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CHAPTER V.
From an examination of the cases which have been forwarded to me by
medical officers it appears that it is quite the exception for the disease, on the
patient's first admission into hospital, to be diagnosed as enteric fever, as in a large
majority it is ascribed to either intermittent, remittent, or continued fever,
and only when enteric complications arise, is the disease changed.
I also notice that the temperature charts in a large number of cases do not
present the same fluctuations as are met with in England or as are depicted by
Wunderlich and other authors as diagnostic of enteric fever. The absence of
the characteristic eruption is also very frequently observed; and sometimes there
appear to be no abdominal symptoms so marked as to attract attention until
a post mortem examination reveals the presence of ulceration in the solitary or
agminated glands of the lower part of the ileum. According to Wilks and Moxon
"the peculiarities of the 'typhoid ulcer' are quite sufficient to distinguish it from
all other ulcers, even from tuberculous ulcerations, which also affect Peyer's
patches," but in India it is not in all cases an easy matter to make a distinction
between it and other ulcers.
Whether infarction or ulceration of the glands in the lower part of
the ileum are to be regarded ipso facto as indisputable evidence that the dis-
ease from which the patient died was enteric fever whether specific or not is a
question that must be left to further investigation at the bedside, in the dead house,
and with the microscope. I would however desire to lay stress on the extreme
importance of making a special enquiry on the spot as to the circumstances
attending the previous history of each individual patient for at least 14 days before
he was first taken ill. This living over again as it were the life of each patient
before his attack with differentiation of his life from that of other people is, as
Dr. Buchanan says, difficult enough even under the conditions of English society ;
but in India with the unintelligent class of men, such as soldiers generally are,
the difficulty is greatly enhanced, especially when it is remembered that the patient
himself is usually so ill as to be unable to recall to recollection what he had been
doing or where he had been for even a much shorter period. The information
on these points obtainable by enquiries from his comrades is almost invariably very
unsatisfactory. At present medical opinion in this country as to the significance
of these lesions is most conflicting. Many medical officers with whom I have had
the advantage of discussing this subject seem to think that the lesions which
would be considered pathognomonic of specific enteric fever in Europe are by no
means conclusive evidence that the disease was induced by a specific morbid
contagium derived from the intestines of a previous case or even from fæcal
poisoning, but agree with Sir Joseph Fayrer that malaria must be admitted among
the exciting causes of the disease he proposes to call endemic enteric or continued
fever as contradistinguished from specific typhoid fever, which he fully acknow-
ledges is met with in India. A late distinguished member of the Bombay Medical
Service, Dr. Morehead, also held that "Disease of Peyer's glands either in a state
of turgescence or ulceration is net a morbid state peculiar to typhoid fever. It
occurs in cholera, in protracted diarrhœa, in acute muco enteritis, as an occasional
complication of remittent fever, and a frequent one in phthisis pulmonalis".
Others, again, hold that the lesions are really as truly pathognomonic of
enteric fever in India as they are in Europe, and that they are solely the result
of a specific morbid contagium.
It may be interesting to give some illustrative cases where doubt as to the
true character of the disease has been entertained.
The first case is that of Private Hands of the 17th Lancers. The two
able and experienced medical officers who attended this man considered he was
suffering on first admission with remittent fever, but three days before his
death the disease was changed to pneumonia.
I notice a discrepancy regarding the date of the commencement of the attack
between the statement made by the patient and that contained in the post-
script. I also think the date of arrival in India, as given in the postscript, can
hardly be correct, as it appears from other documents that the Left Wing arrived
in Bombay on the 11th of November but did not reach Mhow until the 14th.
The symptoms detailed in the case certainly bear a very strong resemblance
to, and lead me to consider it, a case of enteric fever; but in discussing the subject
with Surgeon Major Robinson, who had been with the Regiment in South