Items of Interest

Liquor licenses are to be granted to the druggists of Somerville, Massachusetts, heretofore a banner temperance town.

Dr. Edward S. Peck has been appointed professor of diseases of the eye in the New York Post-Graduate Medical School and Hospital.

To prohibit the issuing of marriage licenses to any person suffering from insanity, dipsomania, syphilis, and tuberculosis, a bill has been introduced into the Maryland Legislature.

The Pennsylvania Sanitary Commission has been organized for the purposes of succoring the sick and wounded during the war and bringing home and burying those who may die.

To found a prize for the best essay on the practical prevention of disease, to be awarded as frequently as the interest thereon shall amount to $100, the late Dr. Oliver A. Judson of this city left $1000 to the College of Physicians.

The bill passed by the New York State Legislature giving shorter hours to drug clerks has been vetoed by Mayor Van Wyck on the ground that the bill gives too much power to the Board of Health, and that this is not in the interest of public policy.

The Alumni Association of the University of Michigan is compiling a directory of all the students who have attended the institution in any of its various departments. Information should be sent to James H. Prentiss, General Secretary of the Alumni Association, Ann Arbor, Michigan.

held a series of

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also acquired at this time the habit of sucking her lower lip, which produced an extensive excoriation, giving her a very repulsive appearance. The marks of this excoriation persisted long after convalescence was estab. lished as a deep line of pigmentation parallel with the red margin of the lip.

At the beginning of the fourth week, localized, dusky red, swollen elevations and patches were discovered on the outer side of the right leg, over the right hip, on the left thigh near the apex of Scarpa's triangle, in the breasts and upon both upper arms. They were knotty and hot, very tender, and interfered with free movement of the limbs. They were evidently areas of thrombophlebitis. Those in the right leg, left arm and both breasts, suppurated, and had to be treated by free incision. There were also a large number of smaller hemorrhagic patches over the trunk and limbs, none of which suppurated.

The urine, which had been albuminous, now became purulent, and, at times, large quantities were passed; on one occasion 132 ounces in one day. The amount of fluid given the patient on that day was 185 ounces. I have found an occasional comment on polyuria during typhoid fever, but no case in which such large quantities were passed. At the end of the fourth week the patient in her delirium complained of excruciating pain in the splenic region, moaning for hours at a time. It was not possible to discover the cause by any physical signs. At intervals the delirium gave place to deep stupor and even coma. On the 15th of September the patient had a general convulsion, followed by a chill; the temperature was 105.8° F.; the pulse varied from 180 to 200. Several days later another convulsion and chill occurred; this was repeated three or four times within the next few weeks. During the entire month, when the patient was not stuporous, she was almost maniacal, and at times was fed with great difficulty. Bedsores developed, which were slow in healing. The respirations were rapid throughout the disease, except on one occasion when the patient presented a peculiar periodic type of breathing, respiratory movements occurring in cycles of two; that is, she would breathe twice, then stop; there being six of these periods in a minute. As

she had received a fourth of a grain of morphin, the abnormal breathing was thought to be due to the action of the drug.

During the sixth week, the fever and all the symptoms described continuing, another phenomenon appeared, viz., peculiar striæ upon the knees, around the ankles, and upon the outer aspect of the upper right arm; they seemed to be fissures in the skin.

Naturally the emaciation was rapid and extreme; the muscles (the biceps for example) having wasted away to a thin band. The fever persisted exactly two months, and declined rather rapidly in the course of a few days to normal, where it remained with slight variations for one month. On November 15th it rose to 104, and until December 5th, fluctuated from 101 in the morning to 103 in the evening. This attack, while it did not have the appearance of a relapse, for there were no other symptoms, is best interpreted in that way.

The nervous symptoms became modified when the fever declined, although it was several weeks before her mind became quite clear. During a period of six weeks, she was alternately delirious, stuporous, comatose, and maniacal, and it was not until December 5th, 110 days after I first saw her, that she began to manifest a natural interest in her surroundings.

Coming now to the treatment2 of the case, I may say that before the diagnosis of typhoid fever was established the patient was treated for influenza.

For the control of the temperature, sponging was employed, the family being unalterbly opposed to the use of the tub. When it became very high cold packs were tried, but had to be abandoned on account of their deleterious effect upon the patient. She became greatly depressed, the pulse was almost imperceptible, and once, after a pack, she went into a rigor, which lasted twelve hours. After some hesitation, I resorted to the use of acetanilid, since external measures, as far the temperature. as they could be used, failed to bring down

Eight grains were given within six hours and the temperature fell from 106 to below 95, that being the initial temperature on

2 I desire express my deep obligation to Dr. David Riesman, who kindly saw this case with me, and to whom much of the treatment, and its successful application, is due.

my thermometer. At the same time the patient had a drenching sweat; the pulse was fluttering and feeble. Under stimulation the temperature rose, registering 95 after two hours, and the heart became stronger.

The rapid action of the heart called for free stimulation, and whisky was given in large quantities, from 20 to 22 ounces daily. Strychnin was also employed throughout the disease by hypodermatic injections. On several occasions the heart seemed to fail almost entirely, the pulse, very thready, rising to 170 and 180. For these attacks of heart-failure, camphor given subcutaneously was found to be the best agent, and never failed. It was given in olive oil, two parts of camphor to ten of oil, through a large needle. It is ex tensively employed as a cardiac stimulant in Germany, but is not much used in this country.

Very early in the course, hypodermoclysis was resorted to, and injections of normal saline solutions were given into the loose tissues of the breast, from one to one and a half pints being used; the effects were striking and unmistakable, the heart became stronger, the pulse fuller, the quantity of urine increased, and for a little while after the patient was always more quiet.

Suppuration of the breasts was probably not connected with the injections, since careful antisepsis was always employed, nor did this have anything to do with the swelling to which I have referred, since it had subsided before the suppuration took place. It seemed to be connected with the thrombosis.

In view of the marked bronchitis, which at times reached such a degree that the existence of pneumonia was suspected, inhalations of oxygen were employed, and though we frequently had trouble in getting the patient to inhale it, whenever we succeeded, improvement was noticeable.

Strong coffee was also employed throughout the height of the disease both by mouth and rectum. The patient took a fair amount of nourishment by dint of persistence on the part of the nurses. sisted of peptonized milk, gruels, liquid peptonoid, etc.

It con

The temperature chart shows that the primary attack lasted 61 days, and including the second attack, with the almost

afebrile interval, the total duration of the disease, as I mentioned before, was 110 days. Menstruation, which had been in complete abeyance during the illness, returned in the second week after she was about.

Having given the clinical features and line of treatment pursued, I shall speak for a few moments on some of the more important and peculiar features of this protracted case of typhoid fever.

The enlargement of the breasts is a rare symptom, and I do not find it mentioned in any of the text-books-even Murchison does not speak of it. There are, however, a few cases reported. Vallin' observed edematous swelling of the breasts in women suffering from typhoid fever, and Leudet reports four cases under like conditions, one terminating in suppuration. All the cases were women. The explanation of the condition. in my own case is difficult, but it is not improbable that it was compensatory for the amenorrhea, although it might occur idiopathically.

Hemorrhagic patches, multiple thromboses, and abscesses in typhoid fever, are not very rare. Nichols reviews the literature and reports cases. The noticeable feature in this case was the great number, and their peculiar distribution, being found where they are not often observed, viz., upon the breasts and hip. It is extremely probable that the acute splenic pain was due to thrombosis in that organ, and it is likely that the appearance of pus in the urine was due to a similar condition in the kidneys. The polyuria is very striking in this case, and I am inclined to think it was due in part to the saline injections.

During the semi-maniacal attacks, the patient's conduct was almost unbearable. She was insulting and vicious, displaying

3 Vallin: Bull, de la Soc. Clin, de Par., 1877, vol. i, p. 148. Lendet: Clinique de l'Hôtel Dieu de Rouen. Reported by Vallin.

Nichols: Montreal Medical Journal, June, 1896.

at times a peculiar cunning, and though she often seemed to understand what was said to her, she was absolutely uncontrollable, and the temperamental traits referred to showed out most clearly during these periods of emotional excitement.

This state is very rare during the course of typhoid fever. It is well known that post-typhoidal mania and other psychic sequelæ, are not infrequent.

The abscesses at first alarmed me very much, as I feared similar conditions might arise in the brain, for the patient certainly had a pyemic condition, but as the case progressed it became evident that they were in a manner beneficial, as with the onset of suppuration the mental phenomena cleared, and there was a distinct improvement in the patient's condition when the abscesses were opened. This curious reaction is not surprising when we remember that grave cases of typhoid fever have been successfully treated by establishing an abscess in some part of the body through the injection of turpentine. These, known as Fochier's abscesses, seem to exert a powerful derivative action; in one case, in which the symp

toms simulated a meningitis," the pus from the artificial abscess showed the bacillus of typhoid. The treatment by producing a collection of abscesses is much in vogue in France.

Convulsions are very rare in typhoid fever; Murchison' says they are rarer than in typhus, and less frequently uremic. In 2,960 cases observed by him in the Fever Hospital only six had convulsions.

The peculiar striæ are most uncommon. Sir Dyce Duckworth reports a case in which these cutaneous lesions appeared some time after the patient recovered from an attack of enteric fever, and in whom they were extremely painful. He refers to a number of cases recorded and concludes that this condition must be a very rare sequela of typhoid fever. In my case the striæ appeared during the height of the patient's illness, and when her mental condition prevented the possibility of determining whether the areas affected were specially hyperesthetic.

British Medical Journal, Epitome 3, July 4, 1896. 7 Murchison: Continued Fevers, 1884, page 541.

8 Dyce Duckworth, British Journal of Dermatology, De cember, 1893.

neck, two or three months previously. With his clothing on he seemed, like the first patient, to be suffering from paresis of the deltoid muscle. He complained of a tender spot in the posterior portion of the neck on the side corresponding to the apparently injured arm. After he was stripped, his right scapula was seen to project outward along the vertebral border, and the supra- and infra spinatus muscles were much atrophied. When the scapula was held against the ribs, and pressed somewhat forward by the hand of the examiner, to replace in this way the action of the paralyzed serratus magnus muscle, the arm could be elevated quite