of the rigor, and from the general appearance of the it was merely to be a case of simple intermittent fever, of which there were eleven or twelve cases in hospital. Temperature 104? F.; he had no pain except a slight headache ; the pulse was full, 100; the tongue was coated with a moist, creamy fur; there was loss of appetite, and slight diarrhoea, amounting to three or four loose motions during the night. He was ordered the following draught:? occurrence
patient thought
Quinse. sulph. Acid sulph dil. Tinct. opii Aquae camph.
..
...
...
....
...
...
...
gr.
x
xv r,\
xx
siss
Mix.
Sit7.?This draught to be taken immediately. April 30th.?Temperature 102-4 ; pulse 94, rather small and thready; the diarrhoea has ceased; the bowels not having beeu His look was one of comparative last note. open since the comfort, but he complained of such excessive weakness that, taking the temperature and pulse into consideration, I had a suspicion that this might be a case of true enteric fever. To continue the treatment by the quinine draught omitting the opium. May Is*.?He passed a very bad night, sleeping little, and looks far worse, is being delirious at times: this morning hehalf open; the skin lying with his eyes pale?and hasgard, felt pungently hot to the touch, and a faint blush was apparent over the chest, especially-round the nipples; temperature 104? F.; pulse 110, rather small, regular; heart-sounds normal. The rifht lung anteriorly gave a normal percussion note, but there was dulness in a stripe along the spinal border of this lung, with subcrepitant rales in the same situation ; the left? lung was normal in all parts; respirations shallow, 32. The lips were dry and rough; the tongue furred in a peculiar two edges of manner, with a central red stripe bordered by very dry, and dirty-looking fur, dry and glazed ; the mouth was the patient complained greatly of thirst; no ulceration or redness of the fauces; no vomiting, nor diarrhoea; bowels not opened since the 30th ultimo; slight wincing, 011 pressure over the abdomen, especially in the left hypochondriac and right iliac regions ; in the former region the spleen can be distinctly felt, and there is gurgling on deep pressure in the right iliac region. No enlargement of the liver could be detected ; urine, normal no albumen, amount passed, high coloured, full of mucus, sp. gr. 1030. The patient was apparently rather deaf, a question having to be repeated three or four times before he would make any attempt at answering it. He was losing strength rapidly. Looking at the general symptoms, the temperature, and the state of the tongue whicft was in itself almost pathognomonic, I felt confirmed in my original opinion that this was undoubtedly a case of enteric fever, and the prognosis was very grave from the excessively high morning temperature. In the hope of lowering the temperature, I ordered for him? Quince sulph gr. xx Sig.?To be taken at once. At 5-30 p.m. he was no better; the temperature was 105-1? To repeat the quinine. 2nd.?A.t the morning visit he was in a state of increasing prostration ; temperature 103-6?. To have five grains of quinine every four hours; with milk ad lib. and two ounces of brandy. 5-30 p.m.?Slightly better; is quite conscious and says he feels "quite well;" temperature 104'3?; pulse 104, weak,regular, not dicrotic ; respirations 32, hurried, shallow, and laboured; aloe nasi working ; crepitant rales audible over both sides anteriorly ; posteriorly crepitant rales with some sibilus. P> Tinct. aconiti nt xii Tinct. digitalis in xx Sp. chloroformi 5ii Aquae ?iv ...
...
...
...
...
....
....
...
...
CASE OF ENTERIC FEVER.
By
G. S. A. Ranking, M.B., B.A Cantab., 2,1th N.I., Bareilly.
Surgeon,
Sepoy S D Hindoo, age 21 years, service 2? years, was admitted on the morning of the 29th April 1876, having had a severe rigor. He had been some days in attendance on a case of abscess of the foot. 1 saw him about an hour after the
Sig.?One tablespoonful every hour. At 11-30, I found him very restless, desiring constantly to get out of bed to " go on guard." His temperature was then 105-4? F. and his pulse 120, very feeble and fluttering ; the respirations were 36. As the temperature wns not lowered by any treatment I determined to resort to Tiemmsen's method, and accordingly had a bath prepared, temperature 95? F. ; he was carefully lifted into this, and it was gradually cooled down to 80.? While in the bath, he recovered consciousness and complained of feeling cold. He was kept in the bath for 15 minutes and removed to bed. His pulse
"THE INDIAN MEDICAL GAZETTE.
242
110, much improved in volume, and the temperature 104-4" p. j respirations still 36. At 12-15, half an hour after the bath, his temperature had fallen to 102?, and the pulse and respirations were respectively 100 and 30. His thirst was very great, and he drank greedily, though his power of swallowing was becoming impaired ; the tongue was very dry and cracked ; ordered? Potass, bromid gr. xv. was now
Quinse sulph Acid
sulph
dil
...
...
..
>tt
...
>>t
Aquce
gr.
x
t>\
x
5
i
Make a draught.?To be taken immediately. He slept quite quietly for three hours after taking this and woke, but shortly after became hard to rouse. The next morning (May 3rd) I found him lying with his knees drawn up and falling outwards ; eyes half open ; sordes on the lips and teeth ; he was with difficulty roused, and swallowed a little brandy with mils ; temperature 103"8?; pulse 120, dicrotic ; respirations To continue the quinine every four hours, and to have milk 28. and brandy in small quantities frequently. 6 p. m.?Temperature lOi'S0; sweating profusely; pulse 120, feeble, dicrotic; respirations 40, laboured. To have a poultice to the chest and back. 9 p. m.?Unconscious ; sweating freely ; temperature 106"4? ; pulse 130, feeble, thready, intermittent ; respirations 44 ; bowels have not been opened ; was put in a cold bath cooled down to 71? F. His pulse flagged and sighing respiration came on after five minutes. He was removed to bed, having recovered consciousness.
Quince sulph. gr. xxx Statim ?To be well fed with milk and brandy. 4th.?Slept two hours after the bath; has taken twelve ounces of brandy and two seers of milk during the night; is conscious and rational, but very weak; temperature 103? F ; pulse 112, better volume; respirations 49; loud moist rales all over the chest posteriorly. 6 p.m.?Seems better, conscious, complaining of great weakabdomen not tumid ; no sign of spots ; ness ; has no pain ; temperature 104 3" F. Continue the brandy and milk. 5th.?8 a.m.?Passed a very bad night; was furiously delirious; did not sleep at all; is now lying unconscious ; urine passing involuntarily ; absolute constipation ; an ill-defined dusky redness visible over abdomen; no spots; teeth covered with sordes; temperature 103*S?; pulse 114, small; respirations 40. The spleen is much larger than at first. .Repeat the quinine, five grains, every four hours; milk and brandy ad lib. 1 p.m.?Evidently much worse ; temperature 106 ?2? ; pulse 128; respirations 52, very shallow; loud moist rales in both lungs, especially in the right; poultice to be re-applied; bath repeated as before for 15 minutes. After this?temperature, not noted; pulse 118; respirations 36. Quinine gr. xxx. statim; lying in a state of profound apathy ; has great difficulty in swallowing, almost choking and returning the greater part given. 6th.?Slightly conscious, but very deaf,?this perhaps is due to the quinine ; wears a very anxious expression, and has evidently pain in swallowing ; temperatnre 102? F. ; pulse 116, dicrotic feeble, ; respirations 40 ; urine running away from him ; 110 action of the bowels ; 110 spots; spleen increasing in size. 6 p.m.?Temperature 106'6? F. ; pulse 120 ; respirations 48 ; ?very weak ; in a hopeless state. 9-30 p.m.?Quite comatose ; temperature 107? F. Repeat cold ...
...
bath. 7th.?The temperature fell after the bath, but he did not recover consciousness; he has quite lost the power of swallowing. (8 a.m.)?very restless; urine dribbling away, bladder not distended; temperature 103*s? P.; pulse 140, much weaker; respirations 52, shallow ; bowels not open ; abdomen not tymbut evidently tender. To have in a wet sheet. enema, and to be wrapped
panitic,
|J,
Quinse sulph
Mucilaginis
... ...
milk and
...
...
xxx
gr. =
brandy by
ii
Ft. enema. 4-30 p.m.?I was called hurriedly as he was said to be dying. On arrival I found him pulseless; but having administered two ounces of brandy in mucilage by the rectum, his pulse became perceptible at the wrist, though itis was too rapid to count. evidently dying. Respirations 52 ; temperature 102? ; 8th.?On going to hospital at 6-30 a.m., I was astonished to his find him conscious, having recovered power of swallowing, and having slept for four hours during the night. He was too weak to speak, but made signs for milk, which he drank freely. Temperature 100'4C'; pulse 140; respirations 48. From the rapid fall of temperature, and the elevation of the pulse, 1 feared an
[September
1, 1S76.
unfavourable result, and at
noon he became suddenly worse and died almost immediately. An autopsy, held three hours after death, revealed extensive ulceration of the ileum and jejunum of the specific enteric nature. The lungs were enormously congested, and the heart contained ante-mortem clots. The spleen was large and soft; the intestines were empty ; the mucous membrane lined with a viscid green mucus. Specimens of the ulcers of the intestines were removed as
they afforded
very good examples. Remarks. This case is noticeable for several reasons : 1. As shewing what extensive ulceration may exist without causing diarrhoea. 2. From the enormously high temperature uncontrolled by any measures. 3. The question hns raised itself in my mind whether the patient was benefited or not by the baths, but on the whole I think he was, as his temperature was so high before them, and fell greatly without a parallel increase of weakness. Again, no other means reduced the temperature, which would assuredly have led to his death on the night of the 6th May. He died from an excessively prolonged high temperature causing paralysis of the heart; this, in the engorged state of his lungs, proving unable to carry on its functions. The right heart was absolutely bulging with blood in both cavities. ?
patient thought
Quinse. sulph. Acid sulph dil. Tinct. opii Aquae camph.
..
...
...
....
...
...
...
gr.
x
xv r,\
xx
siss
Mix.
Sit7.?This draught to be taken immediately. April 30th.?Temperature 102-4 ; pulse 94, rather small and thready; the diarrhoea has ceased; the bowels not having beeu His look was one of comparative last note. open since the comfort, but he complained of such excessive weakness that, taking the temperature and pulse into consideration, I had a suspicion that this might be a case of true enteric fever. To continue the treatment by the quinine draught omitting the opium. May Is*.?He passed a very bad night, sleeping little, and looks far worse, is being delirious at times: this morning hehalf open; the skin lying with his eyes pale?and hasgard, felt pungently hot to the touch, and a faint blush was apparent over the chest, especially-round the nipples; temperature 104? F.; pulse 110, rather small, regular; heart-sounds normal. The rifht lung anteriorly gave a normal percussion note, but there was dulness in a stripe along the spinal border of this lung, with subcrepitant rales in the same situation ; the left? lung was normal in all parts; respirations shallow, 32. The lips were dry and rough; the tongue furred in a peculiar two edges of manner, with a central red stripe bordered by very dry, and dirty-looking fur, dry and glazed ; the mouth was the patient complained greatly of thirst; no ulceration or redness of the fauces; no vomiting, nor diarrhoea; bowels not opened since the 30th ultimo; slight wincing, 011 pressure over the abdomen, especially in the left hypochondriac and right iliac regions ; in the former region the spleen can be distinctly felt, and there is gurgling on deep pressure in the right iliac region. No enlargement of the liver could be detected ; urine, normal no albumen, amount passed, high coloured, full of mucus, sp. gr. 1030. The patient was apparently rather deaf, a question having to be repeated three or four times before he would make any attempt at answering it. He was losing strength rapidly. Looking at the general symptoms, the temperature, and the state of the tongue whicft was in itself almost pathognomonic, I felt confirmed in my original opinion that this was undoubtedly a case of enteric fever, and the prognosis was very grave from the excessively high morning temperature. In the hope of lowering the temperature, I ordered for him? Quince sulph gr. xx Sig.?To be taken at once. At 5-30 p.m. he was no better; the temperature was 105-1? To repeat the quinine. 2nd.?A.t the morning visit he was in a state of increasing prostration ; temperature 103-6?. To have five grains of quinine every four hours; with milk ad lib. and two ounces of brandy. 5-30 p.m.?Slightly better; is quite conscious and says he feels "quite well;" temperature 104'3?; pulse 104, weak,regular, not dicrotic ; respirations 32, hurried, shallow, and laboured; aloe nasi working ; crepitant rales audible over both sides anteriorly ; posteriorly crepitant rales with some sibilus. P> Tinct. aconiti nt xii Tinct. digitalis in xx Sp. chloroformi 5ii Aquae ?iv ...
...
...
...
...
....
....
...
...
CASE OF ENTERIC FEVER.
By
G. S. A. Ranking, M.B., B.A Cantab., 2,1th N.I., Bareilly.
Surgeon,
Sepoy S D Hindoo, age 21 years, service 2? years, was admitted on the morning of the 29th April 1876, having had a severe rigor. He had been some days in attendance on a case of abscess of the foot. 1 saw him about an hour after the
Sig.?One tablespoonful every hour. At 11-30, I found him very restless, desiring constantly to get out of bed to " go on guard." His temperature was then 105-4? F. and his pulse 120, very feeble and fluttering ; the respirations were 36. As the temperature wns not lowered by any treatment I determined to resort to Tiemmsen's method, and accordingly had a bath prepared, temperature 95? F. ; he was carefully lifted into this, and it was gradually cooled down to 80.? While in the bath, he recovered consciousness and complained of feeling cold. He was kept in the bath for 15 minutes and removed to bed. His pulse
"THE INDIAN MEDICAL GAZETTE.
242
110, much improved in volume, and the temperature 104-4" p. j respirations still 36. At 12-15, half an hour after the bath, his temperature had fallen to 102?, and the pulse and respirations were respectively 100 and 30. His thirst was very great, and he drank greedily, though his power of swallowing was becoming impaired ; the tongue was very dry and cracked ; ordered? Potass, bromid gr. xv. was now
Quinse sulph Acid
sulph
dil
...
...
..
>tt
...
>>t
Aquce
gr.
x
t>\
x
5
i
Make a draught.?To be taken immediately. He slept quite quietly for three hours after taking this and woke, but shortly after became hard to rouse. The next morning (May 3rd) I found him lying with his knees drawn up and falling outwards ; eyes half open ; sordes on the lips and teeth ; he was with difficulty roused, and swallowed a little brandy with mils ; temperature 103"8?; pulse 120, dicrotic ; respirations To continue the quinine every four hours, and to have milk 28. and brandy in small quantities frequently. 6 p. m.?Temperature lOi'S0; sweating profusely; pulse 120, feeble, dicrotic; respirations 40, laboured. To have a poultice to the chest and back. 9 p. m.?Unconscious ; sweating freely ; temperature 106"4? ; pulse 130, feeble, thready, intermittent ; respirations 44 ; bowels have not been opened ; was put in a cold bath cooled down to 71? F. His pulse flagged and sighing respiration came on after five minutes. He was removed to bed, having recovered consciousness.
Quince sulph. gr. xxx Statim ?To be well fed with milk and brandy. 4th.?Slept two hours after the bath; has taken twelve ounces of brandy and two seers of milk during the night; is conscious and rational, but very weak; temperature 103? F ; pulse 112, better volume; respirations 49; loud moist rales all over the chest posteriorly. 6 p.m.?Seems better, conscious, complaining of great weakabdomen not tumid ; no sign of spots ; ness ; has no pain ; temperature 104 3" F. Continue the brandy and milk. 5th.?8 a.m.?Passed a very bad night; was furiously delirious; did not sleep at all; is now lying unconscious ; urine passing involuntarily ; absolute constipation ; an ill-defined dusky redness visible over abdomen; no spots; teeth covered with sordes; temperature 103*S?; pulse 114, small; respirations 40. The spleen is much larger than at first. .Repeat the quinine, five grains, every four hours; milk and brandy ad lib. 1 p.m.?Evidently much worse ; temperature 106 ?2? ; pulse 128; respirations 52, very shallow; loud moist rales in both lungs, especially in the right; poultice to be re-applied; bath repeated as before for 15 minutes. After this?temperature, not noted; pulse 118; respirations 36. Quinine gr. xxx. statim; lying in a state of profound apathy ; has great difficulty in swallowing, almost choking and returning the greater part given. 6th.?Slightly conscious, but very deaf,?this perhaps is due to the quinine ; wears a very anxious expression, and has evidently pain in swallowing ; temperatnre 102? F. ; pulse 116, dicrotic feeble, ; respirations 40 ; urine running away from him ; 110 action of the bowels ; 110 spots; spleen increasing in size. 6 p.m.?Temperature 106'6? F. ; pulse 120 ; respirations 48 ; ?very weak ; in a hopeless state. 9-30 p.m.?Quite comatose ; temperature 107? F. Repeat cold ...
...
bath. 7th.?The temperature fell after the bath, but he did not recover consciousness; he has quite lost the power of swallowing. (8 a.m.)?very restless; urine dribbling away, bladder not distended; temperature 103*s? P.; pulse 140, much weaker; respirations 52, shallow ; bowels not open ; abdomen not tymbut evidently tender. To have in a wet sheet. enema, and to be wrapped
panitic,
|J,
Quinse sulph
Mucilaginis
... ...
milk and
...
...
xxx
gr. =
brandy by
ii
Ft. enema. 4-30 p.m.?I was called hurriedly as he was said to be dying. On arrival I found him pulseless; but having administered two ounces of brandy in mucilage by the rectum, his pulse became perceptible at the wrist, though itis was too rapid to count. evidently dying. Respirations 52 ; temperature 102? ; 8th.?On going to hospital at 6-30 a.m., I was astonished to his find him conscious, having recovered power of swallowing, and having slept for four hours during the night. He was too weak to speak, but made signs for milk, which he drank freely. Temperature 100'4C'; pulse 140; respirations 48. From the rapid fall of temperature, and the elevation of the pulse, 1 feared an
[September
1, 1S76.
unfavourable result, and at
noon he became suddenly worse and died almost immediately. An autopsy, held three hours after death, revealed extensive ulceration of the ileum and jejunum of the specific enteric nature. The lungs were enormously congested, and the heart contained ante-mortem clots. The spleen was large and soft; the intestines were empty ; the mucous membrane lined with a viscid green mucus. Specimens of the ulcers of the intestines were removed as
they afforded
very good examples. Remarks. This case is noticeable for several reasons : 1. As shewing what extensive ulceration may exist without causing diarrhoea. 2. From the enormously high temperature uncontrolled by any measures. 3. The question hns raised itself in my mind whether the patient was benefited or not by the baths, but on the whole I think he was, as his temperature was so high before them, and fell greatly without a parallel increase of weakness. Again, no other means reduced the temperature, which would assuredly have led to his death on the night of the 6th May. He died from an excessively prolonged high temperature causing paralysis of the heart; this, in the engorged state of his lungs, proving unable to carry on its functions. The right heart was absolutely bulging with blood in both cavities. ?
