Nov., 1947] UNUSUAL FATAL HAEMORRHAGE: CHHETRI & DE 663

the UNU3UAL FATAL HEMORRHAGE 3 cases, fever was coming down by lysis when and COMPLICATING ENTERIC FEVER vomiting began the temperature maintained normal till death occurred. In one By M. K. CHHETRI, m.b. (Cal.) case, the temperature was subnormal. There was one where Medical Registrar, Medical College Hospital only example the complication started when the and temperature remained high (103?F.). Signs and symptoms of intestinal M. N. M.R.C.P. f.n.i. DE, m.b., (Lond.), f.s.m.p., hsemorrhage with passage of-tarry stools occurred Professor of Medicine, Medical College Hospitals, in 2 cases just previous to the onset of the Calcutta hsematemesis. Three cases had melsena after the Enteric fever is remarkable for the large hsematemesis. In the remaining 5 cases, from the stomach was not associated number of complications which may occur hsemorrhage with visible from other of during its course. Most of them are very well hsemorrhage any part tract. known to the medical profession with their the gastro-intestinal Purpuric spots on forearms in one case pathogenesis ard prognostic significance. In appeared the hands and 2 where the vomited material this paper the waiters intend to discuss a very only. Except cases, was altered blood serious complication which they have met with consisted of frank blood, there matter looked like in the rout:,ie management of their enteric in all the rest and the vomited cases. The literature on the subject is extremely coffee-ground material. In 6 cases, jaundice meagre and their clinical description is hardly developed, preceding or following the hsemate- a or two. found in any textbook. The pathogenesis of mesis by day cases. Blood the condition is a matter of speculation but the Widal reaction was positive in 5 was successful in 3 cases while in prognostic import is very definitely bad. culture 2, It is for these reasons that the subject is brought neither was positive. These latter cases were, forward to elicit opinion and stimulate scientific however, clinically typical enteric fever. Bleed- interest. ing time and coagulation time determined in 3 Clinical features of these cases are as cases after the onset of the vomiting showed follows : A case of long-continued fever normal values. Platelet count was normal. proved bacteriologically and serologically to be Prothrombin time was determined in 3 selected due to one of the enteric group of infections cases in which both the bleeding and coagula- runs were The were its entire course without any incident tion times normal. figures during the first 2 or 3 weeks. Towards the end definitely prolonged in all the 3 cases. of the course of the fever or in some cases even All the 10 cases proved fatal. The average when the temperature has subsided and the period of survival after the onset of this com- patient is in the stage of convalescence and for plication varied between a few hours and six all practical purposes considered fairly out of days. danger, he suddenly has a set-back due to an Case reports unusual complication, viz, vomiting. At first, the Case 1.?Indian Christian, married female of physician takes it to be due to some error in 22 years, admitted on 5th July, 1946, with a 2 diet producing perhaps a mild gastritis. This history of continuous fever for weeks, and had severe headache in the first week. Patient complacence is, however, soon changed into a serious matter when the patient begins to show looked wasted, ansemic and toxsemic. Tongue coated and presence of blood in the vomited matter?either dry. P/R?120/28. Temperature liver and not No frank blood or altered blood or more usually 102?F., spleen palpable. in the heart and Rose coffee-ground material. The quantity may be abnormality lungs. over the chest and abdomen. moderate or large and the number of vomits spots Laboratory : Hb. 32 per cent red cells may be as many as 10 to 12. There may be findings (Hellige), 1.95 millions. W.B.C. 7,200. 64 some mucus along with the blood. With this Polymorphs per 35 1 haematemesis, sconer or later, the patient begins cent, lymphocytes per cent, large monocytes no malarial Widal . per cent, TH> 1 in to pass blood per anum?usually melaena of parasites, urine and stool?no On large or small quantity. In a few cases, the 150, abnormality. 6th, fever to 97?F. and all the and melaena may precede the haematemesis. The dropped signs of Treated patient sooner or later develops some degree of symptoms collapse appeared. with blood transfusion and other jaundice, becomes rapidly anaemic, passes smaller promptly and smaller quantities of urine and finally dies. necessary supportive measures. Temperature rose and fluctuated between 101 ?F. and 103?F. In a group of 10 cases studied, this complica- General condition looked fair. On the tion appeared on an average between the 18th 10th, a and vomited once. and the 24th day of the illness. In 2 cases, patient passed tarry stool The vomited matter contained blood. From 12th however, it started as early as the 10th day, to the had two bouts of whereas in another 2 cases, it appeared as late 14th, patient coffee-ground vomit each remained normal as the 32nd and 52nd days respectively. The day. Temperature Patient temperature, to the onset of the all these days. developed slight jaundice. just previous to 32. time complication, showed interesting features. In P/R?120/30 Bleeding and coagula- tion time were 2 and 5 minutes 5 cases, it was normal for a variable period of respectively. time 44 seconds 1 to 8 days before the haematemesis started. In Prothrombin (normal control 22 664 THE INDIAN MEDICAL GAZETTE [Nov., 1947 seconds). The condition of the patient pro- test in the vomit positive. General condition gressively deteriorated and she died on 15th. No deteriorated. Temperature 98?F. P/R?110/26. autopsy was permitted. Some purpuric spots appeared on the hands and Case 2.?An unmarried Hindu male, aged 20 forearm. Platelet count 250,000 c.mm. Died on years, admitted on 1st July, 1946, with a history 10th July. of continuous fever for 3 weeks and severe head- Case 5.?An unmarried Hindu male, aged 23 ache in the first week. On examination, the years, was admitted on 25th July, 1946, for patient looked anaimic and toxemic. Tongue fever, headache, cough and vomiting of 4 days' coated and furred. Temperature 104?F. P/R? duration. On examination, patient was fairly 112/32. Spleen enlarged 2 fingers, liver not nourished. Tongue was coated in the centre and palpable. Heart?N.A.D. Scattered rhonchi in raw at the edges. Temperature 102?F. P/R? both lungs. Laboratory findings : W.B.C 4,500. 130/40, liver and spleen not palpable. Heart? Polymorphs 60 per cent, lymphocytes 38 per cent, N.A.D. Scattered rales in both lungs. Vomit large monocytes 1 per cent, eosinophils 1 per was bilious in character. Laboratory findings : no Widal cent, malarial parasites detected. Hb. 70 per cent (Hellige), red cells 4.5 millions, reaction and culture both negative. Urine and no malarial parasites. W.B.C. 7,500. Poly- came down stool?normal. On 7th, temperature morphs 65 per cent, lymphocytes 30 per cent, conditions did not to normal but other improve. monocytes 4 per cent and eosinophils 1 On 11th, jaundice appeared and the patient got per cent. Widal reaction was negative. Blood an attack of hsematemesis. Bleeding time and culture positive for B. typhosum. No abnor- coagulation time were within normal limits. mality in urine and stool. Vomiting persisted and Prothrombin time 38 seconds (control 25 on 30th July, 1946, contained streaks of blood. seconds). On 12th, patient got 3 attacks of Occult blood test in vomit was positive. Bleed- hajmatemesis and collapsed. Blood transfusion ing and coagulation times were 4 minutes and was given along with other supportive treatment 5 minutes respectively. Vitamin K was started. but his condition went downhill and he expired. On 4th August, the temperature dropped Case 3.?Indian Christian, married female, aged to 97?F., P/R?96/32. In spite of this, the 40 years, admitted on 12th July, 1946, with condition did not improve much and he now a history of continuous fever and headache for 9 complained of pain in the epigastric region. days and passing tarry stools for 2 days. Jaundice was noticed at this stage. Hemorrhagic On examination, patient restless, general fluid was withdrawn from the stomach by Ryle's condition very low. Extremities cold. P/R? tube after which the viscus was washed out 134/30, temperature 100?F. Tongue coated and with sodi bicarb solution in warm norma) saline. dry. Abdomen soft. Liver and spleen not Prothrombin time determined at this stage was palpable. No abnormal sounds in the lungs. 1 -minute 10 seconds (control 25 seconds). Heart sounds weak. Soon after admission, Vomiting of thick black fluid continued passed a stool with altered blood. Laboratory unabated and the patient died on 5th August. findings : Hb. 45 per cent, red cells 2.5 millions. Case 6.?An unmarried Anglo Indian male, W.B.C. 6,700. Polymorphs 68 per cent, lympho- aged 20 years, was admitted on 1st October, 1946, cytes 30 per cent, large monocytes 2 per cent. for continuous fever for 17 days. On examina- No malarial parasites found. Both Widal reac- tion, he was fairly nourished but toxemic. tion and blood culture negative. On 13th, tem- Tongue coated. Temperature 103?F. P/R? perature became subnormal. Pulse impercept- 116/30. Liver and spleen not palpable. Heart ible. Passed another tarry stool and started ?N.A.D. Both lungs showed rales at the bases. Death vomiting coffee-ground material. occurred Laboratory findings : Hb. 80 per cent (Hellige), the same day. Patient developed jaundice before red cells 4.2 millions. W.B.C. 9,062. Polymorphs death. 92 per cent, lymphocytes 6 per cent, mono- Case 4.?Hindu male, aged 19 years, single, cytes 2 per cent, eosinophils nil. No malarial admitted on 23rd June, 1946, for continuous parasites found. Widal reaction Th 1 in 150 and fever and headache for 8 days. On examination, To 1 in 50. No abnormality in urine and stool. nutrition fair, tongue coated in the centre, edges The patient ran a high temperature varying raw, temperature 103?F. P/R?100/21. Liver between 105?F. and 103?F., his toxemia and spleen not palpable. Heart?nothing abnor- increased and on the third day of his admission mal. Lungs?a few scattered rhonchi. Labor- he had two huge coffee-ground vomits. After atory findings : Hb. 72 per cent (Hellige). this he became pulseless and died in spite of all R.B.C. 3.5 million/c.mm. W.B.C. 5,062. Poly- treatment. morphs 60 per cent, lymphocytes 35 per cent, Case 7.?Hindu female child, aged 8 years, monocytes 4 per cent, eosinophils 1 per cent. was admitted with a history of running a con- M.P.?not found. Widal para B 1/50. tinuous high temperature for 12 days. She had Temperature continued a typical enteric course intense headache at the beginning and bowels till 5th. On 7th, patient had nausea and hiccup. were constipated. On examination, her general Temperature 99 ?F. P/R?98/26. Vomiting health was fair though moderately ansemic. started. The vomited matter was watery at first, Tongue coated and moist. Abdomen was dis- becoming bilious later. On 9th, the patient had tended, the spleen and liver could not be a copious vomit, black in colour, occult blood palpated. She looked toxemic. P/R?136/30 Nov., 1947] UNUSUAL FATAL HEMORRHAGE: CHHETRI & DE 665

were not and temperature 105?F. Heart?N.A.D. Both palpable and there was no abnormality in the heart lungs showed scattered rales and rhonchi. and lungs. Laboratory findings I R.B.C. 3 millions. Hb. Laboratory findings : Hb. 60 per cent (Hellige), 50 per cent (Hellige)'. red cells 3.5 millions. W.B.C. 20,312. Poly- W.B.C. 3,200. Polymorphs 69 per cent, lympho- 25 per 4 morphs 78 per cent, lymphocytes 18 per cent, cytes cent, monocytes per cent 2 cent. monocytes nil and eosinophils 4 per cent. eosinophils per M.P.?none found! Widal blood culture No malarial parasites detected. Widal reaction 1/250, negative. Urine a trace of albumin was negative. A blood culture, however, showed showed and bile; stool revealed B. typhosum. Urine examination revealed plenty of giardia cysts and gave a positive occult blood test. definite albumen with a few hyaline but plenty The remained normal without of granular casts. No abnormality in stools. temperature much clinical and on the 23rd Owing to high leucocytosis the patient was put- improvement day of he had an attack of hsematemesis. on an alkaline diaphoretic mixture and adequate illness was soon followed another attack of doses of M.&B. 693 tablets which were main- This by melsena and he died on 1st tained for 5 days. The temperature dropped hsematemesis and to 99?F. 8 days after admission, 20 days after August, 1946. 30 had a the commencement of her illness and 5 after Case 10.?A Hindu male, aged years, days which M.& B. 693 administration. continuous temperature for 5 weeks during cultuie were Although the temperature declined, she still period Widal reaction and blood looked toxaemic and pale and her urine dimin- both positive. He was treated as typhoid fever, and for the which ished in quantity. Two days later, she had a lung complication developed dark-coloured vomit and dark-coloured stool and during the illness, penicillin was used. The was after died on the 11th day after admission. temperature normal for. 3 to 4 days which it recurred Examination revealed Case 8.?A young boy of 8 years was again. a well-nourished he was admitted on 1st September, 1944,- with a history fairly patient though of continuous fever for a week. The onset was looking pale and toxsemic. Temperature 104?F., insidious and attended with a great deal of P/R?130/34. No abnormality in the heart headache. He had loose motions for 2 days and lungs. Liver and spleen were not palpable. prior to his admission into the There was cedema all over the body with a little hospital. reaction Examination revealed a fairly well-nourished fluid in the peritoneal cavity. Widal was Towards 50th of his ill- boy without ansemia or jaundice but definitely positive. the day ness as touched toxfemic. His tongue was typical, being coated in the temperature gradually the middle and red at the margins. Tempera- normal, he developed jaundice. Two days later, ture 102?F., P/R?120/30. Liver and spleen he got a bout of coffee-ground vomit, passed a stool and in of all treatment 4 were not Heart?N.A.D. There were tarry spite died palpable. afterwards. diffuse rhonchi and rales in both lungs. Labora- days tory findings : Hb. 70 per cent (Hellige), red Comment cells 3.8 millions. W.B.C. 7,812. Polymorphs fever a disease 60 per cent, lymphocytes 32 per cent, mono- Typhoid being essentially characterized by ulceration in the wall of the cytes 8 per cent and eosinophils nil. No gut, is often met with. The reason is malarial detected. Widal reaction haemorrhage parasites because in the evolution of a Blood culture was positive for B. obvious, typhoid negative. a blood vessel be eroded. When such typhosum. No abnormality detected in urine ulcer, may an accident occurs, the picture is and stool. After running a typical course of a characteristic, the severity of the symptoms depending on the severe typhoid fever during the next 8 days, the quantity of blood lost within a given period. It came down to normal by lysis and temperature is natural to expect such a at a time there was an all-round noticeable bleeding improvement when the and the ulceration in the condition. On the 14th sloughs separate patient's day extends which events occur in the after i.e. after 3 weeks from the usually third admission, week of the illness. The extravasated beginning of the fever while the temperature fell blood passes through the rectum and appears as mekena. and the in every respect, patient improved There is no chance of this blood jaundice suddenly. Four days later, going upwards developed to the stomach to be vomited out. Given the boy had two attacks of convulsions in the necessary treatment in the of each a few minutes. Then, all way restoring morning lasting blood volume and blood of a sudden, he had 3 attacks of coffee-ground giving transfusion, patients usually get well and recovery becomes vomit, his rose to 104?F., uncon- temperature The cases under review did not sciousness and death occurred in the complete. supervened feature to resemble such a same afternoon. present any bleeding. It be that a toxic Case 9.?A Hindu aged 38 years, ran a may argued hemorrhagic male, in the course of continuous for 15 days which was gastritis may develop the temperature infectious disease rise to the characteristic enteric in course. On the 15th day the giving typically Such a if it temperature touched normal but he developed vomiting. complication, develops at cannot all the details as Four later, he developed oedema all, explain revealed hiccup. days our cases. Toxic should over the ankles. He was anamiic but there by gastritis develop at the height of toxaemia and it would be was no frank jaundice. Liver and spleen difficult 666 THE INDIAN MEDICAL GAZETTE [Nov., 1947 to such a course invoke complication when the to spontaneous bleeding can be easily explained; the of disease almost terminates or convalescence when the symptoms of haematemesis and melsena sets in. Moreover, jaundice often appears, once start, the condition of the deterio- either patient preceding or following the hsematemesis. rates progressively. The death is usually due to It is a common of of us in experience many cardiac failure consequent on loss of blood. It this in country that the diet and dietetics will be noticed that none of the cases reported typhoid fever is very unscientific. The diet is above survived even after transfusion of blood not only deficient in calories, but in most of these and administration of adequate doses of cases, it also lacks in proteins, minerals and vitamins. vitamins. When this defective dietary method is followed for a prolonged period, patients may Summary on of the ? develop oedema the dorsum feet, 1. Ten cases of enteric fever having puffiness of the face, and ulceration of the lips, developed haematemesis and melaena as unusual and It is in these angles of the mouth tongue. complications are reported. patients that deficiency of other vitamins may 2. Clinically, jaundice which is known to be their Some of the vitamins make appearance. a very rare occurrence in typhoid fever with the are intimately connected coagulation developed in these patients either before or factor of the blood whilst the other is respons- after such a haemorrhage started. ible for the tone and permeability of the 3. Condition of the patients deteriorates capillary wall. In those patients who are kept progressively and rapidly in spite of all treat- on a the such poor diet, deficiency of the latter ment, a fatal termination occurring in 2 to 3 vitamins is likely to manifest symptoms of days. defective coagulation mechanism of the blood 4. A diet with low calories, biological with diminished time of the prothrombin proteins and vitamins is a very important pre- as well as plasma altered permeability of the disposing factor producing amongst other bad capillary blood vessels. Thus, haemorrhagic effects a deficiency of vitamin K and vitamin oozing from the mucous membrane of the P leading to marked changes in the coagulation stomach and intestine which soon comes begins mechanism of the blood and the tone and per- out as hsematemesis and melaena. In order to meability of the capillary wall. A severe corroborate their ideas, the writers are estimat- damage of the liver produced by the enteric time as a routine in ing the prothrombin typhoid fever is perhaps responsible for such a derange- cases snake venom Cases fever using method. ment of the coagulation mechnism, the mainten- with prolonged prothrombin time do not neces- ance of which is one of the important functions end in most the sarily haemorrhage although of of the hepatic organ. cases who subsequently developed haemorrhage The writers are indebted to the had time. Whether this Superintendent, prolonged prothrombin Medical College Hospitals, for his permission to publish hypoprothrombinsemia may have any role to the records of some of the cases and also to the house play in the causation of these haemorrhages is a physicians for their ungrudging help in the management matter for speculation. More work on this line of some of these desparately ill cases. may throw some light on this problem. The causal relationship of vitamin P with these haemorrhages is also a matter for considera- tion. In case no. 4 in our series, there was purpuric haemorrhage on the skin. It appears therefore that some part is also played by the lack of permeability vitamin in these cases pro- ducing an extravasation of blood in the stomach and intestine?a condition resembling sympto- matic purpura having developed. More observa- tions on these lines are necessary before any definite conclusion can be reached. What role is played by the liver in these cases cannot be definitely stated. It will be found that many of the cases in this series developed jaundice either before or soon after the hsemate- mesis and melsena started. It is known fairly well that in typhoid infection the liver may be variously damaged and focal necrosis and damage to the hepatic organ often take place. The jaundice which appeared in these cases was probably the result of a toxic hepatitis and under such circumstances the liver function may be depressed very much producing low plasma pro- thrombin and prolongation of the prothrombin time. If such a hypothesis be correct, tendency