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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.
F. I. CASE 2.
Perforation-Peritonitis, Aneurism superior vena cava. 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. capac'ity, 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 theileocaecal 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.
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 thenormal 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
ity was also filled with a sero-purulent fluid, which was of a yellowish green color; the intestines and all the organs within the peritoneal cavity were coated over with a flocculent lymph. The peritoneum showed the signs of inflammation as well as the mesentery. The tongue was coated with a brownish-white fur and was red at the tip; no sordes was observed. The pharynx and oesophagus were Ilorinal. The stomach was partially filled with a turbid fluid and small masses which resembled casein. The diameter of the pyloric orifice of the stomach was 1.25 cm.; that of the cardiac orifice 2 cm. The small intestine was somewhat inflamed and contained a small amount of faeces. The appendix was firmly bound down by adhesions; it was about 9 cm. in length, about 1 cm. in diameter, and just a short distance (1 cm.) from the distal end there was a constriction in its lumen, and on opening it lengthwise a drop of pus was found in the blind end which had been cut off by the constriction. At the point where the ileum joins the large intestine, opposite to the mesenteric attachment, an oval ulcer was found placed longitudinally. The ulcer had overhanging edges and a smooth base which apparently extended down to the muscular coat; it was grayish in appearance. The large intestine was partially filled with faeces, the head of the caecum was firmly bound down by adhesions to the side of the belly wall, and in its interior were found two oval ulcers nearly opposite the mesenteric attachment, about 2.5 cm. in their greatest diameter. One of the ulcers seemed to be very deep and apparently only had the peritoneal coat for its base. The edges were soft and overhanging. Its greatest diameter was in a longitudinal direction. The capsule of the liver was partially covered with flocculent lymph; it was slightly congested, deep dark red in color—no discoloration—and weighed 1,945 grams. The gallbladder was found with a small amount of bile; no gall stones. The ducts were found patent. The pancreas was very friable; weighed 150 grams. The left kidney was found slightly congested; weighed 210 grams. The right kidney also slightly congested; weighed 200 grams. The pelvis on right side was somewhat thickened; the ureter was constricted and dilated at several points along its course. The left ureter was of proper diameter throughout. The bladder was much below the normal in size, but did not show any signs of acute or chronic inflammation. The urethra was found to contain a stricture of large caliber in the prostatic portion. The prostate gland was not enlarged. The spleen was only very slightly enlarged, friable, and weighed 140 grams. Close to but not attached to the spleen a small, round body about 2 cm. in diameter was found which macroscopically resembled splenic structure. The head was of an average size; the scalp was covered with a growth of stiff hair. The skull was 0.75 inch in thickness at the crown. The membranes of the brain were congested, especially the pia mater. The brain weighed 1,350 grams. The cause of death was undoubtedly peritonitis, which was due to a minute perforation or the direct migration of phthogenic organisms through the thin wall which remained as the bottom of the deep ulcer which was found in the caecum. The adhesion of the caecum to the belly wall can, perhaps, be accounted for by the inflammatory process connecting the peritoneal coat of the caecum with that of the parietal coat, and thus also, perhaps, spontaneously closing the perforation. F. I. CASE 4.
A. B., aged 34 years; nativity, Sweden: admitted to the marine ward of St. Vincent Hospital, Portland, Oreg., May 16, 1898; died May 21, 1898.
History.—The patient complained of languor, muscular weakness, and loss of appetite for fourteen days; also of fever, sweating, and headache in the evenings. Several bloody evacuations, unaccompanied by pain or straining, occurred about thirty-six hours before applying for hospital relief. These tarry stools were the first alarming indication that the patient had that a serious illness might supervene. Physical examination did not greatly aid the diagnosis, for at the time of admission very few of the signs of enteric fever could be found. A few rose spots existed in the upper zone of the abdomen, but a profuse eruption of acne was present. There was no pain or tenderness on pressure in the abdominal cavity. The evening temperature reached 40° C., and gradually declined until the normal point was reached on the morning of the 19th. Symptoms of an acute general inflammatory invasion of the peritoneal cavity supervened on the 18th: such as pain on pressure and at times in paroxysms; vomiting, spontaneous and following the ingestion of food and medicines; distension of the abdomen. The gaseous distension was most prominent the next day, hepatic dullness being almost entirely replaced by a tympanitic note. For two days these symptoms continued, together with a soft and rapid pulse (120), dry, parched, brown tongue, and a temperature of 39° C. A pleuritic friction murmur developed on the right side, but there was no effusion into the cavity. Nearly all pain and discomfort ceased about twenty-four hours before death; consciousness was retained to the last. Necropsy (sixteen hours after death).-Body emaciated and abdomen greatly distended. The bones of the skull were thin, and the cap was removed without difficulty. The longitudinal sinus contains what seems an unusual amount of blood, and many of the meningeal veins are congested. No macroscopic abnormalities could be detected throughout the cerebral substance. The brain weighs about 1,320 grams. Thoracic cavity: The right pleural sac contains about 30 c.c. of a reddish fluid; the lung is adherent by new formations to the diaphragm, and its posterior surface is congested, as is also the parietal pleura. The left sac contains a similar amount of fluid; the base of the left lung is congested, and a small, calcareous tubercle is seen on the inner face of the inferior lobe. There are no adhesions. The pericardial sac contains a reddish fluid, a little more than is usually found. The heart is pale in color and normal in size and situation. On the left side the walls are of the usual thickness and the left ventricle is empty, with the exception of a small clot. The right side contains in both cavities antemortem clots; that in the auricle is especially large. The valves are competent. Abdominal cavity: The position of one or two of the parts is abnormal; the liver is pushed backward by distended coils of the intestines, and on every side are signs of a general peritonitis. All the intestines are inflated, some agglutinated, and there is a faecal odor emanating from the fluid that wells up from the depths. The fluid consists largely of a fibrino-purulent exudate and liquid faecal matter. The great omentum presents a few distended veins and is congested and gummy; the peritoneum is similarly affected and in the right iliac fossa is adherent to intestine. A search reveals a perforated ulcer in the lower ileum about 3 feet from the ilio-caecal valve. The aperture in the lumen of the bowel is very small, its dimensions would hardly admit the body of a pea. Within 2 to 5 inches of the ilio-caocal junction, there are a number of ulcers, about a dozen in all. Denudation of the mucous membrane is complete in spots and has assumed many shapes—some circular or stellate, others oblong, and a few coalescing. Several are the size of a dime, the mucous membrane between them being corrugated, congested, and forming undetached sloughs. The ulcers are, for the most part, situated in the wall opposite to the attachment of the mesentery, and doubtless originated in the Peyerian glands. Solitary and the agnminated follicles are swollen in the lower ileum, and can be distinctly seen by the unaided eye. Many of the mesenteric glands, especially in the ileo-caecal chain, are enlarged and present the so-called medullary appearance. The intestinal contents are not copious, and they differ in different portions of the canal. Soft adherent material, possessing little odor, of a dark green or brown hue, is found in the ileum; near the
ulcers there is some discoloration of the bowel walls, due to the blood pigment. Scybalous masses are found in the rectum and sigmoid flexure. The stomach is distended with gas and contains 100 c.c. of green fluid; the pyloric orifice is normal. The liver is normal in size and color, but is pushed backward and upward by the distended intestines. It has a tough coating of fibrino-purulent exudate. Gall bladder half filled with fluid bile of normal color. The spleen is enlarged; its pulp is friable and abundant, and its color externally is obscured by a covering of plastic material. The other abdominal viscera are normal in consistence, size, and color. The spleen weighed 275 grams, and the liver about 1,895 grams. R. B.
G. S. W.; aged 28; nativity, Michigan; admitted to marine ward of St. Francis Xavier Infirmary, Charleston, S. C., March 4, 1898; died March 11, 1898.
History.—Patient stated that he had cough, fever, and chilliness, with nausea, for several days previous to admission; he also had slight diarrhea and headache, vomiting and anorexia; some abdominal pain; also expectoration, resembling that of bronchitis; sometimes this was sparsely streaked with blood that apparently came from the posterior nares. On day of admission had severe chill, and temperature rose to 40°C., followed by moderate sweating. On the following day temperature reached 40.5° C. and delirium came on, which became at times violent, and eventually patient became comatose, and died in that condition on the morning of the 11th. There had been no tympanitis, gurgling in rightiliac fossa, sudamina, rose spots on abdomen, nor dry and heavily coated tongue, and the diagnosis was uncertain, wavering between malarial disease, influenza with meningitis, and typhoid fever, until the post-mortem revealed the true condition.
Necropsy (fifteen hours after death).-Rigor mortis present; body very slightly emaciated; muscles well developed; skullcap, brain, and membranes normal in appearance; heart and pericardium normal; lungs apparently normal, with some post-mortem congestion posteriorly; pleura normal; omentum somewhat injected; mesenteric glands greatly enlarged and mesenterythickened; spleen enlarged and friable: kidneys apparently normal, with capsules slightly adherent; pancreas normal; bladder normalandfull of urine; prostate, penis, testes, rectum, and stomach normal; stomach empty; small intestines contained thin faeces, yellowish gray in color; intestinal walls were thickened and injected in the lower part of the ileum, and in the neighborhood of the ileo-caecal valve were found numerous ulcers, typically typhoidal. There were no perforations. The solitary glands in the caecum were greatly enlarged, and the caecum itself thickened and injected. Weight of organs: Heart, 330 grams; right lung, 690 grams; left lung, 580 grams; spleen, 420 grams; pancreas, 50 grams; kidneys, 180 grams each; liver, 1,500 grams.
F. F. S.
W. S.; aged 19 years; nativity, New York; admitted to United States Marine Hospital, Cleveland, Ohio, November 4; died November 11, 1897.
History.—Mother died from tubercle of the lungs. Family history otherwise presents nothing of special interest. Patient was ill for ten days before he applied for relief with malaise, pain in the back and limbs, fever, and diarrhea. When admitted he had gurgling in right iliac region, no decided tenderness on pressure, rose spots on abdomen, tongue coated and red at tip and edges, diarrhea, and a temperature on admission of 40.8°C. The urine contained albumen and gave Erlich's diazo reaction. No plasmodium was found in the blood. By the use of