VOL. III Cleveland Journal JANUARY, 1898 No. 1 T A SUPPOSED CASE OF HYDROPHOBIA BY FRANK E. BUNTS, M. D., CLEVELAND HE frequent reports in our daily papers and the general impression which has become prevalent among the laity that many mad dogs have been running at large in our city, and that many people have been bitten and are threatened with the dread disease, were apparently confirmed by the announcement in nearly all of our daily papers that a genuine case of rabies had developed in Ione Carr, residing at 128 Hamilton street. While I am not skeptical as to the existence of rabies, I am convinced that it is one of the rarest diseases, and that in this part of the country it is practically unknown. For eleven years or more I have been watching for such a case to develop and have, up to the present time, failed to hear of an authentic case in this city. I have, therefore, taken considerable interest in the case of Ione Carr, who was kindly placed under my care by Dr. Elliot on the day of the development of supposed hydrophobic symptoms, and I wish to submit the following report of her case to the Society. The patient was a child seven years of age, rather delicate in health and development, and yet never seriously sick, except with chicken-pox and measles. Her father's family is described as a very nervous one, yet no symptoms of insanity have ever developed in any member of it. Her mother is well and belongs to a healthy family. The child has always been rather nervous and during the dentition period was the subject of convulsive attacks. On May 17, 1897, she was bitten just beneath the left eye by a setter dog, which subsequently bit another child and was then shot by a policeman. No further history of the dog could be obtained. Immediately after the injury the wound was cauterized and dressed by Dr. Elliot. I saw her on May 19; the wound was then in a healthy condition and nothing was done further than to apply an antiseptic dressing. Repair of the wound went on rapidly 220854 and the child was soon well and attending school as usual. On Monday, June 14, some one attempted to set a dog on her, and she became excessively frightened and rushed into the house in a state of wild excitement which required a long time to quiet. She recovered from this eventually and continued at school until the close of the week, though her mother noticed on Friday that she was quite nervous and "twitched a great deal." Saturday morning, June 19, the acute symptoms developed and she was taken to the office of Dr. J. B. Elliot. Dr. Elliot informs me that when he first saw her, she was very much excited and her jaw was moving from side to side and occasionally projected forward with a sudden jerk; her speech was spasmodic, and all attempts at voluntary muscular action were characterized by marked incoordination, so much so that he characterized her attempts to walk to him as closely resembling the bounding of a dog, and to him, her articulation occasionally seemed to be identical with that of the barking of a dog. He prescribed medicine for her but any attempt to get her to swallow it was followed by such alarming symptoms of choking that it was given up. She was then taken home and put in bed, but it was very difficult to keep her there. The slightest noise or jar was sufficient to cause her to leap nearly across the bed. During this time she was apparently rational, understanding what was said to her but unable to reply intelligently on account of the persistent spasmodic action of all her muscles. At about twelve o'clock, noon, she had her first distinct convulsion and from that time on she was kept under the influence of chloroform until one o'clock, when Dr. J. P. Sawyer and I saw her in consultation with Dr. Elliot. She was just recovering from the chloroform and had a slight convulsion at this time. Frothing at the mouth occurred during both convulsions, but it was not of a viscid or sticky character. The child was now somewhat delirious and kept up a persistent talk, sometimes loud and excited, sometimes whispered and almost inaudible, but always of a jerky, spasmodic nature. With the consent of Dr. Elliot she was sent to Charity Hospital and placed under the constant personal supervision of one of the house staff. A specimen of urine, passed early in the morning, was obtained at her home and upon examination a very faint trace of albumin was discovered. A specimen passed after entering the hospital was found loaded with albumin and containing numerous granular casts. Although the child was excited and almost unmanageable there was no attempt at violence on her part, nor did she scratch, bite or otherwise attempt to harm anyone. While at the hospital she had numerous hallucinations, fancying that various children whom she saw or heard talk were her brother or cousin or other relative. She talked incoherently of her school and on other subjects. She was given 1-12 grain of morphin hypodermically, and received bromid of potash and digitalis by the rectum. The administration of medicine by the mouth was practically impossible as it was with the greatest difficulty that she could swallow anything. Twice during the afternoon she swallowed a little water and no special paroxysm or convulsion was evoked by the effort. I saw her last about 4:30 p. m. of the same day; she was still talking and whispering and throwing herself violently about the bed at the slightest sudden noise or other excitement. Her pulse was too rapid to count, and her pupils, which had previously been about normal, became dilated, and it seemed evident that the end was not far off. I attempted to give her water in a spoon but she pushed it away crying "poison." This she did several times, but no convulsion or pharyngeal spasm was evoked. Shortly after this she was given a warm bath, which seemed to soothe and quiet her somewhat, but she died about fifteen minutes after being taken from it. During the last hour of her life she had several attacks of coughing, and during these attacks very considerable quantities of mucus and saliva ran from the mouth. The scar resulting from the bite was not altered in appearance, being of a normal paleness. The following report of Autopsy and Experimental Work were furnished me by the kindness of Dr. Gans, Assistant in Western Reserve Pathologic Department: Autopsy held 16 hours after death. Rigor mortis fairly well marked. The body is that of a fairly well-developed child, seven years old. Considerable post-mortem ecchymosis is seen in various portions of body. The muscles seem equally well set. No scars on the body except the ones already mentioned of bite of dog just below the outer margin of the left eye, which presented the ordinary appearance of a wound healed by second intention, a narrow white line, slightly irregular. The thorax is well formed, symmetrical, the ribs smooth, costal cartilages not calcified. The pericardial space is not covered by lung. Both lungs are retracted. On the right side the pleural cavity contains no excess of fluid. No evidences exist of any pleurisy either old or fresh. The lung crepitates everywhere equally well. On section the cut surfaces are somewhat bloody, slightly edematous. The bronchi seem normal. There are no evidences of pneumonia, or tuberculosis. On the left side the pleura and lung show nothing more than on the right side above described. The pericardium contains no excess of free fluid; the epicardium is normal. The left ventricle is rather loosely contracted, about 10 mm. thick, the muscle somewhat pale; no fibrous areas are demonstrable. The right ventricle is 3 mm. thick, the muscle somewhat paler than normal, the valves are all normal, the coronary arteries thickened. The aorta is smooth, elastic, with no calcareous deposits or atheromatous areas. The liver is of ordinary size and appearance, the capsule smooth, without adhesions to surrounding organs. Over the anterior surface of the left lobe are several light-colored areas, which on section extend into the tissue of the liver about three-fourths of an inch, and are of a yellowish-brown color, |