THE DUBLIN JOURN_A_L OF

M E D I C A L S C I E N C E .

J A N U A R Y 1, 1883.

PART I.

O R I G I N A L COMMUNICATIONS.

ART. L--Report of a Case of Enteric Fever treated in the General Itospital, Madras. By SUROEON-MAJOR IIENRr KILO, A.M., M.B.; Physician to the IIospltal; Principal and Professor of Medicine, Madras Medical Collcge.

SO~E explanation is due when an ordinary case of enteric fever is offered for publication. In this instance there are two reasons for my hope that the case may be interesting--the first, that it demonstrates that genuine enteric fever can occur between the tropics as in the temperate zones, and that its victims are not necessarily young persons newly arrived in the country ; the second, that it fixes, for one case at least, the period of incubation.

Sir Joseph Fayrer, ill his recent valuable Croonian Lectures on Indian Climate and Fevers, states that he does not gather from any writings which he had seen by Dr. Gordon (late Surgeon- General of the British Medical Service at Madras), that this officer denies the "existence of enteric fever, identical with what we know in this country, in India; but that he denies its pythogenic origin, and attributes it to climatal, probably malarial, causes. I think I may venture to say that a different impression prevails among medical officers in the Madras Presidency. I t is a grim joke there that Surgeon-General Gordon had " abolished" enteric fever, partly by denying its existence, and partly by making its appearance in returns of sick exceeding troublesome to the dlagnoser through the formidable official catechism to which it led. However this may be, few physicians in military or civil practice

VOL. LXX~ro--NO. 133, T H I R D SERIES. B

2 ~eport of a Case of _t~2nterie Fever.

in India could be found who would deny that both natives and Europeans are liable to a disease undistinguishable in its symptoms and in its lesions from the entaric fever of Europe. I t may be, of course, that such cases arise from malaria or other climatal cause, independently of poisoning by putrefying animal excreta; but it is certain that, if they do, it is not in the absence of the other and ordinary source. However carefully barracks may be swept and garnished, the British sohtier cannot walk through his cantonment, or stroll into the nelghbouring village, without exposing himself to the reeognised causes of enteric fever. I t may be conceded that climate predisposes, but more than this is more than doubtful.

Oil the l l t h of June, 1880, W. R., aged twenty-five, of European birth and parentage, was admitted into the General Hospital, Madras, for epilepsy, l i e had been under treatment in the hospital for the same disorder on several previous occasions ; the last having been in 1874. He attributed the disease to the habit of mastur- bation acquired in England when he was twelve years of age. A t that time the fits came on several times a day. He was benefited by treatment there, lie states, and also in Madras, being admitted to hosi)ital on his arrival from England. :For six years past tie has resided, without any particular employment, on the Shevaroy Ilills (5,700 feet above sea level), and during this period the fits troubled him only about once a month. On the 9th inst. he returned to Madras, and on the l l t h he had a fit. This and subsequent paroxysms were slight in character, and not preceded 1)y premonitory symptoms. The attack is sudden, the patient falling, and coma follows. The circulatory, respiratory, digestive, and integumentary s3"stems are in good working order. I te com- plains of no pain, and sleeps well; but his intellectual power is obviously weakened, t i e sits in bed with a vacuous stare and finds (liMeuity in eollectlng his thoughts and in answering questions; these symptoms being more marked after the occurrence of a fit. I ie was ordered a purgative of castor-oil and turpentine, and put on milk diet.

Next day (12th) lie had two tlts--one at 10 a.m. and one at 7 p.m. IIe was put on bromide of potassium, ten-graln doses three times a day. On the 16th the dose of bromide was increased to fifteen grains, and from this (late until the 21st no fit occurred. There was a slight one on the 21st; and then a free interval until the 28th, when two occurred.

The fits continued with similar occasional intervals. The dose

By SURGEON-MAJOR HENRY KING. 3

of bromide was increased to twenty grains on the 7th July, and to twenty-five on the 10th. On the 12th, extract of belladonna, gr. 4~, was substituted for the bromide ; and there were no fits from the 15th to the 20th- -an interval of six days. On the 24th the dose of belladonna was increased to gr. 31; and on the 28th it was thought advisable to return to the bromide, in twenty-grain doses. On tile 3rd August there were five fits--two severe ones by day and three milder at night. After this there was none until the 20th.

The recurrence of tile attacks after an interval of nineteen days was attributed to exposure to the sun. On lhe 20th the patient obtaincd leave to go out to visit friends ; and he walked from the hospltal to a suburban village, distant about three miles, between 9 and 11 a.m. ]-Ie returncd flushed and weary, and had a fit at 9 o'clock that night. On the 24th there were two fits; on the 25th one ; on the 26th none, but "h is rest was disturbed owing to an attack of fever." On the morning of the 27th August the temperature, hitherto normal, was 102-6 ~ F. Diaphoretic mixture was ordered. In the evening the temperature was 101 ~ The progress of the case to its fatal termination will now be briefly noted : -

Aug. 28 th- -Temp. , 102"2~ vesp., 104"4~ slept fairly; bowels moved twice.

29th.--Temp., 103 ~ vesp., 103"8 ~ slept ill ; was slightly dclirlous during the day; tongue slightly furred, brown; appetite good; bowels moved twice ; ordered powder containing quinine, gr. 5, and pulv. antimon, gr. 3, ter die.

30th.--Temp., 103"2 ~ ; vesp., 103 ~ ; slept well ; bowels moved o n c e .

31st.--Temp., 101"4 ~ ; vesp., 103"6 ~ ; had a fit, lasting about five minutes, at 2 a.m. ; slept well ; no delirium ; appetite good.

Sept. ls t . --Temp., 102"4 ~ ; vesp., 105 ~ ; a f i ta t 1 a.m. ; slept well, without delirium ; bowels not moved yesterday ; tongue still slightly furred, brown; pulse, 112; ordered a seidlitz powder at once.

2nd.--Temp., 102"6~ vesp., 104"4~ no fit, but condition of patient improving; bowels moved thrice; slept well; takes food (milk and mutton broth) readily; pulse 100.

3rd.--Temp., 103~ vesp., 104"4~ reduced by a tepid bath in the course of the day from 104 ~ to 102"2 ~ ; pulse, 108 ; slept well ; bowels moved twice since last report; complains of ringing in the ears; appetite fair ; ordered eight grains of quinine in solution, instead of the powder, thrice daily.

4 Report of a Case of Enteric Fever.

4th. Temp., 103"8 ~ ; pulse, 112 ; respirations, 28 ; bowels moved twice ; tongue ~nore furred and brown ; slept well.

5th.--Temp. at 8 30 a.m., 104"6 ~ ; at 9, after a tepid bath, 102 ~ ; at 11 15, had risen to 104'8 ~ ; fell, in a bath, to 99"2 ~ and was 100 ~ at 12 5 p.m ; at 1 30, 105"4 ~ ; at 4, 105 ~ ; took his food (milk, broth, and some bread) and medicine; had a copious watery motion in the evening; had another bath at 7 45 p.m., temperature being 104"6 ~ before it, and 103 ~ afterwards; during the night bowels were moved five times; two-minim doses of tincture of aconite were given every hour, with a view to reduce the temperature; diet, milk, chicken broth, and brandy, ~ij.

6th.--Temp. vesp., 105~ patient much worse; small red spots over chest, abdomen, and back; crepitation in right lung ante- riorly; great tenderness in right iliac fossa.

7th.--Tcmp., 104 ~ ; vesp., 105 ~ ; bowels moved five times during the night ; stools copious, watery, and yellowish; tongue thickly coated, brown ; pulse, 116 ; ordered acetate of lead with opium.

8th.--Tepid bath at 8 30 a.m. ; temp. before it, 104"6 ~ fell to 100 ~ rising to 101 ~ afterwards; bath repeated at 2 30 p.m. ; temp., 105 ~ reduced to 101 ~ ; bowels moved eight times during the day. At 7 25 bath repeated, reducing temperature from 102"6 ~ to 101~ tenderness of abdomen continues, with tympanites; diet as before, with increased brandy.

9th.---Temp., 104"4 ~ at 8 35 a.m., reduced by tepid bath to 101 ~ at 9; bath repeated at 2 30, reducing temperature from 104"$ ~ to 100 ~ ; again at 7 p.m., with reduction from 105 ~ to 99"6 ~ ; pulse, 108 ; condition of abdomen and chest unchanged ; tendency to bed sores.

10th.--Temp. at 10 a.m., 102~ at 1 p.m., 104"2~ at 9 p.m., 104"6~ bowels moved once during the day.

l l t h . - -Temp , at 8 a.m., 104~ at 11 30, 101"6~ at 1 30 p.m., 103"2~ at 5, 104"6~ temperature at 8 p.m., 101q; at midnight, 100"6~ at 4 15, 10"2~ slept soundly; complained of pain on being moved ; "bowels moved several times, stools copious, dark in colour ; sordes on teeth ; acetate of lead powders (without opium) continued ; chlorate of potassium, gr. 5, in decoction of cinchona, ~ij. every third hour; brandy, 3vj.

12th.---Temp. at 7 40 a.m., 102.6 ~ ; at 11 15, 104"2 ~ ; at 2 25 p.m., 104~ at 5 10, 104"6~ at 7 45, 104~ at 11 15, 102"6~ at 4 15 a.m., 103"8~ drowsiness during the day; diarrhoea continues; cough troublesome ; spots persist ; tenderness ; gurgling, &c., as before.

By SUROEON-~-~xAJOR HENRY KIN(~. 5

I t is unnecessary to continue the history of the case in detail. The patient died on the 14th at 11 25 p.m. The following are the most intcrestlng points of the post mortem examination, made the morning after death : - -

Head.--Nothing abnormal about skull or dura mater; pia mater congested; two small patches of relative softening, one in external aspect of right hemisphere, the other in left posterior lobe or in- ferior surface, neither diffluent under a stream of water ; cerebellum unusually soft. Thorax.~Left lung deeply congested, especially lower lobe, of which portions were completely carnified; upper lobe crepltant, but exuding frothy mucus on section; pulmonary pleura of right lung roughened by recent inflammation ; tissue not so congested as that of left lung ; small puckered cicatrix in apex. A bdomen.--No general peritonitis; some localised inflammation over c~ecum and lower ileum ; spleen weighs 9 oz., firm and normal ; small intestines contain a quantity of pea-soup-looking fluid ; a few scattered patches of hyper~emia of mucous membrane of jejunum and of upper part of ileum ; lower down in ileum the membrane is deeply stained with bile, but otherwise normal until two feet above ileo-cmeal valve, where one of the solitary glands is much enlarged and infarcted with a cheesy-looking substance. For a few inches the mucous membrane is again normal, and then one of Peyer's patches is found in the same state as the solitary gland, except that the ulcerative process has extended nearly to the peritoneal coat; from this on to the valve are other patches and solitary glands in the same state of infarction and ulcerative inflammation, but none of the sloughs has separated ; immediately above the valve the mucous membrane is throughout very hyper~cmic, and the valve itself is covered with sloughing patches; about two inches of the large intestines hypermmic. The restriction of the morbid lesions to the 1)eyer's patches and the solitary glands for two feet above the ileo-cmcal valve is very well marked. The mesenteric glands are only slightly enlarged.

From these notes, greatly abridged from the case as entered in the hospital journal by the clinical clerk, and from the pathologist's report of the autopsy, it appears : - -

1. That the case was one of genuine enteric fever, with temper- ature rising to a maximum of 105"6 ~ on the 22nd day ; and fatal, without perforation, on the 19th.

2. That the period of incubation was six days, the patient having left hospital and gone into town on the 20th August, and having

6 Report of a Case of.Enteric Fever.

exhib i ted pyrex ia on the n i g h t of the 26th . I n a hospi ta l w i thou t a case of en te r ic f eve r in i ts wards, and in which the re a re no sewers, d r y - e a r t h conservancy be ing ca re fu l ly car r ied out, i t m a y be t aken as ce r ta in t h a t the pa t i en t did not con t r ac t the disease wi th in i ts walls.

3. T h a t t h e case was not one of :a fever , r e sembl ing enter ic , a t t a c k i n g a y o u n g E u r o p e a n newly a r r i v e d in Ind ia , the pa t i en t hav ing been six years in the count ry .

4. T h a t there , i s no evidence of mala r ia l in toxica t ion in the ease, t he pa t i en t ( t h o u g h come f rom a malar ious region) hav ing been eleven weeks in hospi tal w i thou t a symp tom of i n t e r m i t t e n t fever , and hav ing g iven no h i s to ry of previous a t t acks of mala r ia l disease.

ARTIFICIAL FEEDING OF INFANTS.

DR..ARTHUR V. ~r has devised a new food with which he states he has attained very good success in as many cases as he has had the oppor- tunity to t ry it. He says that it contains the same elements as are found in human milk, and in more nearly the same proportions than any other food heretofore recommended. I t consists of two parts of cream, one of milk, two of lime water, and three parts of a solution of milk sugar of the strength of 17�88 drachms to the pint of water. The milk to be used should be good ordinary cow's milk, and the cream such as is usually sold in cities, and not too rich~ containing about 16 or 17 per cent. of fat. The quantity of this food taken by a new-born infant should be two or three fluid ounces every two hours, and if it thrives it will soon take as much as a gill every two hours. The best way to prepare and use this food is to order five or six packages of milk sugar, containing 17~ drachms each ; the contents of one of these to be dissolved in a pint of water ; and each time the child is to be fed let there be mixed together~ and then warmed, three tablespoonfuls of the sugar solution, two of lime water, two of cream, and one of milk. This makes about a gill, and as much of it as the child does not take should be thrown out, and a fresh mixture made for the next feeding. The solution of sugar should be kept in a cool place, and at once thrown away if it sours, as occurs if kept more than a day or two in warm weather. The dry sugar keeps in- definitely, and is easily dissolved in warm water. .A pint bottle should be kept for the purpose of containing the solution, to serve also as a measure of the quantity of water to be used with each package dissolved, and also to save further measuring.--Med. News, Nov., 1882.