August 1,
A
1878.]
A MIRROR OF HOSPITAL PRACTICE.
,
CASE OF FATAL THERMAL FEVER.
By
Surgeon-Major Gr. C.
(?) Gribbon, M.B.,
A.M.D.
which has proved perplexing I submit a recent for your opinion, if you will oblige me with it, or that of any of your readers. Mrs. S., fet. 29, a fair-complexioned woman of previous good health (2| years in India), and temperate habits, came to hospital on^ the morning of the 12th, complaining of cramps in arms and legs ; felt weak also, but there was no other subjective symptom. Her history, as far as I can gather, goes to show that she had lately felt the heat (at the time very intense) more than usual. On the 10th she got a fright from the horse in her ghari becoming restive, and she jumped out twice. She was entering, be it observed, the 7th month of pregnancy. She admitted on the 14th that she had become very hot, and ceased to perspire about this time, but when saying this she had begun to sink and the question was put in a_ leading form ; I therefore incline to think the answer is not of much value per se. Of her condition on the 12th I can get no information except in one particular?that she told a neighbour she had not'felt the child'since the day before: she said subsequently however that she did, so this also is a doubtful point. June 13.?Now we come to positive knowledge. I saw her at 7-30 A. M.; she was one mass of prickly heat. From long familiarity with her appearance I was struck at the first glance by a certain unusual look of the eyes ?they were somewhat sunken in their orbits and surrounded by a dark shade. Her manner was calm and easy. She said the cramps bothered her?nothing else; no headache or pain elsewhere. Had taken a little Castoroil which had acted; tongue had a thick brown moist fur ; general surface moist, pulse small and quickened. Now as to the cramps : before I came as she had a severe turn she had a tepid bath which gave her great ease. She had an attack in my presence ; they were tonic spasms lasting about three minutes engaging the extremities only. The second and third phalanges were firmly flexed on the first; arms and legs extended rigidly ; features perfectly natural, and spasms producing discomfort only. There was nothing to fear I thought then mistakenly, and merely gave her grey powder and rhuburb as an alterative ; for nourishment milk, and as a drink some tonic water. She had complete freedom from the cramps throughout the day, and walked about the ward once or twice. In the evening she appeared no worse, and chatted with the other patients. Later cramps returned, and she comdid not plained of a sudden pain in her back; they She was restless remain however in a severe form. through the night, in fact had no sleep. Early in the morning she informed the nurse_ that she had passed no water for three days. Did not like to speak of it before. June 14.?Saw her at 7 a. M., an alarming change set in ; the lichen had become of a livid color ; eyes greatly sunken and with black circles around them ; surface cold and moist; cramps frequent ; no vomiting or purging ; region quite resonant; pulse thready and case
hypogastric
_
rapid ; pupils like pin-heads, fixed; no pain, quite sensible; voice low but distinct; temp. 103-4.? Catheter used but
urine found. I cupped her over the loins without delay, taking away about 4 oz. Beef tea and stimulants, Ice to head, a stimulating enema?all were put into requisition without the least effect. 9. A. M.?Restless, and crying out at times or moaning ; stiffening of extremities persistent; teeth tend to get clenched ; pulse palpable but no more ; surface moderately warm to hand ; temp. 104'6?. no
215
10. A. M.?Unconscious ; pupils widely dilated ; ocular surface insensible ; resp. 27; aire nasi acting forcibly i temp. 106? ; muscular twitchings in limbs; death at 11 A. M. 11-45 A. M. temp, 106-4. twitchings continue. Rigormortis quickly and strongly developed. A p. m. examination was not obtained, which is re-
gretable. Now, I ask your readers of Indian experience, what
was
this case ? Uramic poisoning is the one certain factor in it. What was it connected with ? Suppression of urine is common enough in cholera, but was this cholera with the temperatures noted, not to speak of other adverse conditions. Was it heat apoplexy? if so, then authors should mention ischuria or anuria as a possible symptom. The few I have access to here do nothing of the kind : an contraire incontinence is every where laid down as conspicuous among the prodromata. Here it was conspicuous by its absence. Surgeon-Major Johnston of the I. M. S., at present doing duty in this station, and the benefit of whose advice I have enjoyed, is of opinion from a large experience that ischuria is common in (so to speak) the 1 dark' heat variety as distinguished from coup de soleil. Does this fit in with the experience of others ? I shall be obliged if some will answer this ; if it is so, the sooner text books record it the better. Before concluding let me supply an omission concerning the woman's state of pregnancy. It is likely the foetus perished at an early period. Early on the 14th, seeing the woman's critical condition and in view of the Caasarian operation being indicated, I examined the abdomen carefully ; no foetal sounds were audible, and there was a manifest subsidence of this region. I shall be glad if you will insert this case, in order that it may be pronounced upon by any who have met or read of the like before.
Fysalad,
17th
May,
1878.
" [This case constitutes a good Medical problem," and ought to give rise to an interesting clinical discussion if correspondents will recall cases presenting similar features. Sir Joseph ?' Fayrer in his paper on Sunstroke" (vol. xi. p. 277) mentions suppression of urine as one of the later symptoms of thermal fever. We have not met with a case that we can bring into, close comparison with this one ?Ed., I. M. 0.\
A
1878.]
A MIRROR OF HOSPITAL PRACTICE.
,
CASE OF FATAL THERMAL FEVER.
By
Surgeon-Major Gr. C.
(?) Gribbon, M.B.,
A.M.D.
which has proved perplexing I submit a recent for your opinion, if you will oblige me with it, or that of any of your readers. Mrs. S., fet. 29, a fair-complexioned woman of previous good health (2| years in India), and temperate habits, came to hospital on^ the morning of the 12th, complaining of cramps in arms and legs ; felt weak also, but there was no other subjective symptom. Her history, as far as I can gather, goes to show that she had lately felt the heat (at the time very intense) more than usual. On the 10th she got a fright from the horse in her ghari becoming restive, and she jumped out twice. She was entering, be it observed, the 7th month of pregnancy. She admitted on the 14th that she had become very hot, and ceased to perspire about this time, but when saying this she had begun to sink and the question was put in a_ leading form ; I therefore incline to think the answer is not of much value per se. Of her condition on the 12th I can get no information except in one particular?that she told a neighbour she had not'felt the child'since the day before: she said subsequently however that she did, so this also is a doubtful point. June 13.?Now we come to positive knowledge. I saw her at 7-30 A. M.; she was one mass of prickly heat. From long familiarity with her appearance I was struck at the first glance by a certain unusual look of the eyes ?they were somewhat sunken in their orbits and surrounded by a dark shade. Her manner was calm and easy. She said the cramps bothered her?nothing else; no headache or pain elsewhere. Had taken a little Castoroil which had acted; tongue had a thick brown moist fur ; general surface moist, pulse small and quickened. Now as to the cramps : before I came as she had a severe turn she had a tepid bath which gave her great ease. She had an attack in my presence ; they were tonic spasms lasting about three minutes engaging the extremities only. The second and third phalanges were firmly flexed on the first; arms and legs extended rigidly ; features perfectly natural, and spasms producing discomfort only. There was nothing to fear I thought then mistakenly, and merely gave her grey powder and rhuburb as an alterative ; for nourishment milk, and as a drink some tonic water. She had complete freedom from the cramps throughout the day, and walked about the ward once or twice. In the evening she appeared no worse, and chatted with the other patients. Later cramps returned, and she comdid not plained of a sudden pain in her back; they She was restless remain however in a severe form. through the night, in fact had no sleep. Early in the morning she informed the nurse_ that she had passed no water for three days. Did not like to speak of it before. June 14.?Saw her at 7 a. M., an alarming change set in ; the lichen had become of a livid color ; eyes greatly sunken and with black circles around them ; surface cold and moist; cramps frequent ; no vomiting or purging ; region quite resonant; pulse thready and case
hypogastric
_
rapid ; pupils like pin-heads, fixed; no pain, quite sensible; voice low but distinct; temp. 103-4.? Catheter used but
urine found. I cupped her over the loins without delay, taking away about 4 oz. Beef tea and stimulants, Ice to head, a stimulating enema?all were put into requisition without the least effect. 9. A. M.?Restless, and crying out at times or moaning ; stiffening of extremities persistent; teeth tend to get clenched ; pulse palpable but no more ; surface moderately warm to hand ; temp. 104'6?. no
215
10. A. M.?Unconscious ; pupils widely dilated ; ocular surface insensible ; resp. 27; aire nasi acting forcibly i temp. 106? ; muscular twitchings in limbs; death at 11 A. M. 11-45 A. M. temp, 106-4. twitchings continue. Rigormortis quickly and strongly developed. A p. m. examination was not obtained, which is re-
gretable. Now, I ask your readers of Indian experience, what
was
this case ? Uramic poisoning is the one certain factor in it. What was it connected with ? Suppression of urine is common enough in cholera, but was this cholera with the temperatures noted, not to speak of other adverse conditions. Was it heat apoplexy? if so, then authors should mention ischuria or anuria as a possible symptom. The few I have access to here do nothing of the kind : an contraire incontinence is every where laid down as conspicuous among the prodromata. Here it was conspicuous by its absence. Surgeon-Major Johnston of the I. M. S., at present doing duty in this station, and the benefit of whose advice I have enjoyed, is of opinion from a large experience that ischuria is common in (so to speak) the 1 dark' heat variety as distinguished from coup de soleil. Does this fit in with the experience of others ? I shall be obliged if some will answer this ; if it is so, the sooner text books record it the better. Before concluding let me supply an omission concerning the woman's state of pregnancy. It is likely the foetus perished at an early period. Early on the 14th, seeing the woman's critical condition and in view of the Caasarian operation being indicated, I examined the abdomen carefully ; no foetal sounds were audible, and there was a manifest subsidence of this region. I shall be glad if you will insert this case, in order that it may be pronounced upon by any who have met or read of the like before.
Fysalad,
17th
May,
1878.
" [This case constitutes a good Medical problem," and ought to give rise to an interesting clinical discussion if correspondents will recall cases presenting similar features. Sir Joseph ?' Fayrer in his paper on Sunstroke" (vol. xi. p. 277) mentions suppression of urine as one of the later symptoms of thermal fever. We have not met with a case that we can bring into, close comparison with this one ?Ed., I. M. 0.\
