of rather high colour, not very scanty. A"o headache, although he always presented a look of mental distress. No cpistaxis. Mind quite clear. Wakeful at night. lie was put oil good nourishing diet, and took quinine. I had no actual anxiety as to his recovery at that time. Still lie was in an unsatisfactory state. Instead of improving he eomplaincd more and more, and he became feverish and nervous.
NOTES OF A CASE OF TYPHOID By David B. In Medical
FEVER.
Smith, M.D.,
Charge of
J[ussoorie.
I believe that there are very few* physicians indeed of any not now believe that, in this country experience in India who do with cases of genuine typhoid fever. bs in England, we meet on the subject, it has Since Seriven, Ewart, and others wrote and described. frequently been recognized I have myself seen, at the Ilill Sanitarium from which I undoubted cases of this now write (MussoorieJ, a good many the long course usual disease, occurring late in the year, running in this complaint, and characterized by ro-e-coloured spots, by or 23rd day. diarrhoea, and by a crisis about the 21st Until now, however, I have never had a fatal case. The following notes refer to one lately under my care, not its course as others which I have by any means so marked in looked at in its entirety, an unniistakeable and
obsecved,
yet,
instance of typhoid fever. in India,) aged 26, of Lieutenant , 7? years' service, (5 middle stature, rather slight built, fair, clear complexion, and red hair. My first visit to him was on the 11th November. He had Looked thin and weak, but had just arrived from Roorkee.he had been suffering slightly from Said that no actual fever. intermittent fever before coming np, but that it was never very bad; that he had come up, not on medical certificate, but merely for a short change. Iitthen told him that I thought he would probably be a couple of was very weak, and that months before.lie could safely return to the plains. He was Two days afterwards ho much distressed on hearing this. removed to a small house occupied by a few brother officers ; of the latter two had arrived very ill, ten days before, from Roorkee, suffering from similar fever: they both recovered very
slowly.
On arrival at Mussoorie, he appeared to be suffering from mere debility. He occasionally, however, complained of chills and feverishness; and he 3at over the tire, or moved about feebly
He was not as if in discomfort, physical and mental confined to bed for any part of the day ; and after a few days he was in the habit of going out in a jampan to briug back books from the library, which he was strong enough to read. His countenancc was somewhat pale, and expressive of anxiety. Skin generally dry, occasionally moist. Pulse about 90; feeble. Breathing rather hurried. Tongue moist; red at edges; slightly furred in centre, not cracked. Lips not dry. Loss of appetite and anorexia. Complained of thirst at night. No nausea; no vomiting; no hiccup. No pain on pressure over abdomen. Spleen Bowels constipated, requiring mild aperients. Urine
enlarged.
On my visiting him, day by day, he used to say he did not think ho had any fever, although occasionally lie seemed to have been hot and restless, particularly at night. A low irregularly remittent fever was then on him. But it was not until the 2Gth November (fifteenth day) that this became really well marked. He had then unmistafceable fever, remitting twice in 24 hours. All his symptoms became aggravated. No eruption could be discovered on the abdomen or chest, although it was looked for on several occasions. (The back was not examined with this object)- The pulse became more frequent and more feeble, the tongue more red, r/lazcd, and dry. Small ulcers appeared on the right margin of the tongue, of a tawny asli colour. His appetite decreased. Thirst became more troublesome, particularly at night. Still he had no vomiting. There was now slight tenderness and gurgling on pressure over tbjj There was still 110 diarrhoea; a ccRcuni. but no actual pain. threatening of it only appeared about four days before death. There was no enlargement of the liver, and no jaundice. It was only shortly before death that the urine became scanty. It was then either retained or passed involuntarily, not suppressed. Quinine did not cheek the fever. Profuse sweating occurred, and with increased prostration. The lips became dry, and the pulse smaller and more rapid; there was greater tenderness over the ccecuni; deafness supervened; the pupils were widely dilated; there was a bright pink spot on each check; and slight There were also incoherence and muttering now oecurrcd " cerebral" breathing, subsultus tendinum, and quick, nervous, dorsal decubitus. Shortly after this, active, noisy delirium set in. On one or two occasions, when his attendants were engaged, he got out of bed. He talked vivaciously of a number of friends having arrived.; and of much gaiety about to occur around him. lie also rambled a great deal on the subject of the Abyssinian Expedition, talking loudy about it. Latterly the delirium became more noisy, particuat early night. He called out aloud, and remonstrated violently, when nourishment was offered to him. Still he could be roused, and all along he took his nourishment and medicine. The urine was drawn off twice a day with a catheter; he resisted this being done. The urine was at this time scanty, and had a bloody
tinge.
before death that he had threatening of He had at most three or lour small motions in hours, only for a dav or two. These were not yellow, or of a pea-soup colour, but dark, like bird-lime. During Iiis entire illness he was most faithfully and conscientiously nursed by Sergeant Taylor, of the Bengal Sappers and Miners. Night and day his every want was attended to. His nourishment consisted of strong soups, jellies, tea, milk, barley water, toast water, arrowroot, &c. He took port wine and water, moselle and brandy, la'tcrly, in large quantities. At tlrst, in the way of medical treatment, lie took quinine ; afterwards strychnine, mineral acids, muriate of morphia, chloric a;ther, camphor, . as ' enscs nvi.nt' / *? what degree the most severe remittent 1U se l?tal morbid lesions of the intestinal ff'niiiltj ?1' ^tbogenic fever. A '
Spleen of nearly twice its natural size. On section it was found to be much softened, and of a nry deep purple colour. Kidneys presented no organic lesion. They were slightly conge stal, but nut liypertruphied, or otherwise diseased. bladder contained about two ounces of urine, thick in consistence, and of a dark, bloody tinge. The mucous membrane was
18G8.
iiii
inflamed.
Liver of normal size and consistence, perhaps rather pale in colour. No disease discovered on section. It was neither
[Janttaet 1,
slightly injected.
Stomach in every way healthy. No congestion or softening of the mucous membrane. Dw.dinum and jejunum healthy. No softening or vascularity. Extensive disease was found in about 24 inches of the ileum, jit iis lower extremity, and in an equal length of the colon, as also About ten of Pcyer's patches presented all the 111 the coreum. usual characteristic appearances of the typhoid fever lesion, and a large number (at least sixty) of the solitary glands of the ileum, The larger patches eileum, and colon were similarly diseased. ?were tcund opposite to the inseition of the mesentery, with their long axis parallel to that of the intestine. They were elliptical Some of them were nearly an inch in and irregular in foirn. length, l'neir edges were elevated. Within their ec'ges was either a gritty exudation, or a small tawny slough oi a dirty green colour, the size of a sixpence. Some of them were harder than others; and in some the ulceration had extended as lar as the peritoneum. No perforation, however, was discovered. The solitary tjianils were eimer enlarged to the size of u split pea, presenting a yellow apex, with a surrounuing lringe of vascularity; or they were cup-shaped aud puckered, with softened eloughy matter in the centre, adherent to the edges ol the ulcer. In either of these stages of disease, they were found in the lower '2-1 inches of the ilium, in the caecum, aud along '24 inches of the colcn. Four or five similarly diseased glands were also found in the lower poitionof the descending colon. The sigmoid Jiexure and t ic rictum were normal. Hie Jucal matter was dark, and resembled bird-lime. The vtesi u I eric glands were considerably enlaiged, and purple ou section.
Remakes. There can be very little doubt but that this was a case of genuine tvpl.oid ievtr. it is tine that the gastio-mtestinal symptoms ?were greatly in abeyance; indeed almost entirely latent tinoughTime was no bilious vomiting, no dysentery, no inont. testinal l ienicrrhoge. and scarcely any diarrhoea. No rose-colored spots couid be discovered. 'Ihere were no petechia). \e*t when we consider all the symptoms and signs? tiie hectic flush of the cheek, the red, glazed tongue, the greatly-enlarged spleen, the gurgling over the ileo-ccecal valve, and tne active, noisy delirium ; and couple all these with the very marked and characteristic lesion of the intestinal glands above described,? there is no room for doubt as to the disease which we had here to deal with. It is to be cbserved that the invasion and development of the fever were very insidious indeed; that it was associated with a tendency to intermit, and subsequently to remit. 1 will net here go into the question of the exact relation between genuine malarious fevers and true typhoid. They are sometimes curiously blended. Dr. John Ilarley, in his able essay on Enteric or Typhoid Fever, in the 1st volume of lieynolds' System of Medicine, writes on the subject as follows:? " One ot the mcst general facts observed in reference to enteric fever is the frequent occurrence of lnterniitteuce in the pyrexial condition. The Commissioners appointed to investigate the French epidemics of enteric fever, call attention to the fact that more or less pernicious a intermittent, or at least remittent, chaiacter was manifested under a great variety of circumstances Mcm.de 1'Acad, de filed, torn, xiv, p. 71). A great (Do Claubry, number ol cases of typhoid fever presented, either at the com-
^ mittcnf f'^?S0'p^8 ?
?
?
'
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Wj M,a(^
1? aJIn^
rt
tniCc'ia'I?s '"'l }?*** !?F.ee .-^ u)S('nible, a? ?''V ?
?
l%n ."I' ,araCk;rize
ought
to
bo published
'
aS
throwinS 1;Slit
on
this subject,
NOTES OF A CASE OF TYPHOID By David B. In Medical
FEVER.
Smith, M.D.,
Charge of
J[ussoorie.
I believe that there are very few* physicians indeed of any not now believe that, in this country experience in India who do with cases of genuine typhoid fever. bs in England, we meet on the subject, it has Since Seriven, Ewart, and others wrote and described. frequently been recognized I have myself seen, at the Ilill Sanitarium from which I undoubted cases of this now write (MussoorieJ, a good many the long course usual disease, occurring late in the year, running in this complaint, and characterized by ro-e-coloured spots, by or 23rd day. diarrhoea, and by a crisis about the 21st Until now, however, I have never had a fatal case. The following notes refer to one lately under my care, not its course as others which I have by any means so marked in looked at in its entirety, an unniistakeable and
obsecved,
yet,
instance of typhoid fever. in India,) aged 26, of Lieutenant , 7? years' service, (5 middle stature, rather slight built, fair, clear complexion, and red hair. My first visit to him was on the 11th November. He had Looked thin and weak, but had just arrived from Roorkee.he had been suffering slightly from Said that no actual fever. intermittent fever before coming np, but that it was never very bad; that he had come up, not on medical certificate, but merely for a short change. Iitthen told him that I thought he would probably be a couple of was very weak, and that months before.lie could safely return to the plains. He was Two days afterwards ho much distressed on hearing this. removed to a small house occupied by a few brother officers ; of the latter two had arrived very ill, ten days before, from Roorkee, suffering from similar fever: they both recovered very
slowly.
On arrival at Mussoorie, he appeared to be suffering from mere debility. He occasionally, however, complained of chills and feverishness; and he 3at over the tire, or moved about feebly
He was not as if in discomfort, physical and mental confined to bed for any part of the day ; and after a few days he was in the habit of going out in a jampan to briug back books from the library, which he was strong enough to read. His countenancc was somewhat pale, and expressive of anxiety. Skin generally dry, occasionally moist. Pulse about 90; feeble. Breathing rather hurried. Tongue moist; red at edges; slightly furred in centre, not cracked. Lips not dry. Loss of appetite and anorexia. Complained of thirst at night. No nausea; no vomiting; no hiccup. No pain on pressure over abdomen. Spleen Bowels constipated, requiring mild aperients. Urine
enlarged.
On my visiting him, day by day, he used to say he did not think ho had any fever, although occasionally lie seemed to have been hot and restless, particularly at night. A low irregularly remittent fever was then on him. But it was not until the 2Gth November (fifteenth day) that this became really well marked. He had then unmistafceable fever, remitting twice in 24 hours. All his symptoms became aggravated. No eruption could be discovered on the abdomen or chest, although it was looked for on several occasions. (The back was not examined with this object)- The pulse became more frequent and more feeble, the tongue more red, r/lazcd, and dry. Small ulcers appeared on the right margin of the tongue, of a tawny asli colour. His appetite decreased. Thirst became more troublesome, particularly at night. Still he had no vomiting. There was now slight tenderness and gurgling on pressure over tbjj There was still 110 diarrhoea; a ccRcuni. but no actual pain. threatening of it only appeared about four days before death. There was no enlargement of the liver, and no jaundice. It was only shortly before death that the urine became scanty. It was then either retained or passed involuntarily, not suppressed. Quinine did not cheek the fever. Profuse sweating occurred, and with increased prostration. The lips became dry, and the pulse smaller and more rapid; there was greater tenderness over the ccecuni; deafness supervened; the pupils were widely dilated; there was a bright pink spot on each check; and slight There were also incoherence and muttering now oecurrcd " cerebral" breathing, subsultus tendinum, and quick, nervous, dorsal decubitus. Shortly after this, active, noisy delirium set in. On one or two occasions, when his attendants were engaged, he got out of bed. He talked vivaciously of a number of friends having arrived.; and of much gaiety about to occur around him. lie also rambled a great deal on the subject of the Abyssinian Expedition, talking loudy about it. Latterly the delirium became more noisy, particuat early night. He called out aloud, and remonstrated violently, when nourishment was offered to him. Still he could be roused, and all along he took his nourishment and medicine. The urine was drawn off twice a day with a catheter; he resisted this being done. The urine was at this time scanty, and had a bloody
tinge.
before death that he had threatening of He had at most three or lour small motions in hours, only for a dav or two. These were not yellow, or of a pea-soup colour, but dark, like bird-lime. During Iiis entire illness he was most faithfully and conscientiously nursed by Sergeant Taylor, of the Bengal Sappers and Miners. Night and day his every want was attended to. His nourishment consisted of strong soups, jellies, tea, milk, barley water, toast water, arrowroot, &c. He took port wine and water, moselle and brandy, la'tcrly, in large quantities. At tlrst, in the way of medical treatment, lie took quinine ; afterwards strychnine, mineral acids, muriate of morphia, chloric a;ther, camphor, . as ' enscs nvi.nt' / *? what degree the most severe remittent 1U se l?tal morbid lesions of the intestinal ff'niiiltj ?1' ^tbogenic fever. A '
Spleen of nearly twice its natural size. On section it was found to be much softened, and of a nry deep purple colour. Kidneys presented no organic lesion. They were slightly conge stal, but nut liypertruphied, or otherwise diseased. bladder contained about two ounces of urine, thick in consistence, and of a dark, bloody tinge. The mucous membrane was
18G8.
iiii
inflamed.
Liver of normal size and consistence, perhaps rather pale in colour. No disease discovered on section. It was neither
[Janttaet 1,
slightly injected.
Stomach in every way healthy. No congestion or softening of the mucous membrane. Dw.dinum and jejunum healthy. No softening or vascularity. Extensive disease was found in about 24 inches of the ileum, jit iis lower extremity, and in an equal length of the colon, as also About ten of Pcyer's patches presented all the 111 the coreum. usual characteristic appearances of the typhoid fever lesion, and a large number (at least sixty) of the solitary glands of the ileum, The larger patches eileum, and colon were similarly diseased. ?were tcund opposite to the inseition of the mesentery, with their long axis parallel to that of the intestine. They were elliptical Some of them were nearly an inch in and irregular in foirn. length, l'neir edges were elevated. Within their ec'ges was either a gritty exudation, or a small tawny slough oi a dirty green colour, the size of a sixpence. Some of them were harder than others; and in some the ulceration had extended as lar as the peritoneum. No perforation, however, was discovered. The solitary tjianils were eimer enlarged to the size of u split pea, presenting a yellow apex, with a surrounuing lringe of vascularity; or they were cup-shaped aud puckered, with softened eloughy matter in the centre, adherent to the edges ol the ulcer. In either of these stages of disease, they were found in the lower '2-1 inches of the ilium, in the caecum, aud along '24 inches of the colcn. Four or five similarly diseased glands were also found in the lower poitionof the descending colon. The sigmoid Jiexure and t ic rictum were normal. Hie Jucal matter was dark, and resembled bird-lime. The vtesi u I eric glands were considerably enlaiged, and purple ou section.
Remakes. There can be very little doubt but that this was a case of genuine tvpl.oid ievtr. it is tine that the gastio-mtestinal symptoms ?were greatly in abeyance; indeed almost entirely latent tinoughTime was no bilious vomiting, no dysentery, no inont. testinal l ienicrrhoge. and scarcely any diarrhoea. No rose-colored spots couid be discovered. 'Ihere were no petechia). \e*t when we consider all the symptoms and signs? tiie hectic flush of the cheek, the red, glazed tongue, the greatly-enlarged spleen, the gurgling over the ileo-ccecal valve, and tne active, noisy delirium ; and couple all these with the very marked and characteristic lesion of the intestinal glands above described,? there is no room for doubt as to the disease which we had here to deal with. It is to be cbserved that the invasion and development of the fever were very insidious indeed; that it was associated with a tendency to intermit, and subsequently to remit. 1 will net here go into the question of the exact relation between genuine malarious fevers and true typhoid. They are sometimes curiously blended. Dr. John Ilarley, in his able essay on Enteric or Typhoid Fever, in the 1st volume of lieynolds' System of Medicine, writes on the subject as follows:? " One ot the mcst general facts observed in reference to enteric fever is the frequent occurrence of lnterniitteuce in the pyrexial condition. The Commissioners appointed to investigate the French epidemics of enteric fever, call attention to the fact that more or less pernicious a intermittent, or at least remittent, chaiacter was manifested under a great variety of circumstances Mcm.de 1'Acad, de filed, torn, xiv, p. 71). A great (Do Claubry, number ol cases of typhoid fever presented, either at the com-
^ mittcnf f'^?S0'p^8 ?
?
?
'
't\'
Wj M,a(^
1? aJIn^
rt
tniCc'ia'I?s '"'l }?*** !?F.ee .-^ u)S('nible, a? ?''V ?
?
l%n ."I' ,araCk;rize
ought
to
bo published
'
aS
throwinS 1;Slit
on
this subject,
