TYPHOID FEVER IN DACCA.f
By
James
Wise, M.D.,
Civil
Surgeon,
Dacca.
of the Dacca jail for 1868, I remarked that, the filthy state of the drains of the city, a fever, different from any met with in the North-West, was especially frequent in the cold weather. My remark was as follows:? " Fever of a low asthenic type, often approaching in duration and Iir my
owing
report
to
symptoms to the typhoid fever of the "West, is very common among the natives in the cold months of the year." During the past season I have treated many cases in private families in this
where the
city,
enteric
fever,
or
symptoms
enteritis of the older writers.
spots
;
but I have
could not be
from the fever never
distinguished from accompanied with gastro-
In all such cases I search for
succeeded in
presence until this year. badly-housed residents of
satisfying myself of their Among the dirty, badly-fed, and Dacca, it is almost impossible to ob-
The cases in which I discovered them were those were left in the Mitford Hospital on their Their cases will way to Cachar to join the Looshai expedition. be detailed in full hereafter. The following case, treated in A as an example of this local fever : is November
serve
coolies
them.
who
?
last, quoted Mahomedan, in a good station in life, was taken ill on the 2otli October, with what hakiins call "tup bulghami," i.e., fever due to excess of phlegm. lie was treated by a hakim until the 2nd November, when I was called in to see him, as the fever He had offensive mucous diarrhoea. The fever was increasing. was
strong and continued; the skin
was
hot and
dry, becoming
J This paper has been placed at our disposal by the Inspector-General of Hospitals,?Eds., J. Af, G.
THE INDIAN MEDICAL GAZETTE.
19S
slightly moist in (lie forenoon and evening. At night all the' symptoms became aggravated. I regret not having kept notes of his daily state ; but I recollect well that from the 2nd till 11th there
the
abatement, of the symptoms.
was no
three very offensive stools were passed daily. green in color, and contained much mucus. of the siin
was
In the
iliac
no
right
tenderness
of November
the
always high: region there
was
felt.
was
The
case
Two were
or
often
been returned
as
remittent fever ; but the symptoms
are so con-
tinuous and unchecked by medical treatment, and the cases so rarely fatal, that it does not seem a rash and improper step to classify them as cases of typhoid or pythogenic fever. In private
practice there is no opportunity of making post-mortem examinations, which alone can decide the type of fever ; but from similar cases met with in hospital, where the bodies have been examined, there can be no reasonable doubt that Dacca a fever which, if not the European typhoid, ia
we
have in
one
closely
allied to it. In Dacca we have no sanitation. Drains choked with decaying vegetable and animal matters are to be found on every side. Privy-wells are allowed to be used within a few yards of drinking wells, and privies are erected on the banks of tanks. While such revolting habits are continued, we must expect to find typhoid fever in the city; and it will be fortunate if an epidemic of deadly typhoid does not sooner or later break out among the people. The
cases
I
am
about to record
not suspected in several of They were returned under
were
men
taken ill with
the
The nature of the fever
was
the instances until after death. remittent
fever;
but
the
post-
mortem examination revealed its true character. On the 18th of October a party of 100 coolies, chiefly GoorkliMS, arrived in Dacca from Dnrjeeling, en route to the Chittagong Hill Tracts, to join as constables. They were under command of a head constable, and they had travelled from Dinajpore to this in three native boats fearfully crowded. They hod few blankets among them, and their clothing was insufficient to protect them against the cold at nights. On the 19th October four were admitted into hospital ; all were in a prostrate state from fever, bad food, and want of medical treatment.
I.?Ram Chunder, Goorkha, aged 26, on admission, had high fever, dry tongue, great thirst; and severe diarrhoea. Half a
drachm of ipecacuanha only caused diaphoresis. On the morning of the 20th he was much cooler and the skin moist. Ten grains Diarrhoea continued undiminished; were given. of
quinine appetito gone.
Quinine, with opium, was given every four hours ; and chicken broth, with brandy, frequently. On the 22nd and 23rd he was better. Quinine, in 20-grain doses, was administered. On the 24th diarrhoea was the only bad symptom.
opium, ar.d chloric aether were On the 26th the diarrhoea had previous night, but he became in the day. During the night the
Sulphuric acid, tincture
of
prescribed every four hours. lessened greatly during the warm
and restless
early
diarrhoea re-commenced.
covered with
a
white fur.
stools
stools offensive and
of
disease before arrival in Dacca.
stools
pressure, but treated up to the 5th
remittent; but after administering quinine in doses of twenty grains, podophyllin, diuretics, and diaphoretics, without the slightest reduction of the fever, I stopped giving all such powerful remedies, and contented myself with merely supporting the strength and keeping up a determination to the surface of the body. On the 10th of November, the seventeenth day of the fever, there was profuse sweating, which lasted for several hours. The gravity of all the symptoms abated from that day, and the convalescence, though slow, was uninterrupted by any complication. I am sorry that I have not kept a record of the temperature of this and other cases. In past years such cases have always as a case
Simple diaphoretics were given. On the 28th changed in character, being now of a pulse hard and quick. On 29th the "with blood : slept badly. On 31st, were slightly tinged frothy, copious, and watery; slept a little Inst night; bile.
less fever.
on
On the 27th the tongue
Takes food well.
was
moist and
Urine contained
2, 1872.
still feverish ; stools yellow oclire color;
The temperature never fell below 110.
pulse gurgling was
They
much
[September
November ls?.?Skin hot and dry ; diarrhoea very obstinate ; black, with bile. Astringent mixtures, with
quinine,
were
given.
2nd.?Pneumonia of
both
lungs
detected this
morning;
great debility and increasing stupor. Stimulants were freely given ; but at 5 p.m. he died, fifteen days after admission. As could not talk any language known in Dacca, no of his previous illness could be ascertained. Owing to this same cause the following cases are also imperfect : this
man
particulars
?
Post-mortem at 9 a.m., on the 3rd November.?Both lungs in stage of red hepatisation ; heart filled with white fibrinous clots ; liver large and very soft; gall bladder full of dark thick bile ; spleen enlarged and very fragile. The small intestines had the mucous membrane intensely congested from the pylorus to the cceeal valve. Peyer's glands were raised and
ulcerated; several of these ulcers had almost eaten through the bowel ; several were covered with an ashy-colored slough. This ulceration was most extensive and advanced in the ileum. The mesenteric
enlarged. G-oorkha, aged 24, could speak a few Says he was taken ill on the 9th October, ten days before admission. Had dysentery, his comrades said. Ipecacuanha, as in the former case, only produced copious perspiration. This was followed by quinine, grs. x. every six hours. On the morning of the 21st there was what was supposed to be a distinct remission. On the 22nd he refused food, and was apparently sinking. Stimulants and On the 24th he was better,?there soup were freely given. glands
were
Beer Rai, words of Hindustani.
IT.?Eaj
was
no
diarrhoea;
but
numerous
rose-colored
spots
were
body. (In a case of this kind, where the skin is not overclean, it is extremely difficult to distinguish a mosquito bite from a typhoid fever spot. The bite of a mosquito leaves on the skin of a cachectic subject a spot which lasts for several days. A strong magnifying glass does not always show the central puncture.) In this man's case I was unwilling to pronounce the spots typhoid until after marking them with ink, and watching their progress day by day. The result of this test was, that after a few days the spots disappeared, and were succeeded by others. From the 2Gth to the 31st this detected
over
the
On the 1st November the fever returned. jaundice, and no tenderness of the liver. A few
Goorkha did well. He had doses of
no
quinine,
with alterative
days.
His convalescence
the 9th
January
he
was
was
pills,
were
continued for
a
few
slow, but progressive daily.
discharged,
still
weak,
On but able to move
about. III.?Man Beer. Goorkha, aged 24, does not speak a word He is believed to have been ill nearly ten of Hindustani. days like the former case. On admission he had strong fever ;
great thirst; much prostration.
Laree doses of quinine were given, with apparent benefit. The tongue was covered with a dry dark fur. There were frequent thin yellowish stools. On the 23rd numerous dark livid spots were detected on trunk. After their appearance the fever lessened ; but his dejections were thin and yellowish, sometimes frothy. On the 26th, was free of fever, but very listless and weak. On the 27th, a fresh crop of spots appeared on the forehead, while those on the trunk were disappearing. On pressure these spots faded away ; diarrhoea lessened. On 28th, very weak ; three stools during night; slight symptoms of pneumonia posteriorly ; cough very troublesome. The pneumonia increased, and, on 2nd November, he was again feverish, with a dry skin. This continued till the 8tli, when he appeared much better. On the night of the
September. 2,
1872.]
CHLORIDE 01?
AMMONIUM,
On the a severe and exhausting attack of fever. passed a great many lumbrici after a close of santonine. No organic lesion died during the night of the 16th.
10th lie liad 16th he He was
found in any of the abdominal organs, but the small were ulcerated. Through one of these ulcers a
intestines worm
had made its way into the
These three
cases
undoubtedly typhoid
peritoneal cavity.
very interesting. fever; the two latter
The first case was
are
were
probably
the
The spot3 in the two latter cases were peculiar. They a few came out in successive crops, and, after lasting days, faded away. There were no signs of a scorbutic taint in these instances, so it is difficult to refer them to any disease but
same.
fever. Still, the the case ; and it enteric fever.
typhoid usually
eruptio-i appeared
W:is on
plentiful than face, which is rare
more
the
is in
On the 17th November another batch of coolie3 was loft at Hospital. They had also come from the hills
the Mitford
Darjeelinu, and they were ehiedy Bhooteeas, Nepaulose, They were shockingly filthy, and they had all been ill for days. IV.?Tundoo Sree, Goorkha, aged 24, was admitted in a prostrated state, quite delirious, and without any history of his case. Bowels disordered; diarrhoea troublesome; tongue dry, and covered with a black fur. On the morning of the 18th his pulse was 101. Stimulants and soups revived him a little ; but on the morning of the 21st he was found dead in bed. Post-mortem.?Heart large and flabby; its cavities contained large fibrinous clots ; liver large and congested ; lungs gorged with blood, posteriorly; spleen enlarged ; the stomach contained a large coil of tapeworm. The rest of the worm extended the whole length of the small intestine, and measured 80 cubits (120 feet) in length. The ileo-coe-al valve was much valvulse conniventes" were very prominent thickened. The and hard. Here and there patches of congestion were found, and in places ulceration had begun. Peyer's glands were noraround
and Goorkhas.
"
mal.
V.?Deruttee, Goorkha, aged 28 ; on admission, eyes sunken ; tongue dry and cracked ; body very filthy, but through the dirt numerous dark rose-colored spots were detected. He was in u state of low muttering delirium. On deep pressure in right
region groans were elicited. No diarrhoea now ; but he is stated to have had purging on board the steamer. November \9th.?Teeth covered witli sordes; lips dry and fissured; tongue brown, rough, and parched; pulse 101.
iliac
Quinine,
in
large doses,
was
20th.?Pulse small and
prescribed. weak; delirium continues
;
skin
and soup were given. On the 22nd, For forty-eight hours he remained in this state. however, he again became feverish, with a full strong pulse. cool and moist.
The
Large quantities
of
rum
tongue had become moister and cleaner.
The
parotid
left side is swollen and very painful. The right parotid also became inflamed the following day ; but it subsided
gland
on
application of a few leeches. The left, however, slowly suppurated. On the 6th December he had an attack of diarrhoea, probably brought on by some indigestible food, which continued for nearly a fortnight. Recovery was tedious, but complete. These cases, as I have already pointed out, have been imperfectly kept; and the absence of any record of variations of bodily temperature, increases the difficulty of deciding what these cases of fever really were. At the present time, when typhoid fever and its existence in Bengal are exciting controversy, it is the duty of every Civil Surgeon to assist in determining the different types of fever met with in practice. With one set of writers asserting that typhoid fever is unknown in " India, and another that remittent fever is a myth," it is evident that further inquiry is urgently demanded. If the cases detailed above are not typhoid fever, what are they ? Is there a remittent fever with enteric symptoms, and an eruption after the
&c.?BT W. STE\VrAHT.
199
typhoid-locking spots, running a protracted course, unconby quinine, manifesting itself in those old native cities which are unprovided with any sanitary arrangements, and simulating the typhoid fever of Europe ? I believe that in the course of further inquiry it will be proved that typhoid fever is common in the old cities of Bengal, and that our scepticism concerning its existence lias been due to education and biassed of
trolled
minds.
By
James
Wise, M.D.,
Civil
Surgeon,
Dacca.
of the Dacca jail for 1868, I remarked that, the filthy state of the drains of the city, a fever, different from any met with in the North-West, was especially frequent in the cold weather. My remark was as follows:? " Fever of a low asthenic type, often approaching in duration and Iir my
owing
report
to
symptoms to the typhoid fever of the "West, is very common among the natives in the cold months of the year." During the past season I have treated many cases in private families in this
where the
city,
enteric
fever,
or
symptoms
enteritis of the older writers.
spots
;
but I have
could not be
from the fever never
distinguished from accompanied with gastro-
In all such cases I search for
succeeded in
presence until this year. badly-housed residents of
satisfying myself of their Among the dirty, badly-fed, and Dacca, it is almost impossible to ob-
The cases in which I discovered them were those were left in the Mitford Hospital on their Their cases will way to Cachar to join the Looshai expedition. be detailed in full hereafter. The following case, treated in A as an example of this local fever : is November
serve
coolies
them.
who
?
last, quoted Mahomedan, in a good station in life, was taken ill on the 2otli October, with what hakiins call "tup bulghami," i.e., fever due to excess of phlegm. lie was treated by a hakim until the 2nd November, when I was called in to see him, as the fever He had offensive mucous diarrhoea. The fever was increasing. was
strong and continued; the skin
was
hot and
dry, becoming
J This paper has been placed at our disposal by the Inspector-General of Hospitals,?Eds., J. Af, G.
THE INDIAN MEDICAL GAZETTE.
19S
slightly moist in (lie forenoon and evening. At night all the' symptoms became aggravated. I regret not having kept notes of his daily state ; but I recollect well that from the 2nd till 11th there
the
abatement, of the symptoms.
was no
three very offensive stools were passed daily. green in color, and contained much mucus. of the siin
was
In the
iliac
no
right
tenderness
of November
the
always high: region there
was
felt.
was
The
case
Two were
or
often
been returned
as
remittent fever ; but the symptoms
are so con-
tinuous and unchecked by medical treatment, and the cases so rarely fatal, that it does not seem a rash and improper step to classify them as cases of typhoid or pythogenic fever. In private
practice there is no opportunity of making post-mortem examinations, which alone can decide the type of fever ; but from similar cases met with in hospital, where the bodies have been examined, there can be no reasonable doubt that Dacca a fever which, if not the European typhoid, ia
we
have in
one
closely
allied to it. In Dacca we have no sanitation. Drains choked with decaying vegetable and animal matters are to be found on every side. Privy-wells are allowed to be used within a few yards of drinking wells, and privies are erected on the banks of tanks. While such revolting habits are continued, we must expect to find typhoid fever in the city; and it will be fortunate if an epidemic of deadly typhoid does not sooner or later break out among the people. The
cases
I
am
about to record
not suspected in several of They were returned under
were
men
taken ill with
the
The nature of the fever
was
the instances until after death. remittent
fever;
but
the
post-
mortem examination revealed its true character. On the 18th of October a party of 100 coolies, chiefly GoorkliMS, arrived in Dacca from Dnrjeeling, en route to the Chittagong Hill Tracts, to join as constables. They were under command of a head constable, and they had travelled from Dinajpore to this in three native boats fearfully crowded. They hod few blankets among them, and their clothing was insufficient to protect them against the cold at nights. On the 19th October four were admitted into hospital ; all were in a prostrate state from fever, bad food, and want of medical treatment.
I.?Ram Chunder, Goorkha, aged 26, on admission, had high fever, dry tongue, great thirst; and severe diarrhoea. Half a
drachm of ipecacuanha only caused diaphoresis. On the morning of the 20th he was much cooler and the skin moist. Ten grains Diarrhoea continued undiminished; were given. of
quinine appetito gone.
Quinine, with opium, was given every four hours ; and chicken broth, with brandy, frequently. On the 22nd and 23rd he was better. Quinine, in 20-grain doses, was administered. On the 24th diarrhoea was the only bad symptom.
opium, ar.d chloric aether were On the 26th the diarrhoea had previous night, but he became in the day. During the night the
Sulphuric acid, tincture
of
prescribed every four hours. lessened greatly during the warm
and restless
early
diarrhoea re-commenced.
covered with
a
white fur.
stools
stools offensive and
of
disease before arrival in Dacca.
stools
pressure, but treated up to the 5th
remittent; but after administering quinine in doses of twenty grains, podophyllin, diuretics, and diaphoretics, without the slightest reduction of the fever, I stopped giving all such powerful remedies, and contented myself with merely supporting the strength and keeping up a determination to the surface of the body. On the 10th of November, the seventeenth day of the fever, there was profuse sweating, which lasted for several hours. The gravity of all the symptoms abated from that day, and the convalescence, though slow, was uninterrupted by any complication. I am sorry that I have not kept a record of the temperature of this and other cases. In past years such cases have always as a case
Simple diaphoretics were given. On the 28th changed in character, being now of a pulse hard and quick. On 29th the "with blood : slept badly. On 31st, were slightly tinged frothy, copious, and watery; slept a little Inst night; bile.
less fever.
on
On the 27th the tongue
Takes food well.
was
moist and
Urine contained
2, 1872.
still feverish ; stools yellow oclire color;
The temperature never fell below 110.
pulse gurgling was
They
much
[September
November ls?.?Skin hot and dry ; diarrhoea very obstinate ; black, with bile. Astringent mixtures, with
quinine,
were
given.
2nd.?Pneumonia of
both
lungs
detected this
morning;
great debility and increasing stupor. Stimulants were freely given ; but at 5 p.m. he died, fifteen days after admission. As could not talk any language known in Dacca, no of his previous illness could be ascertained. Owing to this same cause the following cases are also imperfect : this
man
particulars
?
Post-mortem at 9 a.m., on the 3rd November.?Both lungs in stage of red hepatisation ; heart filled with white fibrinous clots ; liver large and very soft; gall bladder full of dark thick bile ; spleen enlarged and very fragile. The small intestines had the mucous membrane intensely congested from the pylorus to the cceeal valve. Peyer's glands were raised and
ulcerated; several of these ulcers had almost eaten through the bowel ; several were covered with an ashy-colored slough. This ulceration was most extensive and advanced in the ileum. The mesenteric
enlarged. G-oorkha, aged 24, could speak a few Says he was taken ill on the 9th October, ten days before admission. Had dysentery, his comrades said. Ipecacuanha, as in the former case, only produced copious perspiration. This was followed by quinine, grs. x. every six hours. On the morning of the 21st there was what was supposed to be a distinct remission. On the 22nd he refused food, and was apparently sinking. Stimulants and On the 24th he was better,?there soup were freely given. glands
were
Beer Rai, words of Hindustani.
IT.?Eaj
was
no
diarrhoea;
but
numerous
rose-colored
spots
were
body. (In a case of this kind, where the skin is not overclean, it is extremely difficult to distinguish a mosquito bite from a typhoid fever spot. The bite of a mosquito leaves on the skin of a cachectic subject a spot which lasts for several days. A strong magnifying glass does not always show the central puncture.) In this man's case I was unwilling to pronounce the spots typhoid until after marking them with ink, and watching their progress day by day. The result of this test was, that after a few days the spots disappeared, and were succeeded by others. From the 2Gth to the 31st this detected
over
the
On the 1st November the fever returned. jaundice, and no tenderness of the liver. A few
Goorkha did well. He had doses of
no
quinine,
with alterative
days.
His convalescence
the 9th
January
he
was
was
pills,
were
continued for
a
few
slow, but progressive daily.
discharged,
still
weak,
On but able to move
about. III.?Man Beer. Goorkha, aged 24, does not speak a word He is believed to have been ill nearly ten of Hindustani. days like the former case. On admission he had strong fever ;
great thirst; much prostration.
Laree doses of quinine were given, with apparent benefit. The tongue was covered with a dry dark fur. There were frequent thin yellowish stools. On the 23rd numerous dark livid spots were detected on trunk. After their appearance the fever lessened ; but his dejections were thin and yellowish, sometimes frothy. On the 26th, was free of fever, but very listless and weak. On the 27th, a fresh crop of spots appeared on the forehead, while those on the trunk were disappearing. On pressure these spots faded away ; diarrhoea lessened. On 28th, very weak ; three stools during night; slight symptoms of pneumonia posteriorly ; cough very troublesome. The pneumonia increased, and, on 2nd November, he was again feverish, with a dry skin. This continued till the 8tli, when he appeared much better. On the night of the
September. 2,
1872.]
CHLORIDE 01?
AMMONIUM,
On the a severe and exhausting attack of fever. passed a great many lumbrici after a close of santonine. No organic lesion died during the night of the 16th.
10th lie liad 16th he He was
found in any of the abdominal organs, but the small were ulcerated. Through one of these ulcers a
intestines worm
had made its way into the
These three
cases
undoubtedly typhoid
peritoneal cavity.
very interesting. fever; the two latter
The first case was
are
were
probably
the
The spot3 in the two latter cases were peculiar. They a few came out in successive crops, and, after lasting days, faded away. There were no signs of a scorbutic taint in these instances, so it is difficult to refer them to any disease but
same.
fever. Still, the the case ; and it enteric fever.
typhoid usually
eruptio-i appeared
W:is on
plentiful than face, which is rare
more
the
is in
On the 17th November another batch of coolie3 was loft at Hospital. They had also come from the hills
the Mitford
Darjeelinu, and they were ehiedy Bhooteeas, Nepaulose, They were shockingly filthy, and they had all been ill for days. IV.?Tundoo Sree, Goorkha, aged 24, was admitted in a prostrated state, quite delirious, and without any history of his case. Bowels disordered; diarrhoea troublesome; tongue dry, and covered with a black fur. On the morning of the 18th his pulse was 101. Stimulants and soups revived him a little ; but on the morning of the 21st he was found dead in bed. Post-mortem.?Heart large and flabby; its cavities contained large fibrinous clots ; liver large and congested ; lungs gorged with blood, posteriorly; spleen enlarged ; the stomach contained a large coil of tapeworm. The rest of the worm extended the whole length of the small intestine, and measured 80 cubits (120 feet) in length. The ileo-coe-al valve was much valvulse conniventes" were very prominent thickened. The and hard. Here and there patches of congestion were found, and in places ulceration had begun. Peyer's glands were noraround
and Goorkhas.
"
mal.
V.?Deruttee, Goorkha, aged 28 ; on admission, eyes sunken ; tongue dry and cracked ; body very filthy, but through the dirt numerous dark rose-colored spots were detected. He was in u state of low muttering delirium. On deep pressure in right
region groans were elicited. No diarrhoea now ; but he is stated to have had purging on board the steamer. November \9th.?Teeth covered witli sordes; lips dry and fissured; tongue brown, rough, and parched; pulse 101.
iliac
Quinine,
in
large doses,
was
20th.?Pulse small and
prescribed. weak; delirium continues
;
skin
and soup were given. On the 22nd, For forty-eight hours he remained in this state. however, he again became feverish, with a full strong pulse. cool and moist.
The
Large quantities
of
rum
tongue had become moister and cleaner.
The
parotid
left side is swollen and very painful. The right parotid also became inflamed the following day ; but it subsided
gland
on
application of a few leeches. The left, however, slowly suppurated. On the 6th December he had an attack of diarrhoea, probably brought on by some indigestible food, which continued for nearly a fortnight. Recovery was tedious, but complete. These cases, as I have already pointed out, have been imperfectly kept; and the absence of any record of variations of bodily temperature, increases the difficulty of deciding what these cases of fever really were. At the present time, when typhoid fever and its existence in Bengal are exciting controversy, it is the duty of every Civil Surgeon to assist in determining the different types of fever met with in practice. With one set of writers asserting that typhoid fever is unknown in " India, and another that remittent fever is a myth," it is evident that further inquiry is urgently demanded. If the cases detailed above are not typhoid fever, what are they ? Is there a remittent fever with enteric symptoms, and an eruption after the
&c.?BT W. STE\VrAHT.
199
typhoid-locking spots, running a protracted course, unconby quinine, manifesting itself in those old native cities which are unprovided with any sanitary arrangements, and simulating the typhoid fever of Europe ? I believe that in the course of further inquiry it will be proved that typhoid fever is common in the old cities of Bengal, and that our scepticism concerning its existence lias been due to education and biassed of
trolled
minds.
