High Fever Case Study

remained in bed ever since. Her temperature was first taken March 28, when it was found to be slightly above normal. Without discoverable local cause, it rose steadily till it reached 108° six days later. It fell to normal two days later, but the evening record has since been several times as high as 99.4°. With the rise in her temperature, her color, previously: very pale, became lemon-yellow, but the conjunctive remained a pearly white. She was greatly ex- hausted and somewhat deliriotis, vomiting occasionally either food or pbile-stained mucus. A very grave prognosis was at this time given by the attending physician. When seen April 9, patient reported herself as feeling very well, and her mental condition was bright. She was markedly anemic, but with only a slight yellow tinge remaining. The tongue and mucous membranes were very pale. There was a deep ulceration on the left side of the nasal septum and several crusts were seen on the right. A systolic murmur was heard in the vessels of the neck. The heart’s apex was in the fifth space in the nipple line. The cardiac dulness extended a finger’s breadth and a half to the right of sternum. A systolic murmur was heard all over the precordia, rough over the base, but becoming softer as the apex was approached and transmitted a short distance into the axilla. The pulmonic second was slightly ac- centuated. The upper border of the liver was at the fifth rib, and its smooth edge could be felt two fingers’ breadth below the costal margin. The edge of the spleen was readily palpated. The ankles were slightly cedematous. The ophthalmoscope showed a normal fundus. Physical examination was otherwise negative. 10 CASE 4— Continued Urine, sp. gr. 1012, pale, acid, contains the slightest possible trace of albumen. Sediment slight, consisting of leucocytes, and a rare normal red cell; no casts. A blood count on April 3 showed 300,000 reds, 5400 whites, Hgb. 10%. A differential count of 400 whites showed polymorphonuclear 72%, large mononuclear 12%, small mononuclear 15%, eosinophiles 1%. Ten megaloblasts, 5 normoblasts, and 3 micro- blasts were seen. Poikilocytosis, macrocytosis, and polychromato- philia were present. A second count made to-day showed 1,000,000 reds, 5800 whites, Hgb. 25%. A differential count of 300 white cells showed no special change in the proportions. Four megaloblasts, 11 normoblasts, and 2 microblasts were found. 1, What are the common causes of frequent micturition in women and in men? In women, (a) nervousness and debility from any cause; (b) less often cystitis (‘“‘simple,” gonorrhceal, tuberculous, or calculous); (c) the pressure of the pregnant uterus or other tumors; (d) pyelitis (tuberculous or septic). In men, (a) prostatic obstruction and its results; (b) cystitis (gonorrhceal, tuberculous, ete.); (c) pyelitis (as in women). Occasionally, in either sex, chronic nephritis may produce frequent as well as profuse micturition. 2. What are the possible causes of a systolic murmur like that here described? (a) Arterio sclerotic roughening of the aortic arch or of the aortic valves; (v) Anemia and other causes of insufficient muscular contraction of the valve-orifices (but such murmurs are usually louder in the pulmonary area). (c) Aneurism of the aorta; (d) Aortic stenosis (provided always that other signs of that lesion are present, thrill and plateau pulse especially). 8. How are the “feverish turns’’ to be explained in this case? Fever in chronic angmia, especially pernicious anemia, is not uncommon. After any profuse hemorrhage it often occurs in neurotic persons. 4. Diagnosis? Prognosis? Treatment? Diagnosis: The blood is characteristic of pernicious anemia. The hemorrhages are probably symptoms, not causes, of the anemia, for such a blood picture rarely if ever results from hemorrhage of the type here described. The respiratory, cardiac, and digestive symptoms, as well as the cedema, weakness, and fever, can be explained by the anemia. Other diseases are excluded by the absence of physical signs pointing to them. Prognosis: A wave of improvement has apparently begun in this case and there may be one or two periods of great improvement, or even perfect health lasting several months each. Within two years death is almost certain to follow. Perhaps two cases in a hundred recover. Treatment: Fowler’s solution, 2 drops after meals well diluted and increased 1 drop daily until toxic symptoms appear, is considered the best method of prolonging life; 50 to 60 drops a day may be taken for some weeks. A few cases have improved after vigorous laxative treatment, i.e., enough cascara to produce several movements daily for weeks at a time. Rest, fresh air, and as much food as the stomach will bear are indicated. Hemorrhages are to be checked by pressure with gauze, with or without adrenalin solution. Iron. oxygen, and bone marrow are of no value. 12 CASE 5 A vigorous man of 62 comes of a gouty family, many members of which have been long-lived. His mother is said to have died of cancer, seat unknown; and a paternal uncle of gastric cancer. In recent years the patient had had two brief attacks of pain and swelling in the great toe-joint; he has also had eczema, said to have been considered of gouty origin. For some years he has occasionally lost moderate quantities of fresh blood from the rectum. He has been a good, though not a free liver; and has always taken much exercise in the open air. Six months ago he was duck shooting on Lake Erie, and, the water being very low, he says that for three weeks he worked harder than ever before in his life, pushing and dragging his boat in shallow water. After returning home he felt tired and was indis- posed to exert himself in ‘any way. Soon after he began to suffer every few days about 1 p.m. from severe continuous pain just below the right costal border and outside the edge of the rectus muscle. The pain bore no apparent relation to the quality of food; the attacks lasted from one half an hour to three hours, and were relieved by the passage of gas upward or downward. Sometimes the escape of gas seemed to be promoted by cooking soda or aromatic spirits of ammonia. The pain is sometimes very sharply localized, even to a point no larger than the finger tip; but sometimes spreads to the left and downward over an area as large as the palm of the hand. Gradually the attacks have increased in frequency and come on daily; of late, toward 5 P.M. There has been at times slight nausea, apparently due to the extreme severity of the pain. He never vomited until two days before he was seen, then repeatedly during the night; the vomitus was not character- istic. Position does not seem to influence the pain except in so far as it may aid the expulsion of gas. A week or ten days before he was seen, he had on two successive days black movements of the bowels, one very copious, unattended by rectal pain, faintness, or subsequent loss of color. Fever has been absent, and the urine negative. The appetite and ordinary digestion have been fair; there has been no noticeable loss of flesh or color. The tongue is slightly coated, the fingers show some gouty deposits, there is some tenderness on deep pressure just above and to the right of the navel; the smooth edge of the liver can be felt to descend below the right costal border, but only on full inspiration. Physical examination is otherwise negative. 1, What diseases often cause epigastric pain relieved by the belching of gas? Dys- pepsia of various types, angina pectoris, neurasthenia. Usually motor dis- turbance and not fermentation is the cause of such belching. oie, nN 14 CASE 5—Continued 2. What type of stomach trouble is to be expected at the age of 62? Cancer; rarely ulcer; sometimes the gastric symptoms depending on gall-stones and their results. 3. What is the relation of the gout to the other symptoms? Gout and arterio- sclerosis are often closely associated. Arterio-sclerosis is one of the diagnoses to be considered in this case. 4. Diagnosis? Prognosis? Treatment? Diagnosis: Duodenal ulcer is strongly suggested by the position and sharp localization of a pain which tends to occur when the stomach is empty, by the tarry stools and the relief by alkalies. Hepatic cirrhosis is possible, but rarely causes such pain and cannot be diagnosed unless evidence of portal stasis appears. Angina pectoris may cause abdominal pain relieved by belch- ing, but never produces mekena. There are no physical evidences of arterio- sclerosis, but it may nevertheless be present. On the whole, the chief symptoms in the case seem best explained by the diagnosis of duodenal ulcer. The course of the case apparently confirmed this diagnosis. Prognosis: Most cases recover under proper treatment in the course of many months, but relapses are not uncommon. Treatment: Exclusive rectal feeding for ten days. Then » gradual retum to full diet with meat and fish almost or quite excluded. Carbohydrates and fats should make up almost the whole of his diet, but milk may be taken freely. If the symptoms persist or recur, operation may be necessary. oom 16 CASE 6 A child, 7 years of age, of healthy parentage, had made frequent complaint of pain in the left side of abdomen and was found by her mother to be rapidly losing flesh and strength. There was also an ac- count of quite frequent voiding of high-colored urine, with a brownish sediment. After several weeks the emaciation progressing, the mother noticed that the left side of the abdomen was larger than the right; that there was pain and tenderness on pressure, and that periods of “constipation” occurred, followed by the escape of large quantities of semi-liquid feces, without much change in the size of abdomen or relief to the pain and tenderness in left lumbar region. About this time the patient was taken to a physician, who confirmed the mother’s observation of loss of flesh and strength, for the child was pale or sallow, emaciated and extremely weak. In the left lumbar region a mass, irregular in outline and surface, painful on palpation, extended into the umbilical region and upwards to the margin of ribs in front; percussion showed tympanitic resonance over the central portion of the tumor. Elsewhere the tumor was flat on percussion. A specimen of urine showed: Reaction, acid; sp. gr. 1014; sediment, brownish and consisting of blood and brown granular matter. There were no casts, and the quantity of albumen present was small. 1, What abdominal tumors are most frequent in children? Sarcoma of kidney; congenital cystic kidney, dilated colon, secondary enlargements of spleen and liver. 2. How are tumors of the kidney to be distinguished from enlargement of the spleen? The sharp edge of the spleen and its notch can usually be felt. The kidney produces a rounded tumor palpable bimanually with one hand in the flank. The inflated colon traverses tumors of the kidney but passes behind those of the spleen. 3. Diagnosis? Prognosis? Treatment? Diagnosis: The age, the tumor, the emaciation, the hematuria without casts, the apparent anemia, strongly suggest malignant disease of the kidney, and at this age sarcoma is the commonest type of malignant renal disease. Con- genital cystic disease of the kidneys does not produce such cachexia and is almost never associated with hematuria. The condition of the bowels ex- cluded dilated colon. The characteristics of this tumor are not those of a spleen. The tympanitic resonance over its centre is very possibly due to the colon. Prognosis: Recovery after operation has occurred, but is rare. Operation in this case confirmed the diagnosis, but was followed by recurrence and death six months later. Treatment: Surgical interference offers the only hope of recovery and should be undertaken at once. Medical treatment can only alleviate the present symptoms, —i.e., the emaciation, hematuria, and pain. 18 CASE 7 A married woman of 50, has had three children, the youngest 17, no miscarriage, and has passed the menopause without disturb- ance. Soon after the birth of her second child she became unconscious with dilated pupils, had convulsions, right hemiplegia and aphasia but recovered entirely. Her domestic life has not been happy for some years. During the eighteen months that she has been under the care of her present attendant she has had emotional attacks, periods of mental depression and insomnia, goes to bed, refuses food, and if crossed becomes hysterical. Passed last summer in the country with benefit. In the autumn she went to the office of her physician for swelling of the face and puffiness of the eyelids, and complained that the skin was dry and perspiration deficient. Nine months later these symptoms persist. She denies special sensitiveness to cold. Several examina- tions of the urine have been made with negative results. The twenty- four-hour quantity is not known. The pulse is 72, regular; the tem- perature normal; the blood negative; the tongue clear. The complexion is somewhat waxy; the eyelids are rather baggy and translucent; the whole face had a puffy look. The skin — on a warm day, June 17 — is slightly moist. Visceral examination is negative except for a mobile right kidney. No motor paralysis; reflexes and sensibility normal. 1. What is the significance of the mobile right kidney in relation to the other symp- toms of this case? It is insignificant and the physician should on no account mention its presence, which may give rise to great alarm. . 2. What was the cause of the hemiplegia and aphasia? The toxemia known as eclampsia seems to account for them. A small cerebral hemorrhage is possible. 8. What test would make the diagnosis easier? (See diagnosis.) 4. Diagnosis? Prognosis? Treatment? Diagnosis: The age and sex, the mental symptoms, the dry skin and puffy, waxy face,-with negative urine and heart, strongly suggest myxcedema. The therapeutic test (see question 3) confirmed this suggestion. Thyroid extragt produced a rapid improvement and final cessation of all the symptoms. The only atypical features of the case are the absence of subnormal tempera- ture and of sensitiveness to cold. The apparently eclamptic seizure in early life is interesting in view of the possible connection between eclampsia and deficient thyroid activity which various writers have recently suggested. Prognosis: Under persistent thyroid treatment she should remain well for her natural term of life. Treatment; Any of the standard thyroid tablets may be given in doses of 2 grains thrice daily, gradually increasing until the pulse rate quickens. The drug should then be continued at whatever dose can be borne without ma- terially increasing the pulse rate above normal. Considerable loss of weight usually takes place in the earlier weeks of treatment. 20 CASE 8 A coachman, 42 years old, of good family history, is seen April 20. Health has always been good except for a severe attack of penumonia three years ago, which was followed by phlebitis in the left femoral vein. The left leg has remained somewhat swollen, and has been tense and rather painful toward night. It has caused rather more discomfort than usual during the past few days. Yesterday morning he got up feeling as usual, but on reaching the house of his employer felt nauseated, and had some diarrhwa, which continued during the day. He felt feverish and weak. Went to work again this morning, but gave up after half an hour owing to nausea and pain in the lower abdomen, and went to bed. At eleven o’clock had a distinct chill. Was seen for the first time at 12.45 p.m. The patient was a stout man who looked acutely sick, The chest was negative. Owing to a thick fat layer, examina- tion of the abdomen was not altogether satisfactory; it was some- what distended and tympanitic and there was considerable tenderness over the lower portion below the level of the iliac crests, but no area of special tenderness, nor could a tumor be felt anywhere. The left leg was somewhat larger than the right throughout. The skin below the knee pitted slightly on pressure. There was a little tender- ness over the femoral ring. The temperature was then 103, pulse 110, respirations 26. At 3 P.M. urgent summons were received to call immediately as the patient had had a convulsion, was breathing rapidly and with great difficulty, and was very cyanotic. 1, What are the commonest causes of cyanosis? Heart disease (valvular or parietal), emphysema, pneumonia, asthma, methsemoglobinemia (usually from acetanilid in headache powders). 2. What important data do you miss in the account of this case? A leucocyte count and urinary examination. 3. Do you expect a leg to remain swollen three years after an attack of phlebitis? ‘Yes; the leg does not often regain its normal size. 4. Diagnosis? Prognosis? Treatment? Diagnosis: The symptoms at the first visit were very indecisive. Diarrhea, nausea, abdominal pain with fever and weakness, suggest nothing more than acute gastro-enteritis, and even the tenderness found in the lower abdomen is not distinctive. Peritonitis (possibly from appendicitis) was considered. But the history of an old femoral thrombosis and the tenderness over the femoral ring lead us to think that the thrombus may have progressed up into the abdominal veins and to interpret the later pulmonary symptoms (sudden onset of dyspnoea and cyanosis) as pulmonary embolism from the thrombosed abdominal veins. Autopsy showed this condition. Prognosis: Pulmonary embolism is almost invariably fatal within a few min- utes or hours, but a few cases with all signs of the disease have recovered. Treatment: Oxygen is usually administered and may possibly be of some ser- vice. Otherwise the treatment is purely expectant and symptomatic. \ 22 CASE 9 J. B., male, aged 32 (occupation, cook), came to the out- patient department of the hospital Jan. 6, 1899. His family history was negative and previous history good. He denied any syphilitic infection, but admitted having had a urethritis some years previously. He had never had an attack similar in character to this. The present illness he dated from December 30, 1898, eight days before applying for relief at the hospital. The first symptoms seemed to have come on rather suddenly with a rigor of marked severity, followed by fever and, later, by profuse sweating. Almost immediately afterward he was seized with intense muscular pains, extending over the trunk and limbs; these pains were agonizing in character, increased on the slightest exer- tion, and had been present, with varying degrees of severity, until his admission. They prevented him from sleeping, and were spoken of by the patient as being not unlike rheumatism, 7.e., dull and aching, while he was in the recumbent posture, becoming intensely lancinating as soon as the slightest exercise was attempted. His appetite, which had previously been of the best, was absolutely lost and he had eaten nothing for three days. With the exception of some slight frequency of micturition and a slight cough with expectoration, there was nothing else of importance in the history of the illness. Examination: The patient is rather a large, well-formed man, the mucous membranes of good color, tongue moist, and with a slight white fur. The eyes are markedly injected, the eyelids slightly but distinctly cdematous, and an erythematous area above the swelling. Negative results were obtained everywhere on auscultation and percussion, except at the bases of both lungs behind, where a few moist rales were made out. The heart sounds were quite clear. The liver and spleen were not palpable; the abdomen was soft and natural in appearance, nega- tive results being obtained on palpation. No rose spots were seen. There was no superficial glandular enlargement. Pulse was 100, respiration 24 to the minute. The temperature ranged in the vicinity of 108° for three weeks and then gradually subsided. The urine was normal in color, acid, sp. gr. 1026. Microscopically,