J R Army Med Corps: first published as 10.1136/jramc-04-03-02 on 1 March 1905. Downloaded from 303 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 <D 9·-·-~ I ~ ~ os~~~; .c~~§it i "',," s ~~t~S a Inocn. Diar. '"'5 ~'§ Rank and name Corps Age ~s"g'S~ Relapse Resnlt Remarks 'a lated rhrea ~=~ ~ii~j o....,ClSB~ 1il ,0"'" "S~-;l fS ~ fl ~QS fa 'S ~ cS ~~ @s'8 ,0 !l.. ~"'''' z .8 Z.882~ ~&l~Il§ z" ... Z .... $o/:: -- -------------. ------------ CD· Private W. S .•• R.A.M.C•.. .. 28 Yes Yes 5 14 14 No R. ... http://militaryhealth.bmj.com/ - CD Trooper G. M ... I.L.H. .. .. 33 No No 14 5 9 For 2 days - i:: Corporal R. .. I. Bushman .. 27 Yes 9 7 18 No " Debility great. rlICD CD~ Private W. C... E. Surrey Regt ... 30 " No 21 3 13 " - ~'fil Trooper T. R. .. I.L.H. 23 " 30 15 18 " " Reported dangerously ill. O::l .. .. CDC) S. M ... .. .. 30 " " 60 11 12 " " Desperately ill. .,~ ",,0 A.P... " .. .. 20 Yes" " 10 11 13 " " - ~.P"'I+>.,.. DriverW. R ... R.F.A." .. .. 30 No " 7 11 14 " " Attacks of syncope fre- .-0 CD " " " quently. ~CD 01& Private W. N ... Somerset L.I. .. .28 10 10 19 - .,.... 01 Sergeant E. S ... Devon, Regt. .. 34 " " 4 11 14 " " Reported dangerously ill. 3l~ Private S. M ... Cheshire Regt. .. 27 " " 7 15 15 " " ::lo Trooper T. B ... I. Bushman 24 " " 8 13 17 " " " " " g'n .. " - 010 Private A. U •.. Derby Regt. .. 32 " " 20 3 and 16 18 Yes " Hremorrhages. Reported S+> " " " dangerously ill. ."n C'I • J. F ... 14th Hussars .. 21 6 6 7 No on September 27, 2021 by guest. Died Post mortem. See below. rlI CD 0 Corporal" T. W. Border Regt. .. 29 " " 6 5 5 Yes, R. - toll; " " for1Odays i::d Trooper J. H ... A.S.C. .. .. 19 7 6 12 No - ...CD'~ Private F. S... Somerset L.I. .. 23 " " 7 20 21 " Reported dangerously ill. CD F.C... 12th Lancers .. 33 " " 5 10 14 " " - t1 " J. M ... Somerset L.I. .. 20 " " 5 17 18 " " " " " " ·1 " - J R Army Med Corps: first published as 10.1136/jramc-04-03-02 on 1 March 1905. Downloaded from 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 306 ,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.