Page:The Journal of Tropical Medicine, volume 6.djvu/209

THE JOURNAL OF TROPICAL MEDICINE. 177

He is very restless, crying all night. day ; he is very restless and cries all the time. ment : strychnine injection every four hours and cham- June 1, 1903. and much mucus. Colic considerable, tenesmus not marked. I gave him } grain morphia hypodermically and 1 drachm of powdered ipecacuanha in a bolus.

Next morning, March 25th, there was still some blood. There had been three stools, but he had only retained the ipecacunaha for an hour. He had slept and felt rather better. March 26.—After a bad night, owing to his vomiting, he was still very depressed. Colic and tenesmus much less; blood and mucus less. Is taking powdered cin- namon and enemata of starch and opium, as he has refused any more ipecacuanha.

March 28.—In the absence of the Station doctor I saw the case again. He was very miserable and lachry- mose, and I found that there had been great trouble in getting him to take food or medicine. He was in a very emotional state and his pulse was small and soft, and for the first time a little irregular. Treatment : champagne and cinnamon. .

March 29.—The dysentery is much better, but the Station doctor tells me that his mental condition re- mains the same, and that the difficulty of getting him to take food remains and that he refuses the champagne. During the night I was called several times, as the patient was giving alarm owing to his weak and rapid pulse. He is very restless, constantly crying and say- ing he will die. He was given J, grain strychnine and 4 grain morphia and champagne every half hour.

March 30.—He is much the same, acutely depressed and tearful, but says he has nothing to worry him except his personal condition. Thinks he will die. Heart apex is outside the nipple; action irregular and intermittent. Loud blowing murmur over pulmonary area. Has about three mucous stools in the day, but no colic. Temperature normal. Injections of #1, grain strychnine every four hours, quinine and champagne by the mouth and milk and Brand’s essence. Also

_ enema of ipecacuanha daily. March 3.—In the absence of the Station doctor I saw him again. Still depressed ; is worried with some colic and flatus. No mucus in stool, which is fecal and formed. He was easier and pulse 120, but stronger and less irregular. During the night I saw him several times as the Station doctor was himself ill with dysen- tery. Heis much worse. Pulse 140 and very irregular. No stools. Is getting champagne and Brand’s essence every hour. Digitalis and ammonia by the mouth.

April 1.—He was steadily going down hill. The heart apex is nearly out to the axilla. Pulse 120, feeble, irregular. Will only take food after great coaxing. His condition remained the same during the Treat-

pagne, milk and Brand’s essence when possible. During the evening he became unconscious. A “ typhoid con- dition” set in, with involuntary passing of urine, &c. No stools. Loud blowing murmur all over chest.

_ Apri 2.—Pulse hardly perceptible. He died quietly at midday.

Previous History.—The previous history of the case ad been shortly this: He had at the time of the onset

} of his illness only returned two months before from leave in England, whither he had gone to recruit after the end of the Soudanese revolt. Before he went on leave he had had a good deal of fever up country, and owing to the nature of the duties and hardships which fell to the lot of all the Government officials during this time he had been a good deal exposed. Conse- quently he was in very poor health when he went on leave. During his leave he married, but owing to the exigencies of the service left his wife in England on his return to Uganda. Moreover, when he reached the coast on his way out, he received the news of the death of a near relative, and there is no doubt that when he left the coast he was in poor health and worried about his affairs, and during the two months’ journey up he had been on and off suffering from slight fever. On the advice of a brother official who had unfortunately been reading of Professor Koch’s work on the relation of quinine to blackwater fever, he had refused to take quinine for his fever. Unfortunately, however, he seems to have been under the impression that phena- cetin (which was a common household remedy in Uganda for the febrile paroxysm) was of the nature of a prophy- lactic and was in the habit of taking one or more 5-grain tabloids daily, so much so that though his travelling companion told me that he had started from the coast with a number of bottles of this drug, there were none in his possession at the time of his death. Whether he had been taking any just previous to his illness I cannot say, but I know that he had none ten days before his illness when I met him on the road with his caravan and he asked me for some.

As I understood he had six bottles each of 100, 5-grain, tabloids when he left the coast, in less than sixty days he must have taken 3,000 grains of the drug. When he was taken ill, I was, as was his regular medical atten- dant, ignorant of this state of things, and it only came to my knowledge on making enquiries, after finding several empty phenacetin bottles among his things after death.

The disease from which he died was an ordinary attack of acute dysentery of a not very severe kind. The ultimate cause of death was undoubtedly the result of failure of the dilated heart. The extraordinary de- pression from which he suffered all through his ilness and the rapid dilatation, which were such puzzling features of the case, may, I think, be fairly attributed to the inordinate use of phenacetin. The dysentery itself was far from being severe, but in this case it was accompanied by an extreme depression and despon- dency followed by acute cardiac dilatation, so rapidly fatal, in spite of treatment.

I am aware that some French observers have noted heart dilatation as a fairly common complication of acute dysentery. This may be so, but has not been my experience either in Uganda or Egypt.

I am sorry that in this case we ever attempted to give the classical ipecacuanha. The melancholy and depression were at first put down to the natural home- sickness of a man just from leave and the treatment was persevered with. In this I think we were wrong. Of all the recognised methods of treatment, it is the most unpleasant, worrying and distressing, and I have long since abandoned it.