THE
CALCUTTA
MEDICAL SOCIETY. "u
i
The Ninth Meeting of 1881 was held at the Medical Colleee on the 14th September ; Moulvie Tameez Khan,' Khan
Bahadur, presiding.
Dr. McLeod showed a patient whose tongue had been entirely extirpated for epithelioma. He demonstrated that the paEienTTEad regained"to-?-1arge extent the faculty of speech. The following are notes of the case by AssistantSurgeon Debendra Nath Dey, M. B. :? Nafar Chunder, a Hindoo labourer, aged 40 years, resident of Hooghly, was admitted into the First Surgeou's Ward on the 5th August 1881 with epithelioma of the tongue.
History.?About
5 months ago he had
a
severe
attack of
headache with a peculiar tingling sensation in the brain. Two or three days after this he began to feel great pain at the root of his tongue, which was followed by the eruption of a number of papules on its dorsum. At this time he gave himself up to excessive drinking, and all these papules disappeared within a week, except one at the root a little to the left side. This gradually attained the size of a pea, and continued to enlarge, with increased pain and great'difficulty in swallowing. About two months ago another papule appeared at the site of it, and increased in size and then _
\jS
286
THE INDIAN MEDICAL GAZETTE.
burst, giving rise to a ragged ulcer, which used to bleed occasionally and produce extreme pain in deglution. Condition on admission.?The patient well nourished, without any visceral disease, organic or functional ; no history of
syphilis or gonorrhoea ; the urine healthy; appetite good. There was a tumour of
bowels regular; the size of a large bead situated on the left side of the base of the tongue on its dorsal aspect, close to it was a ragged ulcer of the size of a four anna bit, with raised thickened margin and surface depressed, uneven and sloughy ; the surrounding parts red and congested, the anterior pillar of the fauces on the left side, as also the uvula and posterior part of the hard palate, were all congested ; the glands along the lower border of the inferior maxilla on the affected side are enlarged and indurated, as also a gland in front of the left sterno-mastoid. Operation.?On the 7th August excision of the tongue was performed under chloroform. As a preliminary step tracheotomy was performed above the isthmus of the thyroid gland without any bleeding, and the tube inserted and tied by means of a tape round the neck, and chloroform was administered through it. A median incision, about an inch and a half long, was made in the sub-mental region above the hyoid bone. The mylo-hyoid was divided at its raphe, and the genio-hyoid and genio-hyo-glossus were separated from each other and from the mylo-hyoid, and the floor of the mouth was reached and opened under the tongue, which was then drawn out by means of a double thread of catgut passed through it by means of a needle and theix knotted at its ends. By this thread the tongue could be pulled from side to side as required. The attachment's of the tongue to the lower jaw were then snipped and cut all around with a pair of curved blunt pointed scissors, and the tongue thoroughly pulled out of the mouth by mea,ns of the thread. A sharp aneurism needle was then passed through the wound and made to transfix the base of the tongue, emerging in front of the epiglottis, and the wire then passed through the wound on the floor of ecraseur the mouth over the needle and then right over the tongue as far back as its root, the mouth being kept open by means of a cork. The eoraseur was then worked tight, but in the process of working it gave way, and became useless. The chain ecraseur was then substituted, and the tougue cut through the epithelial tumour, the ulcer being bisected transversely. The^base of the tongue that was left was then transfixed with the needle in the middle line and the ecraseur passed through the wound and the right half of the base of the tongue removed. The left half was then removed by holding it up by means of the vulsellum forceps, and the ecraseur passed round it and worked till it was severed. Blood was prevented from running back into the fauces by means of a sponge with a thread tied to it, pushed back into the throat. Another sponge was passed into the mouth and a bit of lint into the wound to plug them up. The patient lost about 5 or 6 oz. of blood. Progress.?In the evening the temperature was 102?, patient not restless ; bleeding stopped. The mouth was washed with Condy's gargle and a nutrient enema was given and the patient was also fed with milk poured down into the stomach through the nostrils. The next morning the sponges were taken out and the plug of lint removed. No bleeding followed. The wound inside the mouth was perfectly clean, the pharynx quite clear, and the epiglottis free and not infiltrated. The tracheotomy tube was also taken out and the wound left to heal up by granulations and dressed with boracic gauze. The patient was now fed with a tube through the mouth which was constantly washed with a gargle of Condy's fluid (3 ii to oj water), and carbolic inhalation was given through the mouth by means of the steam spray twice a day for a week to check all fetor of breath ; the patient was perfectly quiet; slept well in the night. The temperature fell to 100? F., and after two days was quite normal. The patient then sat up and commenced to walk about as if nothing had happened to him ; the breathing, was quite free through the natural passage. The V-shaped cleft at the root of the tongue looked perfectly well ; no inflammation of the mucous lnetuuraue of the pharynx or epiglottis, the latter qui te visible. On the fourth day after operation the patient had an attack of diarrhoea which was soon checked by astringents ; the upper ,and lower wounds covered with whitish grey lymph ; the uvula and the fauces a little cedem;uous and covered with whitish stuff ; the floor of the
[October 1,
1881.
mouth sloughy looking. The sloughs separated in 3 or 4 days, and the buccal cavity became quite clean. The patient was with a little troubled cough, and dry rhonchus at the back was heard for four days and then disappeared ; the wound became gradually contracted, clean and healthy, and granulating nicely. The glands in the submaxillary region seemed to become smaller and softer, but were still perceptible ; foetor of breath passed off. The carbolic inhalation was continued for a week and then stopped, but the mouth was continued to be washed with Condy's fluid and the patient fed with the tube for nine days, and then he commenced to swallow pultaceous food. On the 23rd the upper wound was completely cicatrized, a vertical linear cicatrix about J inch long was onlv to be noticed ; the lower wound was filled up with healthy granulations ; buccal cavity clean, floor of the mouth rather but no new uneven, growth was visible. Epiglottis turned upwards and slightly backwards and folded on itself; the anterior and posterior pillars standing prominent on the sides of the palatal arch ; the uvula normal, the the patient could to extent; a visible was pharynx large articulate, though indistinctly, the lingual letters?taka pronounced as aha. On the 26th the buccal cavity was found covered with aphthae, white aphthous patches on the roof of the palate and floor of the mouth, which when examined by the microscope presented fat or milk globules, epithelial cells and mycelium. These were removed by the application of glycerine of borax to the parts thrice a day. The patient now is almost all right, and is in a fit condition .to be discharged ; his sense of taste seems to be hardly affected, for he can distinguish salt from sugar when put into the mouth, and he can articulate with considerable distinctness. Dr. MacConnell's description of the tongue is as follows " The tongue of a native Hindoo male, aged 40 years, removed by Dr. K. McLeod by means of a chain ecraseur for tumour and ulcer at its root. The growth is said to be of 5 months' duration. " Epithelioma of the tongue. The morbid growth is represented by an irregular shaped ulcer about as large as a rupee, situated on the dorsum and left margin of the organ near its base. The margins of the ulcer are hard and eroded, its surface deeply excavated and covered also with small soft nodular excrescences. On microscopic examination all the characters of a true rapidly developing epithelioma are observed. The epithelial proliferation extends downwards from the membrane and papilla? of the tongue into its mucous muscular tissue, the fibres of which in the immediate vicinity of the ulcer are broken down and infiltrated with a small celled or nuclear growth. In the superficial strata and at the are very abunmargins of the ulcer true epithelial elements dant, nucleated, heteromorphous, exhibit numerous nests, and in all respect conform to the usual structure of cancer of this variety. N. B.?The ulcer is seen to have been bisected by the first section made by the ecraseur, and a second was therefore rendered necessary in order to include the whole of the morbid tissue. This seems to have been effectual, for the miedge of the last porcroscopic examination of the tion (base) of tongue removed shows no cancerous infiltration. The muscular and other tissues appear quite healthy." Db. Sanders showed a patient from whose bladder he had removed a large Calculus by litholapaxy. The the instruments, which fragments were also exhibited and were made specially for Dr. Sanders by Weiss, with some modifications, designed to facilitate the entrance of fragments into the catheter and the passage of these into the following notes furnished glass bulb of the aspirator. The record of the case :? by Dr. Sanders contain a detailed The comparative rarity of stone cases in Calcutta has caused me to bring this one to the notice of the Society, especially as it has been treated after the method of Professor
posterior
Bigelow.
Shitaram Satir, Hindu male, into the Mayo Hospital on the 1st
aged^
28 years, was admitted
September 1881.
Previous history.?He noticed difficulty in making water : and general discomfort in his bladder about six months ago these symptoms have lately much increased, and the frequency of micturition and pain led him to seek treatment. Condition on admission.?Thin and anaemic. Bladder very irritable ; constant desire to pass urine, which, is bloody and from passed with great pain and straining ; suffers much was piles. young A large stone was felt in sounding. The man
V
October 1,
1881.]
THE CALCUTTA MEDICAL SOCIETY.
but his health was much broken from constant pain and loss of blood. Operation.?On the 2nd September the patient was placed under chloroform; during the inhalation of choroform and whilst struggling he passed from the urethra a large quantity of bloody fluid which clotted on standing ; the stone was seized by the large lithotrite at once and crushed into several fragments, which were afterwards further comminuted by the smaller lithotrite, when the stone had been well crushed : the bladder was aspirated and the debris came away very rapidly. The lithotrite was introduced three times, and after each introduction the aspirator was used ; after the third aspiration the aspirator was changed and the bladder washed out with clear water; no sand passed and no rattling in the bladder could be detected from fragments striking against the catheter ; a small fragment in the bladder indicates its existence by rattling against the end of the catheter. The nucleus of the stone was very hard, and very considerable force was necessary to crush it. During the took place, probably owing operation slight bleeding to the irritable state of the bladder. The operation lasted nearly 25 minutes. The dried fragments before you weigh 6 drachms, but the full weight of the stone was about one of the fragments and much ounce, as many large portions sand were stated by Dr. Jones to have been accidentally thrown away. Progress and treatment. Had one rigor 4 hours after the operation, and his temp, rose to 104? in the afternoon : there was no retention of urine : his urine for two days was tinged with blood : there was slight pain over the bladhis temperature ranged from 102" der, and whilst this lasted to 104'63, but on the 5th day after the operation the temperature was normal, and all fever and pain passed away. He the first five was kept on low diet for days, and large doses of quinine were given to check rigors and keep down temhis abdomen and barley water perature : fomentations^ to to drink on account of its diuretic action. Since the operation no particle of sand or grit has passed, and on the morning of the 12th his bladder was first carefully sounded and then washed out with quinine solution in the aspirator, but nothing passed out, even a particle of sand. His urine is at present clear, free from sediment and passed naturally and without pain. The instruments used are here shown, those on the right side are what were first sent to me, but that lithotrite was only made to crush large stones, and I found crushing fragments very difficult with it. I therefore ordered a smaller one, which is very efficacious indeed. The catheters first sent only had a round opening, thus only permitting the smallest pieces to enter. I therefore had one made with a large oval opening which admits very large and long pieces into it, but,having this, I found they would not but remained stuck in the catheter pass into the old aspirator, because the opening in the old aspirator is smaller than the openings in the catheters ; I therefore ordered a new aspirator, and directed that the opening int0 it should be altered ; this new aspirator will allow anything to pass into it which can enter the catheter, and it also works very expeditiously ; in my thirty-first case I removed a 2 ounce stone in twenty minutes. Under chloroform there was no difficulty in passing the instruments, in fact they slipped in. without using force of any kind. The success of the case is in great measure due to the unremitting attention paid to it by Dr. Jones and Babus Behari Lai Chakravarti and Sen. ?
Dr. McLeod congratulated Da. Sanders on being the first to perform the operation of litholapaxy in Calcutta, and successfully. He had himself, acting on Professor Bigelow's principle that the bladder was more tolerant of prothe than instrumentation longed perpetual presence of a stone, succeeded on three occasions in at entirely crushing one time stones of moderate size by the ordinary lithotrite introduced repeatedly. Having no aspirator, the fragments had to come away gradually during the next few days. These patients made good and rapid recovery. From inspection of the instruments shown by Dr. Sanders he could readily perceive how much easier and more effectually the operation could be performed with them. Dr. Harvey remarked that these instruments made the operation practicable in India when patients are so averse to submit to repeated operations.
crushing
'
287;
Baboo Behari Lall Chuckerbutty read the following ^ngtes on Tetanus^*.
SEew GoBmHoTa Hindu male, aged about 25 years, was admitted into the Mayo Native Hospital on the 23rd February 1881 with smashed right foot, the result of being run over by a railway engine-wheel. The whole of the foot, as high up as the junction of the scaphoid with the cuneiform bones and middle of the cuboid, was regularly crushed. That very day a modified Chopart's amputation was performed under chloroform. The foot was separated at the junction of the scaphoid with the cuneiform bones, the cuboid being partly sawn off, and a sole flap was taken to cover the stump. The sole flap partially sloughed away, and the patient got tetanus on the 8th March 1881. He gradually recovered from tetanus by the combined effect of chloral and eserine. He was kept on milk and broth all the time. The wound began cicatrizing, when he complained of severe stitching pain in the stump, probably from the pressure on some nervous twigs involved in the cicatricial tissue. The pain became afterwards constant and unbearable, and on the 27th April Syme's amputation was performed. He tetanus when the second operawas just recovering from tion was done. His body was stiff, though there were no more
This operation did not increase his tetanic there was a certain amount of constitutionHe left the hospital with a al disturbance afterwards. useful stump on the 9th August 1881. Recovery from after severe tetanus supervening injury is very rare, though recovered several cases have after slight injuries. Tetanus supervening after amputation of the leg, thigh, forearm, arm, and after compound fractures, almost invariably ends in death. From the beginning of the year 1881 twenty tetanus cases were admitted into the Mayo Native Hospital. Of these 13 were of Traumatic and 7 of origin. Out of these 20, twelve died, and of these 9 of the traumatic variety. The mortality has therefore been greater in the traumatic than in the idiopathic. One case was successfully treated by the hypodermic injection of eserine. This was in a young Mahomedan of 25 years age. He received a severe injury in his left heel, exposing the bone. The sole of the foot for nearly four inches long was separated from the foot in the shape of a flap from the heel towards the tarsal bones. When the wound got cleared of the sloughy tissue, tetanus supervened with regular lock-jaw and involuntary spasm of the limb. The tetanic symptoms were detected rather early, and we at once had recourse to eserine injection, and within three or four days all the tetanic symptoms passed off and the man recovered without any further trouble. In one case we tried amputation of the leg for tetacompound fracture of the legnus, supervening after bones, but the result was as unsuccessful as was expected before the operation. Some are of opinion that the seat of fracture being the constant source of irritation affecting the peripheral nerves, it is justifiable to remove the source of irritation and thereby to give a chance to the patient. In can be recognised, even my opinion, when tetanic symptoms at the very beginning, the disease is no longer peripheral but central, i. e. the spinal cord gets affected first before the disease makes its appearance externally by symptoms. There was one death from tetanus after an operation for scrotal tumour. The man was healthy but aged (55 years). The tumour also was a very big one, weighing 45 lbs. exclusive of fluid. Tetanus after scrotal tumour operation is somewhat rare. In idiopathic cases muscular contraction generally becomes case we have had regular Talipes varus very marked, and in one of both the feet, from the continuous contraction and rigidity of the powerful muscles. The heel is raised by the TendoAchillis, the inner border of the foot drawn upwards by the Tibialis anticus, the outer side of the foot twisted inwards by the Tibialis posticus, and Flexor longus digitorum. When he left the hospital, the deformity remained permanent in the right foot. We gave a fair trial to the following drugs in the treatment of tetanus, viz., Ghloral hydrate, Eserine, Ext Cannabis Indicaa, and Pot. Bromide. Of these four chloral stands first as to the comfort the patient derives from its soothing influence. In one case only eserine acted well, but in five other Pot. Bromide stands next cases it failed to do any good. to chloral. Cannabis Indicse is useful in some cases. The combination of bromide and chloral seemed to act as tetanic fits.
complaint though
idiopathic
/
n/
THE INDIAN MEDICAL GAZETTE.
288
chloral used singly. Feeding up of the of great importance as to ultimate success. the with warm oil relieved the spasms of Rubbing body the limbs, and it is consistent with the old Hindu plan of treatment of rubbing the body, chiefly over the spine, with warm ghee.
effectually patient is
as
Dk. McLeod said that he could hardly assent to the view that the severity of tetanus was proportionate to the gravity of the wound which it succeeded. He was struck with the circumstance that the wounds in both the cases narrated were sloughy or grangrenous. He had recently seen tetanus arise in several instances of putrid and sloughy wounds. This tended to support Professor Billroth's opinion regarding the septic causation of tetanus. On the other hand he had seen tetanus arise in at least two cases where the wounds were perfectly aseptic, and in idiopathic tetanus the septic theory could hardly apply. Dr. Habvey remarked on the seasonal prevalence of tetanus. He had seen 19 cases occur in one month (of the rains) in the horses of the Central India Horse. He asked whether any member had seen recovery from infantile tetanus. He had only met with one case of the kind himself under large and frequently repeated dose of Succus conii. He had tried this drug in other cases without benefit. Db. Juggobundhoo Bose replie'd that he had seen two cases of recovery. This occurred under constant chloroform inhalation and rectal injection of tincture of assafoetida. He had also tried conium without benefit. Db. Chambebs had also seen two recoveries under conium and bromide of potassium and chloroform inhalation. Baboo Behabi Lall Chuckeebutty had seen one recovery under chloral. Me. Wallace had seen three successful cases under local sedatives. Extract Cannabis Indicse was smeared on to poultices applied to the umbilicus. He attached great importance to cleaning out the bowels thoroughly and removing all sources of irritation including worms. Db. Coates attached more importance to allaying irritation and supporting strength than to any special drug. Db. K. G. Sibcab read the following notes on the Treat, Intebmittent Feveb with Iodine :?
ment of
1 purpose first to read the history of seven cases of Intermittent fever treated at the Park Street Dispensary with the tincture of iodine only; and then to consider if the iodine can be looked upon as a substitute for quinia in the treatment of this malady. Case No. 1.?L. R., an East Indian male, aged 53, attended the Park Street Dispensary on the morning of the 11th August for intermittent fever. He used to get the fever every day with ague. I ordered him iodine mixture three times a day. This mixture is made with IT^x. of Tr. of iod. to i of water.
^
On On On On
the the the the
11th 12th 13th 14th
...
...
...
...
...
...
...
...
Slight fever
No fever. do. do.
; no ague.
In the morning of the 15th the patient reported that he was free from fever, and discontinued his attendance. Case No. 2?Moonyah, a sweeper caste female, aged 35, attended the Park Street Dispensary on the morning of the 15th August. She used to get the fever every day with ague. She was ordered the iodine mixture. On the 15th the fever returned with ague at 10 A. M. and left at 2 p. M. On the 16th the fever returned at 10 p. m. and left at 2 p. m., but there was no ague. On the 17th On the 18th On the 19th
...
...
...
...
...
...
...
...
...
No fever. Ditto. Ditto.
In the morning of the 20th she reported that she from fever, and discontinued her attendance.
was
free
Case No. 3.?Giridhary, a Hindoo male, aged 28, attended the Park Street Dispensary on the morning of the 15th August for intermittent fever. He was getting the fever every other dav for the last four days. He was ordered the iodine mixture. On the 15th On the 16th
...
...
There was no return of fever. Ditto.
On the 17th
...
[October 1, There was from
no
1881.
fever but he suffered
slight diarrhoea.
On the 18th Ordered a dose of chalk mixture with nix. of laudanum. This stopped the diarrhoea. There was no return of fever. On the 19th No diarrhoea and no return of fever ...
...
patient did not attend after this day. Case No. 4?Choolye, a Mahomedan male, aged 22, attended the Park Street Dispensary on the morning of the 20th August for intermittent fever which he was getting every day for the last five days with ague. He was ordered the iodine mixture. He was quite free from fever on the 20th, 21st and the morning of the 22nd instant. He discontinued attending the dispensary after the last date. Case No. 5.?Doma, a Hindoo boy aged 3, attended the Park Street Dispensary in the morning of the 20th August for intermittent fever, from which he was suffering for the last three days. I ordered him the iodine mixture. He was The
free from fever on the 20th and 21st instant. Case No. 6.?Mary, a Bengali Christian female, aged 18, attended the Park Street Dispen sary on the morning of the 20th August for intermittent fever, from which she was suffering for the last three days. She used to get the fever every day with ague. She was treated with the iodine mixture. She was free from fever on the 20th and the 21st
instant.
Case No. 7.?Dedarbux, a Mahomedan boy, aged 9 years, attended the Park Street Dispensary on the morning of the 20th August for intermittent fever, from which he was suffering for the last three days. He used to get the fever every day with ague. On the 20th the fever returned at 1 p. M. and left at 3 p. M. On the 21st very slight return of fever. There was no fever on the 22nd, 23rd and 24th instant. On the last day he complained of slight cough, for which he was ordered cough mixture, but he did not attend the dispen-
sary any more. I was led to treat these patients with iodine after perusing Dr. Grinnell's unusual success with this remedy in the treatment of intermittent fever. He says, "One hundred and forty cases were treated with the iodine, and the results were fully equal to those treated with the sulphate of quinine. The remedy seemed to act almost as by magic ; in many instances the paroxysms were not repeated after the medicine was given, though the doses were repeated for a day or two after the cessation of fever."?(Braithwaite's Ketrospect of Medicine, vol. 83). Although I cannot boast of treating such a large number of cases, yet my success with this remedy is not the less. In four cases (Nos. 3, 4, 5 and 6) the fever never returned from the very first day of attendance, i. e. very likely after taking only a single dose of the iodine mixture ; for most of these patients, being unprovided with a bottle, had to content themselves with drinking & single dose of the mixture. In one case (No. 1) the fever did not return from the second checked on the very first day of attendance, and it was greatlythat the patient had the day. In this case I may mention medicine three times a day regularly as he always brought a bottle with him. In the remaining two cases (Nos. 2 and 7) the fever did not return from the 3rd day of attendance, the paroxysms of ague on the second day were comparatively
slight.
After the perusal of the history of these cases I don't think there can be any doubt as to the antiperiodie property of iodine. It can certainly be employed in the treatment of intermittent fever instead of sulphate of quinine, especially when the patients are too poor to pay for it, or when it is not easily procurable. We are all interested in the settlement of this question ; for by finally settling this, we will solve another great difficulty. I mean the question of expense. Although I am led to believe in the antiperiodie property of iodine, yet I look upon theofsulphate of quinine the remedy in the treatment intermittent fever. as But on account of its high price we are constantly led to look for something cheaper that may do work for it in the treatment of this malady. Of course there is arsenic. It is cheap and at the same time efficacious ; but it is an unsafe remedy ; one over dose might be fatal, and its long continued use in minute doses leads even sometimes'to evident and lasting disorder of the health.
October 1, 1881. J
-
THE CALCUTTA MEDICAL SOCIETY.
Then, there is the Cinchona febrifuge, which is certainly of quinine, but nearly sixteen cheaper than the Sulphatetincture of iodine. Besides it times dearer than the disagrees with many stomachs, giving rise to nncontrollable fact nausea and even vomiting. In my experience of this drug is so unsatisfactory that I have long discontinued to emThere is another drug which is ploy it in my private practice. comparatively cheap and somewhat efficacious, but not easily procurable. I mean Carbazotate of ammonia, And lastly there is Eucalyptus. No doubt it is a most useful antiperiodic ; but it is neither so cheap nor so easily procurable as the tincture of iodine. But the tincture of iodine not only surpasses all these as to its cheapness, but it can be procured from any medicine shop owned by a quack even in the remotest part of the country. When administered in sweetened water or milk, it's rather disagreeble smell is not only effectually disguised, but it is decidedly more palatable than either the sulphate of quinine or the cinchona " febrifuge. Dr. Grinnell says, One important item in its favour was the fact that it was much more agreeable to take than quinine, and this with a large part of our population proved a potent argument in. its favour. The iodine at once became a more popular remedy than quinine with the masses of our people." I can testify from my own short experience that none of my patients complained of its disagreeableness altlhough it was administered to them in water only. The best time for its administration (according to Ringer) is soon after a meal, when the mucous membrane is protected by the food contained in the stomach, otherwise, if given in undue quantity, it may irritate the delicate structures of the stomach, inducing pain at the epigastrium, vomiting, diarrhoea &c. But although it was administered on an empty stomach to every patient treated by me, none of these untoward symptoms ever occurred except once. In the Case No. 3 diarrhoea appeared after the iodine mixture was administered for three successive days ; but it was effectually checked by a single dose of chalk mixture combined with laudanum. From what I have said, one may very likely be led to think that Dr. Grinnell was the first to employ iodine in the treatment of intermittent fever : but it is not so. It is a recognized remedy for the treatment of this malady both among the Russian and American physicians. Dr. Bartholow, in his treatise on the Practice of Medicine, makes mention of iodine as a substitute for quinine. His words are, ?" Iodine possesses a high degree of utility in the treatment of malarial intermittents, and may be used in substitution for quinia." Dr. Nephews also mentions it as a remedy for intermittent fever in his Modern Medical Therapeutics. So if the Russian and American physicians could be so very successful in treating intermittent fever with iodine, a priori, I don't see any reason why we could not be equally successful with it. In fact my short experience makes me ultimate our of success. very hopeful But there is a very plausible reason why iodine is so very efficacious in checking the paroxysms 0f intermittent fever. The rapid progress now being made in the investigation of the causation of diseases tends to pr0ve that the malaria poison consists of minute organisms. The late Dr. Niemeyer made this assertion some years ago, but at present it is assuming the certainty of an experimental fact. In the British Medical Journal of the 20th December 1879, Mr. J. Simm writes: The doctrine that ague poison is a microphyte of malarious soil is no longer a mere matter of suspicion, but is a matter of experimental certainty." The recent researches of Professors Klebs and Tommasi-Crudeli point to the conclusion that the malariapoison is an organism which may be obtained from the soil, and may be cultivated in the bodies of animals; and which, infecting the blood, causes a paroxysm of ague. From the recent writings of such men as Drs. Harley, Maclagan, Sir others, it Joseph is evident that this doctrine of the causation of the malarious diseases is commending itself to the approval of the leading members of our profession. Thus Dr. Maclagan writes in of the 21st August, 1880?'- The view that malathe Lancet rial poisons are minute organisms is the only one which even a reasonable afford seems to explanation of the natural history and cause of the fevers to which they give rise." The this is to usual objection tneory that, if such were the nature of the poison, its existence could be demonstrated by the that But by no means follows. The microscope microscope. can demonstrate the existence of very minute organisms;
Fayrer?and
289
but beyond a certain point: it cannot go. Professor Tyndall has demonstrated that the atmosphere habitually teems with particles so minute that they cannot be detected by the highest powers of the microscope, and that many of these particles are organised. With the knowledge that organised particles so minute do exist, we can not. fail to see that our inability to demonstrate that malaria is particulate and organised is no proof that such may not be its nature.* intermittent fever be thus due to an organism, a microphyte, and to no miasm, it is no wonder then that iodine, which is a powerful antiseptic, is sq very efficacious in checking its paroxysms. In conclusion I wish to remark that whatever may be the modus operandi of iodine in this disease, it can be however looked upon as a substitute for quinine when it is found to check the paroxysms of intermittent fever. Moulvie Tameez Khan and several other members thought a more extended trial of the drug desirable, and pointed out that Dr. Sircar had not made sufficient allowance for the natural tendency of intermittent fever to spontaneous cure. He and his colleague Dr. Juggobundhoo Rose had used the cinchona alkaloid largely in the Campbell Hospital without being much embarrassed by its reputed tendency to excite gastric irritability. Db. Coates observed that this effect was mainly observed in the College Hospital in patients in whom visceral complications existed. The proportion of gastric irritation and of visceral complications to the total of cases was found to be almost exactly identical. Db. McLeod read some notes on an Ebuptive Feveb
If"the
PREY AILING IN
CALCUTTA.
the past hot weather and rains I have met with of an eruptive fever which presented varying and anomalous phases. In one case, which I am inclined to consider typical, a boy of about five years of age was suddenfever He had just recovered from an seized with
During
several
cases
ly
high
attack of acute tonsillitis. The pyrexia was very intense and prostrating. Next day a bright rash appeared on his body and extremities. The patches originally small and circular, coalesced and became irregular and somewhat diffuse. They The were slightly if at all raised above the surface. fever subsided on the appearance of this efflorescence. The a rash itself faded away in day or two, and in three or four days from the onset of the disease the boy was quite well. No desquamation or dropsy ensued, and there was neither coryza nor bronchial catarrh. His sister got an attack of acute tonsillitis with fever a few days afterwards, but she had no rash. In another family three children were attacked, but their symptoms presented a good deal of variation. The first case was a baby boy 7 months old. He got high fever suddenly with bronchitis, some tonsillitis and extreme restlessness. The temperature reached 105? in the earlier days of the disease. The symptoms did not present much change for a week. The incisors were tense and prominent, and I lanced the gum over them freely This afforded relief. The fever and bronchitis subsided gradually during the next week and a roseolar rash in large patches appeared on the body and extremities for No desquamation or a few days during its subsidence. anasarca
*
supervened.
.
A little sister, about 2 years old, got during the baby s convalescence an attack of fever, bronchial catarrh and tonsillitis. The same kind of eruption appeared on the second or third day and faded in a day or two. A brother, about 4 years old, got feverish about the same time, and showed the same rash on the second day. He recovered in 4 or 5 days. In another family an infant was attacked exactly in the same way as the baby whose case I have described ; the fever, bronchitis and restlessness being very prominent. On appearance of the rash on the fourth day the symptoms subsided and recovery took place in about a week. In another case a little girl of 3 years got out of sorts, lost her appetite and spirits, and got a furred tongue and constipation. I was treatwith rhubarb and magnesia when roseolar patches ing appeared on the body, lasting for a day or two, and with their disappearance health was restored. Another little .
he'r
girl presented
similar symptoms; but after from the eruptive malady she sorethroat which almost killed her.
precisely
recovery had taken
got
a
place
diphtheritic adult, a married lady, high fever
In an
*
The lancet, July 31, 1880.
set in with
a
V/
290
?
THE INDIAN MEDICAL GAZETTE.
flush of face and body and severe pains in the back and bones. The suffusion lasted for a day or two, and the pyrexia and its concomitant discomforts disappeared in about a week. These cases are very vaguely described from memory, but occurring as they did at short intervals, and without any communication with each other, it appeared to me desirable to appeal to the experience of other practitioners, and I accordingly in my capacity of Health Officer addressed to every medical man practising in Calcutta a circular with a view to elicit information on the subject of this anomalous exanthem. I have been favoured with 19 replies, and though I have reason to believe that more will be forthcoming, those which I have already received contain matter of sufficient interest and detail to stimulate observation and discussion. Thirteen of the 19 had met with cases of fever with eruption, and 6 had not seen any. Some of the reporters had treated many cases?one 50, one 20. But most had encountered a few?from 6 to a dozen. Infants and children were the usual victims, but a few adult cases are described. Only one had seen the disease prove fatal, in 8 cases out of 50. The cases were observed mostly during the months of June, July and August. Opinions vary regarding the type of the disease?some looking upon it as a mild scarlatina, others as a rubeola or rotheln, and others as a mitigated den-
general
gue.
My friend Baboo Kotlas Chundbr Bose gives a good description of the disease from a wide experience. I shall read his report.
" I have seen several cases within the space of the last few months. I think I have seen twenty. The cases I treated were all in children under five years of age. The fever was of a continued type ; the temperature ranging from 102? to 105? F. ; pulse 100 to 130. In some cases the morning temperature was one degree less than the even-
ing.
The eruption was papular; very slightly raised above the surface of the body, red or crimson in colour ; appearing on the second or third day of the fever. The duration of the disease, as I have observed, is from 5 to 10 days, but in one case the fever persisted for more than three weeks. The complication in 5 or 6 of my cases was bronchitis ; in 4 acute tonsillitis ; in 2 cases ulcers within the throat; in 1 dysentery. The other cases were without any complication. I am sorry I have not been able to form any decided opinion regarding the identity of the disease, but from the symptoms I have observed I am inclined to think it to be some mild form of scarlatina. I have seen several cases in one house, and I am of opinion that the disease is infectious. Its causation involves infection. A Mahomedan lad had three playmates who attended his house during his illness. They had separate houses of their own. They all got the disease. Two of these lads had measles some two months before the attack, and I treated them during their illness. I have never seen any fatal case in the disease." Another excellent description of the cases he had met with is given by Dr. J. Anderson. " I have, within the last two months, had about eight or nine cases of fever of the kind you allude to ; and these have been mostly among youug children, from one to eleven or twelve years of age. At first I was disposed to attribute the eruption to the extreme heat of the weather then prein vailing Calcutta, and later on to its being a mild form of Dengue. But the complete absence of its infectiousness, its characteristic pains, and its amenability to ordinary treatment made me abandon that supposition. In those cases that came early under my observation, I noticed, in young children, there was coldness of the extremities with chilliness, manifested by the little sufferer crouching quietly in the bed with a disinclination to be disturbed. The hot stage would follow in an hour or two with a temperature ranging from 103? to 104?; and in about 24 hours a red eruption would make its appearance without any marked diminution of the pyrexia, which generally lasted for two or three days. The eruption did not invade the body in the usual order of fhe exanthemata, but erratically if I may so express it, showing first in the legs and arms, then on the trunk, and lastly on the neck and face. In some I have noticed it as being confined to the lower half of the body. This eruptive stage
[October 1,
1881.
only lasted for a couple of days, and in some cases less ; and the eruption gradually faded away with no perceptible desquamation. I also noticed some congestion of the conjunctivas ; a furred, white tongue, anorexia, thirst, restlessness, with scanty urine?which in the two or three instances that I examined showed no traces of albumen. The bowels were generally confined from sluggishness of the liver. One girl, about 11 years of age, complained of severe frontal headache and nausea. Younger children could not express their sensations ; but from their appearance I had reason to believe that headache was not absent, and nausea also prevailed. In one or two instances there was a tendency to diarrhoea with bronchial complications. In the treatment I adopted I found much benefit from small doses of aconite combined with an ordinary diaphoretic mixture in the hot stage ; and quinine with minute doses of Pulv. Jacobi Yeri with aromatic powder in the absence of fever, and subsequently Bark with either Spirit, ammonite aromatic, or one drop of Liquor arsenicalis two or three times a day proved very useful. I am unable to assign any circumstances as to the causation of the disease. My patients were all more or less among the well-to-do classes residing in very good localities: and I have had no fatal cases among my patients." Dr. Bowsek gives a short description of evidently the same disease which I shall read :? " I have had several cases?a couple of dozen or more? during the months of May, June and July, in and around Hastings, Kidderpore, &c. All among the Christian residents (European and Eurasian), and in the persons of infants, from a few months to 6 years of age. The fever was of the remittent type, with in many cases a at different very high temperature. The eruptions appeared timesfrom the commencement, ranging from, thefirst advent The cases lasted from a of thefever to within the 3rd day? week to 10 days. The cases were all decidedly a Rubeola, but the eruptions and were very were not so well marked as in true Rubeola, mean that the ; by this I eruptions ephemeral or evanescent away, with the rise faded a good deal, in some cases entirelyseveral times during and fall of temperature. Frequently the 24 hours. There was not the slightest idea of coryza as in cases. There was, Rubeola, a marked in any one of the tendency to bronchial complications. between the cases in The only but marked difference was the ephemeral character of the question and Rubeola eruptions, and the total absence of coryza. in naming the disease I had no hesitation at the time " Rubeola-notha?Rotheln, or ' German measles' of disease is given by A description of a severe form Baboo JOGENDKO NATH GhOSE. 1. "I have seen such cases of fever accompanied by _
_
cutaneous eruption. 2. About (10) ten cases, of which no notes were taken of the first five cases. 3. All in children under 12 years, except one in an old man of about 50 years. 4. (a)-?The fever is of a remittent type. (b).?A measly eruption appearsinfirst on the face then distinct crops. Comspreads to the trunk and the limbs and mences as small red points ; these gradually becomes enlarged, raised and papular, and at last become flattened and coalesce. In some cases distinct scattered patches are seen; feel distinct and coarse at the beginning, pressure slightly removes the colour temporarily. The cuticle desquamates, but not in all cases. In one case the eruptions receded on the third a
day.
(,c.)?The eruptions generally appear at the end of the first week and last for about a week. (d.)?The duration was two to three weeks or more. (e.)?Complications of ordinary remittent fever ; congestion of the brain, bronchitis, catarrhal pneumonia, occasional diarrhoea (but the bowels generally remain costive at the beweak, ginning), prostration, sometimes extreme, heart's action varying from 101? pulse varies from 80 to 120. temperature to 105? F.; conjunctive injected and the eyes are watery, and remain so even after recovery ; slight catarrh, pain in the joints, congestion of the throat and fauces ; heaviness and sense of fulness over the frontal bone, tongue thickly coated and lips red, slight enlargement of the lymphatic glands of the neck, urine high coloured and micturation at times difficult? these are the prominent symptoms. These symptoms aggravate
October 1,
CORRESPONDENCE.
1881.]
and the patient becomes irritable and delirious. In drowsiness continues for days together. 5. The disease is not identical with any named exanthem, but more like measles. The eruptions are bigger and more raised than measles, and appear later and last longer than it. 6. I had no occasion to see two cases in one family. 8. Only one death occurred in an aged person, in which the eruptions were quite unlike to any of the exanthems, being red, flattened and raised patches all over the body, eruptions appeared with the fever, and the patient died on the 5th day with head symptoms." These descriptions give, I think, a fair representation of the disease. Other reporters have laid stress on the early appearance of the eruption and the pains, and incline to pronounce the malady to be a non-epidemic Dengue. This is the opinion of Drs. Waller, Raye and Kernot. Another medical man describes 50 cases which occurred in February and March when measles were prevalent, and which were evidently cases of that disease. Babu Dwarkanath Goopta states, and this I have had confirmed by other testimony, that the disease is known among natives as minmina or a mild form of measles. On the whole I incline to believe that the disease is Rubeola or Rotheln. The symptoms are certainly not those of scarlatina .or measles as ordinarily .seen, nor do they correspond with those of dengue, as we saw it here in 1872. I have however thrown these notes together for discussion, and shall be glad if members of the Society will give us the benefit of their observations and opinions. Dr. Juqgobhundoo Bose remarked that during the last 10 or 13 years he had noticed during the rains an eruptive fever similar to that alluded to. It was decidedly different from measles or scarlatina. There was distinct fever with considerable prostration with increased evening exacerbation. Delirium sometimes appeared at night. The eruption fourth day?not so well marked appeared from the first to theand on the face as on the trunk extremities. It consisted of 60 or so minute papules constituting small patches. The fever lasted from 12 to 14 days.^ The eyes .were watery and conjunctivas very red as if papilated. The heart was weak and irritable, pulse from 120 to 140 small jerky, temperature ranged from 102 to 104?. Infants and children from 5 to 20 were mostly affected,?rarely grown up people. There was sometimes desquamation,- sometimes not. The disease was seen had He two not infectious. or three deaths this year. Want of power of deglutition was a prominent feature in bowels some cases ; generally constipated. Bronchitis of a dry kind sometimes occurs. Urine very high coloured ; no
at
night,
some cases
??
'
subsequent dropsy. At this stage the discussion
was
adjourned.
i'
291
CALCUTTA
MEDICAL SOCIETY. "u
i
The Ninth Meeting of 1881 was held at the Medical Colleee on the 14th September ; Moulvie Tameez Khan,' Khan
Bahadur, presiding.
Dr. McLeod showed a patient whose tongue had been entirely extirpated for epithelioma. He demonstrated that the paEienTTEad regained"to-?-1arge extent the faculty of speech. The following are notes of the case by AssistantSurgeon Debendra Nath Dey, M. B. :? Nafar Chunder, a Hindoo labourer, aged 40 years, resident of Hooghly, was admitted into the First Surgeou's Ward on the 5th August 1881 with epithelioma of the tongue.
History.?About
5 months ago he had
a
severe
attack of
headache with a peculiar tingling sensation in the brain. Two or three days after this he began to feel great pain at the root of his tongue, which was followed by the eruption of a number of papules on its dorsum. At this time he gave himself up to excessive drinking, and all these papules disappeared within a week, except one at the root a little to the left side. This gradually attained the size of a pea, and continued to enlarge, with increased pain and great'difficulty in swallowing. About two months ago another papule appeared at the site of it, and increased in size and then _
\jS
286
THE INDIAN MEDICAL GAZETTE.
burst, giving rise to a ragged ulcer, which used to bleed occasionally and produce extreme pain in deglution. Condition on admission.?The patient well nourished, without any visceral disease, organic or functional ; no history of
syphilis or gonorrhoea ; the urine healthy; appetite good. There was a tumour of
bowels regular; the size of a large bead situated on the left side of the base of the tongue on its dorsal aspect, close to it was a ragged ulcer of the size of a four anna bit, with raised thickened margin and surface depressed, uneven and sloughy ; the surrounding parts red and congested, the anterior pillar of the fauces on the left side, as also the uvula and posterior part of the hard palate, were all congested ; the glands along the lower border of the inferior maxilla on the affected side are enlarged and indurated, as also a gland in front of the left sterno-mastoid. Operation.?On the 7th August excision of the tongue was performed under chloroform. As a preliminary step tracheotomy was performed above the isthmus of the thyroid gland without any bleeding, and the tube inserted and tied by means of a tape round the neck, and chloroform was administered through it. A median incision, about an inch and a half long, was made in the sub-mental region above the hyoid bone. The mylo-hyoid was divided at its raphe, and the genio-hyoid and genio-hyo-glossus were separated from each other and from the mylo-hyoid, and the floor of the mouth was reached and opened under the tongue, which was then drawn out by means of a double thread of catgut passed through it by means of a needle and theix knotted at its ends. By this thread the tongue could be pulled from side to side as required. The attachment's of the tongue to the lower jaw were then snipped and cut all around with a pair of curved blunt pointed scissors, and the tongue thoroughly pulled out of the mouth by mea,ns of the thread. A sharp aneurism needle was then passed through the wound and made to transfix the base of the tongue, emerging in front of the epiglottis, and the wire then passed through the wound on the floor of ecraseur the mouth over the needle and then right over the tongue as far back as its root, the mouth being kept open by means of a cork. The eoraseur was then worked tight, but in the process of working it gave way, and became useless. The chain ecraseur was then substituted, and the tougue cut through the epithelial tumour, the ulcer being bisected transversely. The^base of the tongue that was left was then transfixed with the needle in the middle line and the ecraseur passed through the wound and the right half of the base of the tongue removed. The left half was then removed by holding it up by means of the vulsellum forceps, and the ecraseur passed round it and worked till it was severed. Blood was prevented from running back into the fauces by means of a sponge with a thread tied to it, pushed back into the throat. Another sponge was passed into the mouth and a bit of lint into the wound to plug them up. The patient lost about 5 or 6 oz. of blood. Progress.?In the evening the temperature was 102?, patient not restless ; bleeding stopped. The mouth was washed with Condy's gargle and a nutrient enema was given and the patient was also fed with milk poured down into the stomach through the nostrils. The next morning the sponges were taken out and the plug of lint removed. No bleeding followed. The wound inside the mouth was perfectly clean, the pharynx quite clear, and the epiglottis free and not infiltrated. The tracheotomy tube was also taken out and the wound left to heal up by granulations and dressed with boracic gauze. The patient was now fed with a tube through the mouth which was constantly washed with a gargle of Condy's fluid (3 ii to oj water), and carbolic inhalation was given through the mouth by means of the steam spray twice a day for a week to check all fetor of breath ; the patient was perfectly quiet; slept well in the night. The temperature fell to 100? F., and after two days was quite normal. The patient then sat up and commenced to walk about as if nothing had happened to him ; the breathing, was quite free through the natural passage. The V-shaped cleft at the root of the tongue looked perfectly well ; no inflammation of the mucous lnetuuraue of the pharynx or epiglottis, the latter qui te visible. On the fourth day after operation the patient had an attack of diarrhoea which was soon checked by astringents ; the upper ,and lower wounds covered with whitish grey lymph ; the uvula and the fauces a little cedem;uous and covered with whitish stuff ; the floor of the
[October 1,
1881.
mouth sloughy looking. The sloughs separated in 3 or 4 days, and the buccal cavity became quite clean. The patient was with a little troubled cough, and dry rhonchus at the back was heard for four days and then disappeared ; the wound became gradually contracted, clean and healthy, and granulating nicely. The glands in the submaxillary region seemed to become smaller and softer, but were still perceptible ; foetor of breath passed off. The carbolic inhalation was continued for a week and then stopped, but the mouth was continued to be washed with Condy's fluid and the patient fed with the tube for nine days, and then he commenced to swallow pultaceous food. On the 23rd the upper wound was completely cicatrized, a vertical linear cicatrix about J inch long was onlv to be noticed ; the lower wound was filled up with healthy granulations ; buccal cavity clean, floor of the mouth rather but no new uneven, growth was visible. Epiglottis turned upwards and slightly backwards and folded on itself; the anterior and posterior pillars standing prominent on the sides of the palatal arch ; the uvula normal, the the patient could to extent; a visible was pharynx large articulate, though indistinctly, the lingual letters?taka pronounced as aha. On the 26th the buccal cavity was found covered with aphthae, white aphthous patches on the roof of the palate and floor of the mouth, which when examined by the microscope presented fat or milk globules, epithelial cells and mycelium. These were removed by the application of glycerine of borax to the parts thrice a day. The patient now is almost all right, and is in a fit condition .to be discharged ; his sense of taste seems to be hardly affected, for he can distinguish salt from sugar when put into the mouth, and he can articulate with considerable distinctness. Dr. MacConnell's description of the tongue is as follows " The tongue of a native Hindoo male, aged 40 years, removed by Dr. K. McLeod by means of a chain ecraseur for tumour and ulcer at its root. The growth is said to be of 5 months' duration. " Epithelioma of the tongue. The morbid growth is represented by an irregular shaped ulcer about as large as a rupee, situated on the dorsum and left margin of the organ near its base. The margins of the ulcer are hard and eroded, its surface deeply excavated and covered also with small soft nodular excrescences. On microscopic examination all the characters of a true rapidly developing epithelioma are observed. The epithelial proliferation extends downwards from the membrane and papilla? of the tongue into its mucous muscular tissue, the fibres of which in the immediate vicinity of the ulcer are broken down and infiltrated with a small celled or nuclear growth. In the superficial strata and at the are very abunmargins of the ulcer true epithelial elements dant, nucleated, heteromorphous, exhibit numerous nests, and in all respect conform to the usual structure of cancer of this variety. N. B.?The ulcer is seen to have been bisected by the first section made by the ecraseur, and a second was therefore rendered necessary in order to include the whole of the morbid tissue. This seems to have been effectual, for the miedge of the last porcroscopic examination of the tion (base) of tongue removed shows no cancerous infiltration. The muscular and other tissues appear quite healthy." Db. Sanders showed a patient from whose bladder he had removed a large Calculus by litholapaxy. The the instruments, which fragments were also exhibited and were made specially for Dr. Sanders by Weiss, with some modifications, designed to facilitate the entrance of fragments into the catheter and the passage of these into the following notes furnished glass bulb of the aspirator. The record of the case :? by Dr. Sanders contain a detailed The comparative rarity of stone cases in Calcutta has caused me to bring this one to the notice of the Society, especially as it has been treated after the method of Professor
posterior
Bigelow.
Shitaram Satir, Hindu male, into the Mayo Hospital on the 1st
aged^
28 years, was admitted
September 1881.
Previous history.?He noticed difficulty in making water : and general discomfort in his bladder about six months ago these symptoms have lately much increased, and the frequency of micturition and pain led him to seek treatment. Condition on admission.?Thin and anaemic. Bladder very irritable ; constant desire to pass urine, which, is bloody and from passed with great pain and straining ; suffers much was piles. young A large stone was felt in sounding. The man
V
October 1,
1881.]
THE CALCUTTA MEDICAL SOCIETY.
but his health was much broken from constant pain and loss of blood. Operation.?On the 2nd September the patient was placed under chloroform; during the inhalation of choroform and whilst struggling he passed from the urethra a large quantity of bloody fluid which clotted on standing ; the stone was seized by the large lithotrite at once and crushed into several fragments, which were afterwards further comminuted by the smaller lithotrite, when the stone had been well crushed : the bladder was aspirated and the debris came away very rapidly. The lithotrite was introduced three times, and after each introduction the aspirator was used ; after the third aspiration the aspirator was changed and the bladder washed out with clear water; no sand passed and no rattling in the bladder could be detected from fragments striking against the catheter ; a small fragment in the bladder indicates its existence by rattling against the end of the catheter. The nucleus of the stone was very hard, and very considerable force was necessary to crush it. During the took place, probably owing operation slight bleeding to the irritable state of the bladder. The operation lasted nearly 25 minutes. The dried fragments before you weigh 6 drachms, but the full weight of the stone was about one of the fragments and much ounce, as many large portions sand were stated by Dr. Jones to have been accidentally thrown away. Progress and treatment. Had one rigor 4 hours after the operation, and his temp, rose to 104? in the afternoon : there was no retention of urine : his urine for two days was tinged with blood : there was slight pain over the bladhis temperature ranged from 102" der, and whilst this lasted to 104'63, but on the 5th day after the operation the temperature was normal, and all fever and pain passed away. He the first five was kept on low diet for days, and large doses of quinine were given to check rigors and keep down temhis abdomen and barley water perature : fomentations^ to to drink on account of its diuretic action. Since the operation no particle of sand or grit has passed, and on the morning of the 12th his bladder was first carefully sounded and then washed out with quinine solution in the aspirator, but nothing passed out, even a particle of sand. His urine is at present clear, free from sediment and passed naturally and without pain. The instruments used are here shown, those on the right side are what were first sent to me, but that lithotrite was only made to crush large stones, and I found crushing fragments very difficult with it. I therefore ordered a smaller one, which is very efficacious indeed. The catheters first sent only had a round opening, thus only permitting the smallest pieces to enter. I therefore had one made with a large oval opening which admits very large and long pieces into it, but,having this, I found they would not but remained stuck in the catheter pass into the old aspirator, because the opening in the old aspirator is smaller than the openings in the catheters ; I therefore ordered a new aspirator, and directed that the opening int0 it should be altered ; this new aspirator will allow anything to pass into it which can enter the catheter, and it also works very expeditiously ; in my thirty-first case I removed a 2 ounce stone in twenty minutes. Under chloroform there was no difficulty in passing the instruments, in fact they slipped in. without using force of any kind. The success of the case is in great measure due to the unremitting attention paid to it by Dr. Jones and Babus Behari Lai Chakravarti and Sen. ?
Dr. McLeod congratulated Da. Sanders on being the first to perform the operation of litholapaxy in Calcutta, and successfully. He had himself, acting on Professor Bigelow's principle that the bladder was more tolerant of prothe than instrumentation longed perpetual presence of a stone, succeeded on three occasions in at entirely crushing one time stones of moderate size by the ordinary lithotrite introduced repeatedly. Having no aspirator, the fragments had to come away gradually during the next few days. These patients made good and rapid recovery. From inspection of the instruments shown by Dr. Sanders he could readily perceive how much easier and more effectually the operation could be performed with them. Dr. Harvey remarked that these instruments made the operation practicable in India when patients are so averse to submit to repeated operations.
crushing
'
287;
Baboo Behari Lall Chuckerbutty read the following ^ngtes on Tetanus^*.
SEew GoBmHoTa Hindu male, aged about 25 years, was admitted into the Mayo Native Hospital on the 23rd February 1881 with smashed right foot, the result of being run over by a railway engine-wheel. The whole of the foot, as high up as the junction of the scaphoid with the cuneiform bones and middle of the cuboid, was regularly crushed. That very day a modified Chopart's amputation was performed under chloroform. The foot was separated at the junction of the scaphoid with the cuneiform bones, the cuboid being partly sawn off, and a sole flap was taken to cover the stump. The sole flap partially sloughed away, and the patient got tetanus on the 8th March 1881. He gradually recovered from tetanus by the combined effect of chloral and eserine. He was kept on milk and broth all the time. The wound began cicatrizing, when he complained of severe stitching pain in the stump, probably from the pressure on some nervous twigs involved in the cicatricial tissue. The pain became afterwards constant and unbearable, and on the 27th April Syme's amputation was performed. He tetanus when the second operawas just recovering from tion was done. His body was stiff, though there were no more
This operation did not increase his tetanic there was a certain amount of constitutionHe left the hospital with a al disturbance afterwards. useful stump on the 9th August 1881. Recovery from after severe tetanus supervening injury is very rare, though recovered several cases have after slight injuries. Tetanus supervening after amputation of the leg, thigh, forearm, arm, and after compound fractures, almost invariably ends in death. From the beginning of the year 1881 twenty tetanus cases were admitted into the Mayo Native Hospital. Of these 13 were of Traumatic and 7 of origin. Out of these 20, twelve died, and of these 9 of the traumatic variety. The mortality has therefore been greater in the traumatic than in the idiopathic. One case was successfully treated by the hypodermic injection of eserine. This was in a young Mahomedan of 25 years age. He received a severe injury in his left heel, exposing the bone. The sole of the foot for nearly four inches long was separated from the foot in the shape of a flap from the heel towards the tarsal bones. When the wound got cleared of the sloughy tissue, tetanus supervened with regular lock-jaw and involuntary spasm of the limb. The tetanic symptoms were detected rather early, and we at once had recourse to eserine injection, and within three or four days all the tetanic symptoms passed off and the man recovered without any further trouble. In one case we tried amputation of the leg for tetacompound fracture of the legnus, supervening after bones, but the result was as unsuccessful as was expected before the operation. Some are of opinion that the seat of fracture being the constant source of irritation affecting the peripheral nerves, it is justifiable to remove the source of irritation and thereby to give a chance to the patient. In can be recognised, even my opinion, when tetanic symptoms at the very beginning, the disease is no longer peripheral but central, i. e. the spinal cord gets affected first before the disease makes its appearance externally by symptoms. There was one death from tetanus after an operation for scrotal tumour. The man was healthy but aged (55 years). The tumour also was a very big one, weighing 45 lbs. exclusive of fluid. Tetanus after scrotal tumour operation is somewhat rare. In idiopathic cases muscular contraction generally becomes case we have had regular Talipes varus very marked, and in one of both the feet, from the continuous contraction and rigidity of the powerful muscles. The heel is raised by the TendoAchillis, the inner border of the foot drawn upwards by the Tibialis anticus, the outer side of the foot twisted inwards by the Tibialis posticus, and Flexor longus digitorum. When he left the hospital, the deformity remained permanent in the right foot. We gave a fair trial to the following drugs in the treatment of tetanus, viz., Ghloral hydrate, Eserine, Ext Cannabis Indicaa, and Pot. Bromide. Of these four chloral stands first as to the comfort the patient derives from its soothing influence. In one case only eserine acted well, but in five other Pot. Bromide stands next cases it failed to do any good. to chloral. Cannabis Indicse is useful in some cases. The combination of bromide and chloral seemed to act as tetanic fits.
complaint though
idiopathic
/
n/
THE INDIAN MEDICAL GAZETTE.
288
chloral used singly. Feeding up of the of great importance as to ultimate success. the with warm oil relieved the spasms of Rubbing body the limbs, and it is consistent with the old Hindu plan of treatment of rubbing the body, chiefly over the spine, with warm ghee.
effectually patient is
as
Dk. McLeod said that he could hardly assent to the view that the severity of tetanus was proportionate to the gravity of the wound which it succeeded. He was struck with the circumstance that the wounds in both the cases narrated were sloughy or grangrenous. He had recently seen tetanus arise in several instances of putrid and sloughy wounds. This tended to support Professor Billroth's opinion regarding the septic causation of tetanus. On the other hand he had seen tetanus arise in at least two cases where the wounds were perfectly aseptic, and in idiopathic tetanus the septic theory could hardly apply. Dr. Habvey remarked on the seasonal prevalence of tetanus. He had seen 19 cases occur in one month (of the rains) in the horses of the Central India Horse. He asked whether any member had seen recovery from infantile tetanus. He had only met with one case of the kind himself under large and frequently repeated dose of Succus conii. He had tried this drug in other cases without benefit. Db. Juggobundhoo Bose replie'd that he had seen two cases of recovery. This occurred under constant chloroform inhalation and rectal injection of tincture of assafoetida. He had also tried conium without benefit. Db. Chambebs had also seen two recoveries under conium and bromide of potassium and chloroform inhalation. Baboo Behabi Lall Chuckeebutty had seen one recovery under chloral. Me. Wallace had seen three successful cases under local sedatives. Extract Cannabis Indicse was smeared on to poultices applied to the umbilicus. He attached great importance to cleaning out the bowels thoroughly and removing all sources of irritation including worms. Db. Coates attached more importance to allaying irritation and supporting strength than to any special drug. Db. K. G. Sibcab read the following notes on the Treat, Intebmittent Feveb with Iodine :?
ment of
1 purpose first to read the history of seven cases of Intermittent fever treated at the Park Street Dispensary with the tincture of iodine only; and then to consider if the iodine can be looked upon as a substitute for quinia in the treatment of this malady. Case No. 1.?L. R., an East Indian male, aged 53, attended the Park Street Dispensary on the morning of the 11th August for intermittent fever. He used to get the fever every day with ague. I ordered him iodine mixture three times a day. This mixture is made with IT^x. of Tr. of iod. to i of water.
^
On On On On
the the the the
11th 12th 13th 14th
...
...
...
...
...
...
...
...
Slight fever
No fever. do. do.
; no ague.
In the morning of the 15th the patient reported that he was free from fever, and discontinued his attendance. Case No. 2?Moonyah, a sweeper caste female, aged 35, attended the Park Street Dispensary on the morning of the 15th August. She used to get the fever every day with ague. She was ordered the iodine mixture. On the 15th the fever returned with ague at 10 A. M. and left at 2 p. M. On the 16th the fever returned at 10 p. m. and left at 2 p. m., but there was no ague. On the 17th On the 18th On the 19th
...
...
...
...
...
...
...
...
...
No fever. Ditto. Ditto.
In the morning of the 20th she reported that she from fever, and discontinued her attendance.
was
free
Case No. 3.?Giridhary, a Hindoo male, aged 28, attended the Park Street Dispensary on the morning of the 15th August for intermittent fever. He was getting the fever every other dav for the last four days. He was ordered the iodine mixture. On the 15th On the 16th
...
...
There was no return of fever. Ditto.
On the 17th
...
[October 1, There was from
no
1881.
fever but he suffered
slight diarrhoea.
On the 18th Ordered a dose of chalk mixture with nix. of laudanum. This stopped the diarrhoea. There was no return of fever. On the 19th No diarrhoea and no return of fever ...
...
patient did not attend after this day. Case No. 4?Choolye, a Mahomedan male, aged 22, attended the Park Street Dispensary on the morning of the 20th August for intermittent fever which he was getting every day for the last five days with ague. He was ordered the iodine mixture. He was quite free from fever on the 20th, 21st and the morning of the 22nd instant. He discontinued attending the dispensary after the last date. Case No. 5.?Doma, a Hindoo boy aged 3, attended the Park Street Dispensary in the morning of the 20th August for intermittent fever, from which he was suffering for the last three days. I ordered him the iodine mixture. He was The
free from fever on the 20th and 21st instant. Case No. 6.?Mary, a Bengali Christian female, aged 18, attended the Park Street Dispen sary on the morning of the 20th August for intermittent fever, from which she was suffering for the last three days. She used to get the fever every day with ague. She was treated with the iodine mixture. She was free from fever on the 20th and the 21st
instant.
Case No. 7.?Dedarbux, a Mahomedan boy, aged 9 years, attended the Park Street Dispensary on the morning of the 20th August for intermittent fever, from which he was suffering for the last three days. He used to get the fever every day with ague. On the 20th the fever returned at 1 p. M. and left at 3 p. M. On the 21st very slight return of fever. There was no fever on the 22nd, 23rd and 24th instant. On the last day he complained of slight cough, for which he was ordered cough mixture, but he did not attend the dispen-
sary any more. I was led to treat these patients with iodine after perusing Dr. Grinnell's unusual success with this remedy in the treatment of intermittent fever. He says, "One hundred and forty cases were treated with the iodine, and the results were fully equal to those treated with the sulphate of quinine. The remedy seemed to act almost as by magic ; in many instances the paroxysms were not repeated after the medicine was given, though the doses were repeated for a day or two after the cessation of fever."?(Braithwaite's Ketrospect of Medicine, vol. 83). Although I cannot boast of treating such a large number of cases, yet my success with this remedy is not the less. In four cases (Nos. 3, 4, 5 and 6) the fever never returned from the very first day of attendance, i. e. very likely after taking only a single dose of the iodine mixture ; for most of these patients, being unprovided with a bottle, had to content themselves with drinking & single dose of the mixture. In one case (No. 1) the fever did not return from the second checked on the very first day of attendance, and it was greatlythat the patient had the day. In this case I may mention medicine three times a day regularly as he always brought a bottle with him. In the remaining two cases (Nos. 2 and 7) the fever did not return from the 3rd day of attendance, the paroxysms of ague on the second day were comparatively
slight.
After the perusal of the history of these cases I don't think there can be any doubt as to the antiperiodie property of iodine. It can certainly be employed in the treatment of intermittent fever instead of sulphate of quinine, especially when the patients are too poor to pay for it, or when it is not easily procurable. We are all interested in the settlement of this question ; for by finally settling this, we will solve another great difficulty. I mean the question of expense. Although I am led to believe in the antiperiodie property of iodine, yet I look upon theofsulphate of quinine the remedy in the treatment intermittent fever. as But on account of its high price we are constantly led to look for something cheaper that may do work for it in the treatment of this malady. Of course there is arsenic. It is cheap and at the same time efficacious ; but it is an unsafe remedy ; one over dose might be fatal, and its long continued use in minute doses leads even sometimes'to evident and lasting disorder of the health.
October 1, 1881. J
-
THE CALCUTTA MEDICAL SOCIETY.
Then, there is the Cinchona febrifuge, which is certainly of quinine, but nearly sixteen cheaper than the Sulphatetincture of iodine. Besides it times dearer than the disagrees with many stomachs, giving rise to nncontrollable fact nausea and even vomiting. In my experience of this drug is so unsatisfactory that I have long discontinued to emThere is another drug which is ploy it in my private practice. comparatively cheap and somewhat efficacious, but not easily procurable. I mean Carbazotate of ammonia, And lastly there is Eucalyptus. No doubt it is a most useful antiperiodic ; but it is neither so cheap nor so easily procurable as the tincture of iodine. But the tincture of iodine not only surpasses all these as to its cheapness, but it can be procured from any medicine shop owned by a quack even in the remotest part of the country. When administered in sweetened water or milk, it's rather disagreeble smell is not only effectually disguised, but it is decidedly more palatable than either the sulphate of quinine or the cinchona " febrifuge. Dr. Grinnell says, One important item in its favour was the fact that it was much more agreeable to take than quinine, and this with a large part of our population proved a potent argument in. its favour. The iodine at once became a more popular remedy than quinine with the masses of our people." I can testify from my own short experience that none of my patients complained of its disagreeableness altlhough it was administered to them in water only. The best time for its administration (according to Ringer) is soon after a meal, when the mucous membrane is protected by the food contained in the stomach, otherwise, if given in undue quantity, it may irritate the delicate structures of the stomach, inducing pain at the epigastrium, vomiting, diarrhoea &c. But although it was administered on an empty stomach to every patient treated by me, none of these untoward symptoms ever occurred except once. In the Case No. 3 diarrhoea appeared after the iodine mixture was administered for three successive days ; but it was effectually checked by a single dose of chalk mixture combined with laudanum. From what I have said, one may very likely be led to think that Dr. Grinnell was the first to employ iodine in the treatment of intermittent fever : but it is not so. It is a recognized remedy for the treatment of this malady both among the Russian and American physicians. Dr. Bartholow, in his treatise on the Practice of Medicine, makes mention of iodine as a substitute for quinine. His words are, ?" Iodine possesses a high degree of utility in the treatment of malarial intermittents, and may be used in substitution for quinia." Dr. Nephews also mentions it as a remedy for intermittent fever in his Modern Medical Therapeutics. So if the Russian and American physicians could be so very successful in treating intermittent fever with iodine, a priori, I don't see any reason why we could not be equally successful with it. In fact my short experience makes me ultimate our of success. very hopeful But there is a very plausible reason why iodine is so very efficacious in checking the paroxysms 0f intermittent fever. The rapid progress now being made in the investigation of the causation of diseases tends to pr0ve that the malaria poison consists of minute organisms. The late Dr. Niemeyer made this assertion some years ago, but at present it is assuming the certainty of an experimental fact. In the British Medical Journal of the 20th December 1879, Mr. J. Simm writes: The doctrine that ague poison is a microphyte of malarious soil is no longer a mere matter of suspicion, but is a matter of experimental certainty." The recent researches of Professors Klebs and Tommasi-Crudeli point to the conclusion that the malariapoison is an organism which may be obtained from the soil, and may be cultivated in the bodies of animals; and which, infecting the blood, causes a paroxysm of ague. From the recent writings of such men as Drs. Harley, Maclagan, Sir others, it Joseph is evident that this doctrine of the causation of the malarious diseases is commending itself to the approval of the leading members of our profession. Thus Dr. Maclagan writes in of the 21st August, 1880?'- The view that malathe Lancet rial poisons are minute organisms is the only one which even a reasonable afford seems to explanation of the natural history and cause of the fevers to which they give rise." The this is to usual objection tneory that, if such were the nature of the poison, its existence could be demonstrated by the that But by no means follows. The microscope microscope. can demonstrate the existence of very minute organisms;
Fayrer?and
289
but beyond a certain point: it cannot go. Professor Tyndall has demonstrated that the atmosphere habitually teems with particles so minute that they cannot be detected by the highest powers of the microscope, and that many of these particles are organised. With the knowledge that organised particles so minute do exist, we can not. fail to see that our inability to demonstrate that malaria is particulate and organised is no proof that such may not be its nature.* intermittent fever be thus due to an organism, a microphyte, and to no miasm, it is no wonder then that iodine, which is a powerful antiseptic, is sq very efficacious in checking its paroxysms. In conclusion I wish to remark that whatever may be the modus operandi of iodine in this disease, it can be however looked upon as a substitute for quinine when it is found to check the paroxysms of intermittent fever. Moulvie Tameez Khan and several other members thought a more extended trial of the drug desirable, and pointed out that Dr. Sircar had not made sufficient allowance for the natural tendency of intermittent fever to spontaneous cure. He and his colleague Dr. Juggobundhoo Rose had used the cinchona alkaloid largely in the Campbell Hospital without being much embarrassed by its reputed tendency to excite gastric irritability. Db. Coates observed that this effect was mainly observed in the College Hospital in patients in whom visceral complications existed. The proportion of gastric irritation and of visceral complications to the total of cases was found to be almost exactly identical. Db. McLeod read some notes on an Ebuptive Feveb
If"the
PREY AILING IN
CALCUTTA.
the past hot weather and rains I have met with of an eruptive fever which presented varying and anomalous phases. In one case, which I am inclined to consider typical, a boy of about five years of age was suddenfever He had just recovered from an seized with
During
several
cases
ly
high
attack of acute tonsillitis. The pyrexia was very intense and prostrating. Next day a bright rash appeared on his body and extremities. The patches originally small and circular, coalesced and became irregular and somewhat diffuse. They The were slightly if at all raised above the surface. fever subsided on the appearance of this efflorescence. The a rash itself faded away in day or two, and in three or four days from the onset of the disease the boy was quite well. No desquamation or dropsy ensued, and there was neither coryza nor bronchial catarrh. His sister got an attack of acute tonsillitis with fever a few days afterwards, but she had no rash. In another family three children were attacked, but their symptoms presented a good deal of variation. The first case was a baby boy 7 months old. He got high fever suddenly with bronchitis, some tonsillitis and extreme restlessness. The temperature reached 105? in the earlier days of the disease. The symptoms did not present much change for a week. The incisors were tense and prominent, and I lanced the gum over them freely This afforded relief. The fever and bronchitis subsided gradually during the next week and a roseolar rash in large patches appeared on the body and extremities for No desquamation or a few days during its subsidence. anasarca
*
supervened.
.
A little sister, about 2 years old, got during the baby s convalescence an attack of fever, bronchial catarrh and tonsillitis. The same kind of eruption appeared on the second or third day and faded in a day or two. A brother, about 4 years old, got feverish about the same time, and showed the same rash on the second day. He recovered in 4 or 5 days. In another family an infant was attacked exactly in the same way as the baby whose case I have described ; the fever, bronchitis and restlessness being very prominent. On appearance of the rash on the fourth day the symptoms subsided and recovery took place in about a week. In another case a little girl of 3 years got out of sorts, lost her appetite and spirits, and got a furred tongue and constipation. I was treatwith rhubarb and magnesia when roseolar patches ing appeared on the body, lasting for a day or two, and with their disappearance health was restored. Another little .
he'r
girl presented
similar symptoms; but after from the eruptive malady she sorethroat which almost killed her.
precisely
recovery had taken
got
a
place
diphtheritic adult, a married lady, high fever
In an
*
The lancet, July 31, 1880.
set in with
a
V/
290
?
THE INDIAN MEDICAL GAZETTE.
flush of face and body and severe pains in the back and bones. The suffusion lasted for a day or two, and the pyrexia and its concomitant discomforts disappeared in about a week. These cases are very vaguely described from memory, but occurring as they did at short intervals, and without any communication with each other, it appeared to me desirable to appeal to the experience of other practitioners, and I accordingly in my capacity of Health Officer addressed to every medical man practising in Calcutta a circular with a view to elicit information on the subject of this anomalous exanthem. I have been favoured with 19 replies, and though I have reason to believe that more will be forthcoming, those which I have already received contain matter of sufficient interest and detail to stimulate observation and discussion. Thirteen of the 19 had met with cases of fever with eruption, and 6 had not seen any. Some of the reporters had treated many cases?one 50, one 20. But most had encountered a few?from 6 to a dozen. Infants and children were the usual victims, but a few adult cases are described. Only one had seen the disease prove fatal, in 8 cases out of 50. The cases were observed mostly during the months of June, July and August. Opinions vary regarding the type of the disease?some looking upon it as a mild scarlatina, others as a rubeola or rotheln, and others as a mitigated den-
general
gue.
My friend Baboo Kotlas Chundbr Bose gives a good description of the disease from a wide experience. I shall read his report.
" I have seen several cases within the space of the last few months. I think I have seen twenty. The cases I treated were all in children under five years of age. The fever was of a continued type ; the temperature ranging from 102? to 105? F. ; pulse 100 to 130. In some cases the morning temperature was one degree less than the even-
ing.
The eruption was papular; very slightly raised above the surface of the body, red or crimson in colour ; appearing on the second or third day of the fever. The duration of the disease, as I have observed, is from 5 to 10 days, but in one case the fever persisted for more than three weeks. The complication in 5 or 6 of my cases was bronchitis ; in 4 acute tonsillitis ; in 2 cases ulcers within the throat; in 1 dysentery. The other cases were without any complication. I am sorry I have not been able to form any decided opinion regarding the identity of the disease, but from the symptoms I have observed I am inclined to think it to be some mild form of scarlatina. I have seen several cases in one house, and I am of opinion that the disease is infectious. Its causation involves infection. A Mahomedan lad had three playmates who attended his house during his illness. They had separate houses of their own. They all got the disease. Two of these lads had measles some two months before the attack, and I treated them during their illness. I have never seen any fatal case in the disease." Another excellent description of the cases he had met with is given by Dr. J. Anderson. " I have, within the last two months, had about eight or nine cases of fever of the kind you allude to ; and these have been mostly among youug children, from one to eleven or twelve years of age. At first I was disposed to attribute the eruption to the extreme heat of the weather then prein vailing Calcutta, and later on to its being a mild form of Dengue. But the complete absence of its infectiousness, its characteristic pains, and its amenability to ordinary treatment made me abandon that supposition. In those cases that came early under my observation, I noticed, in young children, there was coldness of the extremities with chilliness, manifested by the little sufferer crouching quietly in the bed with a disinclination to be disturbed. The hot stage would follow in an hour or two with a temperature ranging from 103? to 104?; and in about 24 hours a red eruption would make its appearance without any marked diminution of the pyrexia, which generally lasted for two or three days. The eruption did not invade the body in the usual order of fhe exanthemata, but erratically if I may so express it, showing first in the legs and arms, then on the trunk, and lastly on the neck and face. In some I have noticed it as being confined to the lower half of the body. This eruptive stage
[October 1,
1881.
only lasted for a couple of days, and in some cases less ; and the eruption gradually faded away with no perceptible desquamation. I also noticed some congestion of the conjunctivas ; a furred, white tongue, anorexia, thirst, restlessness, with scanty urine?which in the two or three instances that I examined showed no traces of albumen. The bowels were generally confined from sluggishness of the liver. One girl, about 11 years of age, complained of severe frontal headache and nausea. Younger children could not express their sensations ; but from their appearance I had reason to believe that headache was not absent, and nausea also prevailed. In one or two instances there was a tendency to diarrhoea with bronchial complications. In the treatment I adopted I found much benefit from small doses of aconite combined with an ordinary diaphoretic mixture in the hot stage ; and quinine with minute doses of Pulv. Jacobi Yeri with aromatic powder in the absence of fever, and subsequently Bark with either Spirit, ammonite aromatic, or one drop of Liquor arsenicalis two or three times a day proved very useful. I am unable to assign any circumstances as to the causation of the disease. My patients were all more or less among the well-to-do classes residing in very good localities: and I have had no fatal cases among my patients." Dr. Bowsek gives a short description of evidently the same disease which I shall read :? " I have had several cases?a couple of dozen or more? during the months of May, June and July, in and around Hastings, Kidderpore, &c. All among the Christian residents (European and Eurasian), and in the persons of infants, from a few months to 6 years of age. The fever was of the remittent type, with in many cases a at different very high temperature. The eruptions appeared timesfrom the commencement, ranging from, thefirst advent The cases lasted from a of thefever to within the 3rd day? week to 10 days. The cases were all decidedly a Rubeola, but the eruptions and were very were not so well marked as in true Rubeola, mean that the ; by this I eruptions ephemeral or evanescent away, with the rise faded a good deal, in some cases entirelyseveral times during and fall of temperature. Frequently the 24 hours. There was not the slightest idea of coryza as in cases. There was, Rubeola, a marked in any one of the tendency to bronchial complications. between the cases in The only but marked difference was the ephemeral character of the question and Rubeola eruptions, and the total absence of coryza. in naming the disease I had no hesitation at the time " Rubeola-notha?Rotheln, or ' German measles' of disease is given by A description of a severe form Baboo JOGENDKO NATH GhOSE. 1. "I have seen such cases of fever accompanied by _
_
cutaneous eruption. 2. About (10) ten cases, of which no notes were taken of the first five cases. 3. All in children under 12 years, except one in an old man of about 50 years. 4. (a)-?The fever is of a remittent type. (b).?A measly eruption appearsinfirst on the face then distinct crops. Comspreads to the trunk and the limbs and mences as small red points ; these gradually becomes enlarged, raised and papular, and at last become flattened and coalesce. In some cases distinct scattered patches are seen; feel distinct and coarse at the beginning, pressure slightly removes the colour temporarily. The cuticle desquamates, but not in all cases. In one case the eruptions receded on the third a
day.
(,c.)?The eruptions generally appear at the end of the first week and last for about a week. (d.)?The duration was two to three weeks or more. (e.)?Complications of ordinary remittent fever ; congestion of the brain, bronchitis, catarrhal pneumonia, occasional diarrhoea (but the bowels generally remain costive at the beweak, ginning), prostration, sometimes extreme, heart's action varying from 101? pulse varies from 80 to 120. temperature to 105? F.; conjunctive injected and the eyes are watery, and remain so even after recovery ; slight catarrh, pain in the joints, congestion of the throat and fauces ; heaviness and sense of fulness over the frontal bone, tongue thickly coated and lips red, slight enlargement of the lymphatic glands of the neck, urine high coloured and micturation at times difficult? these are the prominent symptoms. These symptoms aggravate
October 1,
CORRESPONDENCE.
1881.]
and the patient becomes irritable and delirious. In drowsiness continues for days together. 5. The disease is not identical with any named exanthem, but more like measles. The eruptions are bigger and more raised than measles, and appear later and last longer than it. 6. I had no occasion to see two cases in one family. 8. Only one death occurred in an aged person, in which the eruptions were quite unlike to any of the exanthems, being red, flattened and raised patches all over the body, eruptions appeared with the fever, and the patient died on the 5th day with head symptoms." These descriptions give, I think, a fair representation of the disease. Other reporters have laid stress on the early appearance of the eruption and the pains, and incline to pronounce the malady to be a non-epidemic Dengue. This is the opinion of Drs. Waller, Raye and Kernot. Another medical man describes 50 cases which occurred in February and March when measles were prevalent, and which were evidently cases of that disease. Babu Dwarkanath Goopta states, and this I have had confirmed by other testimony, that the disease is known among natives as minmina or a mild form of measles. On the whole I incline to believe that the disease is Rubeola or Rotheln. The symptoms are certainly not those of scarlatina .or measles as ordinarily .seen, nor do they correspond with those of dengue, as we saw it here in 1872. I have however thrown these notes together for discussion, and shall be glad if members of the Society will give us the benefit of their observations and opinions. Dr. Juqgobhundoo Bose remarked that during the last 10 or 13 years he had noticed during the rains an eruptive fever similar to that alluded to. It was decidedly different from measles or scarlatina. There was distinct fever with considerable prostration with increased evening exacerbation. Delirium sometimes appeared at night. The eruption fourth day?not so well marked appeared from the first to theand on the face as on the trunk extremities. It consisted of 60 or so minute papules constituting small patches. The fever lasted from 12 to 14 days.^ The eyes .were watery and conjunctivas very red as if papilated. The heart was weak and irritable, pulse from 120 to 140 small jerky, temperature ranged from 102 to 104?. Infants and children from 5 to 20 were mostly affected,?rarely grown up people. There was sometimes desquamation,- sometimes not. The disease was seen had He two not infectious. or three deaths this year. Want of power of deglutition was a prominent feature in bowels some cases ; generally constipated. Bronchitis of a dry kind sometimes occurs. Urine very high coloured ; no
at
night,
some cases
??
'
subsequent dropsy. At this stage the discussion
was
adjourned.
i'
291
