ON ENTERIC FEVER. By Surgeon W. E. Saunders, a.m.d.
/.?Introductory. At the and
beginning of the present century typhus
enteric fever
disease,
looked upon as itself sometimes in
were
manifesting
one one
form, and sometimes in the other. The idea that
in
reality two distinct diseases, was first originated in Paris by Prost ; but although the subject was not altogether dropped, the views did not take definite shape until Louis, in his treatise on the Parisian fever," as it was then called, accurately described the anatomical sign," or lesion of they
were
"
"
March, 1883.]
Payer's patches found
on
and other intestinal
examination,
post-mortem
glands,
as
and
gave exhaustive account of the symptoms met with during life. The subject attracted much atten-
an
tion in the
and America at the time, and view was adopted by many observers.
England
new
At first
England, there appears to strong prejudice against this divarication ; but Murchison, Jenner, Budd, and others have by their writings convinced the large majority of the profession, (although advocates for the old opinion are still to be found,) and have brought our knowledge of these diseases as they occur in Europe to a high pitch of perfection. have been
however,
in
now
however, that
diseases have been
several
recognized running part of their course together in the same patient. Typhus fever protects the system against two
his first few years of service, especially in India. During 1879 in India alone there were 331 cases and 143 deaths from enteric fever; the
majority being under 22 years of age, and one year's residence there ; but as far as admissions are concerned, this probably falls far short of actual numbers attacked.
Slight
a
So clear is the distinction the
63
SAUNDERS ON ENTERIC FEVER.
on
occasions
second attack ; if therefore enteric fever follows immediately an attack of typhus, the
a
of the
must be
admitted
or
ill
cases, and those where
developed
the remittent type is marked, are probably for the most part returned as S. C. fever, diarand many of the fatal
rhoea, remittent fever, &c.; cases
have often been found
only
when
the
nature
be enteric fever
to
of the intestinal lesion
post-mortem examinaIn the army during the year 1879, there evident
became tion.
the
at
appear to have been 1,252 admissions and 380 deaths from enteric fever alone; and from these
figures some idea may be formed of the loss to the State every year, when it is remembered that in few of the cases where recovery follows can the soldier become fit for military duty under 3 months ; many of them require to be invalided to England from long distances, and
by any have appeared of late years in the medical journals, and the case is established beyond any possibility of
greatest attention of the
deserving of the Army medical officer,
doubt.
for the disease is
to
duality one
poison
open to conviction. Such
cases
Enteric fever
though, perhaps, one of the most preventible diseases, is nevertheless one that causes more sickness, and perhaps more deaths, than any other disease throughout the world. The terrible results have hardly yet been realised ; partly from its being ever among us and partly because of the insidious nature of the disease, it often passes unrecognised. According to the statistics of the RegistrarGeneral, there are in the United Kingdom alone as
many
260,000
as
cases
and
26,000 deaths
every year from this disease, and this doubtless by no means represents the actual numbers.
Although
the disease is
acknowledged
to be
their
places
filled
the State.
to
troops
as
is
It is
prevalence among troops tropical countries.
on
in
admitted
however to be the disease
par excellence of the
young
soldier
during
at
great expense
generally
the
be found wherever
case
in India and the
Colonies. The
may be increased by heat and other climatic conditions, and it may closely re-
fatality
semble
remittent
some
or
tropical
forms of
disease. Dr.
Bryden
in his works
teric fever is
over
no new
points out that enIndia, although
disease in
of late years ; morethe fact that natives suffer from this disease
it has
only
been
recognised
discovered a few years ago, and this much from the value of the expressed detracts
was
only
escape without
or
men
especially when large together with native
trcops are quartered, numbers are encamped
estimate
its
more
our
opinions
of
other
It is therefore
the great scourge of armies in the field in time of war, we have not as yet formed a correct active service
by
of old Indian observers.
It has been of late noticed some cases
that few corps of enteric fever ap-
pearing during the first year after this has probably always been the The general idea in England
landing, and case (Bryden).
seems to be
that
we
THE INDIAN MEDICAL GAZETTE.
64 know
enteric fever than
about
more
we
do
about any other form of fever prevalent in the British Isles ; indeed a leading physician in not
London little
ago said that regarding it.
long
to learn
more
had very Is this so?
we
It may be true of the common form met with in England, where one case can generally be
assigned
to
a
case, and
previous
traced to contamination
be
water
or
air
the
by
dejecta
each outbreak
of the
of
drinking suffering
a
person the disease ; but it cannot in like manner be held as true of the common phase of this from
disease
as
India, China, and other
met with in
I take it that any one who has treated cases, and investigated outbreaks of this " we have disease in Inida, cannot honestly say hot countries.
but little the ous
to
learn"
pathology, disease,
so
or
regarding
either the
prevalent
so
that the number of Britain is small
am
convinced in
Great
occurring compared with what prevails the globe, and which is often
of this disease
so
as
teric fever is the chief soldiers
I
cases
in other parts of unrecognised, because
phase
foreign stations, during their first
at most
fatal to young soldiers few years of foreign service. and
etiology,
the treatment of this insidi-
little is known of the
met with abroad.
cause
En-
of sickness amongst
all
foreign stations, though unwilling to admit it, preferring to designate it by various names, such as bilious, remittent, pernicious, tropical fever and our
at
are
many
It would appear to me, as the result of experience of this disease in Europe, Asia, and Africa, that there are three varieties so on.
some
or
phases 1.
with in 2.
of enteric fever, viz. :? enteric, or the epidemic form
True
England. malarial,
The
met
with,
met
and endemic in
[March, 1883.
the
Although always
eruptions are quite distinct, it is easy to diagnose the disease on active service. Dr. Perry, of Glasgow, was, I believe, the first to maintain the complete difference of the two eruptions of typhus and entenot
ric fevers. The
of enteric
eruption that
resemble
of
fever, however, fever ; during
typhus
may the
Zulu
campaign I saw many cases where the eruption had become petechial, and similar to the typhus rash to a certain extent, being also thickly sprinkled over the body and extremities, the only difference being in the subcuticular rash which
typhus
was
not
well marked
so
as
in
cases.
I would class such of enteric
variety
fever,
less due to the disease affected
by
under the scorbutic
cases
for the effect is doubt-
attacking
men
already
malarial form
of this
the scorbutic taint.
There is another
or
disease often met with in
countries and
tropical only the fatal cases are returned as enteric fever, the others being styled remittent fever, typho-malarial, &c. Many cases are classed under the prominent symptom, such as diarrhoea, dysentery, pneumonia, bronchitis, the nature of the affection only becoming evident on the post-mortem table, or if not fatal or not subjected to the test of a P.M. examination, often passing unrecognised. This form is prevalent chiefly in the spring and autumn, and is really an example of de I would term it the malarial or novo origin. endemic variety of enteric fever. True enteric fever, or as I prefer to call it epidemic enteric fever, appears to be essentially the same disease all the world over, and is always traceable to a previous case of either variety. in the
of which
field,
hot countries.
When
3. The scorbutic active service.
attacked about the same time, and the cases are from the first ; but in the case of the
The last another
forms,
most
common
on
varieties have often gone under and been called " Typho-malarial."
two
name
Enteric fever has
always been a prominent mortality in war-time ; and no doubt much of the typhus fever which prevailed in old wars was really enteric fever. cause
of sickness and
outbreak of this
an
typical
endemic
or
malarial variety it often
diarrhoea, or-ill developed resemble some remittent disease, cases case
and it
have is
occurs
is
There
that
is,
begins by
which often
tropical
or
not
occurred
seen.
cases,
until a
are
many
form
many
of
such
well-developed
moreover,
in
such
March, 1883.] outbreaks
no
history
of
importation
;
instan-
with every year in India, where investigated by medical officers from all
met
ces are
they are
parts of the United Kingdom, who discover
cause
a
can
seldom
It is certain that enteric fever exists in India no
history
of
importation
be traced
can
under circumstances most favourable for such instate of the stations
The
vestigations.
rule most
arrangements
sanitary satisfactory,
gradual week.
and the conservancy are all that can be desired; the
which
are
disease
well ventilated.
more
surely
the existence of certain in and about
How
can
Yet it is said that
indicates
by
common
its
no
occurrence
sanitary
defects
dwellings.
it be accounted for ?
entering into a discussion on the etioperhaps be advisable to come to an logy, understanding as to what is meant by the term Before
it will
enteric fever. Aitken
in his admirable work thus defines
the disease.
"
A continued fever associated with
eruption on the skin of rose-coloured spots, chiefly on the abdomen, appearing generally from the eighth to the twelfth day, occurring in crops, each spot continuing visible about three an
days. Languor "
and feebleness
the first, attended
are
prominent
from
by headache, abdominal pains,
(early) by spontaneous
diarrhoea ; with the
The average duration of the fever is 23
"
Death in the
resonance, and tenderness of the or
less
some
albumen.
There
are
abdomen,
more
natural lineaments of the
belly ; gurgling in the iliac fossa;; increased splenic dulness. The specific lesions are enlargement of the mesenteric glands, with deposit in the glands of Peyer and in the minute solitary glands of the "
small intestine." Such is the disease
as
met with in
temperate
although it is not necessary that all these conditions should be present, still as a climates ;
rule there is sufficient resemblance to The
the disease. in
about
(Tanner),
eruption
identify
for instance is absent
per cent, of cases in England but in at least half the cases abroad. 12
"
When it occurs, This successive daily eruption of a few small very slightly elevated rosecoloured spots, disappearing on pressure, each spot continuing visible for three 01* four days only,
peculiar to, and absolutely diagnostic of, typhoid fever." (Aitken). In tropical countries this eruption, even when present, may be overlooked, or easily mistaken, is
unless great
is taken ; spots so often occur insects, heat and other causes.
care
from bites of
diagnosis is still more difficult when the eruption is absent, as is frequently the case abroad, owing to the great prevalence of febrile attacks ; more especially when the type of the fever is somewhat intermittent, the patient having previously suffered from ague, or of the remitting type, which even in England is not The
uncommon,
and
heading
of soluble salts and
cases occurs
with entire effacement of the
tympanitis,
the
proportion
fatal
of the third week.
symptoms also associated with the characteristic lesion of this form of fever, namely, fulness,
remittent fever
discharges being for the most copious, of a bright yellow colour, devoid of mucus, occasionally containing altered blood ; in reaction alkaline, and containing a large
majority of the
towards the end
advance of the disease the diarrhoea
increases, part liquid,
favourably by a during the fourth
days.
are
.dry earth system is worked well, the refuse all being carried far away and buried; and there are or sewers to pollute the dwellings, no drains
and
may terminate restoration to health
1
taught, jn Europe; and have in many instances taken refuge in the theory that heat .and moisture acting on young lads have given rise to the disease. There are stations, however, where these factors exist in abundance, and yet no enteric fever occurs. Something more is evidently required,but I must enter into this more fully when discussing the etiology of the disease.
as a
The disease
in accordance with the doc-
trines
where
65
SAUNDERS ON ENTERIC FEVER.
it is
makes it resemble of
no
the
doubt
the
true
under which
tropics, frequently
classed in
consequence. The disease, moreover, is of a most insidious nature, and men sometimes continue at their
duty,
even
performing heavy work, daily loading
THE INDIAN MEDICAL GAZETTE.
66
throughout a primary attack, coming to hospital only when a relapse occurs, which is then of a most dangerous nature, and frequently proves fatal. Perhaps the only history you will elicit from these cases is, that they felt a little seedy, and had some looseness of the bowels at times for some weeks previous. Indeed a sense of lassitude is often, even in England, the only symptom before a general peritonitis resulting from perforation of the bowel. I remember such a case when a student, and the physician who in the out-patients' department, saw the case a tonic and recommended a brisk prescribed walk daily. Two days afterwards a fatal took place, and, except for this acciperforation waggons,
dent, the
nature of the
would
case
never
How man)- such
been
have
recognised. day it is impossible even to surmise. Cases called simple continued fever, are often in reality enteric attacks, and if the fever lasts over ten days, particularly if there be any disorder of cases
occur
every
the bowels, with
marked
a
absence of correla-
pulse and temperature, should be looked upon with suspicion. The use of the thermometer, although of the greatest assistance in deciding cases in England, does not prove of such value in the diagnosis during the early stages abroad. For instance, it has
tion between the
been laid down that if the temperature on two of the first three evenings is the same ; or if the temthe first two da
/.?Introductory. At the and
beginning of the present century typhus
enteric fever
disease,
looked upon as itself sometimes in
were
manifesting
one one
form, and sometimes in the other. The idea that
in
reality two distinct diseases, was first originated in Paris by Prost ; but although the subject was not altogether dropped, the views did not take definite shape until Louis, in his treatise on the Parisian fever," as it was then called, accurately described the anatomical sign," or lesion of they
were
"
"
March, 1883.]
Payer's patches found
on
and other intestinal
examination,
post-mortem
glands,
as
and
gave exhaustive account of the symptoms met with during life. The subject attracted much atten-
an
tion in the
and America at the time, and view was adopted by many observers.
England
new
At first
England, there appears to strong prejudice against this divarication ; but Murchison, Jenner, Budd, and others have by their writings convinced the large majority of the profession, (although advocates for the old opinion are still to be found,) and have brought our knowledge of these diseases as they occur in Europe to a high pitch of perfection. have been
however,
in
now
however, that
diseases have been
several
recognized running part of their course together in the same patient. Typhus fever protects the system against two
his first few years of service, especially in India. During 1879 in India alone there were 331 cases and 143 deaths from enteric fever; the
majority being under 22 years of age, and one year's residence there ; but as far as admissions are concerned, this probably falls far short of actual numbers attacked.
Slight
a
So clear is the distinction the
63
SAUNDERS ON ENTERIC FEVER.
on
occasions
second attack ; if therefore enteric fever follows immediately an attack of typhus, the
a
of the
must be
admitted
or
ill
cases, and those where
developed
the remittent type is marked, are probably for the most part returned as S. C. fever, diarand many of the fatal
rhoea, remittent fever, &c.; cases
have often been found
only
when
the
nature
be enteric fever
to
of the intestinal lesion
post-mortem examinaIn the army during the year 1879, there evident
became tion.
the
at
appear to have been 1,252 admissions and 380 deaths from enteric fever alone; and from these
figures some idea may be formed of the loss to the State every year, when it is remembered that in few of the cases where recovery follows can the soldier become fit for military duty under 3 months ; many of them require to be invalided to England from long distances, and
by any have appeared of late years in the medical journals, and the case is established beyond any possibility of
greatest attention of the
deserving of the Army medical officer,
doubt.
for the disease is
to
duality one
poison
open to conviction. Such
cases
Enteric fever
though, perhaps, one of the most preventible diseases, is nevertheless one that causes more sickness, and perhaps more deaths, than any other disease throughout the world. The terrible results have hardly yet been realised ; partly from its being ever among us and partly because of the insidious nature of the disease, it often passes unrecognised. According to the statistics of the RegistrarGeneral, there are in the United Kingdom alone as
many
260,000
as
cases
and
26,000 deaths
every year from this disease, and this doubtless by no means represents the actual numbers.
Although
the disease is
acknowledged
to be
their
places
filled
the State.
to
troops
as
is
It is
prevalence among troops tropical countries.
on
in
admitted
however to be the disease
par excellence of the
young
soldier
during
at
great expense
generally
the
be found wherever
case
in India and the
Colonies. The
may be increased by heat and other climatic conditions, and it may closely re-
fatality
semble
remittent
some
or
tropical
forms of
disease. Dr.
Bryden
in his works
teric fever is
over
no new
points out that enIndia, although
disease in
of late years ; morethe fact that natives suffer from this disease
it has
only
been
recognised
discovered a few years ago, and this much from the value of the expressed detracts
was
only
escape without
or
men
especially when large together with native
trcops are quartered, numbers are encamped
estimate
its
more
our
opinions
of
other
It is therefore
the great scourge of armies in the field in time of war, we have not as yet formed a correct active service
by
of old Indian observers.
It has been of late noticed some cases
that few corps of enteric fever ap-
pearing during the first year after this has probably always been the The general idea in England
landing, and case (Bryden).
seems to be
that
we
THE INDIAN MEDICAL GAZETTE.
64 know
enteric fever than
about
more
we
do
about any other form of fever prevalent in the British Isles ; indeed a leading physician in not
London little
ago said that regarding it.
long
to learn
more
had very Is this so?
we
It may be true of the common form met with in England, where one case can generally be
assigned
to
a
case, and
previous
traced to contamination
be
water
or
air
the
by
dejecta
each outbreak
of the
of
drinking suffering
a
person the disease ; but it cannot in like manner be held as true of the common phase of this from
disease
as
India, China, and other
met with in
I take it that any one who has treated cases, and investigated outbreaks of this " we have disease in Inida, cannot honestly say hot countries.
but little the ous
to
learn"
pathology, disease,
so
or
regarding
either the
prevalent
so
that the number of Britain is small
am
convinced in
Great
occurring compared with what prevails the globe, and which is often
of this disease
so
as
teric fever is the chief soldiers
I
cases
in other parts of unrecognised, because
phase
foreign stations, during their first
at most
fatal to young soldiers few years of foreign service. and
etiology,
the treatment of this insidi-
little is known of the
met with abroad.
cause
En-
of sickness amongst
all
foreign stations, though unwilling to admit it, preferring to designate it by various names, such as bilious, remittent, pernicious, tropical fever and our
at
are
many
It would appear to me, as the result of experience of this disease in Europe, Asia, and Africa, that there are three varieties so on.
some
or
phases 1.
with in 2.
of enteric fever, viz. :? enteric, or the epidemic form
True
England. malarial,
The
met
with,
met
and endemic in
[March, 1883.
the
Although always
eruptions are quite distinct, it is easy to diagnose the disease on active service. Dr. Perry, of Glasgow, was, I believe, the first to maintain the complete difference of the two eruptions of typhus and entenot
ric fevers. The
of enteric
eruption that
resemble
of
fever, however, fever ; during
typhus
may the
Zulu
campaign I saw many cases where the eruption had become petechial, and similar to the typhus rash to a certain extent, being also thickly sprinkled over the body and extremities, the only difference being in the subcuticular rash which
typhus
was
not
well marked
so
as
in
cases.
I would class such of enteric
variety
fever,
less due to the disease affected
by
under the scorbutic
cases
for the effect is doubt-
attacking
men
already
malarial form
of this
the scorbutic taint.
There is another
or
disease often met with in
countries and
tropical only the fatal cases are returned as enteric fever, the others being styled remittent fever, typho-malarial, &c. Many cases are classed under the prominent symptom, such as diarrhoea, dysentery, pneumonia, bronchitis, the nature of the affection only becoming evident on the post-mortem table, or if not fatal or not subjected to the test of a P.M. examination, often passing unrecognised. This form is prevalent chiefly in the spring and autumn, and is really an example of de I would term it the malarial or novo origin. endemic variety of enteric fever. True enteric fever, or as I prefer to call it epidemic enteric fever, appears to be essentially the same disease all the world over, and is always traceable to a previous case of either variety. in the
of which
field,
hot countries.
When
3. The scorbutic active service.
attacked about the same time, and the cases are from the first ; but in the case of the
The last another
forms,
most
common
on
varieties have often gone under and been called " Typho-malarial."
two
name
Enteric fever has
always been a prominent mortality in war-time ; and no doubt much of the typhus fever which prevailed in old wars was really enteric fever. cause
of sickness and
outbreak of this
an
typical
endemic
or
malarial variety it often
diarrhoea, or-ill developed resemble some remittent disease, cases case
and it
have is
occurs
is
There
that
is,
begins by
which often
tropical
or
not
occurred
seen.
cases,
until a
are
many
form
many
of
such
well-developed
moreover,
in
such
March, 1883.] outbreaks
no
history
of
importation
;
instan-
with every year in India, where investigated by medical officers from all
met
ces are
they are
parts of the United Kingdom, who discover
cause
a
can
seldom
It is certain that enteric fever exists in India no
history
of
importation
be traced
can
under circumstances most favourable for such instate of the stations
The
vestigations.
rule most
arrangements
sanitary satisfactory,
gradual week.
and the conservancy are all that can be desired; the
which
are
disease
well ventilated.
more
surely
the existence of certain in and about
How
can
Yet it is said that
indicates
by
common
its
no
occurrence
sanitary
defects
dwellings.
it be accounted for ?
entering into a discussion on the etioperhaps be advisable to come to an logy, understanding as to what is meant by the term Before
it will
enteric fever. Aitken
in his admirable work thus defines
the disease.
"
A continued fever associated with
eruption on the skin of rose-coloured spots, chiefly on the abdomen, appearing generally from the eighth to the twelfth day, occurring in crops, each spot continuing visible about three an
days. Languor "
and feebleness
the first, attended
are
prominent
from
by headache, abdominal pains,
(early) by spontaneous
diarrhoea ; with the
The average duration of the fever is 23
"
Death in the
resonance, and tenderness of the or
less
some
albumen.
There
are
abdomen,
more
natural lineaments of the
belly ; gurgling in the iliac fossa;; increased splenic dulness. The specific lesions are enlargement of the mesenteric glands, with deposit in the glands of Peyer and in the minute solitary glands of the "
small intestine." Such is the disease
as
met with in
temperate
although it is not necessary that all these conditions should be present, still as a climates ;
rule there is sufficient resemblance to The
the disease. in
about
(Tanner),
eruption
identify
for instance is absent
per cent, of cases in England but in at least half the cases abroad. 12
"
When it occurs, This successive daily eruption of a few small very slightly elevated rosecoloured spots, disappearing on pressure, each spot continuing visible for three 01* four days only,
peculiar to, and absolutely diagnostic of, typhoid fever." (Aitken). In tropical countries this eruption, even when present, may be overlooked, or easily mistaken, is
unless great
is taken ; spots so often occur insects, heat and other causes.
care
from bites of
diagnosis is still more difficult when the eruption is absent, as is frequently the case abroad, owing to the great prevalence of febrile attacks ; more especially when the type of the fever is somewhat intermittent, the patient having previously suffered from ague, or of the remitting type, which even in England is not The
uncommon,
and
heading
of soluble salts and
cases occurs
with entire effacement of the
tympanitis,
the
proportion
fatal
of the third week.
symptoms also associated with the characteristic lesion of this form of fever, namely, fulness,
remittent fever
discharges being for the most copious, of a bright yellow colour, devoid of mucus, occasionally containing altered blood ; in reaction alkaline, and containing a large
majority of the
towards the end
advance of the disease the diarrhoea
increases, part liquid,
favourably by a during the fourth
days.
are
.dry earth system is worked well, the refuse all being carried far away and buried; and there are or sewers to pollute the dwellings, no drains
and
may terminate restoration to health
1
taught, jn Europe; and have in many instances taken refuge in the theory that heat .and moisture acting on young lads have given rise to the disease. There are stations, however, where these factors exist in abundance, and yet no enteric fever occurs. Something more is evidently required,but I must enter into this more fully when discussing the etiology of the disease.
as a
The disease
in accordance with the doc-
trines
where
65
SAUNDERS ON ENTERIC FEVER.
it is
makes it resemble of
no
the
doubt
the
true
under which
tropics, frequently
classed in
consequence. The disease, moreover, is of a most insidious nature, and men sometimes continue at their
duty,
even
performing heavy work, daily loading
THE INDIAN MEDICAL GAZETTE.
66
throughout a primary attack, coming to hospital only when a relapse occurs, which is then of a most dangerous nature, and frequently proves fatal. Perhaps the only history you will elicit from these cases is, that they felt a little seedy, and had some looseness of the bowels at times for some weeks previous. Indeed a sense of lassitude is often, even in England, the only symptom before a general peritonitis resulting from perforation of the bowel. I remember such a case when a student, and the physician who in the out-patients' department, saw the case a tonic and recommended a brisk prescribed walk daily. Two days afterwards a fatal took place, and, except for this acciperforation waggons,
dent, the
nature of the
would
case
never
How man)- such
been
have
recognised. day it is impossible even to surmise. Cases called simple continued fever, are often in reality enteric attacks, and if the fever lasts over ten days, particularly if there be any disorder of cases
occur
every
the bowels, with
marked
a
absence of correla-
pulse and temperature, should be looked upon with suspicion. The use of the thermometer, although of the greatest assistance in deciding cases in England, does not prove of such value in the diagnosis during the early stages abroad. For instance, it has
tion between the
been laid down that if the temperature on two of the first three evenings is the same ; or if the temthe first two da
