AND INTERESTING SOME PECULIAR OASES AT POONAMALLEE, MADRAS, FROM 1883?1385. By Surgeon John D. T.
(Continued Case
Reckett, 233.)
M. S.
from page
Y.? Phthisis?Pleuritic
Aspiration?Recovery. May 31s?, 1884.?Sergeant
effusion?
Charles W.
sent from Bangalore for hepatitis contracted fit Secunderabad. No mention is made of the
diseased condition of right lung, which, at the present time, is extensively affected. There is considerable dulness over the base and apex, increased vocal fremitus, expectoration of thick purulent sputa, anasmia and much emaciation. Evening temperature ranges from 100? to 103?. Cough troublesome and much
dyspnoea.
Treatment.?Rest and ordered Amm. chloride gr. 20, ter die. He continued to take this drug for nearly a month, and was then ordered Ferri et quin. cit. gr. 5, ter die. Hot linseed poultices to chest. June 27th, 1884.?More reduced and dysmore troublesome. To have Anunon. carb., Yin. ipecac., and Tinct. scillje, and continue poultices. Diet to consist of beef'tea, with milk, and 6 oz. of tarragona daily. pnoea
July lsif, 1884.?In the night he complained of a tearing pain in right side, and on examination there is hyper-resonance all over the lower part of right lung, indicating emphysema, great dyspnoea. Moist rales all over the left lung. Hot linseed poultices every three hours. 1884.?Chest measurement: Right. level of nipples?18 inches. Left?at level of nipples?16 j inches. Free expectoration of viscid sputa.
July 5th,
?at
1884.?Dulness at lower part of chest right very pronounced, but there is resonance above. Says he feels a splashing on rising suddenly from the recumbent position. Distinct metallic tinkling heard over 6th, 7tli, and 8th ribs, and particularly when lie shakes himself from side to side. August 5th, 1884.-?There is bulging of right intercostal spaces and complete dulness from nipple downwards. No vocal fremitus and no respiratory murmur lower than 6th rib. To have full diet with 1 pint of claret. September 24tli, 1884.?The signs of accumulation of fluid continue in spite of diuretics and blisters. Accordingly, the chest was aspirated between 5th and 6th ribs, and 28 ounces of fluid (straw coloured) drawn off. September 28th, 1884.?Much easier, but there is still a considerable amount of air and fluid iu pleural cavity. To take Syr. ferri iodid. nnd cod oil. He is taking half diet with a bottle of Bass's beer, and some eggs for breakfast.
July 13tli,
42
J
\yf
THE INDIAN MEDICAL GAZETTE.
326
[Nov.,
1887.
November 3rd, 1884.?Examined chest again; stantly coughing up small quantities of blood. dulness extending from nipple downwards and Particularly complained of a peculiar sensation below right nipple just before an attack of from the inferior angle of scapula downwards Avith very feeble respiratory murmur over this haemoptysis. Dulness below right nipple and moist rales continued, and when not expectoratdull area, and it is clear the lung has not expanded after the serous fluid was removed on Sep- ing blood, yellow coloured sputa took its place. " tember 24th. The left lung gives increased He describes the cough as hacking." Pie convocal fremitus both in front and behind and tinued to cough up blood, and complain of pain Moist rales at below right nipple, to lose weight, and become from below clavicle to nipple. left apex, no doubt due to tubercular ulceration. more and more anaemic. Came under my care on November 18th, 1884.?Apparently much bet- November 1st with diagnosis of phthisis. Treatment by Dr. Grant consisted of Gallic acid and ter, and so discharged and placed on convalescent Acid sulph. dil. and other astringents with linseed duty. to right chest, and a diet 13 1885.?Re-admitted. poultices General consisting of th, January and chicken broth, and perfect rest. beef'tea, milk, Anaemia appearance and health fairly good. November 9?/t,1884.?Physical examination reand coughs a little. No pain but dulness over the whole of right chest with bulging, indicat- veals only slight dulness along the base of right ing reaccumillation of fluid. Slight respiratory scapula. Here vocal fremitus is increased and murmur. Dyspnoea when walking briskly. "moist rales heard. No pain but a sensation of rattling." To have a blister over this part. Ordered Pot. iodid with Tinct. cinchonas co. Ferri sulph., Alum sulph., Acid sulph. Ordered 1885.?No so February 24th, improvement, in mixture. dil., between 6th and 7th and ribs, aspirated again November 15tli, 1884.?Daily haemoptysis. drew off 48 fluid ounces of serum of an opaque Ordered Plumbi acet. in pillawith Ext. ergotae straw colour. February '25th, 1885.?Goodnight. No pain. liquid m. 15, ter die. November 21 st, 1884.?Very restless. HaemNo cough. March optysis last night. Ordered at bed-time Pot. broto
\Oth, 1885.?Continuing
improve,
and discharged to proceed to England. There remained dulness from nipple downward, and in this situation there is only very faint respiratory murmur and no vocal resonance. Above this line there is also dulness, but it is not marked, and the respiratory murmur is present. Puerile respiration of left lung. Remarks. On July 1st, lie complained of severe pain of right side,and the hyper-resonance observed at the morning examination. The dyspnoea and other signs of emphysema gave rise to the belief that a lung cavity had given way, and so admitted air into the pleural space. Pleurisy followed, and there was much effusion. The metallic tinkling and splashing were remarkably distinct, and were two of the interesting features of this long and tedious illness. Case VI.?Hepatic Abscess (?)? Violent He?
moptysis?Recovery. September 3rd, 1884.? Schoolmaster
John H.
sent to Poouamallee for phthisis weeks some ago, and admitted to hospital under }
cat.
28,
Sui?geon-Major Grant, M. S., with haemoptysis which frequently recurred. Complained of pain in chest under right mamma and behind right scapula. Moist rales and crepitation all over rio-ht lung. Temperature varies from 100? to 103?. Very weak and with distressing cough.
Suspicious phthisical family history.
Served
in South Africa for about two years before at Secuncoming to India. States that whilst
derabad, previous
to
coming
to
Poouamallee,
he had several attacks of haemoptysis, and one day he suddenly coughed up about 4 ounces of blood and matter, and since then has been con-
midgr.25,Tinct. hyosc. |dr., Aq. camph.ad.l^oz. November 27th, 1884. ?Free haemoptysis at
morning visit. Blood is florid, red colour. Continual cough of a spasmodic nature. December 2nd, 1884.?Considerable haemoptysis last night; about J a pint of blood. To continue ergot and acid, and to have the infra scapular region rubbed night and morning with Tine, crotonis. Temperature varies from 100? in morning to 102? in evening. December 9th, 1884.?Expectorated above a pint of florid blood last night, and is very feverish this morning. Temperature 102?. Pneumonia suspected. To have Vin. antim. tart. Tinct. aconitas Aq. ad ...
...
... ..
3 ii.
m.36. 3 vi.
"
A table spoonful every 3 hours." December 10th, 1884.?Haemoptysis to \ a pint last night with spasmodic pains in chest and continual hacking cough. To continue mixture and to have Plumbi acetat gr.3 ,Pulv opii gr.| in pill, ter die. Beeftea with milk, eggs and acid water. December Wtli, 1884.?A little better. Even-
ing temperature 104,? morning 102?, Complains soreness and cough. Looks fearfully ill. Tohavehotlinseed poultices to base of right, lung. December 13th, 1884.?No bleeding since 10th.
of much
Less pain, but the temperature is 103? at night. December 18th, 1884.?Very weak from continuous haemoptysis and cough. No inclination for food. Evening temperature 103?, To have Quiu. sulph. gr. 15 at bed-time. December 19th, 1884.?Gravely ill last night. Temperature 104*8 Profuse sweating.and slight
Dr. BECKETT'S CASES.
Nov., 1887.]
delirium. Ordered brandy ^oz. every hour uuti l delirium disappears. Temperature in morning 102?. December 21st, 1884.? A little better. Cou^h ^ very troublesome and expectoration very abundant, consisting of yellowish white frothy mucopurulent matter. Has been taking for three days Pot. chlor. and Tinct. cinchonas co., and for the cough Ext. conii gr. 4, Sp. chlorof. m. 20, Tinct. camph. co. m. 30, Aq. 1 oz. when required. January ls?, 1885.?Much better. Very little pain or expectoratiou,and cough less troublesome. January 2nd, 1885.?Examined chest thoroughly, which,owing to his very grave condition since December 19th, I was uuable to do. There is slight dulness below right nipple and clavicle. Remainder of lung seems unaffected. It is evident that the dulness below the right nipple points to pneumonia caused by the violent haemoptysis into the lung substance. This stage of his illuess was attended by delirium and hyperpyrexia. The good effect of antimony combined with aconite during the acute symptoms (which at one time made our prognosis doubtful) seems to have been clear, and the pneumonia has apparently sealed the blood vessels and checked the haemoptysis. January 7 th, 1885.?Not so well, and complains of gastric pain. Diet therefore reduced to beeftea, 3 pints chicken broth, 1 pint milk. To have Mistura alb. 2 oz. Complains of pain in January 9th, 1885. lumbar aud region. Tongue coated epigastrium Urine sp. gr. 1020, alkaand mind restless. line and dark in colour. To have Acid phosph. dil., with Pot. bromid. and Tinct. hyosc. Hot turpentine fomentations to painful parts. January 10th, 1885.?Not so well. Restless and in pain. Gastric catarrh present, causing much pain and vomiting on taking food. To have Mist, effervescence withLiq. morphias mur. m. 15 and Acid prussic m. 2. January 18 th, 1885.?-Still complains of hypogastric and epigastric pain. Very little couch. To have Bismuth tris nit. gr. 5, Sodas bicarb o-r. 10, Acid prussic m. 2, Tinct. nucis vom. m. 10, Aq. ad 1 oz., ter die. January 22 nd, 1885.?Siuce taking the mixture last ordered has been much better. He has been fed for severaldays with nutrient enemataofmilk,portwine and eggs and scarcely any thing by mouth. January 29th, 1885.?Much better after two returns of severe pain in epigastrium, accompanied by vomiting. To continue medicine. Able to be moved from ground floor to one of the large wards on upper floor. February 18th, 1885.?Examined chest thoof phthisis. roughly, and found no signs before an 20th, 1885.?Brought February invaliding board and ordered to Eugland for change. He is now taking Easton's syrup, with of mutton, milk, rice, pudding, and a a diet Bass's beer every day. of bottle i
?
i
?
327
February 25th, 1885.?Severe eczema of scrotum, soon relieved by a Lotion of Tannic acid. March 3rd, 1885.?Weighed yesterday, and found to have gained 10 lbs. in five weeks. Gained 5 lbs. in last March 10th, 1885. well. seven Feels days. quite Discharged previous to proceeding to England via Deolali. I have described this case at Remarks. as it was to me particularly length, interesting in several points and from the complications which arose during the treatment. The disease ?
?
was positively diagnosed by many surgeons under whom he came as phthisis, and he was That sent to Poonamallee for this affection. this diagnosis was well founded was apparently clear enough when we revert to the various symptoms and physical signs, and which, in the face of the most prominent one?haemoptysis?were enough to deceive us. It is true that decided dulness, crepitation, vocal fremitus, and purulent sputa, characteristic of tuberculosis were never noticeable to auy very appreciable extent; and indeed I had frequently examined his liver for signs of abscess, living as I was in such an hepatic abscess atmosphere, and I was impressed with the idea that his symptoms in some degree adverse to our primary were diagnosis. I thought from previous experience of phthisis, and particularly the tubercular form that had he been suffering so long from this disease, excessive expectoration of purulent; sputa as a consequence of lung ulceration and also symptoms of cavities, would have been preseut, and that the frequently recurring haemoptysis would have been succeeded by acute phthisis ; but instead, and just when we were fully apprehensive of his very dangerous condition from the effects of such great loss of blood, acute pneumonia supervened and saved him. There is, no doubt, that the cause of this pneumonia was mechanical by what the physicians of the last generation termed pulmonary apoplexy, and that the process of repair sealed up the bleeding points aud arrested the haemoptysis, and I suspect that this condition was produced by ulceration of a hepatic abscess through the diaphragm and into the right lung, and involving either the phrenic artery or the pulmonary branches?perhaps both. Gastric catarrh causing him great pain and vomiting, seriously complicated the case, and for about 10 days nutrient enemata had to be given, as he could take no food, nothing excepting a little soda water and ice. Then excessive sweating brought on extensive eczema of the scrotum and thighs, but this soon yielded to a tannic lotion. He left India for England on April 1st, in high spirits at having almost regained his usual health and strength, and I had little doubt of his ultimate complete recovery. (2'o be continued.) -
(Continued Case
Reckett, 233.)
M. S.
from page
Y.? Phthisis?Pleuritic
Aspiration?Recovery. May 31s?, 1884.?Sergeant
effusion?
Charles W.
sent from Bangalore for hepatitis contracted fit Secunderabad. No mention is made of the
diseased condition of right lung, which, at the present time, is extensively affected. There is considerable dulness over the base and apex, increased vocal fremitus, expectoration of thick purulent sputa, anasmia and much emaciation. Evening temperature ranges from 100? to 103?. Cough troublesome and much
dyspnoea.
Treatment.?Rest and ordered Amm. chloride gr. 20, ter die. He continued to take this drug for nearly a month, and was then ordered Ferri et quin. cit. gr. 5, ter die. Hot linseed poultices to chest. June 27th, 1884.?More reduced and dysmore troublesome. To have Anunon. carb., Yin. ipecac., and Tinct. scillje, and continue poultices. Diet to consist of beef'tea, with milk, and 6 oz. of tarragona daily. pnoea
July lsif, 1884.?In the night he complained of a tearing pain in right side, and on examination there is hyper-resonance all over the lower part of right lung, indicating emphysema, great dyspnoea. Moist rales all over the left lung. Hot linseed poultices every three hours. 1884.?Chest measurement: Right. level of nipples?18 inches. Left?at level of nipples?16 j inches. Free expectoration of viscid sputa.
July 5th,
?at
1884.?Dulness at lower part of chest right very pronounced, but there is resonance above. Says he feels a splashing on rising suddenly from the recumbent position. Distinct metallic tinkling heard over 6th, 7tli, and 8th ribs, and particularly when lie shakes himself from side to side. August 5th, 1884.-?There is bulging of right intercostal spaces and complete dulness from nipple downwards. No vocal fremitus and no respiratory murmur lower than 6th rib. To have full diet with 1 pint of claret. September 24tli, 1884.?The signs of accumulation of fluid continue in spite of diuretics and blisters. Accordingly, the chest was aspirated between 5th and 6th ribs, and 28 ounces of fluid (straw coloured) drawn off. September 28th, 1884.?Much easier, but there is still a considerable amount of air and fluid iu pleural cavity. To take Syr. ferri iodid. nnd cod oil. He is taking half diet with a bottle of Bass's beer, and some eggs for breakfast.
July 13tli,
42
J
\yf
THE INDIAN MEDICAL GAZETTE.
326
[Nov.,
1887.
November 3rd, 1884.?Examined chest again; stantly coughing up small quantities of blood. dulness extending from nipple downwards and Particularly complained of a peculiar sensation below right nipple just before an attack of from the inferior angle of scapula downwards Avith very feeble respiratory murmur over this haemoptysis. Dulness below right nipple and moist rales continued, and when not expectoratdull area, and it is clear the lung has not expanded after the serous fluid was removed on Sep- ing blood, yellow coloured sputa took its place. " tember 24th. The left lung gives increased He describes the cough as hacking." Pie convocal fremitus both in front and behind and tinued to cough up blood, and complain of pain Moist rales at below right nipple, to lose weight, and become from below clavicle to nipple. left apex, no doubt due to tubercular ulceration. more and more anaemic. Came under my care on November 18th, 1884.?Apparently much bet- November 1st with diagnosis of phthisis. Treatment by Dr. Grant consisted of Gallic acid and ter, and so discharged and placed on convalescent Acid sulph. dil. and other astringents with linseed duty. to right chest, and a diet 13 1885.?Re-admitted. poultices General consisting of th, January and chicken broth, and perfect rest. beef'tea, milk, Anaemia appearance and health fairly good. November 9?/t,1884.?Physical examination reand coughs a little. No pain but dulness over the whole of right chest with bulging, indicat- veals only slight dulness along the base of right ing reaccumillation of fluid. Slight respiratory scapula. Here vocal fremitus is increased and murmur. Dyspnoea when walking briskly. "moist rales heard. No pain but a sensation of rattling." To have a blister over this part. Ordered Pot. iodid with Tinct. cinchonas co. Ferri sulph., Alum sulph., Acid sulph. Ordered 1885.?No so February 24th, improvement, in mixture. dil., between 6th and 7th and ribs, aspirated again November 15tli, 1884.?Daily haemoptysis. drew off 48 fluid ounces of serum of an opaque Ordered Plumbi acet. in pillawith Ext. ergotae straw colour. February '25th, 1885.?Goodnight. No pain. liquid m. 15, ter die. November 21 st, 1884.?Very restless. HaemNo cough. March optysis last night. Ordered at bed-time Pot. broto
\Oth, 1885.?Continuing
improve,
and discharged to proceed to England. There remained dulness from nipple downward, and in this situation there is only very faint respiratory murmur and no vocal resonance. Above this line there is also dulness, but it is not marked, and the respiratory murmur is present. Puerile respiration of left lung. Remarks. On July 1st, lie complained of severe pain of right side,and the hyper-resonance observed at the morning examination. The dyspnoea and other signs of emphysema gave rise to the belief that a lung cavity had given way, and so admitted air into the pleural space. Pleurisy followed, and there was much effusion. The metallic tinkling and splashing were remarkably distinct, and were two of the interesting features of this long and tedious illness. Case VI.?Hepatic Abscess (?)? Violent He?
moptysis?Recovery. September 3rd, 1884.? Schoolmaster
John H.
sent to Poouamallee for phthisis weeks some ago, and admitted to hospital under }
cat.
28,
Sui?geon-Major Grant, M. S., with haemoptysis which frequently recurred. Complained of pain in chest under right mamma and behind right scapula. Moist rales and crepitation all over rio-ht lung. Temperature varies from 100? to 103?. Very weak and with distressing cough.
Suspicious phthisical family history.
Served
in South Africa for about two years before at Secuncoming to India. States that whilst
derabad, previous
to
coming
to
Poouamallee,
he had several attacks of haemoptysis, and one day he suddenly coughed up about 4 ounces of blood and matter, and since then has been con-
midgr.25,Tinct. hyosc. |dr., Aq. camph.ad.l^oz. November 27th, 1884. ?Free haemoptysis at
morning visit. Blood is florid, red colour. Continual cough of a spasmodic nature. December 2nd, 1884.?Considerable haemoptysis last night; about J a pint of blood. To continue ergot and acid, and to have the infra scapular region rubbed night and morning with Tine, crotonis. Temperature varies from 100? in morning to 102? in evening. December 9th, 1884.?Expectorated above a pint of florid blood last night, and is very feverish this morning. Temperature 102?. Pneumonia suspected. To have Vin. antim. tart. Tinct. aconitas Aq. ad ...
...
... ..
3 ii.
m.36. 3 vi.
"
A table spoonful every 3 hours." December 10th, 1884.?Haemoptysis to \ a pint last night with spasmodic pains in chest and continual hacking cough. To continue mixture and to have Plumbi acetat gr.3 ,Pulv opii gr.| in pill, ter die. Beeftea with milk, eggs and acid water. December Wtli, 1884.?A little better. Even-
ing temperature 104,? morning 102?, Complains soreness and cough. Looks fearfully ill. Tohavehotlinseed poultices to base of right, lung. December 13th, 1884.?No bleeding since 10th.
of much
Less pain, but the temperature is 103? at night. December 18th, 1884.?Very weak from continuous haemoptysis and cough. No inclination for food. Evening temperature 103?, To have Quiu. sulph. gr. 15 at bed-time. December 19th, 1884.?Gravely ill last night. Temperature 104*8 Profuse sweating.and slight
Dr. BECKETT'S CASES.
Nov., 1887.]
delirium. Ordered brandy ^oz. every hour uuti l delirium disappears. Temperature in morning 102?. December 21st, 1884.? A little better. Cou^h ^ very troublesome and expectoration very abundant, consisting of yellowish white frothy mucopurulent matter. Has been taking for three days Pot. chlor. and Tinct. cinchonas co., and for the cough Ext. conii gr. 4, Sp. chlorof. m. 20, Tinct. camph. co. m. 30, Aq. 1 oz. when required. January ls?, 1885.?Much better. Very little pain or expectoratiou,and cough less troublesome. January 2nd, 1885.?Examined chest thoroughly, which,owing to his very grave condition since December 19th, I was uuable to do. There is slight dulness below right nipple and clavicle. Remainder of lung seems unaffected. It is evident that the dulness below the right nipple points to pneumonia caused by the violent haemoptysis into the lung substance. This stage of his illuess was attended by delirium and hyperpyrexia. The good effect of antimony combined with aconite during the acute symptoms (which at one time made our prognosis doubtful) seems to have been clear, and the pneumonia has apparently sealed the blood vessels and checked the haemoptysis. January 7 th, 1885.?Not so well, and complains of gastric pain. Diet therefore reduced to beeftea, 3 pints chicken broth, 1 pint milk. To have Mistura alb. 2 oz. Complains of pain in January 9th, 1885. lumbar aud region. Tongue coated epigastrium Urine sp. gr. 1020, alkaand mind restless. line and dark in colour. To have Acid phosph. dil., with Pot. bromid. and Tinct. hyosc. Hot turpentine fomentations to painful parts. January 10th, 1885.?Not so well. Restless and in pain. Gastric catarrh present, causing much pain and vomiting on taking food. To have Mist, effervescence withLiq. morphias mur. m. 15 and Acid prussic m. 2. January 18 th, 1885.?-Still complains of hypogastric and epigastric pain. Very little couch. To have Bismuth tris nit. gr. 5, Sodas bicarb o-r. 10, Acid prussic m. 2, Tinct. nucis vom. m. 10, Aq. ad 1 oz., ter die. January 22 nd, 1885.?Siuce taking the mixture last ordered has been much better. He has been fed for severaldays with nutrient enemataofmilk,portwine and eggs and scarcely any thing by mouth. January 29th, 1885.?Much better after two returns of severe pain in epigastrium, accompanied by vomiting. To continue medicine. Able to be moved from ground floor to one of the large wards on upper floor. February 18th, 1885.?Examined chest thoof phthisis. roughly, and found no signs before an 20th, 1885.?Brought February invaliding board and ordered to Eugland for change. He is now taking Easton's syrup, with of mutton, milk, rice, pudding, and a a diet Bass's beer every day. of bottle i
?
i
?
327
February 25th, 1885.?Severe eczema of scrotum, soon relieved by a Lotion of Tannic acid. March 3rd, 1885.?Weighed yesterday, and found to have gained 10 lbs. in five weeks. Gained 5 lbs. in last March 10th, 1885. well. seven Feels days. quite Discharged previous to proceeding to England via Deolali. I have described this case at Remarks. as it was to me particularly length, interesting in several points and from the complications which arose during the treatment. The disease ?
?
was positively diagnosed by many surgeons under whom he came as phthisis, and he was That sent to Poonamallee for this affection. this diagnosis was well founded was apparently clear enough when we revert to the various symptoms and physical signs, and which, in the face of the most prominent one?haemoptysis?were enough to deceive us. It is true that decided dulness, crepitation, vocal fremitus, and purulent sputa, characteristic of tuberculosis were never noticeable to auy very appreciable extent; and indeed I had frequently examined his liver for signs of abscess, living as I was in such an hepatic abscess atmosphere, and I was impressed with the idea that his symptoms in some degree adverse to our primary were diagnosis. I thought from previous experience of phthisis, and particularly the tubercular form that had he been suffering so long from this disease, excessive expectoration of purulent; sputa as a consequence of lung ulceration and also symptoms of cavities, would have been preseut, and that the frequently recurring haemoptysis would have been succeeded by acute phthisis ; but instead, and just when we were fully apprehensive of his very dangerous condition from the effects of such great loss of blood, acute pneumonia supervened and saved him. There is, no doubt, that the cause of this pneumonia was mechanical by what the physicians of the last generation termed pulmonary apoplexy, and that the process of repair sealed up the bleeding points aud arrested the haemoptysis, and I suspect that this condition was produced by ulceration of a hepatic abscess through the diaphragm and into the right lung, and involving either the phrenic artery or the pulmonary branches?perhaps both. Gastric catarrh causing him great pain and vomiting, seriously complicated the case, and for about 10 days nutrient enemata had to be given, as he could take no food, nothing excepting a little soda water and ice. Then excessive sweating brought on extensive eczema of the scrotum and thighs, but this soon yielded to a tannic lotion. He left India for England on April 1st, in high spirits at having almost regained his usual health and strength, and I had little doubt of his ultimate complete recovery. (2'o be continued.) -
