REPORTS OF FATAL CASES, WITH NECROPSIES.

ENTERIC FEVER.

CASE 1.

Cerebro spinal meningitis.

F. G.; aged 29 years; born in Austria; admitted to marine ward, German Hospital, Philadelphia, Pa., March 8, 1898; died March 13, 1898.

Family history.-Negative. For past week has had feeling of general malaise, intense headache from beginning of attack. Bowels have not moved for past four days. Has had chills at irregular intervals since beginning of attack; were not followed by distinct fever or sweats. Headache is general in character but more severe in occipital region. Has had no epistaxis, cough, or expectoration. He felt sick enough from beginning of attack to be in bed. On admission temperature 38.2° C., pulse 98, good volume and compressible. Pupils about normal in size. Tongue heavily coated. Abdomen was scaphoid; no tenderness or gurgling in right iliac fossa. Area of splenic dullness enlarged. No eruption was noticed on any portion of body. Examination of heart was negative. Lungs normal except at left apex, at which point there was dullness on percussion and complete absence of breath sounds. Examination for malarial organisms was negative. Widal's reaction was positive both by city board of health and German Hospital laboratory. Three days after admission there was conjugate deviation. Urine showed trace of albumen, many leucocytes, hyaline, epithelial, and pale granular casts. Face cyanosed. On day of death, about twelve hours before his demise, there were physical signs of consolidation of greater portion of lower left lung. Opisthotonos present.

Autopsy. Height about 1.73 meters. Post-mortem lividity very marked. Rigor mortis also very marked, and could only be broken up in arms, for instance by applying a great amount of force. General nourishment very good. Pupils equal and moderately dilated. The heart weighed, after opening, 430 grams. The mitral, aortic, tricuspid, and pulmonary valves were all found in good condition. The aortic and pulmonary were found competent by the hydrostatic test. The walls of the ventricles were normal macroscopically, and the usual proportion of 4 to 1 was maintained. The thoracic aorta was found clear and smooth throughout. The abdominal aorta also found clear and smooth, except where the bifurcation into the iliacs takes place there were a few specks of atheromatous change. The femoral and other arteries and veins, so far as observed, were found normal. The nares, larynx, and trachea presented no marked pathological changes. The left lung weighed 1030 grams. The pleural cavity was moistened by a serum-like fluid. Near the apex the cavity was nearly obliterated by many dense adhesions which were broken up with some difficulty. The entire lower lobe of the lung appeared to be consolidated, red in color, friable, and portions when placed in water sank at once, also did not crepitate when squeezed between the fingers, and gave sense of resistance when pressed upon, like a

piece of liver for instance. The right lung weighed 820 grams. Nothing abnormal was noticed about pleural cavity, except at apex, where it was obliterated. The pleura was bound down in many places by adhesions to the pleural wall, which apparently were recent in character and readily broken up. The middle and lower lobes presented a normal appearance. In the greater portion of the upper lobe, but especially toward the apex, the lung showed evidences of consolidation. Near extreme apex and posteriorly there was a cavity about 5 cm. in diameter, in which there was a caseous material; many bronchi were bunched together, the lung structure apparently having been destroyed between them; the cavity was near the surface. Lower down there were several masses of fibrous tissue, encapsulated in the lung structure, very resistant on section, firm, and inelastic. The lung structure on section presented many tubercles about the size of a millet seed. The peribronchial glands were much enlarged and softened. On section they presented a caseous material, also some tubercles. The organs all bore the normal relationship to each other. The omentum was somewhat shortened. The peritoneum showed no pathological changes. Tongue was heavily coated with brownish-white fur. The pharynx was congested. The oesophagus showed no pathological change. The stomach contained a small amount of fluid which resembled curdled milk. Walls were coated with a tenacious slimy material. The diameter of the pylorus was 1.5 cm.; the diameter of the cardiac orifice 2.5 cm. The small intestine was congested. The ileum presented six oval ulcers in its lowest portion, opposite to the mesenteric attachment, their long axis in the long axis of the gut, their floor smooth and slimy, edges thickened and undermined. Mesenteric glands were enlarged, especially those in direct connection with that portion of the intestine in which the ulcers were found. Small areas of the large intestine were congested at points. The hepatic flexure and transverse colon were filled with hard fecal masses, which when mixed with water made a pea-soup material in appearance. Rectum was found, patulous and not altered from normal. The capsule of the liver was adherent, especially the diaphragmatic side; on attempting to strip it much difficulty was experienced, small bits of liver tissue being torn away. Macroscopically the condition presented a perihepatitis. The liver was chocolate red in color, weighing 1,600 grams, resistant to the touch and cut harder than normal, and on section presented the macroscopical appearance of an oncoming cirrhosis. The microscopical examination will be appended. The gall bladder was about half filled with bile. The ducts all found patulous, the wails somewhat thickened. Pancreas: Normal in appearance; weight, 115 grams. Left kidney weighed 150 grams. Appeared larger than normal; was congested. On section the cortical portion was found thickened; small areas of hemorrhagic change were found in medullary portion. Capsule stripped readily. Right kidney weighed 190 grams and presented the same general characteristics as the left. The pelvis contained a small amount of fluid which resembled cloudy serum. Pelvis and ureters: These parts appeared normal. The urethra had about the normal caliber throughout; on the introduction of the sound no strictures were observed. On longitudinal section the penile portion was somewhat congested; otherwise was normal. The prostate was palpated through the rectum and not found enlarged. On section no changes had taken place. The right and left suprarenal bodies showed no macroscopical changes, each weighing 10 grams. The general shape of the head had a tendency to squareness or box shape. The skull proper was of average thickness. The membranes of the brain were deeply congested. The veins and arteries were engorged. A large vein running in the membrane that covered the upper portion of the right occipital lobe had in its course an air or gaseous embolus, upon either side of which there was blood; no puncture in the vein could be observed. On the cortex there was much lymph, especially on either side of the longitudinal sinus. This lymph was immediately under the arachnoid and was of a yellowish

white color and of a caseous consistency. The brain to either side of the longitudinal fissure was covered with a sero-purulent material which filled the various fissures and sulci to about the general brain level. The medulla was well covered with a purulent exudate. The brain weighed 1,320 grams. Spinal canal: The canal was opened throughout the entire extent; the membranes were deeply congested; veins much engorged; at the greater and lesser curvature of the spine there was a bulging of the coverings of the cord; on palpation a sense of fluctuation was imparted to the fingers. On incision a purulent exudate was found at these points, just below the arachnoid; the cord was covered throughout with a lympho-caseous material, but at point mentioned above it existed in much larger quantities. Cultures taken from the surface of the brain and at several points along the cord revealed a growth of staphylococcus aureus and albus. A culture taken from the spleen immediately after opening the body revealed a growth of pure typhoid bacilli. Death was due to cerebro-spinal meningitis, complicating enteric fever. Addendum: Liver-Microscopical examination of the organ revealed marked increase in interstitial tissue around the blood vessels, the vessels themselves being thickened. The liver cells contained a pigment, part of which was a hæmotogeneous material, reacting to the appropriate chemical test.

CASE 2.

Perforation-Peritonitis-Aneurism superior vena cava.

F. I.

R. L. (colored); aged 33; nativity, Maryland; was admitted to the United States Marine Hospital, Baltimore, Md., April 9, 1898, and died April 28, 1898.

History.-Four days previous to admission to hospital he received a severe blow in the left hypochondriac region. The next day there was great soreness over the abdomen. Had one stool from the time of the receipt of injury until admission to hospital, and some blood, he says, was passed at that time. On admission temperature was 40.2° C. Patient complains of tenderness in abdomen; bowels are constipated, and slight tympanitis is noticed. Tongue is heavily coated, pulse rather rapid. Constipation persisted for several days and cathartics were given several times before a stool was passed. When the tendency to constipation was overcome a diarrhea set in and stools of a very dark color and of foul odor were voided. Later on the stools changed in character, being ochre yellow in color and of typhoid character. Urine examined showed no albumen nor sugar, and examination of the blood for malarial organisms was also negative. On April 19 the blood gave Widal reaction and diagnosis of typhoid was made. Meanwhile some pain in the abdomen continued and an abscess pointed in the ischio-rectal region, and on being evacuated was found to contain a dark foul-smelling fluid of the same general character as the diarrheal fluid already mentioned, although at the autopsy there was found to be no connection with the pelvic cavity. Patient had a severe chill, followed by a temperature of 40° C., on the 10th, and several at irregular intervals later. Cold baths were given at short intervals and strychnia sulph. administered every three hours, and salol and bismuth subnit. every four hours. A quiet delirium set in a few days before death and the patient was unable to control the evacuation of the rectum or the bladder. He gradually sank and died about 5 p. m. April 28, 1898.

Necropsy (eighteen hours after death).-Body much emaciated; rigor mortis marked. Heart appeared normal; a small sacular aneurism, of about 50 c. c. capacity, of the superior vena cava was found near its entrance into the auricle. No other abnormality of the mediastinal spaces was found. The lungs showed a slight degree of hypostatic congestion posteriorly, but in other respects appeared normal. Upon opening the abdominal cavity the intestines were found matted together by exudate, and a considerable quantity of sanguineous purulent fluid

was present in the peritoneal cavity. The serous coat of the bowels was much inflamed, and for a distance of from 20 cm. to 40 cm. from the ileocæcal valve the tissue of the small intestine was breaking down and several perforations were to be seen. The stomach contained a small amount of undigested milk and was slightly distended with gas. The liver and kidneys appeared normal and the gall bladder contained a small amount of bile. The urinary bladder was empty and contracted. The spleen was considerably enlarged. Other organs appeared

normal.

C. H. G.
G. P.

CASE 3.

F. E. C.; aged 31 years; nativity, Massachusetts; admitted to marine ward, German Hospital, Philadelphia, Pa., November 12, 1897; died November 24, 1897, 8.10 a. m.

History.-Patient had a chill about one week ago, which was followed by a fever and a sweat; he also had a severe headache, pain in the back and legs, anorexia, constipation, general malaise. The above paroxysm was repeated every day for one week. He took a large dose of quinine before coming to the hospital. On admission the tongue was heavily coated, broad and flabby. Spleen was enlarged. Heart was irregular in action, with a double beat with every cardiac cycle. Lungs were negative. Three days later remissions ceased to occur in the temperature, which became continuous in type; pupils were dilated; pulse became dicrotic; headache was continuous; spleen became more enlarged. Widal's reaction for enteric fever was positive. On the evening of November 20 he was seized with a sudden sharp acute pain in the right iliac fossa, which was tender on pressure. Two hours later there was rigidity of the right rectus; abdomen became somewhat distended. Several hours later there was a boardlike hardness all over the abdomen, tympanitis was much increased, hepatic dullness was almost obscured, and the abdomen became exceedingly tender to touch. For next few days temperature gradually fell, spleen became diminished in size. Patient gradually grew weaker until death took place.

Necropsy (three hours after death).-Rigor mortis was not apparent; post-mortem lividity was well marked, especially around the neck. General nourishment was very good. Left pupil was much larger than right. The heart stopped beating in diastole. The heart weighed 400 grams, was deeply congested, the coronary veins being much distended and tortuous. The pericardial sac was apparently normal, the serum being of a pale straw color and about 15 c. c. in amount. The aortic, mitral, and pulmonary valves were examined in turn, and not the slightest imperfection could be detected. The left ventricle bore the normal relation in thickness of wall to the right 4 to 1. The muscular structure of the heart did not seem to be quite as firm as the normal. The right ventricle was partially filled with a post-mortem clot; papillary muscles were found intact. The thoracic aorta showed a few very minute specks of atheroma. The abdominal aorta was smooth throughout its entire course. Other arteries and veins were normal so far as observed. The nares were slightly congested. Larynx and trachea were clear and patent throughout. The left lung weighed 350 grams, was bound down by many adhesions, and there was a slight hypostatic congestion at the base; the lung when placed in water floated very readily. The right lung weighed 550 grams, was slighly congested, floated readily in water, and was so strongly bound down by adhesions anteriorly and at the sides that it was removed only with the greatest difficulty. The condition of the pleural cavity could not be accurately observed, owing to dense adhesions. The abdomen was much distended, and on careful opening, in order that the intestines might not be disturbed, it was found that a large amount of gas was emitted from the cavity and collapse of the walls immediately occurred; the intestines were not greatly distended. The cav