and two from dysentery. In none there any signs or symptoms of enteric fever. Amongst Europeans and Natives, the same symptoms and signs were met with, but varying in intensity, and in the cases treated by me, they tallied with the descriptions obtained from Deobund and the district at large, except that in these latter, death often ensued with great rapidity. Into the symptoms I need not In most without marked proenter at large. dromata, although most often it could be elicited that the patient had not been himself for a few days, there was a sudden onset of fever, with chilliness and rigors of varying intensity and duration, and in a large number of instances accompanied by nausea and incontrollable vomiting and purging. It was succeeded by a true hot stage, and, finally, by sweating, often not very marked. Intense headache and lumbar neuralgia amongst adults and convulsions often in infants accompanied the fever. In many instances the fever for a few days more was remittent, there being no distinct intermission, and in these the nausea and vomiting continued. Subsequently, the intermission became distinct, and vomiting and purging returned with each The cases were, as I saw them, all paroxysm. amenable to treatment by qni?iine. In all, the prostration following the fever was intense, and the convalescence long, with a tendency to recurrence of intermittent paroxysms, quotidian, tertian or quartan. In those parts of the district where the fever was worst, an algide condition, similar in many respects to cholera, followed the intense vomiting and purging, from which the patient rallied with difficulty or not at all, death ensuing in
pneumonia,
were
REMARKS ON FEVER MORTALITY AT DEOBUND IN 1884. By Brigade-Surgeon A.
GARDEN,
M. D.
(Continued from page, SCO.) In the absence of more direct evidence gained from personal observation, and accurately noted cases, collateral evidence must be made use of, such as can be gained from the characters of the fever as seen elsewhere. Descriptions sent in from all sides tallied with what was going on under my own eyes. All classes alike?Europeans, Eurasians, and Natives, rich and poor, suffered from the fever, bnt, the results differed. Where the individuals lived under favourable conditions, hygienic and social, the numbers attacked were large, the casualties small. The return from the staff of the S. P. and D. Railway and their families was as under :? Admission
Population
Men ... Woman Children
...
..
Total
...
from
Fever.
WlioW
January
year.
July.
112
90 54 241
385
98 70 175
348
22 33 107
341
547
162
87
to
Auir. to
Sep.
There were two deaths only traceable in any way to the fever, infants who died from convulsions. There was not one case of enteric fever. In the Jail with an adult population of 243 there were during 1884, 250 admissions from fever, 48 during the months from January to July, and 202 during the months from August to November. No cases were admitted in December. The 202 attacks in the second period occurred i" 129 individuals;. 77 were attacked once, 27 twice, 12 three times, 5 four times, and 3 five times. Four deaths occurred, two from
a
day
or
two
or
more.
I may further add that during the ensuing cold weather and the next year, there was a vast number who presented themselves with chronic enlargement of the spleen traced to the attacks in 1884, and that during this time quartan fever prevailed to a most unusual extent.
After careful consideration there remains in my mind no doubt that the fever, as in 1859, 1869, 1870, and 1879, was in 1884 essentially malarious, and that enteric fever was absent. At one time it appeared to me as if I had to deal .with a few cases of recurrent fever amongst the prisoners ; but the majority of cases amongst them were undoubtedly malarious. The question then arises what was it that led to the exceptional mortality in Deobund ? In such epidemics we have always two factors at work?producing and increasing sickness and mortality and requiring separate consideration. (?) The epidemic itself. (?) Local conditions, rendering those exposed more liable to take and less able to cope with the fever.
THE INDIAN MEDICAL GAZETTE.
(?) The epidemic itself was not confined to Saharanpur, but visited the neighbouring districts and the Punjab, and reached as far as the
Bolan. Its intensity varied much, and it chose, as a rule, those parts in which malaria always is strong to show itself in its most virulent form, and this was the case in the tract of land in which Deoband and Nananta stand. In the rural circles in this tract we find the mortality was? Total death-rate. Deobund
(rural) Budgaon (rural) Nananta (rural)
... ... ...
Jan.
per mille 68 79 per mille 76'26 per mille 72*3
to
Aug.
to
Dec.
July. 23-7
48 6
16*83 21-20
51'96 55*06
These rates were the highest rural rates in the whole district. The land is flat and difficult to drain. It is (most of it) in the midst of irrigation. Rice is largely cultivated and malaria is always present. The people are poor,
cachetic, apathetic, indolent. Any
extra
severity
of fever would find a fit pabulum in such a populace; and there need be no wonder that they suffered more heavily than elsewhere. (b) Accepting the highest of the above rural rates as the one dependent on the fever epidemic, we find in Deobund town an excess mortality of 62 per mille, or rather more, which in the maiu may be ascribed to purely local causes. "What these are is fairly evident from the short description of Deobund and its people which 1 gave in a former part of this paper, viz., intense poverty, bad food?defective alike in nutritient qualities and in quantity?poor cloth-
ing, imperfect protection at night, overcrowding, universal insanitary conditions, non-attendance to
hygenie, filth
and bad
of person, filth of
water.
All these conditions
surroundings,
found in Deobund and all are productive of a lowered standard of health, even in the absence of malarious cachexia. The main element, I believe, in producing the extra mortality was simply poverty, and much of it arose from the want of food. In the presence of full granaries and plenty, for there was no hint of anything Ike a scarcity of food material in the country, to talk of starvation as a cause of high mortality is most unorthodox, yet there may be wide-spread and fatal want in the midst of plenty. The greatest mortality was amongst those who were unable to take care of themselves and were dependent on others for their daily portion, viz., infants, and those under five years, and the aged and debilitated who are little able to provide for themselves. After five years of age we may presume that the natural elimination of the weakest by disease had left only the strongest aud fittest, and these,
amongst the
are
large majority,
.
as age increased, of themselves.
were
better able
to
take
care
[Jan.,
1888.
Adults suffered least. Women suffered more than men. Tliey are always the weakest, and in home lite come second best off in every way ; and finally the poorest and dirtiest of the whole. The Mahomedans suffered greatly, more than the Hindus. In a community like that of Deobund, where poverty is chronic and intense, and where the will to work is, even at the best, wanting, the ordinary iucome whether from land, rent, or daily wage, is little more than sufficient for the daily wauts, and little is left to lay by for emer-
gencies.
Thus, when the day of great sickness comes, there is no means of purchasing delicacies such as the invalid requires, and those who live by their daily labour can earn nothing even were they able. At one time all work in Deoband was at a stand-still.
pended,
and
Agricultural operations even
flour had
to be
were
sus-
imported,
as
there were none in the town capable of grinding the corn. The bazaars were empty, and the town was almost like a city of the dead. The bread winners, one and all, were too ill to work, even had there been work for them to Their small savings, their power of bordo. rowing, or their credit with the banniahs had to be depended on. All were ill, weak, and exhausted. Food, inferior in quality, insufficient in quantity, and miserably prepared, was all that could be got, and this at a time when life depended on a liberal supply of nutritive, well-cooked food. In Unao, in 1879, I saw the same state of things, and came to the same conclusion, that what saved the European, the well-to-do native, and the prisoner in jail, was the power of getting suitable food, and that the opposite led to much of the terrible mortality amongst the masses. This is the outcome of the general economical condition of the people, and is in 110 way As long as the the fault of the authorities. masses are miserably poor, as long as bad seasons occur, and as long as violent outbreaks of fever visit the land, such events must happen. They, at least, help to keep down the too rapid growth of population. After snch a history the question is natural?what is the remedy for all this ? As long as the three conditions necessary to the production of malaria continue to exist,
viz.,
high temperature, lengthened permanent
moisture of the soil, and free exposure to the oxygen of the air, it is hopeless, in such a country as this, to try and get rid of the fever
entirely.
The fever has
always been there, and will the climate and the lay of the And so, also, with land are such as they are. We must expect the periodical outbreaks. them to return and return. Much , however, may be done to rcduce the remain
as
long
as
Jan., 1888.]
Dr. GARDEN ON FEVER AT DEOBUED.
evil to its minimum by efficient drainage and attention to local hygiene and to the water-
supply.
Whilst the epidemic and mortality were fresh and vivid in men's minds, measures for the improvement of the drainage of Deoband were discussed and settled. I believe that still, in September 1887, the condition of affairs remains as it was; and as it is a question of expenditure of money, will remain so until another catas-
trophe
occurs.
A vast deal too may be done in the way of cleaning and keeping clean the town, and, more important than all, the interior of the houses. But these are matters of every day hygiene, and require no discussion here. To improve the condition of the people seems almost a hopeless task, until, with improved surroundings, they become more healthy and less apathetic. This might well happen if the amount of permanent malaria could in any way be reduced. This can be only done by thorough drainage efficiently maintained, and the provision of an ample supply of good drinking-water. To obtain this latter, all the wells now in existence should be closed. They receive their water entirely from the foul surface, and the water must be more or less contaminated. To wage war with these people's customs of dirt?personal, and in their houses and surround-
ings?inattention to ventilation, crowding gether, &c., is a vast undertaking. They are poor, very poor, and must, I afraid, remain
Government
to-
am
do nothing to raise them from this condition, and they will All that can be done iu not help themselves. the preventive way is to drain, fill up tanks, provide good wells, and insist on outward cleanliness, and effective conservancy. There remains still the question what is to be done in the midst of such epidemics. All the trained medical establishment we can gather together is quite inadequate to the demands of such a time. It must be remembered that in this deadly sickness there is no rule of thumb by which a mere tyro, a c/iuprasee, or a school-master can treat the cases with any chance of success. Skilled attendance is necessary, and constant watching is required until convalescence is fairly established. Such skilled labour is not at command, and all the establishment we have, would not suffice to cope with the disease in one town such as Deobund, let alone the eutire so.
can
district. Iu addition to the hospital assistants at the various dispensaries, who find full occupation in their own circles, we have only, as a rule, the district vaccinators. These are iu a way trained, that is, they pick up what they can on the diagnosis and treatment of syphilis, consumption, and fever, during one month's attendance at the sadr
dispensary once a year. But even were they highly trained, they could do but little relatively. The only other remedy at present is the extensive distribution of pills of cinchona febrifuge. Of these many thousands were sent out North, South, East and West, and it would be
curious to find out the ultimate destination of Granted, they did finally reach the human stomach, this would go but a short way in treating a serious case, for even in such a matter as the timely administration of an ante-periodic drug, brains are required. However, that some good arose and arises from this distribution, seems to be evidenced by the fact that the people now ask for the febrifuge, and are disappointed if they do not get it. We must do our little best and leave the rest
most.
to
Providence.
But until we can reach the sick with proper food and nursing, our drugging will be of only partial avail. It may aid in saving the strong and those who are only mildly attacked, but will not ward off death in the worst cases. And here comes the saddest part of it all. The Government cannot undertake this task of feeding the masses, and it should be done by private charity. Such charity does not exist. I have put the question before well-to-do natives, but they cannot see that it is their duty. They will spend fabulous sums on marriages and funeral ceremonies, they will feed crowds of lazy brahmans, but in the time of need they will not assist their neighbours. NOTE. Dr. Chevers in his work on the " Diseases of India" goes fully into the question of enteric fever in India, and as to whether it is an old disease not recognised, or one of recent importation. Since 1859, when I first found myself face to face with one of these overwhelming epidemics of fever, which swept over Ghazipore in October of that year, I have been constantly on the watch for enteric fever and possibly too intent to find it. My diagnosis, that the fever which then destroyed thousands, sweeping off entire families almost in a few days or weeks, was malarious, was based on careful observation of hundreds of cases and notes taken at the time. My opinion was, however, traversed by Dr. Walker, who pronounced it to be typhoid, but I have found no reason to alter my first diagnosis. Since then, I have seen many cases of enteric fever amongst Europeans and some amongst natives, and it seems to me that the number of cases increases yearly. I was Civil Surgeon of this district from 1864 to 1874. During that time I did not meet with one case amongst Europeans, though after the opening of the S. P. and D. Railway in 3
[Jan.,
THE INDIAN MEDICAL GAZETTE.
10
1869,
a
considerable
European
and Eurasian
One or two cases amongst staff resided here. In 1875, I met with a large natives I did see. number of cases in Mussoorie. In October 1871 and 1879 in Assam I saw one or two doubtful cases. In 1879-1880 in Cawnpore, I had several amongst Europeans and Eurasians and also a few cases amongst natives. At the end of 1883, I returned to Saharanpur and found a greatly increased population of Europeans and Eurasians, who are entirely under my charge. In 1884, during the fever epidemic, I did not meet with one case amongst Europeans and Eurasians, and any such could hardly have escaped my notice, nor amongst natives, in jail in 1885. My expeor free ; and it was the same was 1886 in different; rience amongst Europeans and Eurasians I had seven cases in which no mistake could be made, though as all recovered, the crucial test could not be applied. I had also two cases in jail which presented most of the symptoms of enteric fever. I have given this short detail of my own experience during 32 years of professional life in India as it seems to me to show that however long enteric fever may have existed in India, it has become more pronounced and shows itself now-a-days in places in which it was unknown before, at least amongst Europeans and Eurasians. This, however, does not deal with the larger and more important problem of its greater or less prevalence amongst natives which has as " yet to be solved. Dr. Chevera says, I think that a minute inquiry into the prevalence of enteric fever among the natives of India is still a desideratum," and with this, no one who has thought on the subject can disagree. Enteric fever might well be frequent and yet escape notice if not treated in public institutions, such as hospitals, jails, &c. My own experience of it is not is that in fact, I have common; jails only met with it in a very few instances. It is also very rarely met with in civil hospitals?so rarely indeed, that those who study in our medical schools, may go through a successful course of instruction and yet know nothing of the disease except from books. The result of this is that when they, for the first time, find themselves in its presence, their diagnosis may fail, and the case be classed as one of malarious fever. The fact is that, for various reasons, our civil hospitals and dispensaries can furnish little or no evidence on the nature of the fevers prevalent, beyond those usually classed as malarious. Not one case of typhoid may be recorded amongst many thousands* treated,simply because such either did not occur or _
1888.
Iii the out-patient department in which the larger part of the work, though not the most important, is done, most of the patients come in person, a few are represented by friends. In the former instance, diagnosis is rapidly framed
from the patients' own statements, and the fact that the patient is there, almost in itself precludes the idea of enteric fever at that stage in which a fairly accurate diagnosis could be made straight off, for it will be readily admitted that peculiar care is required in India in diagnosing the disease in its first onset. In the case of those represented by friends, ignorance and defective intelligence combined with a foregone conclusion that all fever must bo " tap juree" (ague) precludes any such accurate information being given as would aid diagnosis even if the prescribing officer took any trouble to make searching inquiries, for when crowds are impatiently waiting, there is little time for much
questioning.
found amongst the f would not be adalmost invariably and severe are cases mitted, treated at home. Here they are in the midst of friends and relatives who can tend them without ceasing from their ordinary bread-winning occupations, which they would have to do if they left home to nurse their sick in our hospitals. Moreover, there is a strong disfavour shown to entering these institutions originating in the, idea, once stronger than it is now, that those who enter there, must leave all hope behind. This is perhaps not an unnatural result of the numbers who really did die, poor wretches brought at their last extremity when beyond hope to see if any thing can be done for them, after baid and hakeem had done their best and failed. Equally deterrent is the notion still fairly common that all who enter hospital will for certain have some limb or part of limb lopped off. This is the outcome of a too eager pursuit of surgery at all costs?of surgery at Few
cases
house-patients.
of fever
Slight
are
cases
high
pressure. In the face of such difficulties we must depend for our knowledge of fevers amongst the population at large on those whose daily practice lies in their midst; but these as yet require that practical education which will enable them when they meet cases to recognise what they have before them.
escaped recognition.
*
In the Saharanpur Civil Hospital and Dispensary, during the ten years ending 18SG, 457 house-patients and 19,418 out-patients were" admitted for Fever not onq of which was diagnosed Enteric." "
"
?f With the exception of tlio Polico who are treated in, tbe City Hospital. No case of enteric fever has beeu evei1 > > met with amongst them.
pneumonia,
were
REMARKS ON FEVER MORTALITY AT DEOBUND IN 1884. By Brigade-Surgeon A.
GARDEN,
M. D.
(Continued from page, SCO.) In the absence of more direct evidence gained from personal observation, and accurately noted cases, collateral evidence must be made use of, such as can be gained from the characters of the fever as seen elsewhere. Descriptions sent in from all sides tallied with what was going on under my own eyes. All classes alike?Europeans, Eurasians, and Natives, rich and poor, suffered from the fever, bnt, the results differed. Where the individuals lived under favourable conditions, hygienic and social, the numbers attacked were large, the casualties small. The return from the staff of the S. P. and D. Railway and their families was as under :? Admission
Population
Men ... Woman Children
...
..
Total
...
from
Fever.
WlioW
January
year.
July.
112
90 54 241
385
98 70 175
348
22 33 107
341
547
162
87
to
Auir. to
Sep.
There were two deaths only traceable in any way to the fever, infants who died from convulsions. There was not one case of enteric fever. In the Jail with an adult population of 243 there were during 1884, 250 admissions from fever, 48 during the months from January to July, and 202 during the months from August to November. No cases were admitted in December. The 202 attacks in the second period occurred i" 129 individuals;. 77 were attacked once, 27 twice, 12 three times, 5 four times, and 3 five times. Four deaths occurred, two from
a
day
or
two
or
more.
I may further add that during the ensuing cold weather and the next year, there was a vast number who presented themselves with chronic enlargement of the spleen traced to the attacks in 1884, and that during this time quartan fever prevailed to a most unusual extent.
After careful consideration there remains in my mind no doubt that the fever, as in 1859, 1869, 1870, and 1879, was in 1884 essentially malarious, and that enteric fever was absent. At one time it appeared to me as if I had to deal .with a few cases of recurrent fever amongst the prisoners ; but the majority of cases amongst them were undoubtedly malarious. The question then arises what was it that led to the exceptional mortality in Deobund ? In such epidemics we have always two factors at work?producing and increasing sickness and mortality and requiring separate consideration. (?) The epidemic itself. (?) Local conditions, rendering those exposed more liable to take and less able to cope with the fever.
THE INDIAN MEDICAL GAZETTE.
(?) The epidemic itself was not confined to Saharanpur, but visited the neighbouring districts and the Punjab, and reached as far as the
Bolan. Its intensity varied much, and it chose, as a rule, those parts in which malaria always is strong to show itself in its most virulent form, and this was the case in the tract of land in which Deoband and Nananta stand. In the rural circles in this tract we find the mortality was? Total death-rate. Deobund
(rural) Budgaon (rural) Nananta (rural)
... ... ...
Jan.
per mille 68 79 per mille 76'26 per mille 72*3
to
Aug.
to
Dec.
July. 23-7
48 6
16*83 21-20
51'96 55*06
These rates were the highest rural rates in the whole district. The land is flat and difficult to drain. It is (most of it) in the midst of irrigation. Rice is largely cultivated and malaria is always present. The people are poor,
cachetic, apathetic, indolent. Any
extra
severity
of fever would find a fit pabulum in such a populace; and there need be no wonder that they suffered more heavily than elsewhere. (b) Accepting the highest of the above rural rates as the one dependent on the fever epidemic, we find in Deobund town an excess mortality of 62 per mille, or rather more, which in the maiu may be ascribed to purely local causes. "What these are is fairly evident from the short description of Deobund and its people which 1 gave in a former part of this paper, viz., intense poverty, bad food?defective alike in nutritient qualities and in quantity?poor cloth-
ing, imperfect protection at night, overcrowding, universal insanitary conditions, non-attendance to
hygenie, filth
and bad
of person, filth of
water.
All these conditions
surroundings,
found in Deobund and all are productive of a lowered standard of health, even in the absence of malarious cachexia. The main element, I believe, in producing the extra mortality was simply poverty, and much of it arose from the want of food. In the presence of full granaries and plenty, for there was no hint of anything Ike a scarcity of food material in the country, to talk of starvation as a cause of high mortality is most unorthodox, yet there may be wide-spread and fatal want in the midst of plenty. The greatest mortality was amongst those who were unable to take care of themselves and were dependent on others for their daily portion, viz., infants, and those under five years, and the aged and debilitated who are little able to provide for themselves. After five years of age we may presume that the natural elimination of the weakest by disease had left only the strongest aud fittest, and these,
amongst the
are
large majority,
.
as age increased, of themselves.
were
better able
to
take
care
[Jan.,
1888.
Adults suffered least. Women suffered more than men. Tliey are always the weakest, and in home lite come second best off in every way ; and finally the poorest and dirtiest of the whole. The Mahomedans suffered greatly, more than the Hindus. In a community like that of Deobund, where poverty is chronic and intense, and where the will to work is, even at the best, wanting, the ordinary iucome whether from land, rent, or daily wage, is little more than sufficient for the daily wauts, and little is left to lay by for emer-
gencies.
Thus, when the day of great sickness comes, there is no means of purchasing delicacies such as the invalid requires, and those who live by their daily labour can earn nothing even were they able. At one time all work in Deoband was at a stand-still.
pended,
and
Agricultural operations even
flour had
to be
were
sus-
imported,
as
there were none in the town capable of grinding the corn. The bazaars were empty, and the town was almost like a city of the dead. The bread winners, one and all, were too ill to work, even had there been work for them to Their small savings, their power of bordo. rowing, or their credit with the banniahs had to be depended on. All were ill, weak, and exhausted. Food, inferior in quality, insufficient in quantity, and miserably prepared, was all that could be got, and this at a time when life depended on a liberal supply of nutritive, well-cooked food. In Unao, in 1879, I saw the same state of things, and came to the same conclusion, that what saved the European, the well-to-do native, and the prisoner in jail, was the power of getting suitable food, and that the opposite led to much of the terrible mortality amongst the masses. This is the outcome of the general economical condition of the people, and is in 110 way As long as the the fault of the authorities. masses are miserably poor, as long as bad seasons occur, and as long as violent outbreaks of fever visit the land, such events must happen. They, at least, help to keep down the too rapid growth of population. After snch a history the question is natural?what is the remedy for all this ? As long as the three conditions necessary to the production of malaria continue to exist,
viz.,
high temperature, lengthened permanent
moisture of the soil, and free exposure to the oxygen of the air, it is hopeless, in such a country as this, to try and get rid of the fever
entirely.
The fever has
always been there, and will the climate and the lay of the And so, also, with land are such as they are. We must expect the periodical outbreaks. them to return and return. Much , however, may be done to rcduce the remain
as
long
as
Jan., 1888.]
Dr. GARDEN ON FEVER AT DEOBUED.
evil to its minimum by efficient drainage and attention to local hygiene and to the water-
supply.
Whilst the epidemic and mortality were fresh and vivid in men's minds, measures for the improvement of the drainage of Deoband were discussed and settled. I believe that still, in September 1887, the condition of affairs remains as it was; and as it is a question of expenditure of money, will remain so until another catas-
trophe
occurs.
A vast deal too may be done in the way of cleaning and keeping clean the town, and, more important than all, the interior of the houses. But these are matters of every day hygiene, and require no discussion here. To improve the condition of the people seems almost a hopeless task, until, with improved surroundings, they become more healthy and less apathetic. This might well happen if the amount of permanent malaria could in any way be reduced. This can be only done by thorough drainage efficiently maintained, and the provision of an ample supply of good drinking-water. To obtain this latter, all the wells now in existence should be closed. They receive their water entirely from the foul surface, and the water must be more or less contaminated. To wage war with these people's customs of dirt?personal, and in their houses and surround-
ings?inattention to ventilation, crowding gether, &c., is a vast undertaking. They are poor, very poor, and must, I afraid, remain
Government
to-
am
do nothing to raise them from this condition, and they will All that can be done iu not help themselves. the preventive way is to drain, fill up tanks, provide good wells, and insist on outward cleanliness, and effective conservancy. There remains still the question what is to be done in the midst of such epidemics. All the trained medical establishment we can gather together is quite inadequate to the demands of such a time. It must be remembered that in this deadly sickness there is no rule of thumb by which a mere tyro, a c/iuprasee, or a school-master can treat the cases with any chance of success. Skilled attendance is necessary, and constant watching is required until convalescence is fairly established. Such skilled labour is not at command, and all the establishment we have, would not suffice to cope with the disease in one town such as Deobund, let alone the eutire so.
can
district. Iu addition to the hospital assistants at the various dispensaries, who find full occupation in their own circles, we have only, as a rule, the district vaccinators. These are iu a way trained, that is, they pick up what they can on the diagnosis and treatment of syphilis, consumption, and fever, during one month's attendance at the sadr
dispensary once a year. But even were they highly trained, they could do but little relatively. The only other remedy at present is the extensive distribution of pills of cinchona febrifuge. Of these many thousands were sent out North, South, East and West, and it would be
curious to find out the ultimate destination of Granted, they did finally reach the human stomach, this would go but a short way in treating a serious case, for even in such a matter as the timely administration of an ante-periodic drug, brains are required. However, that some good arose and arises from this distribution, seems to be evidenced by the fact that the people now ask for the febrifuge, and are disappointed if they do not get it. We must do our little best and leave the rest
most.
to
Providence.
But until we can reach the sick with proper food and nursing, our drugging will be of only partial avail. It may aid in saving the strong and those who are only mildly attacked, but will not ward off death in the worst cases. And here comes the saddest part of it all. The Government cannot undertake this task of feeding the masses, and it should be done by private charity. Such charity does not exist. I have put the question before well-to-do natives, but they cannot see that it is their duty. They will spend fabulous sums on marriages and funeral ceremonies, they will feed crowds of lazy brahmans, but in the time of need they will not assist their neighbours. NOTE. Dr. Chevers in his work on the " Diseases of India" goes fully into the question of enteric fever in India, and as to whether it is an old disease not recognised, or one of recent importation. Since 1859, when I first found myself face to face with one of these overwhelming epidemics of fever, which swept over Ghazipore in October of that year, I have been constantly on the watch for enteric fever and possibly too intent to find it. My diagnosis, that the fever which then destroyed thousands, sweeping off entire families almost in a few days or weeks, was malarious, was based on careful observation of hundreds of cases and notes taken at the time. My opinion was, however, traversed by Dr. Walker, who pronounced it to be typhoid, but I have found no reason to alter my first diagnosis. Since then, I have seen many cases of enteric fever amongst Europeans and some amongst natives, and it seems to me that the number of cases increases yearly. I was Civil Surgeon of this district from 1864 to 1874. During that time I did not meet with one case amongst Europeans, though after the opening of the S. P. and D. Railway in 3
[Jan.,
THE INDIAN MEDICAL GAZETTE.
10
1869,
a
considerable
European
and Eurasian
One or two cases amongst staff resided here. In 1875, I met with a large natives I did see. number of cases in Mussoorie. In October 1871 and 1879 in Assam I saw one or two doubtful cases. In 1879-1880 in Cawnpore, I had several amongst Europeans and Eurasians and also a few cases amongst natives. At the end of 1883, I returned to Saharanpur and found a greatly increased population of Europeans and Eurasians, who are entirely under my charge. In 1884, during the fever epidemic, I did not meet with one case amongst Europeans and Eurasians, and any such could hardly have escaped my notice, nor amongst natives, in jail in 1885. My expeor free ; and it was the same was 1886 in different; rience amongst Europeans and Eurasians I had seven cases in which no mistake could be made, though as all recovered, the crucial test could not be applied. I had also two cases in jail which presented most of the symptoms of enteric fever. I have given this short detail of my own experience during 32 years of professional life in India as it seems to me to show that however long enteric fever may have existed in India, it has become more pronounced and shows itself now-a-days in places in which it was unknown before, at least amongst Europeans and Eurasians. This, however, does not deal with the larger and more important problem of its greater or less prevalence amongst natives which has as " yet to be solved. Dr. Chevera says, I think that a minute inquiry into the prevalence of enteric fever among the natives of India is still a desideratum," and with this, no one who has thought on the subject can disagree. Enteric fever might well be frequent and yet escape notice if not treated in public institutions, such as hospitals, jails, &c. My own experience of it is not is that in fact, I have common; jails only met with it in a very few instances. It is also very rarely met with in civil hospitals?so rarely indeed, that those who study in our medical schools, may go through a successful course of instruction and yet know nothing of the disease except from books. The result of this is that when they, for the first time, find themselves in its presence, their diagnosis may fail, and the case be classed as one of malarious fever. The fact is that, for various reasons, our civil hospitals and dispensaries can furnish little or no evidence on the nature of the fevers prevalent, beyond those usually classed as malarious. Not one case of typhoid may be recorded amongst many thousands* treated,simply because such either did not occur or _
1888.
Iii the out-patient department in which the larger part of the work, though not the most important, is done, most of the patients come in person, a few are represented by friends. In the former instance, diagnosis is rapidly framed
from the patients' own statements, and the fact that the patient is there, almost in itself precludes the idea of enteric fever at that stage in which a fairly accurate diagnosis could be made straight off, for it will be readily admitted that peculiar care is required in India in diagnosing the disease in its first onset. In the case of those represented by friends, ignorance and defective intelligence combined with a foregone conclusion that all fever must bo " tap juree" (ague) precludes any such accurate information being given as would aid diagnosis even if the prescribing officer took any trouble to make searching inquiries, for when crowds are impatiently waiting, there is little time for much
questioning.
found amongst the f would not be adalmost invariably and severe are cases mitted, treated at home. Here they are in the midst of friends and relatives who can tend them without ceasing from their ordinary bread-winning occupations, which they would have to do if they left home to nurse their sick in our hospitals. Moreover, there is a strong disfavour shown to entering these institutions originating in the, idea, once stronger than it is now, that those who enter there, must leave all hope behind. This is perhaps not an unnatural result of the numbers who really did die, poor wretches brought at their last extremity when beyond hope to see if any thing can be done for them, after baid and hakeem had done their best and failed. Equally deterrent is the notion still fairly common that all who enter hospital will for certain have some limb or part of limb lopped off. This is the outcome of a too eager pursuit of surgery at all costs?of surgery at Few
cases
house-patients.
of fever
Slight
are
cases
high
pressure. In the face of such difficulties we must depend for our knowledge of fevers amongst the population at large on those whose daily practice lies in their midst; but these as yet require that practical education which will enable them when they meet cases to recognise what they have before them.
escaped recognition.
*
In the Saharanpur Civil Hospital and Dispensary, during the ten years ending 18SG, 457 house-patients and 19,418 out-patients were" admitted for Fever not onq of which was diagnosed Enteric." "
"
?f With the exception of tlio Polico who are treated in, tbe City Hospital. No case of enteric fever has beeu evei1 > > met with amongst them.
