of the plains. It might be argued that the scrofulous lad is the fire-ball, who in his own body develops typhoid, possibly fatal to himself, dangerous to others susceptible, yet harmless to many more, including the strong middle-aged, or those protected by a previous attack. Heat, foul air, and over-fatigue telling on new comers, who suddenly find themselves transported from England to India, all encourage the birth of typhoid. Menstruation, pregnancy, clothing, in-door life, somewhat protect women, but after menorrhagia or hemorrhagic labours

THE INDIAN MEDICAL GAZETTE.

292

or if irregular or barren, they are susceptible. The congested liver cannot neutralize the poison nor arrest putrefaction ; the ?weak points, whether in heart, lung, brain, or kidney go to the "wall; the impoverished blood is vitiated, and the delicate vascular of the lower portion of the ilium may rapidly become

glands

of the bowel take place. All gangrenous, and perforation this terrible trouble often springs from preventible causes. For 15 months Croydon had 1,200 cases, 90 fatal. No precautions had been adopted to cut off direct communication of sewer with Sewers were unventilated. The water-pipes in house drain. had such relations with the sewer, that during intermis-

places

sewage was sucked into the water supply ; the The water supply, same resulted with the pipes running full. after a fashion continuous, started pure from the fountain head,

sion of

service,

No rainbut sewer gas getting into the pipes polluted the flow. fall connection had the fever. In India, under an entirely different and primitive system, the filth-trenches in a waterlogged soil may be too deep, instead of near the surface, any

well may thus be polluted: on

in the

blazing

no

hot weather.

drying up Under such

or

disinfection goes this

circumstances,

refusa retains its virulence until the rains and the sun's fierce play after, when our enervated bodies, enfeebled by the prolonged previous heat, are so liable to attacks of disease. According to

Anneslev, typhoid

has

always

existed in India under other

; and tne treatment formerly included scruples of calomel, drachms of jalap, sulphate of soda in abundance, scores of leeches, with very little reference to wine support and suitable names

It is not clear whether

food.

or no

dysentery, hepatic abscess, or subjects, there is a tendency

induce

this

particular poison

can

rheumatism.

"With to bed-sores from the very some first, and with others to ulceration and sloughing of the cornea: occasionally hematuria may occur. Not long ago, a young acute

teething infant at Meerut, whilst suffering from fever, passed bloody urine until the ague was checked by quinine. Typhoid

may be confounded with acute tuberculosis, but in the latter the pain is not localized, and a lengthened period of ill-health precedes- One disease may divert into the other. Typhoid may be imported, remaining dormant until encouraged by heat,

irregularity of diet, defective sanitation, poisoned putrid air. It may be that the seeds of disease finding no welcome, wither away in certain bodies considered susceptible. The incubation may be long, 6 weeks or longer, but tlie average is from 7 to 21 days. One definition is, that the disease is an insidious, congestive, intestinal fever or internal fermentation, the contagion not conveyed by medical men. There is prolonged vascular congestion, and the poison rapidly conveyed to the liver sets up functional paralysis and a putrefactive action. All agree that the Peyers-patches in the ilium are specially attacked, that the blood i3 poisoned simultaneously, and that the nervous symptoms depend on inanition. Comparatively easy is it in England to recognize the spots, but out here, what with dusky skins, flea or musquito bites or prickly heat, it fatigue,

water or

becomes very difficult to make certain ; but we do not want the spots for diagnosis, when so many other symptoms stamp the disease. According to Bryden, spontaneous origin of the disease was undoubted at Rawul Pindee, Mean Meer, Jullunder, Agra, and Hazareebagh. It at first may be

cunningly disguised, either as simple or remittent fever, ague, dengile, tonsillitis, diarrhoea, colic, hepatitis, pneumonia, rheumatism, bronchitis, epilepsy, inflammation of brain or spleen ; and it may not be suspected, or diagnosed till after death. Very many never develop diarrhoea, and some rapidly sink, comatose, as if poisoned by chloroform, alcohol, prussic acid, atropine, or snake-bite. At Poonah, an old soldier, aged 40, fatally collapsed after ague, had the peculiar ulcers of the bowels. Old people who have never left their homes, are occasionally stricken. The abdomen mav be soft, supple, undistended, free from pain, clear cf eruption, and yet typhoid may be present. Extensive lung disease has caused death, when the ulcers in the ilium had barely commene-

ed.

[November 1,

There

may be granular or those of the legs incline to

muscles,

It is said that the disease is

more

waxy waste

prevalent

degeneration

187G.

of the

and may rupture. in the cold weather,

sunstroke may be contracted at Christmas in India, the European, excepting in the early morning, is ever exposed to heat. "With great curiosity reference is made to a Report of Observabut

as

the Soil in its Relation to Disease, by Drs. Lewis and worked out at Calcutta. The amount of moisture in the soil, its temperature, and the amount of carbonic acid in soil air, were carefully investigated for a year. For car-

tions

on

D. D.

Cunningham,

bonic acid, observations were taken at 3 and 6 feet from the surface, and in the upper layer there was a fall until May, a rise in June, fall in July, great rise in August and September; and, little difference, the same results were observed with the In January there was a short rise in each layer. There were curious variations in the amount of carbonic acid in the soil at short distances apart. No clear relation of any kind existed between atmospheric temperature and amount of carbonic acid in the soil. There was a coincidence of conditions with with

a

lower

layer.

general coincidence with the water level, velocity of the wind. The greatest prevalence of fevers occurred, coincidently with the period of maximum carbonic acid and highest water level. It is noticed also that the casualty reports on enteric, allude to lung infiltration, pneumonia, phthisis, dysentery, peritonitis, hepatitis, tonsillitis, abscess of muscles, collapse ; to the curious and varied complications of remittent fever, convulsions, embolism, clots in left hemisphere of the brain, phlegmasia dolens, neuralgia, otorrhoea, enlargement of spleen or liver, the frequency of epistaxis, stupor, intestinal haemorrhage, deafness, delirium, the association of tape-worms, the enlargement of the solitary glands, and above all things, the risk of perforation when a hole (even two or three), the size of sixpence, may be found the but

also a with the

rainfall, none

Any sudden strain or movement, sneeze cough, irritating food or medicine, a fit of anger, distress of distended bladder, a thousand things may irritate the corroding

in the small intestine. or

ulcers,

and

rupture,

or

follow the extension of sloughing, Klein fancies the intestinal lesions to be and micrococci. Typhoid attacks all

perforation

laceration.

connected with fungi classes of society, but the prognosis is often worse in females, the aged, or the new arrivals in infected districts. Persons in good

often attacked, and the existence of other maladies may not avert attacks of this particular fever. The greatest aid to diagnosis is the thermometer, which proves that temperature rises during the congestive stage, remains stationary during ulceration, and then falls gradually in favourable cases. health may

are

or

The ascent, as pointed out by "VVunderlich, Aitken, Roberts, and others, is quite regular and gradual, and continues for four or five days. The evening temperature is about 2? higher than that of the morning, and there is a remission each morning of about 1? compared with the previous evening, so that there is a daily rise of about 1?, and at last the evening temperature eofnes to be from 103-5 to 104. The stationary period varies, according to severity, perhaps between 104? and 106? in the evening, the morning remission being very slight. Roberts, just now quoted,

states the temperature may reach 107? or 108.? The decline is gradual, and indicated by a more distinct morning remission ; in three or four days, the evening temperature falls, and the morning

remissions indicate a difference of 2?, 3?, or more. Complications, sequelae, irregularities, or a relapse will shoot up the temperature again, Cases are seldom recognized until the second week. The patient wonders why his nose bleeds, why he is so sleepy, listless, torpid, fatigued hy day, restless, hot and

burning

at

night

;

tongue, muscular pains, fort

or

wind about the

no

appetite,

nervous

excessive

tremor, great

bowels,

headache,

thirst, kunkurdebility, discomnausea,

irritable

stomach, foul breath, amongst other symptoms are noticed. Very often the poor fellow, troubled by constipation, has taken an aperient, which acting violently, sends him to hospital.

Noyembeti There,

his

1,1876.]

drawn,

NOTES ON ENTERIC EEYETC.?BY F.R. HOGG, M.D.

anxious face arrests

attention,

the

pupils

are

dilated, the pulse small and feeble ; the thermometer tells the rest, and the patient is put to bed, if possible, in a separate room, with strict injunctions as to disinfection of excreta at once. In England milk conveys the disease, and amongst other

youth, autumn drought, improper diet, fatigue, excitement, heat, are noted. Sour beer has been blamed, also tough meat, the flesh being of a flabby consistency and of a dusky dead hue; but it may be due to general or local causes, or cliThe poison works slowly. In a room at matic influences. Gwalior, where everything but the walls and ceiling had been cleansed, one man died in February. At the beginning of causes,

another brought his bedding and cot to same room, and the 21st, died of undoubted typhoid, which the first man had, according to belief, imported. The 11th Ilussars had typhoid at Colchester in 1866 ; they carried the same to Mhow, where another regiment had been stationed for years, free and

April,

on

healthy, and at Muttra as well as Umballa cases occurred, until eventually the fire burnt itself out. A young French army sent out to Algeria, a young American army thrown into the Southern States, and also young English regiments landing at the Mediterranean stations, the Cape, China, Japan have all been stricken with typhoid. The poison, said to be heavy, is not portable like variola, scarlatina, or measles: there are no doubts about spontaneous origin where places are favourable, snd where bodies are susceptible, as in schools, with a history of fascal emanation, sewage air, sewage water, or with, perhaps, With a full belief that the poison has been rats in the cistern. maturated in the human body, all practitioners arc fully impressed with the expediency of disinfecting excreta, which must be kept separate to prevent spread of disease by inhalation. In India, where it is not always practicable to isolate patients, the sweepers have to be constantly watched, and unless attendants are conscientious, trustworthy, fully alive to every emergency, the patients run great risks, and.the poison spreads. So it does, if any important duty is delegated to a native, who cannot understand, or in the slightest degree sympathize with the case. In busy times, the excellent Medical Subordinate Department may be short-handed or over-worked, so it is a capital plan to train soldiers, as orderlies, instead of taking any man haphazard to wait

on a

critical

case.

Lord Napier never could forgive a drunken attendant, for mercy in such a matter, cruelly punishes the helpless sick and

Buffering. An intelligent, zealous man, with an aptitude for the work, down on the clinical chart Boon picks up the essentials and dots the events of the day. These charts can be made very simple, go that at a glance, pulse, respiration, temperatuie, excreta, skin, urine, night report, special or local symptoms, any change, effect of medicines or baths are noticed, and also preserved for daily reference. To test the uriae for chlorides or albumen is a very simple matter of routine. When women are stricken, it depends very much on the season of year, whether relays of competent nurses are procurar ble in feverish stations, when either husband, wife or child being sick, upsets all arrangements. For disinfection, Dr. Kellett believing in large ovens for bed-steads, small portable ones for camps, suggests that all sxcreta be received into chloride of lime first, then place the same in a 10-gallon glazed earthen-ware vessel, cover contents with charcoal, place in a furnace and burn. Suspicious bedding or clothing to be burnt also if not disinfected by heat? a point not easily determined, nor will cotton fabrics stand a heat 28 degrees more than that of boiling water, without beiDg damaged. Afterwards the patient, if possible, should be separated from those susceptible, and for a long time should use a special atrine. If dysentery follows blows on the head, it is reasonable to believe that exposure to the sun of a weakly lad, iudiflerenl-

293

ly protected about the head, might conduce to typhoid. Some boys in hospital will get out of bed without leave, fling off bedclothes or belly-binders on chilly nights, or manage to indulge the craving for interdicted food. When the temperature suddenly falls, with intense pain over the bowels, irritation of the bladder, the patient collapsed and blue, the pulse thready, the skin clammy, the breath cold as in cholera, perforation has occurred, and the end is at hand almost invariably. A young soldier aged 23, whilst under treatment for enteric in Canada, was ordered by Dr. Boileau not to sit up, but the poor fellow disobeyed, and whilst taking a drink, suddenly died. The enfeebled heart propelling poisoned blood became paralysed, and the right side was filled by a fibrinous clot. The heart is often weak and feeble, the intermittent pulse perhaps sinks afterwards to 40, and the prominent pulsation in the epigastric region, associated with hepatic enlargement or dilatation of the right ventricle, is sometimes suggestive of One objection raised to hydropathic treatment is aneurism. the tendency to constipation. What matter is it if the bowels be locked up a week or longer; it is easy to use mild warm water or olive oil enemata at intervals. Castor oil, ^eidlitz powders, preparations of nux vomica, violent inunctions or galvanism, may only irritate the old, or start fresh ulcers. Each ulcer taking 14 days to cicatrize, commences this process in the third week; the healing is accomplished without any puckering, contraction, or constriction of the gut, and there is no induraBut the process of healing may tion as in tuberculous ulcers. be long delayed, and the cicatrices are seen years after. After injudicious purgatives, the temperature shoots up, the patient starts, twitches, grows deafer, and grinds his teeth ; there may be high morning temperature, short remissions, quivering of the tongue, jerking of tendons, vomiting, diarrhoea, delirium,

Instances are on record of return of abdominal distention. merchants in their offices, or clergymen in the pulpit dying of bowel perforation, and patients cannot afford to have relapses. A tight belt, muscular fatigue, bringing a gun into -

action

or

military

excessive

riding, would

of course be detrimental to

convalescents.

Amongst the many remedies, unless the patient is reduced there appears no objection to mild leeching the bowels, but adopting hydropathic treatment dispenses with depletion. Cases can and have been personally treated without a drop of any stimulant whatever, but such practice is not commendable, for wine is a grand medicine. West has satisfactorily given 12 ounces of wine and 4 of brandy to children even, not above ten years of age, as a daily allowance. So long as ice is kept to the scalp and stupor averted, the

by heat or malaria,

over

of wine can be increased. The only plan to check the craving hunger at times, is to give the patient small dose3 of ipecacuanha in pills, and in the opinion of many, this drug has some specific beneficial effect in these cases. The influence of fatigue conducing to enteric, must not be forgotten, nor that

amount

of climate, enervation, as well as the unknown risks connected with damp or infected straw in beds, or the insufficient airing of bedding. The young arrival, after a restless night of heat, and off to when reveille discomfort, musquitoes, just drops sleep sounds; the exigencies of duty may involve his remaining some time in the forge, or in a hot harness-room, polishing

chains, bits and buckles, which in certain seasons at various places are so difficult to keep blight, glistening, and fit for inspection. Thirsty after riding-school, the incautious, ignorant new comers are apt to court cramp or colic, by drinking excessively of cold water, and it does not follow that the enterprising "pop-wallah" uses unpolluted water in his manufactory

in the bazar.

In this fever, some consider that a watery acid bile is secreted, instead of a thick, heavy, alkaline fluid. The liver, bv its antiseptic properties, should prevent the decomposition of chyme, and if it cannot do this, fermentation, foul gas, abdo-

THE INDIAN MEDICAL GAZETTE.

294

minal distention follow. The evacuations are usually ochrey, ' but Farrell in India, finds them brown, black, or many-tinted ; and he particularly notices abdominal tenderness, frequent epistaxis, uncertainty of eruption, and the paroxysmal character of the fever. Most writers agree that the ulcers range from a line to an from a hemp seed to a crown-piece in dimensions, and Murchison states there is no commence about the 9th day. previous congestion, and that a deposit has been met with on

inch,

the 1st or 2nd day, whilst Trousseau believes in the 4th or 5th. The blood poison may act very rapidly, with a small, rapid pulse, quivering or retracted tongue, cold, clammy sweats, smell, and gas has been detected in the veins of the

putrid

neck. may be associated with

pleurisy, scarlatina, dipherysipelas. Heavy drinkers occasionally escape, and as at Bermuda; probably the toptrs were middle-aged less susceptible. Indian troop-ship's arrangements and rations were for a time blamed, but the case was not proved. Typhoid

theria, croup,

or

The instances either of scarlet

mostly

occur

in vessels

or

enteric fever in the navy, the

frequently communicating with

shore.

epidemic at Lyons from April] to May 11874, adult females suffered mostly, and next, boys of the children class; great debility, epistaxis,rheumatic pains, bronchitis were especially noticed. The abdomen marked with rose spots was generally supple, undistended, insensible to pressure; diarrhoea was very exceptional. Amongst the poor, where certain sewers In

an

did not exist, there was no fever. In an Irish epidemic in 1826, traced to sewer gas plus something, Stokes records the association of jaundice, black vomit and evacautions; the nose cold, pale, livid, purple, and inclined to gangrene, the spleen enlarged, soft; the liver as also the extremities; In my note-book amongst brief extracts, of enteric have been traced to strangers using dung heaps as latrines ; instances of well to-do persons affected in isolated healthy localities; of drunkards dying in 14 days,

as a

rule, healthy.

I find that

cases

by diarrhoea and haemorrhage ; and the case of a boy who at the age of 9 died of enteric fever, when besides the usual characteristic ulcers, his liver was a mass of small abscesses. In India, the question crops up concerning the risk of locating troops on ground, loug occupied by natives. At Hazareebagh?2,014 feet, rainfall 52 inches, humidity 42, exhausted at

Bristol,

between 61 in December to 86 in June, sanitarium?enteric has fastened on new A great deal might be said concerning the pulse incomers. creasing in beat (not in volume), its intermission, and slowfeeble character. Mahomed notices the pulse may not be dicrotic, else fully or hyper-dicrotic; full, hard, not dicrotic

average temperature a

74,

bracing, healthy

when Elbumen co-exists;

undulating and hyper-dicrotic with lung complication, flickering after severe haemorrhage. Amongst the many consequences or complications, the debility, mental and bodily, the stupidity, emaciation, deafness, chance of paralysis, the lighting up of mischief in brain, heart, lung, kidney, liver or spleen, the various ulcerations, bed-sores, the risk of damage to the eyes, joints, glands, veins, muscles, bones or throat, have all to be thought of. A man and his wife fell sick immediately on arrival at Meerut in 1874 ; he recovered after a desperate attack of enteric, and she died of abscess of the liver. The urine in enteric is diminished, and uric acid are in excess, chlorides conspicuously absent, and albumeu occasionally present. The excreta contain albumen, chloride of Bodium, carbonate of ammonia, crystals of

urea

triple phosphates, epithelium, mucous corpuscles, small yellow flocculi, shreds of slougb, blood, &c. Very often in India, the term typho-malarial more aptly defines ent6ric fever. Authenticated instances of water poisoning are on record, also the immunity conferred by drinking from canals or rivers

instead of wells, in

England,

or

[November 1,

1876.

vice versa at times; the outbreaks of enteric adulteration with sewage water,

traced to milk

proved facts.

Jenner, Murchison, Budd, Simon, Stokes, particular views; and whether enteric arise spontaneously, be propagated by the law of continuous succession, be allied or not with malaria, scarlet or other fevers, none of these distinguished investigators denies the influences of heat, filth, moisture, sewage air, or faecal water, plus local, bodily, and meteorological conditions. "When, in spite of all precautions, enteric (endemic or introduced) bursts out, there is a choice of disinfectants especially to antagonize the virulence of bowel discharges?sulphates of iron or copper, chlorides of zinc, calcium, magnesium or aluminium; and for general purposes, chlorine, iodine, nitrous or sulphurous acid, turpentine, charcoal, creosote, nitrate of lead, and especially carbolic acid, but in crowded houses or hospitals, disinfectants may be powerless. Fire, fresh air, and the red hot rays of the blazing sun before the rains, should be utilized whenever practicable in Bengal. Treatment.?In cold weather, short easy marches and the

are

Harley,

and other authorities have

evacuation of barracks may be necessary. Placing men under canvas in warm

weather,

would

only

increase and intensify disease. If they remain in barracks, the hospital treatment includes early recognition, isolation, general disinfection, especially of excreta, judicious nursing, milk diet, and taking the patient's case, so as to find out all about him,

medically, before delirium sets in. It makes all the difference in the world, whether or no, there has been previous mischief in brain, lung, heart or kidney before enlistment. Many a case has been damaged by excess of physic or too vigorous remedies, for instance, such as purgatives or emetics. It is the custom with many, to commence with a mild dose of castor oil,

warm

2

3

bath, diaphoretics, perhaps every

3

or

4

hours for

powder containing a scruple of soda, 5 grains of chalk and opium, 3 of grey powder. Mercurial inunction may be very valuable, so may 6 leeches applied over the -iliac regions, the bleeding checked as the leeches drop off. It is often expedient to apply poultices of linseed meal and mustard, else nim leaves, or turpentine fomentations over the abdomen, which for the night should be packed in tow, covered with carbolized oil and firmly bandaged. With young, fairly constitutioned new arrivals shewing head symptoms early, it will often be expedient to apply a couple of leeches to each temple, or

days,

a

besides iced lotions to the head, mustard to the back of the neck, hot bottles to the feet. It is very satisfactory, as a rule, to shave the head early, so that cold lotions may be the more easily applied and delirium averted. To moderate diarrhoea there is no objection, but when excessive, the remedies to select from, include chalk,

a quarter to a grain of nitrate of silver or sulphate of copper, with compound soap and opium pill. A good remedy is dilute sulphuric acid, 20 minim doses, combined with 10 of laudanum in cinnamon water: else 5 grains of lead and opium pill, or 3 grains of acetate of lead,

bismuth, catechu, kino, opium,

acetic acid, 20 minims of liquor of water every four hours. Possibly, bael, isphagul seeds, decoction of babul bark, infusion of sweet flag, butoea gum, decoction of pomegranate may be useful. Neither sulphate of copper, nitrate of silver, nor preparations of zinc have answered personal expectation. Enemata of a 15

minims

of

morphite acet, in

aromatic

an ounce

tea-spoonful of laudanum in 4 ounces of starch, of a teaspoonful of perchloride of iron in water, or a drachm of ipecacuanha in solution, else suppositories of opium and belladona will be useful. Sometimes perforation has been prevented by keeping the patient half narcotized (presuming the renal functions are satisfactory), and 3 grain suppositories of belladonna will keep the bowels quiet at times. Sedative liniments, externally applied, have their yalue, so haye blisters

November 1,

1876.]

NOTES ON ENTERIC EEVER.?BY E. R. HOGG, M.D.

applied over the iliac regions, or else the hypodermic injection morphia commencing with one-fifth of a grain, though in former years the doses were considerably larger.

of

To relieve distressing vomiting, either bismuth, or effervescents containing prussic acid, draughts containing soda and hot water, hot tea, cold tea, oxalate of cerium, charcoal, creosote, small doses of calomel, each have their advocates; but when

depending on cerebral causes, the vomiting must be treated by applications to the head, leeches, blisters, &c. Should haemorrhage occur, perchloride of iron by mouth or injection, turpentine the same, gallic acid, cannabis indica, iced enematn, bladders of ice over abdomen, ergot of rye, ergotine hypodermically injected; in mild cases where arterial action is much excited, 15 minims of tincture of digitalis combined with 30 of perchloride of iron, in draught may be employed. The great object is to gain time by careful diet and nursing, to keep diarrhoea under control, and by firm bandaging of the bowels to prevent meteorism, abdominal distention, the retention and rapid formation of flatus. Turpentine by mouth or enemata, rue, assafsetida the same, charcoal, nux vomica; soda, the various ethers, camphor, are all useful; not forgetting abdominal inunction and the careful introduction of the long tube. It has been recommended to aspirate the distended abdomen, a proceWhen the pulse is fast and dure open to endless objections. feeble, opium is contra-indicated for head symptoms, and not improbably, permanent deafness has been provoked by quinine in large doses, given at the wrong time. For chest symptoms, ammonia, ipecacuanha, senega, besides sinapisms and blisters, may be required, but ammonia encourages diarrhoea and blisters may produce gangrenous ulcers. Turpentine, which by the mouth relieves constipation, diarrhoea, and tympanites, also clears the clogged-up lungs, besides being invaluable for local applications; but however useful as a stimulant, turpentine is not generally considered an antiseptic in the same light as quinine. There is no doubt that calomel and soda in combination, have, under favourable conditions, some specific value in local

preventing secondary ulcers of the bowel, but when mercury is required, inunction is the best procedure. The only medicines really required in an ordinary case, where food, nursing, and general management are properly understood and undertaken, include dilute nitro-hydrochloric acid and quinine in small doses. Even these might be dispensed with. Sometimes in spite of cleanliness and care, bed-sores start

Bathing with brandy or solution of at the commencement. tender parts with cotton wool or in covering spirit, camphor soft thick soap plaster: or the adoption of circular pillows ?with hollow centres, air or water beds may early be required. Bread Powdered chalk or magnesia will protect thin skin. ?

poultices mixed with mutton suet relieve excoriations, and when the vexation and worry of sloughing commence, ointments of creosot#, carbolic acid or zinc are recommended?say, liquefied carbolic acid 2 drachms ; linseed oil, 1 ounce; prepared We may try carron oil, tincture of benzoin (a Peruvian balsam, red wash, black wash or The practitioner must ever be hopeful, for basilicon dressing. bed-sore after bed-sore may appear, both eyes may be in great jeopardy, and yet the patient can recover, especially after a trip to the hills. The most disheartening symptom aliaost to encounter is that termed coma-vigil by Sir William Jenner, when the patient lies with his eyes "wide open, perfectly unconscious, the pupils paralyzed ; and yet such cases have recovered. flilDesperandum. Enumerating other remedies for enteric, certain practitioners believe in the treatment by internal disinfection, doses of the sulpho-carbolates every 4 for chalk 4 ounces.

capital remedy,)

instance, scruple

Some of the recorded results are very encouraging. Last but not least, comes for consideration the treatment by baths. Murchison believes that the cooling of the body may not influence the conditions, on which the development of heat depends ; with reduced heat is diminished metamorphosis, and hours.

295

the non-elimination of the products which intensify the dangers of fever. Other objectors state that drain of heat may cause death by exhaustion, the heart becoming enfeebled, and the lungs engorged. There are records of fatal consequences

following

the bath treatment of rheumatic fever. Very likely, because this special treatment is not adapted for that particular disease. A boy aged 17, suffering from enteric, died 16 hours after a bath, when perforation was discovered. The chances are the bath was not ordered until too late, instead of at the commenceBaths have been given too frequently, and ment of sickness. it is complained that haemorrhage, diarrhoea, pneumonia, bronchitis may follow their use. Yet out of 170 cases thus treated, Brand of Stettin lost but one. At Leipsic, similarly satisfactory " Lancet" the were recorded, also at Calcutta, and in the

results

" " Fractitioner," and still more convincing in the Indian Medical Gazette" the praises of the baths have been sung. Between 1864 and 1873 at Heidelberg, 648 cases were thus treated. Contra indicated in neuralgia and hyperesthesia, the baths did good in lung complications, but were mischievous in intestinal hcemorrA aged 7 months, somewhere in India, rapidly

child, hage. 'running down

hill' with diarrhoea, fever, tendency to coma, recovered after 7 baths in 22 hours. limited personal experience, small as it is, includes cases

My thermal, remittent, enteric and intermittent fever treated at Meerut, and by baths ; the charts and records are preserved the results were so satisfactory that all other remedies for the of

future will be abandoned. In the hot weather at Meerut, the ordinary temperature of well water from mid-day until sunset is about 80? F. So in the treatment of fever drifting into delirium, with a hot, dry, blazing, burning skin, the suggestion is to place the man at in this bath of 80?, for 15 minutes, whilst 3 or 4 full

length

emptied over his head. All this is done in the patient having been well soaped first to anticipate bed-sores. Afterwards rapidly rubbed, dried, put to bed, he either soon goes to sleep, or bursts out into a refreshing perspiration, and gradually feels much better. Exceptionally Sometimes very few are the baths required twice in the day. baths are necessary, but altogether the average number is about 18 or 20. At night if the patient be restless, 10 or mussacks are verandah, the

15 grains of bromide of potassium are given. Pulse, respiration, temperature are noted before, during, and after each bath. The temperature falls, only to rise again ; and on one occasion a hypodermic injection of quinine, 5 grains of the neutral sulphate applied beneath the scapula, with the view of prolonging the interval and preventing this rise, did harm. Twitchings, startings, grinding of the teeth, jerking of the tendons, taught a lesson not to be forgotten. Nor was there any appreciable diminution of temperature. Still the inclination is to give small doses of quinine by the mouth, from the very beginning unless contra-indicated. The many phases and complications would fill a volume, but the belief is that the baths preventing complications, mitigate the severity of the disease which safely runs on to convalescence. The patients gradually enjoy the baths; the tranquil expression of countenance, the freedom from pain and delirium are remarkably satisfactory. No endeavour is made to explain the therapeutic All the way through the case, the packing of the action. bowels in carbolized oil and firm bandaging afterwards, are "When the lungs are oppressvery essential requirements. ed, it is very easy to relieve the breathing by slackening or removing the bandage. Diet?Iced milk with a little lime water of milk or carbonate of soda added; the quantity gradually increased to about six pints a day. Dr. Chambers speaks of 2 or 3 ounces every hour, or else every 2 hours, so as to get down a quart and a half per diem. Eggs taken raw and diluted with milk or water, however nutritious, may decompose. Sour buttermilk he partially recommends. In certain cases 20 grains of pepsine a day guarded by opium to avert

diarrhoea',

INDIAN MEDICAL GAZETTE.

296

may be added to food. Haw meat juice is very uncertain, tlie tendency to diarrhoea provocation being sometimes inseparable? an objection equally applicable to Liebig's Extract, yet every man can testify to the extreme value of both preparations at times.

a nutrient enema. Take of beef tea half a pint and thicken it with a tea-spoonful of tapioca, reduce 1| ounces of raw beef to a fine pulp, pass it through a fine cullender, and mix the whole up with 20 grains of acid pepsine and 4 grains of diastase, or a dessert-spoonful of malt flour. Not more than a quart-

Chambers suggests

should be used, and that

slowly. Depending eliminating urea, or jellies, and give many Others again arrow-root, vermicelli, ground rice and cocoa. night and day give beef tea, gelatine, egg-flip, later on custards, boiled fish, avoiding potatoes for a while. As regards wine, it is given by many authorities to support cardiac action, without reference to delirium, or dry brown or even moist tongue. Others allow 6 to 8 ounces of wine, or 4 ounces of brandy in the 24 hours, if the pulse be under 120 and of moderate volume ; but the quantity can be increased until the heart responds, even to the extent of half an ounce or more of brandy every hour, provided the renal functions are unimpaired. According to Murchison, alcobol acts rather as a medicine like opium and quinine, and not like milk or beef tea. Flagging of the heart is the guide for stimulants. Many believe in port wine and beef tea given constantly, especially at night. Beer, brandy, whiskey, gin, hollands are all good according to circumstances, and at Meerut reliance can be placed on madeira. The stimulants less liable to derange the liver are claret, hock, moselle, dry sherry, gin or whiskey largely diluted. It is ever of

er

on

pint

at

once

milk in

enteric, and on tea and coffee practitioners exclude animal broths

for

td be remembered that Indian milk is poor, often watered and soon decomposes, and that a quart of broth contains but six drachms of solid nutriment, two being saline ingredients. Bread is adulterated with alum, soups are often devoid of nourishment, butter is made from milk instead of cream, and in the bazar is mixed with ghee or boiled mutton suet; puddings are thickened with flour instead of eggs, aud water takes the place of milkall

according

to the

supervised. not nice for

"

Pioneer."

and apathetic unless constantly Tough meat, and a quis separabit" chicken are a weakly convalescent.

Cooks are verv

dirty, lazy

"

[November 1,

187G.