A Few Observations on Enteric or Typhoid Fever: Apropos of a Report on the Same in Relation to British Troops in the Madras Command

also "febricula"; a case of "fever, diarrhoea and abdominal pain, and disease in a few days clearly recognized as enteric," " rose coloured eruption," " blood passing from bowels at end of 4th week" and dying from coma preceded by convulsions after 36 days in hospital, is thus remarked on ; " from the history as given in the case-book, the case is more like one of ardent fever terminating in heat apoplexy than any thing else" (14, page 44) Apart from errors in diagnosis by some, it is the height of improbability, nay impossibility, for so many medical men, over a period of six yqars, all to have mistaken enteric fever ; a most culpable ignorance (to say the least) must be general in the department to allow of even an approximation to such a state of affairs. Limiting ourselves to the seven cases whose abstracts stand the test of rigid scrutiny and comparison, we cannot resist the conclusion that we have here corroborative evidence that typhoid or enteric fever (clinically and pathologically similar to the European disease) is one of the diseases met with in India. How then stands the causation??Parkes, 4th ed., Hygiene, p. 454, writes :?" External cause.?A poison of animal origin ; one mode of propagation is by the intestinal discharges of persons sick of the disease; other modes of origin and transmission are not disproved." And at p. 123 it is stated that,l almost all the events which have been recorded in connection with the origin of typhoid fever" are explained by " the doctrine that a specific cause is necessary for its production." Aitken, 6th ed., vol. I, p. 577, writes:?"The history of enteric fever, whose leading features have been described in the previous pages, is wholly inexplicable upon the 'pythogenic theory' of Dr. Murchison. On the contrary it is emphatically the history of a specific disease generating a specific poison, and propagating itself by it." This also is the opinion of Dr. Budd. This specific theory requires the introduction of a case into a community where the disease is not, to allow of its existence and spread in that community; it excludes all other theories of propagation ; it asserts that the disease may be stamped out. On the other hand we have the " pythogenic theory" which regards the disease as dependent on the introduction into the body of the elements arising from putrefactive processes ; hence the requisites are, filth in a state of decomposition, and a recipient human body. It denies the necessity of a specific virus?an individual suffering from the disease?for originating the disease in a healthy community, it asserts a spontaneous origin. It is needless to say, that if this be the true theory the disease cannot be stamped out, but will spring up whenever and wherever unsanitary conditions exist and human beings are exposed to these. A third theory is given in the Report of the State Board of Health of Massachusetts,?" that it is putrefaction of animal and vegetable substances, under cover, which gives typhoidthis clearly is an extension of the Murchison theory as to the noxious elements, a limitation of it to certain necessary conditions. A fourth theory is,?that the present limits of asserted causation of the disease must be extended, but that the disease once produced may be propagated to others ; this, the latest, is also American. Here then is a range of causation which cannot be termed exclusive ; there is one undoubted fact? that typhoid fever is communicable by the intestinal discharges of one sick of the disease. Do the Indian cases conform to any one or all of these, or must we still further extend the etiology circle ? It is needless to show that any theory to stand its ground must embrace all the known circumstances of each case. An answer to this question of a satisfactory nature has not hitherto been forthcoming, nor does the report of the disease in the Madras Command throw much light on the subject. These cases range from 1871 to 1877. The abstracts give no clue to any real or probable oxpossible causation. The sanitary reports on the barracks, &c., bear date none earlier than March 1878, and although the attention of the medical officers then doing duty. with the corps was directed to the subject of causation, yet " it will be observed that only at a very small number of the places mentioned is an allusion made in regard to the existence of recognized causes of enteric fever, and that where such allusions occur, they are expressed in terms so problematic as to indicate the undecided views held by medical officers while writing about them" (p. 101 of Report). In the tabulation of cases in the appendix, columns for "particulars in regard to exposure or otherwise to emanations of animal or vegetable origin"?" other apparent cause of attack, infectious or otherwise"?" any other particulars likely to elucidate the etiology of the disease in individual c-.ises."?are given, yet the replies convey but little information ; apparently because none was forthcoming. ' No history,' ' not traceable to exposure,' 1 no evidence,' 'nothing of a definite character,' 'not stated,''none traceable,' ' exposed only to effluvium from latrines in barracks,' 'unknown,'?such are the staple replies ; on the positive or rather inclining to the positive, side of the subject we have :?' possible infection' 3, ' suppose'! infection' 2, t ti-aced to exposure' 1, ' following attendance on his brother ill of the disease" 1, 'unsatisfactory state of latrines' 1. It is clear that as a basis of causation these cases are next to worthless, but, when it is remembered that a considerable period of time (years in many instances) had elapsed between the case and this enquiry, it is not to be wondered at that the answers are so often negative. If any good is to come out of an enquiry into the subject it must start from a recognition of the disease at the bedside, and a careful scrutiny into the previous surroundings of the individual made without delay and by competent enquirers. The scattered nature of these cases (sporadic) tends in itself to show that the causation was not to be found in the barracks but in a something to which the individual alone was exposed apart from the company or corps of which he formed a component ; had it been otherwise, localized outbreaks would have been the result, arguing from the ascertained facts of the disease in Europe. The soldier has a wide range of wandering, through bazaars, native haunts, adjacent villages, and is consequently exposed to many sources of disease ; and it is impossible to overlook this important fact in endeavouring to trace the exciting cause of such a disease as enteric fever. How do the ascribed causes of the disease in Europe stand as possible factors of the disease in India ? Specific factor.?Is there a case in existence to propagate its kind ? The answer surely must be in the affirmative for India generally, and if we want late information of the Madras Presidency, we can find it in the Sanitary Commissioners report for March? June 1878. At page 91 for March and April it is stated that " 3 cases of undoubted enteric fever have been admitted in the hospital (Madras) during the past month, two of I Eurasians who are recovering, and on* of a native who I died, and in whom the diagnosis was confirmed by a January 1, 1879.] REVIEW. 27 post-mortem? And at, page 105, "the occurrence of cases of typhoid fever in the compound of the ' Seven Wells' is reported, under conditions very similar to what is f iund in Europe." At page 135 of the report for M iy ? June, enteric fever is reported as existent in the Lawrence Asylum, Ootacamund, " at the present time," and men tion is made of an outbreak also there in 1876 77. Animal putrefaction.?The existence of th's factor cannot again be doubted. To speak of no other smells, the presence of human excrement can hardly be avoided ; the native squats wherever he may happen to be. If effluvia from decomposing human ordure can originate the disease, we have undoubtedly a potent and common cause in our midst; while if the disease be present in the native community, then considering the certainty of possible propagation through the medium of the intestinal discharges, the probability of its transmission by air and water contamination is very strong indeed. Vegetable putrefaction.?Here again no doubt of its existence can arise, whatever doubt we may have as to its power in originating this disease. What then is the summary ??(1) that enteric fever, similar clinically and pathologically to that of Europe, does exist in India. (2) That the causes ascribed to the disease in Europe are also present in India. (3) That the evidence necessary to connect these in India is not forthcoming, and that the etiology of the Indian disease is a work for future enquirers.