EXTRACTS FROM A DIARY KEPT DURING A VISIT

TO BURDWAN IN SEPTEMBER 1873.

By Surgeon-Major Albert M. Verchere, I.M.S.

(Continued from Vol. VIII., page 312.) ^

A third constable, Kashee Nath, was found to have conti-

nued fever, and I will give here a few details of his case. Constable Kashee Nath, Burdwan Police, was attacked at

Burdwan on the 1st of September 1873, and admitted into hos-

pital on the 3rd September. The Native Doctor recorded the

case as " ague."

4th September 1873 (4th day).?The fever has been continued from the beginning ; pulse quick ; skin 'not; eyes watery and anxious; tongue furred with thick creamy fur ; much fear of

death; begged to be allowed to go away; ha3 had quinine mixture since admission.

5th September 1873 (5th day).?Same as before. t. p. e.

11 a.m. 103-4 94 ? ?

6 p.m. 102-2 92 ?

6th September 1873 (6th day).?Says he slept a little at night; five or six stools yesterday, natural; urine high coloured and scanty; tongue with thick creamy fur, reddish and spotted at tip; eyes and pupils natural; no headache; no spots; much thirst.

T. P. E. 9-30 a.m. 101-8 97 26 6 p.m. 102-2 97 ?

1th September 1873 (7th day).?Pulse in morning 92, Very soft and compressible ; tongue more thickly coated with a dirty creamy fur and cracked in centre, reddish and spotted at tip ; eyes watery, not red ; pupils natural; spleen and liver natural; about seven spots on the right side, five on the left side, two or three on abdomen, and two or three on back. They are undoubted fever-spots ; they are pale and faint, as would be expected in so mild a ease of fever, but they feel sensibly elevated on passing the finger over them. The patient was carefully examined several times before for spots, but none were detected till to-day ; they certainly were not there yester- day ; constipation ; two or three micturitions ; urine scanty; face more pinched ; no subsultus; not in the typhoid state.

T. P. E.

10 a.m. high 92 ?

Noon 102 2 ? ?

3 P.M. 104- ? ?

6 P.M. 103-2 ? ?

9 P.M. 1016 ? ?

8th September (8th day).?Better to-day; copious perspira- tion ; and a good deal of sleep last night; tongue moist and getting clean; eyes natural; no motion; abdomen flaccid; spots fading, four or fire of them distinct under the right nipple; defervescence began last evening.

T P. E. 6 a m. 97 4 ? ? 9 a.m. 97-6 78 24 Noon 97 ? ?

6 p.m. 97-6 86 22 8 P.M. 97'6 86 20

In the evening he feels well but weak and languid; face pinched and fatigued ; he has lost flesh a good deal.

9th September 1873 (9th day).?Slept two hours; one natural stool; eyes normal; face pinched ; tongue moist and clean; feels hungry; convalescent; but looks much pulled down, thin and wan.

T. P. E.

6 a.m. 97 2 ? ?

9 a.m. 97-2 76 Normal. Noon 97-2 ? ?

6 P.M. 97 6 ?

January 1, 1874.] EXTRACTS FKOM A DIARY AT BTTIIDWAK?BY A. M. YERCHERE.

Now what fever was it we observed in Kashee Nath ? It

had none of the symptoms of ague or aguish remittent; the

pyrexia was less high than in those diseases, and there was neither intermission nor remission, no well defined cold, hot and

sweating stages, no vomiting, no ague pains. It was not

either the continued fever of tropical climates (ardent con-

tinued fever) ; there was not the full and firm pulse, the great heat, severe headache, flushed face, herpetic eruptions, &c. ;

there had been no great exposure to the sun, and the weather

was at the time cool and showery, with a 6ky almost always cloudy.

It differed from relapsing fever in not having a relapse after a few days, in its accession not being sudden but gradual, in the absence of severe muscular and arthritic pains, of enlargement of liver or spleen, and of jaundice; it had fever spots, pale-red and elevated, and such spots are so rare in relapsing fever that

they may be said not to exist in that disease ; in the few exam-

ples where they have been seen the cases occurred in epidemics where typhus and relapsing fever were mixed.

It was not "ephemeral fever," as it lasted seven days. "We

need hardly say that it was neither enteric fever nor yellow fever ; it was therefore as " synochaof seven days' duration, with a

temperature not very high, want of power in the heart, and

fever spots on the body. We may call it an "asthenic simple continued fever," but the symptoms, although mild, are so very identical with those observed in the cases given before that one cannot resist the inference that the disease is essentially the same as that observed in Ham Ohtar, Oli Mahomed, and

Oboyia, only in its mildest form, and there is nothing outre in proposing to regard such cases as the mildest manifestations of typhus. Murchison has observed cases of short mild typhus in Great Britain; he says,

" in my experience, mild cases

of typhus (with eruption) have sometimes terminated on the

tenth and even as early as the eighth day. (Cases xvi andxvii). It is pi'obable, moreover, that many cases of so-called Febricula, where the fever lasts only two or three days, and is not attended

by rash, occasionally result from a small dose of the typhus- poison, at all events, cases answering to that description some times occur in the same family, and at the same time as true

typhus."* Dr. Jacquot, in his

" Du Typhus de 1' Armee D'Orient," Paris, 1858, admits also abortive attacks of typhus and very mild cases, which he considers to be due to a small dose of the

typhus-poison or as he calls it "

typhisation a petite dose"

In Kashee Natli, the state of languor and general dibility, noticeable during convalescence, was out of all proportion to what one is accustomcd to see after a week of a mild illness of

any kind. The fever, call it as we may chose, has the power, even when in its mildest form, to exhaust the patient.

6th September.?In the morning visited jail-hospital, chari- table dispensary, and police-hospital; no new cases.

Eead various reports during day. Mr. W. E. Ward's report, dated 25th May 1870, is accompanied by a sketch of the history of the fever in 18G9-70. All officers then at Burdwan seem to have agreed that the fever was something more than the

ordinary " malarious" fever of Lower Bengal. "The malarious fever had for some years past visited the town, as it does most towns in Lower Bengal, during the rains ; but in 1868 the fever assumed a somewhat more severe type"?(W. E. Ward.) The Civil Surgeon reports on 24th May 1869, " during the last two or three years fever of a more virulent type than the ordinary malarious fever had appeared in Burdwan." We are also told by Mr. Ward that, in the middle of July 1869, the fever " assumed

a more virulent aspect." In September 1869, police report is

received that in the village of Saraitikkur, lying immediately outside municipal limits, 100 persons had been attacked with

fever, of whom 40 had died and 60 were lingering. The

Chairman of the Municipal Commissioners visited the above- mentioned village, and

" regreted to say that in tin's village and in Chota Nilpore nearly 10 per cent, of the population had been parried off by the fever within the last two months." On

the 28th September 1869, Mr. Ward reports that the disease is not abating, but on the contrary

"

appears to spread itself

witli more or less virulence all over the town." In the begin-

ning of December 1869, the fever began to show signs of being on the decrease. Assistant Surgeon W. Jackson, who had

been appointed to conduct the special medical duties con-

nected with relief, did not arrive till the 20tli December 1869;

and Mr. Ward remarks that " soon after Dr. Jackson took

charge, the health of the people showed signs of material

improvement." It is evident that Dr. Jackson did not arrive

till the fever was just dying out for that season* and that he

had but very few, if any, opportunities of seeing aught, but cases of sequelee intermixed with cases of ordinary ague, and with cases of ague occurring in convalescents of the epidemic fever. He was relieved, or rather made over charge of his

special duties to the Civil Surgeon on the 21st April 1870, long before a fresh outbreak occurred.

In January 1870, a temporary hospital was opened at Pry- aribagh, in the town of Burdwan, for the treatment of in-door

patients. "Endeavours were made to induce all the worst

cases to frequent this hospital, and it was soon full. The hos-

pital was capable of accommodating 30 persons." There are

no records, no case books, no clinical notes of any kind to be

discovered at Burdwan with reference to that hospital. Dur-

ing the time it was opened, the epidemic fever had almost

completely disappeared, and the cases treated must have been

mostly cases of seqUelas.

By Februray 1870, matters had so much improved that " it became necessary to adopt measures for reducing the number of food-relief applicants."

I will quote a few words moce of Mr. Ward's: " The epi- demic was over for that year; it had lasted from May 1869 to March 1870." I need hardly call attention to the fact, that aguish diseases are at their minimum in May and June, and that if the disease was " exaggerated ague," the time of its incidence was very unusual and altogether inexplicable. Again, the year 1869 was a year of little rain in Bengal, and ague was under the average in all the native regiments serving in Lower Bengal and in most of the jails. It was a year of great rain in the

Punjab and in Central India, and the aguisli diseases in those provinces were much in excess of the average. We know pre- cious little about the cause or causes of aguish diseases; but I think that we know this much, that, when the rains are sensibly above the average of a locality, the amount of ague in that

locality is also sensibly above the average. In 1869 both rains

and aguish diseases were below the average, and yet we are

seriously told that an epidemic fever, which killed in Burdwan

town and suburbs some 16 to 18,000 souls out of a population of 48,000, between the 1st April 1869 and 31st March 1870, was nothing but an " exaggerated ague." At the same time

we cannot help remarking that Central India and the Punjab, where rains were in excess, had a general excess of aguish complaints ; but nothing reminding one in the least of what

occurred in Burdwan. The " exaggerated ague" manifested itself in that part of India where aguish diseases were below the average of ordinary years, and did not manifest itself in the other part of the empire where aguish diseases were much in excess of the average.

I wonder whether a man could be found to say that the

* Treatise on the continued fevers of Great Britain, by Charles Murchi- son, M.D., the 2nd edition, 1873, page 187.

10 THE INDIAN MEDICAL GAZETTE. [January 1, 1874-

whole malaria due to Lower Bengal was, on account of some- thing or another, concentrated into the attacked tract in

Burdwan. In these days of air-born theories, which must be defended quibuscunque modis, we may expect anything. But all this is digressive.

At 4 P.M., Dr. French, Mr. H. Blanford, (who had arrived in the day to set the meteorological observatory at Burdwan) and myself, went to see a native doctor, who was reported to have been four days ill with fever. The case was found to be

an aguish remittent, with much bilious vomiting and diarrhoea.

Temperature had been taken by Dino Bundhoo Dutt, and we took some notes of the case. The diagnosis between this case and the cases I have described before was not at all difficult:

pyrexia is common to both, but very little else; and even the

pyrexia registers were very different in the two maladies. The

difference between the case of the native doctor and the cases

observed at the police hospital was as great as that between a case of ordinary diarrhoea and a case of cholera. A com-

plete remission occurred on the fourth day, and the patient began at once to improve. Dr. French had now under treat- ment a lady who lias just gone through a similar attack of

four days' aguish remittent, and the lady's husband has just been attacked with the same disease. There is no difference between those cases of remittent and the cases seen everywhere in Bengal during the rainy and autumn seasons. We then went to see a woman who bad been eight days in con-

turned fever. She has unfortunately a severe attack of bron-

chitis, with profused bronchial expectoration, some dulness

on percussion on both sides, and an immense amount of coarse crepitation and sibilant ronchus all over the chest. Fever

high face pinched and anxious ; tongue beginning to brown in centre; pains in limbs; could not detect any spots, but quite dark and only a cJiiragh for a light. The case was considered

too complicated to be a good one to study. (I heard since from Dr. French that it passed into severe broncho-pneumonia.) Went to police hospital; cases already given ; then home.

Long talk after dinner; discussing what we had seen and read and heard about the fever. Agreed that the first thing to do

is to determine what the disease is. When we have determined

the " species," then it will be time to begin the study of its

natural history. The only way of determining the species of the disease is to examine specimens of it when the malady is

beginning and is typical and uncomplicated. It is of no use

to look at a case when it has fallen into the typhoid state, as all

febrile diseases may fall into that state. Typhus, enteric fever, relapsing, remittent, yellow, and puerperal fevers, peritonitis, renal diseases, pyaemia, small-pox, sloughing wounds, &c., &c., are all liable to drop into the typhoid state as one of the

pathological accidents of the observed cases, that state, being common to so many diseases, is very liable to mark the typical symptoms of the specimen cases we may study in our endea-

vours to determine the species of the malady. Similarly, coma and collapse are two states or pathological accidents common to

many diseases, and the occurrence of early coma or early collapse, or collapse at certain periods of the malady, is a useless

symptom in a study of the " species" of the disease. It is on

account of the above views that I was anxious to see sporadic cases, cases mild or medium, without complications, without

pathological accidents, but running their course naturally. There will be a link missing of course, and that is, that it

will remain to be proved that the sporadic cases studied at

present are identical to the epidemic cases raging during the outbreaks. This link will have to be proved to exist by three different kinds of study?first, by collecting the descriptions given by visitors during the epidemic, and comparing those descriptions with our sporadic cases ; secondly, by watching the present sporadic cases and noticing whether they will lead

in time to the development of sequel? similar to the sequelae seen now in Burdwan; and thirdly, by observing closely cases

occurring in localities where an outbreak is actually taking place, and noticing whether the epidemic cases have the same specific characters discovered in the sporadic cases.

'7th September.?Tiiis morning went to see the dhobee's

daughter and the policemen; see cases given before. Went to charitable dispensary and saw several cases of

sequela?, mostly in children. Auscultated several children; first sound of heart very feeble in all; a well marked souffle in one

child and a confused one in another. Heart's sounds remind

one of heart in scurvy. There is almost invariably aguish scurvy (malarial scurvy, if you wish it) in the cases of sequelae I have seen. No new cases of continued fever.

Read a lot of reports to-day. Not a single case clinically recorded is to be discovered anywhere. Dr. Elliot gives a

good description of the disease in 1864; I will quote it by and bye.

(To be continued.)