J R Army Med Corps: first published as 10.1136/jramc-04-03-02 on 1 March 1905. Downloaded from
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A FEW NOTES ON ENTERIC FEVER. By MAJOR J. S. EDYE. Royal Army Medical Corps.
CAPTAIN E. A. BOURKE's notes on seventy-five cases of enteric fever in India, in the JOURNAL OF THE ROYAL ARMY MEDICAL CORPS for September, 1904, and in which he eulogises the value of carbolic acid, leads me to think of two series of cases of my own-the one in Africa, the other in Bermuda-which may interest your readers. Many years ago, in India, I was much impressed with the earnestness with which an apothecary-as they were then called spoke to me of the value of carbolic acid in the disease, and in the result of the few trials I gave this drug; and subsequently by the articles of Colonel Quill, R.A.M.C. In the Transvaal, in 1901, I was in charge of the enteric section Protected by copyright. of a large general hospital, and for four months I had '150 beds constantly full of undoubted cases of enteric fever .. Great care was taken upon the arrival-usually twice weekly-of a large batch of sick, only to pass into these twenty-five marquees undoubted cases of enteric fever, and at this selection I had the assistance of a very able Civil surgeon of Johannesburg; and upon the following day, and also twice weekly, the Principal Medical Officer and myself again very carefully went over the cases, in order that we might eliminate any doubtful case.
The following five tables will briefly show the results of four http://militaryhealth.bmj.com/ lines of treatment employed. With reference to the only fatal case in the first series, Private J. F., he was a most intelligent man, and I obtained a distinct history of ailing only six days before admission; and his temperature had been normal for some twenty-five hours before his sudden death, about 8 a.m. On the' evening before his death he had stated to the Sister "he never felt so well since he arrived in hospital" (six or seven days previously), "and was going to ask the doctor if he could get up." He had a good night, and was laughing and chatting the next morning, his temperature was normal, and he was propped up on September 27, 2021 by guest. in bed for the orderly to sponge over his face, &c., when he put his hand to his chest, complained of pain, gave a few gasps, and fell back dead. Here we have a distinct history of at most thirteen days' illness up to date of death, the temperature having been normal for twenty- J R Army Med Corps: first published as 10.1136/jramc-04-03-02 on 1 March 1905. Downloaded from Protected by copyright.
TABLE I.-THE. CARBOLIC ACID AND IODINE TREATMENT IN NINETEEN CASES. ., ~'1:l "" ~"i~~ .. ~1=3 cP.9.f!i
J. 8. Edye 305 five hours previous to death, and mark the post-mortem signs three hours later. All the organs were examined and were normal. Upon slitting up the right pulmonary artery I soon came to a large fresh clot, extending into the vessel and its ramifications; the clot in places was beginning to get decolourised. The smaller ramifications of the leftpulmonary artery contained a dark clot. The small intes tine showed congestion over its lower five feet, most intense towards the valve, and scattered throughout these five feet were swollen and congested Peyer's patches, some granular and about to bre~k down, and one a typical enteric ulcer. A few of the solitary glands of the large gut were swollen, and the stomach was congested. Now here is a proven case of enteric fever, with a normal tem perature for the whole of the seventh day he was under treatment, and a clear history of only six days' prior ailing; but many would say-had the man recovered-CC Oh, it could not have been a case of enteric fever"; and it only corroborates what I have before said, that these apparently trivial cases of continued fever, with the Protected by copyright. other symptoms of enteric fever, well or slightly marked, when they do die from any accidental cause, invariably show postmortem typical enteric lesions. At the same time, I unhesitatingly say there is a continued malarial fever, such as one sees especially in the Punjab, Hong Kong, and other parts of the world, but then you have few, if any, of the symptoms typical of enteric fever. I would like here to say that it was noticeable under the carbolic acid treatment that, though the temperature fell early, thereby grea.tly husbanding the patient's strength, the tongue often remained foul,
with red tip and edges, or even dry or brown, for some days or weeks http://militaryhealth.bmj.com/ after the temperature became normal, all-d had not the patient been mercilessly kept on slops-though plenty of them-for two or three weeks after the temperature was normal, I should have had relapses and trouble. Quinine, 5 grs., was given, usually at 2 p.m. daily, to check the evening rise of temperature and counteract any malarial tendency, and as an antiseptic. Three or four doses of turpentine . in 10-minim doses, and as stupes, were invaluable for tympanites; and the ice-bag to the iliac fossa, with 10 grs. of gallic acid, in hromorrhage, two doses being usually sufficient of the gallic acid. In two cases slight congestion of the lungs threatened., but tur on September 27, 2021 by guest. pentine liniment rubbed into the back, with creosote inhalations, and omitting the carbolic acid treatment and giving alternately a dose of ammon. carb., with cinchona bark, and'a mixture of digitalis and iron for forty-eight hours, was productive of the best results. There was no carboluria. J R Army Med Corps: first published as 10.1136/jramc-04-03-02 on 1 March 1905. Downloaded from
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,Private F. S~,. Somerset L.I., was at one time in such a desperate condition that strychnine and iron were given for forty-eight hours. Phenacetin was occasionally given for very severe headache, but the patients were always sponged all over at least once a daYt and I had splendid J+ursing. The routine treatment was a 4-grain calomel powder upon admission, and ~. Acidi carbolic 1I1.i. Tr. iodidii •• 1I1.iv. Syrupus aurantii •• . . 15i. Aqua ad Si. Sig. One ounce thrice daily. Hence, with the quinine, a patient received four doses of an anti septic in the day, and the stomach was allowed to rest through the night, except for any nourishment. In using iodine one need not use such large doses of carbolic acid, and you do away with the objections to that drug; and the use of iodine, besides being tonic in Protected by copyright. its action, is well known as a stimulant to ulcers on the surface of the body, and I did not find that it caused vomiting in anyone of these cases. . My special contention is that, when the case is obtained early, this line of treatment very frequently causes it to abort. For diar . rhrea a dose of sulphuric acid and opium, followed by a lead and opium pill, rarely failed. The ice-cap and spinal ice-bag were occa sionally used, and insomnia was met with 20 grs. of sulphonal. Constipation continuing after the first dose of calomel was met by enemata, and the diet was fairly generous, consisting of milk and barley water, with Brand's essence, and some brandy and beaten-up http://militaryhealth.bmj.com/ eggs gradually added; occasionally champagne was used.
EIGHTEEN CASES OF ENTERIC FEVER TREATED WITH THE PERCHLORIDE OF IRON. Some time ago I read one or two articles in the British Me,dical Journal on this line of treatment in the disease, and with Olie of these articles I was much- impressed, so I determined to place some ' of my cases on this drug and watch events. They were dotted about
in the marquees with the other enteric fever patients, and were on September 27, 2021 by guest. treated during the same period, and in every way were under the same conditions of food and nursing, and they all had calomel upon admission, and were sponged daily. Fifteen minims of tr. ferri perchlor. was given with sp. chloroform thrice daily. Six or eight of these cases complained of pain and tenderness in the epigastrium after a few days-some gastritis, I presumed-and I more or less had to intermit or omit the treatment. J R Army Med Corps: first published as 10.1136/jramc-04-03-02 on 1 March 1905. Downloaded from Protected by copyright.
TABLE H.
~ r;s--.s e_-"'bD .. "'~ ...... cS@~S.9..p ~ .~" ., """ ,8!lS!l ., .. ~gslg ~g~g~ " 4-0 bD'''' Inocu· Diar· ""o"S ~ eJ: gpS .g e'g'O ! 50... Rank and name Corps Age ~::::'t:S Relapse Result Remarks lated rhrea C1) .... QS ca.B1·~~ 'C.fZ Cl! «).,p etJll~ ~ ~ -a" ~ ~~.s ~~ ~ ".S.@~ " .e S""" ..... S Po" El" Z Jl ~e.=? Q Z.21~ Z""S"~!;ll" ... ------Private D. McL. Imp. Yeomanry .. 34 No Yes 5 20 25 No R. Very seriously ill. Corpora.l W. B. .. 23 No 11 13 17 - Trooper H. P ... Roberts's" Horse" " 18 " 5 6 .10 " http://militaryhealth.bmj.com/ " Tongue bad for some time, " " " " weak and emaciated. Private A. M ... E. Surrey Re/rt; ... 20 4 8 16 - Trooper J. T .... Scottish Horse .. 21 Yes" " 2 16 17 " " - Corporal H. G .. Worcester Regt ... 23 No " 4. 13 15 Yes," for 2 " Phlebitis. " days " D.J .. 1st R. Welsh Regt. 22 8 26 30 No Phlebitis, both legs; .dan- " " " " gerously ill ; high tern· ,....,0 peratures. Trooper J. B. .. N.Zealand Oontgt. 24 Yes Yes 9 ..,0 6 16 - ,...., Private H. B. .. 10th Hussars .. 32 No No 10 15 17 " " - ..; Trooper H. M .. S.A. Constabulary 30 8 6 13 " " Very ill on arrival; tongue 0 " " " " bad for some time Z Private H. W .. 19th Hussars .. 20 Yes 8 10 16 Reported dangerously ill.
A.B ... A.S.C ...... 25 " No 8 12 16 " on September 27, 2021 by guest. " High temperatures. " A.A ... 1st Suffolk Regt. \!2 " 14 14 22 " " Hremorrhagefrom bowels, " " " " " reported dangerously ill. G. K ... K.R.R...... " 20 6 5 16 Yes Very seriously ill; bad " " " " tongue for some time. Trooper G. D ... S.A. Constabulary 20 Yes Yes 3 16 17 No - W.W .. K.R.R. .. .. 28 No No 10 9 13 Yes :"" Dyspepsia. " R. MeA. .. .. 29 5 13 ]6 - " T.H.•. K.S.L.!." .. .. 26 " " 7 4 10 No" " Tongue bad for some time. " " " " J R Army Med Corps: first published as 10.1136/jramc-04-03-02 on 1 March 1905. Downloaded from Protected by copyright.
TABLE TIl.
., Inocu· Diar· ! Rank IInd name Corps Age lated rhrea Result Remarks
Private W. W. 6th Dragoon Grds. ~-;:- Yes ~--1-4--1--3-;---;:---;-http://militaryhealth.bmj.com/ Aftertendaystreatment.stopped, because of a scalding pain on micturition, when temperature began to rise. After seven days of no medicine he recommenced .. . the turpentine . Trooper S. A. . . S.A. Constabulary 23 10 20 34 .. Dangerously ill; delirious. Private W. BoO' K.R.RoO' oo 20 " 8 6 13 " Tongue bad for some time. .. R. G. • . 13th Hussars • • 27 .. 10 7 13 " " M. Boo. 1st Welsh Regt.. . 20 6 6 7 " Dangerously ill, and high tem. .. " perature during the relapse. Corporal A. D. • 12th Lancers 23 No No 5 6 9 Private C. S.: •• K.R.R. 21 8 23 26 No " High temperature; hremorrhage " " .. from bowels; reported danger. ously ill. " A. B. .. 2nd Somerset L.I. 22 6 16 18 .. .. on September 27, 2021 by guest. Tongue bad for some time. Trooper W. 0.. S.A. Constabulary 20 " 21 On 10th day of illness Died Dangerously ill; delirious. .. pneumonia, and treat· ment changed F.:I. oo 21 5 22nd day after admittance - Dangerously ill; delirium. .. .. " " " temperature not normal, and I left J R Army Med Corps: first published as 10.1136/jramc-04-03-02 on 1 March 1905. Downloaded from
J. s. Edye 309
TEN CASES OF ENTERIC FEVER TREATED WITH TURPENTINE. These cases were dotted about in the same marquees and at the same time as those cases on the carbolic acid-iodine treatment, and the iron treatment, and came under the same conditions of food and nursing. Calomel was given upon admission, and any symptoms, such as diarrhooa, were combated in the same way as mentioned in the early part of this article. Ten minims of turpen tine were given in mucilage and peppermint water thrice daily for seven days, and then twice daily. In the marquees Nos. 1 to 10 there were four or five cases of phlebitis, I remember,towards the latter end of the four months during which time I was making these notes, and I remember they all occurred within a few days of each other, two being in contiguous beds. I mention this on account of the apparent impossibility of infection or contagion, and yet it has frequently been noticed that, given one case of phlebitis, others will occur. Protected by copyright.
THE CHLORINE TREATMENT. I now bring to notice some cases which were treated by mistura chlorine and quinine. A few were under my own personal care, and I was responsible for all the others, they being in Nos. 11 to 25 marquees, and under the immediate care of a very able medical officer. I regret I only have brief notes of these cases, but such as they are I have set them down. Where the columns are blank I have not the particular record to
insert, but they arrived twice weekly as the others did, and during http://militaryhealth.bmj.com/ the same period, and were in no way selected, being distributed as the others were to anyone of the marquees 11 to 25, in the square occupied by marquees 1 to 25, and they had the same advantages of food and day and night nursing, all of which was as good as possibly could be. '
CAMP OF THE PRISONERS OF WAR (BERMUDA). There were seven isolated islands, more or less cleared of brush wood, and an encampment was formed of some 5,000 prisoners on September 27, 2021 by guest. here, guarded by the Royal Warwickshire Regiment, all old soldiers, and the survival of the fittest from South Africa. The hospital was on one island, and all sick prisoners were sent to it, and there were a certain number of cases of enteric fever; but the sick of the Royal Warwickshire Regiment were sent to a permanent hospital on one J R Army Med Corps: first published as 10.1136/jramc-04-03-02 on 1 March 1905. Downloaded from
TABLE IV.-TwENTY-NINE CASES OF ENTERIO FEVER TREATED BY MISTURA OHLORINE (BURNEYProtected by copyright. YEO TREATMENT).
, Numberof Number of days before days before Relapses Number of I temperature (after tem. temperature normal, perature cal Corps Age Inoeulated Diarrhooa normal. Remark~ Marquee Rank and name da~f~~~ng culated from momiugand nonnal, Result admission evening, from morning date of date of and cominl( under coming under evening) treatment treatment --I Private ;---.-. ------1------~--~------i " S. .. 28 28 Unknown .. 9 10 .. 10 11 .. 12 19 http://militaryhealth.bmj.com/ .. 13 21 .. 15 21 " .. 17 24 " .. 18 24 .. 20 24 " .. 20 24 " .. 22 27 • • -,j 'Cl -,j 'Cl 11 22 28 . • ~ ~ 1) l:l 0 24 28 .. ~ ~ ~ ~ ~ 24 39 •• 0 28 41 o .. Z Z z Z Z 28 445 Z .. 33
Pri~~te C. .. 22 24 on September 27, 2021 by guest. .. L. .. 12 19 " B. .. 12 Unknown S. •. 9 10 " J. .. 22 24 " B. .. 18 24 R. 10 11 T. 15 21 K. 24 41 " MeR; •. 20 27 R. 13 24 " J R Army Med Corps: first published as 10.1136/jramc-04-03-02 on 1 March 1905. Downloaded from
J.B. Edye 311
TABLE V.-FORTY CASES OF ENTERIC FEVER IN THE WORCESTER REGIMENT AND ROYAL ENGINEERS AT BERMUDA, TREATED WITH CARBOLIC .ACID AND IODINE.
"" ~'i~~ ~.§" al~~.S~ ~e'-''''~ , .,., ~~ .. Si) ]t:5~§§ "0 i38s ~.~ a.> c:,) S g'§ ~e'O~~ Re· Rank and name . Age ... "0 '0 ~i'Oj lapse Result Remarks 0" ~.s .. ,$ t;.E~~~ ... " .o,s"" 'S~g.at ! ~.~.@ ~ S" ~ig!g z".0 z..,§~U] ... ------BoyS••• .. 16 3 12 14 No R. - Sergeant R. .. 26 4 10 12 Yes Died - Private T. .. 20 2 15 16 No R. - E. .. 21 5 - - - Died - " S. .. 23 4 25 25 No R. - SergeantN." .. 30 5 16 26 - Private A. .. 20 1 9 17 " " - Corporal B. .. 20 7 16 19 " " - Qmr.-Sergt. B. 35 3 10 14 " " A perfect wreck. Sergeant W. .. 42 5 6 30 Yes" " Protected by copyright. Private M. .. 30 7 42 42 No " " "- Sergeant D. .. 21 12 8 15 " - Private B. .. 18 7 15 16 " " A perfect wreck. BoyH.•• .. 16 12 9 12 " " - Private Y. .. 23 6 9 11 " " - P. .. 26 5 13 21 " " - " J. .. 31 2 9 11 " " - " M. .. 20 3 22 24 y~s Died" - " V. .. 20 4 9 11 No R. - " F. .. 25 4 8 21 - Sergeant" M. .. 20 8 5 15 " " - Private W. .. 25 4 12 20 Yes" " -- H. .. 20 4 4 15 No " - " D. .. 23 3 12 12 " -
Sapper" W., R.E. 24 4 4 6 " " - http://militaryhealth.bmj.com/ Private S. .. 19 3 10 11 " " - Corporal G. .. 20 4 3 17 " "." - Sergeant K. .. 29 5 2 8 " -- Sapper H., R.E. 21 7 - --" Died" - Private M. .. 26 2 9 27 Yes, R. - ; twice W. .. 36 14 3 5 No - Corporal" M. .. 41 4 - - - Died" - Sapper K., R.E. 2L 3 12 18 No R. - B., 24 4 5 20 Died of syncope, some time " " " " after being up and about, and having been trans· ferred as a convalescent to another hospital. Private S. .. 20 4 11 17 - on September 27, 2021 by guest. J. .. 20 14 9 9 " " - Boy" R. •• .. 16 3 14 15 " " - Sapper J., R.E. 23 2 17 19 " " - Private W. .. 22 3 12 12 " " - M. .. 29 2 2 11 " " - " " " J R Army Med Corps: first published as 10.1136/jramc-04-03-02 on 1 March 1905. Downloaded from
312 A Few Notes on Enteric .F'eve1' of the permanently occupied islands, where chiefly Royal Engineer and Royal Artillery troops were quartered. I believe I am right in saying there was not one single. case of enteric fever amongst them. But after about a year the Worcestershire Regiment from Malta relieved the Royal Warwickshire Regiment, and forthwith enteric appeared amongst them, and about this time I was sent to the island in charge of the permanent brick and mortar hospital, and where the Royal Engineers and ~oyal Artillery were quartered. There were sixty-two beds (with rarely one empty), but forty-four, I think, on paper, a marquee being in use. There was a. hospital staff numbering six to eight, three orIour of whom were fairly reliable, and even two of these absented them selves for five days when they were paid their "war gratuity," and this, too, in the middle of the epidemic. Towards the end of the epidemic another medical officer arrived. I had, however, all the food and drugs I wanted, and I lived only about 300 yards off-that is to say, I only had to go about this Protected by copyright. distance for my meals and to sleep, for I rarely left the hospital during the epidemic; except for seven or eight hours each night. I append a similar table on page 311 to those given on the former pages. The cases were treated as the first series were, viz., by carbolic acid and iodine. After about half these cases had been admitted, the General Officer Commanding took the whole regiment off the Prison Islands, and placed them under canvas on the Royal Engineers' and Royal Artillery's Island. The Royal Artillery were a long way off, but
the Royal Engineers were close to the camp. Note how the Royal http://militaryhealth.bmj.com/ Engineers became at once infected, proving the disease to have been enteric fever. The last case to report sick occurred twenty four days after the arrival of the whole regiment under canvas. on September 27, 2021 by guest.