heavy dull distinguish
look with great prostration help to the true euterica from malarial remitteut fever. The condition of the abdomen in the early stages caunot be relied on to distinguish the two fevers, as tumidity of the abdomen, gurgling and tenderness are common symptoms in remittent fever. (Case of Lieut. 0 E. Lane. Regt., who acquired the , malarial poison in the Chin Expedition, illustrates this point well.) The pulse-rate in remittent's has been found proportional to the fever; but in euterica it is often slow, aud a difference of 10 to 30 beats may be met with on different dajs CLINICAL NOTES ON CASES OF ENTERIC without any corresponding change in the fever FEVER. or the By Surgeon-Captain W. B. HOB-ROOKS, m.s. patient's general condition. The -postmortem appearances consist in enlargement and Enteric Fever in Iudiaisseen under many ulceration of Peyer's patches, and the solitary phases. Three types, however, stand out speintestine ; aud in some cases in small the glands cially for description. In the early stages they the solitary glands in the large intestine were are indistinguishable, but their later develop- found markedly enlarged and ulcerated. The ments and post-mortem appearances are quite intestinal were always found much enlargcharacteristic. The first type is exceedingly ed and glands congested. The second type illustrated common, and occurs not only in young recruits the case of Bombdr. Gostello, R. H. A., is by fresh out from home, but also in men who have and might be confounded with dysentery. served five or six years in India, It is the rare, In this type the lesions are confined to the classical fever described in the text-books. The solitary glands of the large intestine. The apappearance of the patient is the heavy dull pearances, however, exactly correspond to those look, flushed face and dilated pupils; the tongue seen in the large intestine of the typical enteric dry, a triangular patch at the apex, with a cases, but without any implication of the Peyer's tendency to crack transversely; the tumid patches and solitary glands of the small inabdomen with pain and tenderness over the testine. The symptoms closely resemble those right iliac fossa; the presence of diarrhoea of the typical enteric cases, and could not be with yellow flaky stools; a little bronchitis; confounded with those of tropical dysentery. and the characteristic chart can leave no doubt The microscopical appearances of the ulcers, in any one's mind as to the nature of the disease. the biological results, and the whole course of These cases usually pass through a typical course the disease strongly incline to the belief that of three to four weeks' fever and ultimately Dr. Cayley,, are true cases of euterica. they convalesce, the convalescence being marked by in his edition of Murchison, mentions such a extreme debility. Haemorrhage, peritonitis and case reported by Hamilton, and Dr. Hilton perforation are not unfrequently met with as Fagge also described cases of euterica in which complications. It is worthy of remark that the the lesions were confined to the large intestine. fevei^ even in men who have served some time The third type is one that has given rise to in India and are presumably more or less satu- much discussion in India, and at one time was rated with the malarial poison, is quite uu- J described as a separate disease, i.e., typhainfluenced by quinine. After 30-grain doses malarial fever. In the Lucknow Station Hosa fall of one or two points of a degree may be pital Returns this type of disease has been'inseen, but no permanent effect is produced even cluded under enteric fever. In the table' for when large doses have been given after the the year 1891 a group of cases will be seen temperature has fallen under the influence occurring in men who had served 3 to 5 years. of antipyretics and cold baths. During the These men were all very malarious, having convalescence aguish attacks are not uncommon, come from Peshawur, The characteristics of the and are easily distinguished by shivering, sweats, fever are long-continued pyrexia, associated and type of chart, from the fever of a relapse with extreme wasting.* In the early stages and that produced by the resumption of solid a typical enteric chart is seen with fulness and food. These aguish attacks are readily in- tenderness of the abdomen. Constipation is the fluenced and controlled by quinine. The onset but towards the end of the case diarrhoea rule, of the true enterica may in the same way be intractable nature often sets in. Rose of a often preceded by malarial attacks either of the rash very is seldom present. The liver and spleen continued or intermittent type. The diagnosis j are At the height of: the enlarged. usually of this type is often rendered somewhat diffi- fever a typhoid condition is often developed. cult by the absence of any characteristic rash and the common tendency to constipation. Still See Charts, Lance-Corporal Healey. the appearance of the tongue and a peculiar j
j
i
INDIAN MEDICAL GAZETTE.
364
The
cases
usually
end in recovery.
In some,
Type II.?Gunner A.
[Dec. Gostello,
R. H.
1892.
A.,
age
21 years, service two years and one month, during the decline of the fever, rheumatic pains in India three months. accompanied by effusion into the joints occur. Private H 16th Lancers, is a typical case Admitted into the Station Hospital on of this nature ; and during the first 14 days of 1st January, suffering from fever aud diarrhoea. his illness his symptoms, including the typical He stated that he had then been ill for two tongue and stools, were quite characteristic of days. Fever of continued type, accompanied enteric fever. Post-mortem examination in by diarrhoea, continued until 3rd January, the fatal cases showed exactly the same condi- when he was transferred to the special tion in every case, i.e., extreme wasting of the ward. He was then well nourished; his face coats of the small intestine; no traces of Peyer's was flushed aud pupils dilated. The tongue patches or the solitary glands were to be seen. was coated, and down the centre was a red patch One case died from dysentery after being in from which the superficial epithelium appeared hospital nearly 100 days; his chart is appended. to have separated. The abdomen was a little He was convalescent and slowly gaining strength distended and gurgling readily obtained; no rash when acute dysentery suddenly developed and was There was no diarrhoea. The present. rapidly carried off the patient. During the liver and spleen appeared normal. On 6th Janucamp of exercise at Lucknow in 1891 several ary the tongue became quite dry; he passed were admitted to ,
of the same nature These were all old soldiers who had served in different parts of India, and showed by their medical history sheets distinct malarial poisoning. Having marched into a district where the enteric poison was virulent, some of them developed type No. I; others, like the men of the It. I. Regt., type No. III. Remittent fever, even when long-continued, does not appear to produce type No. Ill; as illustrated by the case of Private D I. Regt., who , R. was treated in months for for three hospital continued malarial fever, and died suddenly cases
one
hospital.
distended. On 9th January haemorrhage about one ounce of dark red clotted blood being passed; on the 8th and 9th there was slight recurrence of the haemorrhage. From this date the patient gradually became weaker; on the 18th he became uuconscious, subsultus, etc., came on, and he died in the evening. Post-mortem.?The spleen was found large and soft. The small intestine was congested iu patches, but there were no signs of enlargement of Peyer's patches. The large intestine from the caecum to the rectum contained a large number of ulcers, some circular, others oblong, all with thickened edges aud presenting the same appearances exactly as the ulcers seen in the large intestine in the typical enteric cases. The tissue of the gut did not show that general thickening aud induration so characteristic of tropical dysentery. In fact, the majority of the ulcers seemed to be due to engorgement and subsequent necrosis of the solitary glands.
from heat-stroke. Post-mortem.?The small intestine
mucous
membrane of the
quite normal up to the cajcum; Peyer's patches presented the normal appearances, and no trace of their having was
found
been in any way diseased could be detected. There was no marked wasting of the mucous membrane either of the large or small intestine. Type No. Ill, though not so frequent as type No. I, as young soldiers are more susceptible,
is still by no means a rarity ; for in the year 1891 there are records of six typical cases under treatment during the cold weather; and this year, 1892, three cases are now under observation. The two cases of type III reported occurred in comparatively young soldiers. Private U.B had served in Peshawur and suffered severely from malaria. Lance-Corporal H? had served for nearly two years, and of that time 1^ year had been passed in Lucknow; his case is an exception to the general rule, and can only be explained on the supposition that he was extremely susceptible to malarial poisoning, and had gradually absorbed the virus of this disease in Lucknow, where remitteut fever of a severe type is by 110 means uncommon in young residents, often
to death, but never producing, when uncombined with the enteric poison, the condition described in the cases of Lance-Corporal H and Private U. B
leading
.
loose yellow stool and the abdomen became
more
came on,
Type I.
?
Private J.
White,
E. Lane.
Regi-
ment, age 22 years, service two years and two months, iu India six months. Admitted into Hospital on 28th December 1891, suffering from fever. For the first week his symptoms were undefined, though the temperature chart showed a rather charateristic ascent. On 9th January his face was flushed aud pupils dilated. The tongue was furred and dry in a triangular patch at the apex. The abdomen was distended and gurgling readily obtained on There was no rash. He suffered from pressure. diarrhoea, yellow and flaky stools being loose. The He had slight epistaxis from time to time. urine the normal. was but spleen enlarged, He continued in the same condition until the 14th, when he became delirious. On the 19th Vomithis face assumed a parched blue look. ing set in aud the abdomen became very tender on palpation. He died at 3-30 p.m. on the
19th,
Deo.
1892.]
HORROCKS'S CLINICAL NOTES ON CASES
OP ENTERIC FEVER.
365
Post-mortem. ?General recent peritonitis was fever and great depression continued up to found. The Peyer's patches in the lower third lltli December. On 14th December the temperaand the patient became delirose to 106, of the ileum were and but ture
enlarged
ulcerated,
ulcer had perforated. The solitary^glands the ulcers had a typical were also enlarged ; enteric appearance; the caecum contained two The mesenteric glands small circular ulcer?. were much enlarged. The spleen was large and soft, and pulpy in consistence. no
Type I.?Case of Private T. Sullivan, R. M. F., age
21
months,
years, service two years and in India two months.
two
Admitted into
Hospital on 9th January 1892, and diarrhoea. fever from Diarrhoea suffering ceased on the third day, and was followed by constipation. On admission his tongue was furred but moist, face flushed and pupils dilated. The abdomen was not distended; no rash was A present. The liver and spleen were normal. little bronchitis was present. On 16th January the abdomen became tumid, and on the 19th was markedly distended. The tongue then became quite dry, and the patient heavy and drowsy. On the 20th haemorrhage came on but ceased on the 23rd, and the tongue then began to clean a little. On the 24th and 25th there was a little dark blood passed with the faeces. On 28th January the abdomen became very swollen and the veins enlarged. On the 30th the transOn 31st verse colon was markedly distended. he became quite deaf and very restless. Death occurred on 1st February. Post-mortem.?The intestines were found matted together with recent lymph. In the ileo-ccecal area on separating the adhesions two perforations The liver conwere seen just above the csecum. tained an embolus on the upper surface which had partially suppurated. The lower half of the ileum was much ulcerated ; the ulcers in most cases were old with thin undermined edges. The base of the ulcers in several cases being only formed of peritoneum. Two perforations were present close to the caecum. The ulcers In the large were in the site of Peyer's patches. intestine the solitary glands were enlarged and superficially ulcerated. One ulcer showed signs of recent haemorrhage. Type I.?Case of Private Smith, R. I. Regiment, No. 2304, age 24, service five years and nine months, in India five years one mouth. Admitted into Hospital on 18th November, suffering from diarrhoea. On 7 th December he
transferred to the special ward, and then to be suffering from continued fever, accompanied by diarrhoea. He was very weak and tremulous, and slightly deaf. The face was flushed, and tongue dry down the centre. The abdomen was full, and gurgling readily obtained iu the right iliac fossa. There was no rash. The spleen was enlarged, and the urine contained a trace of albumen. Diarrhoea with continued was
found
He continued in a semi-delirious condirious. tion with picking at the bed clothes, &c., until 20th December ; when haemorrhage occurred, about a pint of dark clotted blood being passed per rectum. The haemorrhage continued on the 21sfc and 22nd in smaller quantities, and death took place on the 22nd from syncope. Post-mortem.?The spleen was found enlarged, dark and soft in consistence. The kidneys and intensely congested. The were enlarged, mesenteric glands were large and congested. In the small intestine numerous circular ulcers with heaped-up edges were found. One ulcer about a foot above the cajcum has perforated; the peritoneal surface being disintegrated and giving the base of the ulcer a sieve-like apSome of the ulcers were large and pearance. the Peyer's patches, others were small occupied The large and involved the solitary glands. intestine was congested and contained numerous The circular ulcers with heaped-up edges. lungs were congested. The muscle tissue of the right ventricle of the heart was largely infiltrated with fat. Type I.?Case of Private Jenner, 16th Lancers, age 20, service one year, in India four months. Admitted into Hospital on 19th January 1892, having felt ill for two days. On admission his face was flushed, pupils dilated, and the tongue was slightly coated. The abdomen was rather full, slightly tender on palpation, and gurgling was present. He had no rash. The spleen was enlarged. He suffered from diarrhoea, the stools being loose aud yellow in colour. The temperature chart was somewhat characteristic. On the 10th day of disease a rose rash appeared on the abdomen. On the 13th day of disease vomiting with hiccough came on, and the abdomen became very tender on palpation and fixed. The patient rapidly passed into a condition of collapse, aud died on the 28th after sudden profuse emesis. Post-mortem.?Recent peritonitis was found on the lower part of the ileum aud caecum. About two inches above the caecum two perforations were noticed in the ileum, through which faeces were exuding into the pelvis. Peyer's patches were found intensely engorged aud ulcerated ; the ulceration increasing in depth with proximity to the caecum. The caput caecum contained several ulcers. The mesenteric glands were enlarged. Type III.?Case of Lance-Corporal Healey, 16th Lancers, age 25, service one year and ten months, in India one year aud four months. most marked
Admitted into Hospital on 22nd February On admission lie states that he had felt 1892. 48
366
INDIAN MEDICAL GAZETTE.
ill for 14 days; his symptoms were then chiefly those of rheumatic fever, the knee and ankle joints being swollen. On 27th and 28th February, his temperature became normal and he was But on the considered to be convalescing. 29th his temperature began to rise again in a manner characteristic of enteric fever. He gradually developed the characteristic tongue, his abdomen became swollen and tender ; a few rose spots were seen, and the spleen and liver became enlarged. He had no diarrhoea, but a distinct tendency to constipation. He continued in this condition for several weeks : his tongue then gradually cleaned, and the abdominal symptoms subsided. On the 8th day after admission his temperature became normal for three days. He then suffered from an irregular type of fever for about 70 days and became extremely The fever was finally controlled by emaciated. large doses of quinine and arsenic. He is now. 200 days after admission, daily convalescing and able to take solid food, and walk about the ward For some weeks, after his temperature a little. had become normal, any attempt to feed him with solid food produced sharp attacks of diarrhoea, verging at times almost into dysentery. The case of Private M. Bowe, R. I., was of exactly the same nature, but he had no initial rheumatic symptoms, and on the 82nd day of disease he was seized with dysentery and died on the 98th day. Post-mortem.?Extreme wasting of the coats of the small intestine was found ; no traces of Peyer's patches on the solitary glands could be detected. The large intestine showed the usual changes characteristic of acute dysentery.
[Dicc.
1892.
look with great prostration help to the true euterica from malarial remitteut fever. The condition of the abdomen in the early stages caunot be relied on to distinguish the two fevers, as tumidity of the abdomen, gurgling and tenderness are common symptoms in remittent fever. (Case of Lieut. 0 E. Lane. Regt., who acquired the , malarial poison in the Chin Expedition, illustrates this point well.) The pulse-rate in remittent's has been found proportional to the fever; but in euterica it is often slow, aud a difference of 10 to 30 beats may be met with on different dajs CLINICAL NOTES ON CASES OF ENTERIC without any corresponding change in the fever FEVER. or the By Surgeon-Captain W. B. HOB-ROOKS, m.s. patient's general condition. The -postmortem appearances consist in enlargement and Enteric Fever in Iudiaisseen under many ulceration of Peyer's patches, and the solitary phases. Three types, however, stand out speintestine ; aud in some cases in small the glands cially for description. In the early stages they the solitary glands in the large intestine were are indistinguishable, but their later develop- found markedly enlarged and ulcerated. The ments and post-mortem appearances are quite intestinal were always found much enlargcharacteristic. The first type is exceedingly ed and glands congested. The second type illustrated common, and occurs not only in young recruits the case of Bombdr. Gostello, R. H. A., is by fresh out from home, but also in men who have and might be confounded with dysentery. served five or six years in India, It is the rare, In this type the lesions are confined to the classical fever described in the text-books. The solitary glands of the large intestine. The apappearance of the patient is the heavy dull pearances, however, exactly correspond to those look, flushed face and dilated pupils; the tongue seen in the large intestine of the typical enteric dry, a triangular patch at the apex, with a cases, but without any implication of the Peyer's tendency to crack transversely; the tumid patches and solitary glands of the small inabdomen with pain and tenderness over the testine. The symptoms closely resemble those right iliac fossa; the presence of diarrhoea of the typical enteric cases, and could not be with yellow flaky stools; a little bronchitis; confounded with those of tropical dysentery. and the characteristic chart can leave no doubt The microscopical appearances of the ulcers, in any one's mind as to the nature of the disease. the biological results, and the whole course of These cases usually pass through a typical course the disease strongly incline to the belief that of three to four weeks' fever and ultimately Dr. Cayley,, are true cases of euterica. they convalesce, the convalescence being marked by in his edition of Murchison, mentions such a extreme debility. Haemorrhage, peritonitis and case reported by Hamilton, and Dr. Hilton perforation are not unfrequently met with as Fagge also described cases of euterica in which complications. It is worthy of remark that the the lesions were confined to the large intestine. fevei^ even in men who have served some time The third type is one that has given rise to in India and are presumably more or less satu- much discussion in India, and at one time was rated with the malarial poison, is quite uu- J described as a separate disease, i.e., typhainfluenced by quinine. After 30-grain doses malarial fever. In the Lucknow Station Hosa fall of one or two points of a degree may be pital Returns this type of disease has been'inseen, but no permanent effect is produced even cluded under enteric fever. In the table' for when large doses have been given after the the year 1891 a group of cases will be seen temperature has fallen under the influence occurring in men who had served 3 to 5 years. of antipyretics and cold baths. During the These men were all very malarious, having convalescence aguish attacks are not uncommon, come from Peshawur, The characteristics of the and are easily distinguished by shivering, sweats, fever are long-continued pyrexia, associated and type of chart, from the fever of a relapse with extreme wasting.* In the early stages and that produced by the resumption of solid a typical enteric chart is seen with fulness and food. These aguish attacks are readily in- tenderness of the abdomen. Constipation is the fluenced and controlled by quinine. The onset but towards the end of the case diarrhoea rule, of the true enterica may in the same way be intractable nature often sets in. Rose of a often preceded by malarial attacks either of the rash very is seldom present. The liver and spleen continued or intermittent type. The diagnosis j are At the height of: the enlarged. usually of this type is often rendered somewhat diffi- fever a typhoid condition is often developed. cult by the absence of any characteristic rash and the common tendency to constipation. Still See Charts, Lance-Corporal Healey. the appearance of the tongue and a peculiar j
j
i
INDIAN MEDICAL GAZETTE.
364
The
cases
usually
end in recovery.
In some,
Type II.?Gunner A.
[Dec. Gostello,
R. H.
1892.
A.,
age
21 years, service two years and one month, during the decline of the fever, rheumatic pains in India three months. accompanied by effusion into the joints occur. Private H 16th Lancers, is a typical case Admitted into the Station Hospital on of this nature ; and during the first 14 days of 1st January, suffering from fever aud diarrhoea. his illness his symptoms, including the typical He stated that he had then been ill for two tongue and stools, were quite characteristic of days. Fever of continued type, accompanied enteric fever. Post-mortem examination in by diarrhoea, continued until 3rd January, the fatal cases showed exactly the same condi- when he was transferred to the special tion in every case, i.e., extreme wasting of the ward. He was then well nourished; his face coats of the small intestine; no traces of Peyer's was flushed aud pupils dilated. The tongue patches or the solitary glands were to be seen. was coated, and down the centre was a red patch One case died from dysentery after being in from which the superficial epithelium appeared hospital nearly 100 days; his chart is appended. to have separated. The abdomen was a little He was convalescent and slowly gaining strength distended and gurgling readily obtained; no rash when acute dysentery suddenly developed and was There was no diarrhoea. The present. rapidly carried off the patient. During the liver and spleen appeared normal. On 6th Janucamp of exercise at Lucknow in 1891 several ary the tongue became quite dry; he passed were admitted to ,
of the same nature These were all old soldiers who had served in different parts of India, and showed by their medical history sheets distinct malarial poisoning. Having marched into a district where the enteric poison was virulent, some of them developed type No. I; others, like the men of the It. I. Regt., type No. III. Remittent fever, even when long-continued, does not appear to produce type No. Ill; as illustrated by the case of Private D I. Regt., who , R. was treated in months for for three hospital continued malarial fever, and died suddenly cases
one
hospital.
distended. On 9th January haemorrhage about one ounce of dark red clotted blood being passed; on the 8th and 9th there was slight recurrence of the haemorrhage. From this date the patient gradually became weaker; on the 18th he became uuconscious, subsultus, etc., came on, and he died in the evening. Post-mortem.?The spleen was found large and soft. The small intestine was congested iu patches, but there were no signs of enlargement of Peyer's patches. The large intestine from the caecum to the rectum contained a large number of ulcers, some circular, others oblong, all with thickened edges aud presenting the same appearances exactly as the ulcers seen in the large intestine in the typical enteric cases. The tissue of the gut did not show that general thickening aud induration so characteristic of tropical dysentery. In fact, the majority of the ulcers seemed to be due to engorgement and subsequent necrosis of the solitary glands.
from heat-stroke. Post-mortem.?The small intestine
mucous
membrane of the
quite normal up to the cajcum; Peyer's patches presented the normal appearances, and no trace of their having was
found
been in any way diseased could be detected. There was no marked wasting of the mucous membrane either of the large or small intestine. Type No. Ill, though not so frequent as type No. I, as young soldiers are more susceptible,
is still by no means a rarity ; for in the year 1891 there are records of six typical cases under treatment during the cold weather; and this year, 1892, three cases are now under observation. The two cases of type III reported occurred in comparatively young soldiers. Private U.B had served in Peshawur and suffered severely from malaria. Lance-Corporal H? had served for nearly two years, and of that time 1^ year had been passed in Lucknow; his case is an exception to the general rule, and can only be explained on the supposition that he was extremely susceptible to malarial poisoning, and had gradually absorbed the virus of this disease in Lucknow, where remitteut fever of a severe type is by 110 means uncommon in young residents, often
to death, but never producing, when uncombined with the enteric poison, the condition described in the cases of Lance-Corporal H and Private U. B
leading
.
loose yellow stool and the abdomen became
more
came on,
Type I.
?
Private J.
White,
E. Lane.
Regi-
ment, age 22 years, service two years and two months, iu India six months. Admitted into Hospital on 28th December 1891, suffering from fever. For the first week his symptoms were undefined, though the temperature chart showed a rather charateristic ascent. On 9th January his face was flushed aud pupils dilated. The tongue was furred and dry in a triangular patch at the apex. The abdomen was distended and gurgling readily obtained on There was no rash. He suffered from pressure. diarrhoea, yellow and flaky stools being loose. The He had slight epistaxis from time to time. urine the normal. was but spleen enlarged, He continued in the same condition until the 14th, when he became delirious. On the 19th Vomithis face assumed a parched blue look. ing set in aud the abdomen became very tender on palpation. He died at 3-30 p.m. on the
19th,
Deo.
1892.]
HORROCKS'S CLINICAL NOTES ON CASES
OP ENTERIC FEVER.
365
Post-mortem. ?General recent peritonitis was fever and great depression continued up to found. The Peyer's patches in the lower third lltli December. On 14th December the temperaand the patient became delirose to 106, of the ileum were and but ture
enlarged
ulcerated,
ulcer had perforated. The solitary^glands the ulcers had a typical were also enlarged ; enteric appearance; the caecum contained two The mesenteric glands small circular ulcer?. were much enlarged. The spleen was large and soft, and pulpy in consistence. no
Type I.?Case of Private T. Sullivan, R. M. F., age
21
months,
years, service two years and in India two months.
two
Admitted into
Hospital on 9th January 1892, and diarrhoea. fever from Diarrhoea suffering ceased on the third day, and was followed by constipation. On admission his tongue was furred but moist, face flushed and pupils dilated. The abdomen was not distended; no rash was A present. The liver and spleen were normal. little bronchitis was present. On 16th January the abdomen became tumid, and on the 19th was markedly distended. The tongue then became quite dry, and the patient heavy and drowsy. On the 20th haemorrhage came on but ceased on the 23rd, and the tongue then began to clean a little. On the 24th and 25th there was a little dark blood passed with the faeces. On 28th January the abdomen became very swollen and the veins enlarged. On the 30th the transOn 31st verse colon was markedly distended. he became quite deaf and very restless. Death occurred on 1st February. Post-mortem.?The intestines were found matted together with recent lymph. In the ileo-ccecal area on separating the adhesions two perforations The liver conwere seen just above the csecum. tained an embolus on the upper surface which had partially suppurated. The lower half of the ileum was much ulcerated ; the ulcers in most cases were old with thin undermined edges. The base of the ulcers in several cases being only formed of peritoneum. Two perforations were present close to the caecum. The ulcers In the large were in the site of Peyer's patches. intestine the solitary glands were enlarged and superficially ulcerated. One ulcer showed signs of recent haemorrhage. Type I.?Case of Private Smith, R. I. Regiment, No. 2304, age 24, service five years and nine months, in India five years one mouth. Admitted into Hospital on 18th November, suffering from diarrhoea. On 7 th December he
transferred to the special ward, and then to be suffering from continued fever, accompanied by diarrhoea. He was very weak and tremulous, and slightly deaf. The face was flushed, and tongue dry down the centre. The abdomen was full, and gurgling readily obtained iu the right iliac fossa. There was no rash. The spleen was enlarged, and the urine contained a trace of albumen. Diarrhoea with continued was
found
He continued in a semi-delirious condirious. tion with picking at the bed clothes, &c., until 20th December ; when haemorrhage occurred, about a pint of dark clotted blood being passed per rectum. The haemorrhage continued on the 21sfc and 22nd in smaller quantities, and death took place on the 22nd from syncope. Post-mortem.?The spleen was found enlarged, dark and soft in consistence. The kidneys and intensely congested. The were enlarged, mesenteric glands were large and congested. In the small intestine numerous circular ulcers with heaped-up edges were found. One ulcer about a foot above the cajcum has perforated; the peritoneal surface being disintegrated and giving the base of the ulcer a sieve-like apSome of the ulcers were large and pearance. the Peyer's patches, others were small occupied The large and involved the solitary glands. intestine was congested and contained numerous The circular ulcers with heaped-up edges. lungs were congested. The muscle tissue of the right ventricle of the heart was largely infiltrated with fat. Type I.?Case of Private Jenner, 16th Lancers, age 20, service one year, in India four months. Admitted into Hospital on 19th January 1892, having felt ill for two days. On admission his face was flushed, pupils dilated, and the tongue was slightly coated. The abdomen was rather full, slightly tender on palpation, and gurgling was present. He had no rash. The spleen was enlarged. He suffered from diarrhoea, the stools being loose aud yellow in colour. The temperature chart was somewhat characteristic. On the 10th day of disease a rose rash appeared on the abdomen. On the 13th day of disease vomiting with hiccough came on, and the abdomen became very tender on palpation and fixed. The patient rapidly passed into a condition of collapse, aud died on the 28th after sudden profuse emesis. Post-mortem.?Recent peritonitis was found on the lower part of the ileum aud caecum. About two inches above the caecum two perforations were noticed in the ileum, through which faeces were exuding into the pelvis. Peyer's patches were found intensely engorged aud ulcerated ; the ulceration increasing in depth with proximity to the caecum. The caput caecum contained several ulcers. The mesenteric glands were enlarged. Type III.?Case of Lance-Corporal Healey, 16th Lancers, age 25, service one year and ten months, in India one year aud four months. most marked
Admitted into Hospital on 22nd February On admission lie states that he had felt 1892. 48
366
INDIAN MEDICAL GAZETTE.
ill for 14 days; his symptoms were then chiefly those of rheumatic fever, the knee and ankle joints being swollen. On 27th and 28th February, his temperature became normal and he was But on the considered to be convalescing. 29th his temperature began to rise again in a manner characteristic of enteric fever. He gradually developed the characteristic tongue, his abdomen became swollen and tender ; a few rose spots were seen, and the spleen and liver became enlarged. He had no diarrhoea, but a distinct tendency to constipation. He continued in this condition for several weeks : his tongue then gradually cleaned, and the abdominal symptoms subsided. On the 8th day after admission his temperature became normal for three days. He then suffered from an irregular type of fever for about 70 days and became extremely The fever was finally controlled by emaciated. large doses of quinine and arsenic. He is now. 200 days after admission, daily convalescing and able to take solid food, and walk about the ward For some weeks, after his temperature a little. had become normal, any attempt to feed him with solid food produced sharp attacks of diarrhoea, verging at times almost into dysentery. The case of Private M. Bowe, R. I., was of exactly the same nature, but he had no initial rheumatic symptoms, and on the 82nd day of disease he was seized with dysentery and died on the 98th day. Post-mortem.?Extreme wasting of the coats of the small intestine was found ; no traces of Peyer's patches on the solitary glands could be detected. The large intestine showed the usual changes characteristic of acute dysentery.
[Dicc.
1892.
