8th.?Dry tongue; severe pnin in the head; a fresh crop of spots appeared oyer abdomen and chest. 9th-?Bowels moved once during the night?stools watery, of a greenish-yellow color, with white particles floating in it. 10th.?Purged once last night?stools typhoid; pain and gurgling as before. On May 13th (or 19th day of the fever) the care of the case devolved upon me. He had been purged three times since the morning before ; the motions were loose and watery, having a bright yellow color with bran-like particles floating in them ; some fresh spots made their apriearance; his tongue was scaly in part, and he had sordes on the lips and teeth; there was pain and gurgling in the right iliac fossa; he slept pretty well the night before and was not delirious; he had epistaxis. Towards evening his tongue was black and his pulse was weak. rose

14th.?Rose spots visible on the abdomen; he was rather better in the morning; bowels moved once?motion very characteristic of enteric fever. The radial pulse was most remarkable, being of that peculiar redoubled or dicrotous variety so well described by the late Dr. Graves and others. He


There was pain, tenderness, and gurgling in the iliac fossa; the tongue, though moist at the edges, was dry in the centre. The character of the pulse in the morning led us to anticipate a haemorrhage, most probably from the nose or bowel, a


and in this










The columns of the Indian Medical Gazette for the past year contain several papers showing the prevalence of typhoid or enteric fever to some extent in certain Indian stations, and as many of the cases therein detailed appeared to me most conclusive, it was with no little surprise I recently heard that there were a few physicians still sceptical as to the existence of this fever in India. This is my apology for bringing to the notice of my professional brethren the following fatal case; for though in some an instructive one, its chief claims to attention are the typical.character of the symptoms, the remarkable normality of its course, and the conclusive evidence of the post-mortem dissection. On the 23rd May, 1872, No. 1627, Private T. B., 63rd ("West Suffolk) Regiment, aged 20 years, 2-162- years in the service, was admitted into the regimental hospital, Hazareebaugh, under the care of Assistant Surgeon Ilannah. He stated he had had feverish symptoms for some eight days previous. On admission, he had a pale and anxious countenance, diarrhoea, severe pain and gurgling in the right iliac regionj his tongue was covered with a white fur; the thermometer in the axilla registered 1-10? F., and there were 96 beats of the radial









visible over any

part of

the trunk. May 4th (10th day of the pyrexia).?There was no improvement ; his bowels were not moved ; the skin was bathed in perspiration; abdominal pain and gurgling continued; no eruption; appetite very indifferent. 5th (11th day).?There were about half a dozen rose spots over the abdomen; he had pain on pressure, and gurgling

the coocum, towards evening he complained of headache and profuse diaphoresis; lie bled from the nose three times. 6th.?He had an olive-oil enema, which brought away it was fluid," of a bright a copious stool of enteric character; yellow' color, having white, bran-like particles floating in it.


Pain and




alarming epistaxis~ plugging and purged twice during


strong astringents to control it. He was the day?stools typhoid. 1 oth (21st day.)?His tongue was black, and the teeth and gums were covered with sordes ; he was three times at the


O'Farrell, M.D.,

not mistaken,

evening, necessitating

occurred towards

gurgling continued; eruption fading;


fresh spots

stool since the evening visit of the day before?stools as before but very offensive ; abdomen tympanitic and painful. Vespere.?Felt a little better; was only purged once during the day?stool was of the same bright yellow color; abdomen painful and distended. 16^/t (22nd day.)?Spent a bad night; was very delirious, and his cough was worse; abdomen distended ; only one rose spot could be detected. His intellect was clear; he was twice at the stool?character as before.

Vespere.?He slept a little during the day; he looked very low; his tongue was glazed, red, dry, and protruded with difficulty. 17th.?He was very delirious last night; he had seven motions from the bowels, three of whieh he passed in ted ; his tongue was dry and glazed; there was no pain nor abdominal

tympanism. In the evening, however, there was extensive swelling of the belly; the tongue was black, glazed, fissured, and bleeding. 18th (24th day.)?There was no improvement; the breathing The tongue was black, papillae prominent, was more affected. and the dorsum of the tongue had a purulent appearance; abdomen distended; sudamina over the trunk; urine drawn off by catheter. much worse; was purged" seven times, distressing hiccoughs supervened. 19th.?Unconscious, with low muttering delirium ; tympanitis; tongue glazed, black, and bloody ; sordes ; slight hiccough. Vespere.?Much the same; he was thrice at the stool,?it was loose, of a greenish color, with whitish particles in it. 2Qth (26th day.)?He kept constantly moaning; diarrhoea continued unabated. He passed his stools involuntarily. A large congested patch appeared on the right buttock. The urine was drawn off by a catheter; he became more delirious, and

Vespere.?He great tympanitis





4 p.m.

proceeding to the post-mortem examination, I take the liberty of bringing to the notice of the reader the following table, showing the correlation between the pulse, temperature, and respirations, together with the daily condition of the urine Before

with respect to the presence


absence of albumen.

December 2,









Max 1872.











0f fever-


9th 10th Uth 12th 13th Uth 15th 16th

17th 18th 19th 20tli 21st 22nd 23rd 24th 25th 26th

... ... ... ... ... ... ... ... ... ... ... ... ... ...

,.. ... ...

J01 101 1032 103-2 1?3 102 102 102 102-2 100 102 102-3 102 103 103-3 104-i 104

Dep. 102 104-3 104-2 104-2 102*3 103 102-2 101-1 103 101-2 101-2 103 102-2 103 3 104'4 104 3 1043



104 104-1 104 103-1 102-2 1"4 102-2 102-1 1033 102-2 100 100 102-3 103-3 104 103-3 104

103 104-2 104-2 102-2 104-2 103 103 4 103 102-2 103 101 103-1 I114 103-2 104 104 103

86 84

80 72 78 68 80 64

"'84 112 62 72


shows that digitalis, like veratrum and other medicines which diminish the number of pulse strokes, has at the same time a marked effect in lowering the fever heat; and it appears probable, that unlike, nitrite of amyl, which causes relaxation of the organic muscular fibres of the small arteries, quinine, veratrum, digitalis, and probably ergot of rye, owe their pyrexial properties to inducing contraction of the same vessels, acting, most likely, through the great system of vaso-motor rves.

practical hint error likely

is derivable from a study of the table, occur if only morning and evening records of the temperature are kept, for in many cases it will be ei en that in the short space of four hours there is a difference of

viz., the


two, and sometimes three degrees Fahrenheit. These comsudden variations of temperature, which reach the maximum in the agues, I have met with in many cases of typhoid fever in this country. The table also shows, as pointed out on a previous occasion, that "although, as a rule, the evening is higher than the one,


morning temperature, still the greatest elevation necessarily occur at that time."

does not

Under the head of urine collected will be found the quantity but it is not

procured in 24 hours on five or six occasions; pretended to be sufficiently accurate to lead to

any conclusion the amount of water excreted, even were we in a position to determine the quantity of that fluid got rid of in the profuse diaphoresis, diarrhoea, and by the lungs. They may however be used in the determination of the amount of urea by Dr. Samuel Ilaughton's tables. s Autopsy (fifteen hours after death). T!igT mortis had set in; body tolerably well nourished; post-mortem congestion of the posterior part of the trunk, as well as congestion of the scrotum with effusion of serum under the cuticle. Read.?But little blood escaped on opening the skull; there was some serum in the lateral ventricles, with a congested state to

blood-vessels; weighing 31t> 2oz.

of their


the brain and cerebellum were

Thorax,?Neck?The thyroid gland


None None None

1032 1024 1032

12-3 28-1 19-3

None None

1026 1024

22 8

None N one None None None None None None


Yes, ith

It is however necessary to mention that from the 5th to the 12th May, inclusive, he was treated with the infusion of digitalis in the manner and quantities recommended by Wunderlich. The effect of that drug in diminishing the relaxation of the arteries and number of pulse beats was very evident. This table


Specific gravity.





divided into fifths of






N.S.?The thermometers used







Specific gravity.

None None

1024 1024

None None None

1030 1022 1024

7-9 21-8 26-4

i'o20 1020 1020 1020 1020 1020 1012

19-3 12-3 38 16 17-6


of the neck

gorged with blood ; papilloe of the tongue prominent; dirty greenish-looking matter in the oesophagus; trachea congested. Lungs?Bronchial glands enlarged; no pleuritic adhesions; apparent thickening of the pleura covering the left lung. The inferior and posterior parts of each lung congested, hut float on water; weight of right lung ljfb, left ,ljlb; no tubercle. Heart?There were four ounces of fluid in the pericardium, some fat on the heart, a small blood-clot in right ventricle. Heart substance, the cavities, and their openings were healthy. Abdomen.?Liver friable; weighed 4lb 8oz.; gave no re-action with iodine. The gall bladder contained ^oz. of fluid bile. Pancreas normal; 5oz. Spleen much enlarged?lib. 2oz., friable. Kidneys weighed 9oz. each ; cortical and medullary substance there


very distinct, with apparent increase of the former; substance no amyloid. Intestines?The mucous membrane of the small gut, from the jejunum down, was studded with small elevations, evidently due to enlargement or distension of the solitary glands; a markedly racemose condition of the intestinal bloodvessels was observed. The first of Peyer's patches met with was


healthy, the next was enlarged, the succeeding ones thickened and presented spots of commencing ulceration. As the coecum was approached, both the solitary and agminate glands were completely ulcerated. About a foot from the coecum, an oblong oval ulcer | inch by 2| inches, occupied the position of a Peyer's patch ; in this patch were other smaller and deeper ulcers with undermined edges, and only separated by the peritoneum from its cavity. In the immediate vicinity of the coecum there was ulceration of the mucous membrane all round, but chiefly in the solitary glands. The mesenteric glands were much enlarged, and most of them had small abscesses in them. There were no entozoa. The bladder contained ooz. of urine. The large

were healthy.Solitary glands invisible. Barley's description (Reynolds's system) of the usual condition of the mesenteric glands in cases of typhoid is an exact representation of the slate in which we have found them after death from that disease at this station, I hope I may be excused for quoting it. He says "in every crrse of enteric fever we find that the mesenteric glands are more or less congested, swollen, find softened; they are usually of a darkpurple color, and of the size of hazel-nuts. Some often attain Bisected with a sharp scalpel, the outer the size of a walnut. portions are seen to be of ? uniform dark-purple color, the

intestines As Dr.


270 central parts

chyma ance

are less vascular, and tlie yellowish-white parenis veined with diffuse purple streaks, and a mottled appear-

thus produced."

This mottled appearance is always Well marked, but abscesses in the glands we have met for the first time in the above case. The peculiar sudden variations of temperature alluded to as being common, though indifferent degrees, to the agues and enteric fever, suggests the existence between these two diseases of something more than the"* ordinary fraternity which links most of the exanthemata, and it seems probable that this intimate connexion between the so-called paludal diseases and the one now under consideration, is one of a common causation, and that wo are to look to vegetable rather than animal decomposition, for the principal factor in the production of the typhoid fever of India.


This subject i3 of such great importance, more especially as perhaps it is in this circumstance we are to find the clue to the great difficulty of diagnosis in many Indian fevers, that I may be excused for reminding those who have been kind enough to have followed me so long, of some of the chief points of similarity between these two diseases. Both complaints are characterised by profuse diaphoresis, sudden variation of temperature, intense headache, and sometimes by diarrhoea and vomiting. Enlargement and turgescence of liver and spleen are found in both, and autumn is the period of the year in which they are most prevalent. Still more markedly do the accounts (though meagre) of remittent fever point to a close relationship of symptoms, and those whose attention has been drawn to the subject of enteric, fever in this country will agree with me in stating that there is no more common

symptom met with in the so-called malarious fevers

peculiar tenderness and gurgling along the course of the great gut, but especially well marked over the angle of junction



of the ileum and coecum.Thoso pathologists who hold that the liver is the starting point within the body, in the evolution of a case of typhoid, will see nothing odd in this connection of the two diseases. Dr. Harley, in the article above alluded to, points out this con-

nection, and shows the frequent occurrence of typhoid and ague under similar conditions, and from the same locality. He quotes authorities to prove the fact of enteric fever being in some cases ushered in by intermittent symptoms, and vice versa, well as the occurrence of remittent or intermittent phenoin the course of a case of typhoid. The truth of these observations we have seen clinically proved in cases of typhoid fever in India: for example, in some instances the primary symptoms were so like those of remittent fever, and the symptoms of typhoid were so conspicuous by theira bsence, as to lead to the conclusion that the case was an example of the former, Whereas the post-mortem dissection left no doubt as to its having been a genuine case of the latter ; and last year, when my colleague and myself were paying great attention to the subject of enteric fever, wo were very much dissapointed by one of our pet cases. Suddenly the temperature fell, and this peculiar occurrence was followed by most of the phenomena of a quoti-



dian ague. Dr. Harley believes that the variety which he calls paludal enteric fever is the most commcn. Arguing from a clinical study of this disease in India from its almost non-contagious

and from some of the above considerations, I am led the conclusion that though the paludal diseases and enteric fever differ in many important particulars with respect to symptoms, mode of termination, prognosis, mortality, and treatment, yet we should not lose sight of the existence of certain circumstances which point to a common parentage, and further-

character, to

that the non-recognition of this kinsmansliip may account for some of the scepticism and a good many of the diagnostic difficulties met with in Indian fevers.







\ /

[December 2,


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