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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 normal.

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 fæces. 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 fæces, the head of the cæcum 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 gall bladder 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 pathogenic organisms through the thin wall which remained as the bottom of the deep ulcer which was found in the cæcum. The adhesion of the cæcum to the belly wall can, perhaps, be accounted for by the inflammatory process connecting the peritoneal coat of the cæcum 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 fæcal odor emanating from the fluid that wells up from the depths. The fluid consists largely of a fibrino-purulent exudate and liquid fæcal 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-cæcal 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-cæcal 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 agminated 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-cæcal 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.

CASE 5.

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 40.5o 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 right iliac 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 mesentery thickened; spleen enlarged and friable; kidneys apparently normal, with capsules slightly adherent; pancreas normal; bladder normal and full of urine; prostate, penis, testes, rectum, and stomach normal; stomach empty; small intestines contained thin fæces, yellowish gray in color; intestinal walls were thickened and injected in the lower part of the ileum, and in the neighborhood of the ileo-cæcal valve were found numerous ulcers, typically typhoidal. There were no perforations. The solitary glands in the cæcum were greatly enlarged, and the cæcum 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. J. V.

CASE 6.
Supernumerary spleen.

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

frequent baths and intestinal antisepsis the temperature was diminished, but the patient's general condition did not improve; the diarrhea became troublesome, the tongue dry and brown, with sordes on the teeth, the tympanites excessive and distressing; delirium set in, and he died on November 11, seven days after admission.

Necropsy (twenty hours after death).—Cadaveric rigidity present. Post-mortem staining on dependent portions of body. Abdomen greatly distended. Brain not examined. Chest: Heart in systole; moderate in size; left ventricular wall 1.50 cm. thick, right 0.310 cm. Valves normal. No pleuritic adhesions. Lungs show hypostatic congestion. A small leucomatous patch the size of a dime was found in the apex of the left lung; otherwise both lungs normal and crepitant throughout. Abdomen: Liver normal. Stomach and intestines, large and small, greatly distended by gas. External surface of ileum shows points of congestion opposite Peyer's patches. Peyer's patches ulcerated and softened, ulcers numerous, and two, the size of a navy bean, have extended down to the peritoneal coat. Mesenteric glands much enlarged. Small intestine contains semifluid ochre-colored fæces. Descending colon congested in patches above the sigmoid flexure. Spleen enlarged, softened, and a supernumerary spleen 5 cm. by 7.5 cm. and 0.625 cm. thick was found, attached by a fibrous band, bearing blood vessels, to the spleen proper. Kidneys large, congested, and cortical portion increased in amount. Ureters, bladder, and urethra normal.

D. A. C.

CASE 7.
Typho-malarial fever.

H. F. H.; aged 35 years; nativity, Wisconsin; admitted to the United States Marine Hospital, Cairo, Ill., November 10, 1897; died November 14.

Clinical history.-Employed on the dredge Beta two months at St. Louis, Mo., coming to East Cairo, Ky., August 19, 1897, and to Point Pleasant September 1, where he worked on the same dredge until taken ill, on October 29, 1897. On September 1, before going to Point Pleasant, he applied for treatment at the hospital in Cairo. Diagnosis, ulcer of cornea and intermittent malarial fever. The last illness began October 29 with a dumb chill. He kept about the vessel, not being confined to bed until November 8. He had been able to eat something, but had little appetite. When admitted his bowels were constipated, and he was mildly delirious. His skin was clay colored, indicating malaria; 12th, still delirious; continued quinine through the day; 13th, congestive chill; delirious all through the night; tried to get out of the window. At 6 a. m. patient's pulse very weak; unconscious, and he is apparently dying; hypodermic of nitroglycerine given, and patient's condition improved. At 10 a. m. patient was given 3 grams of quinine by rectal injection, partly or wholly voided an hour later; 1.30 grams by stomach at 1 p. m., repeated at 6 p. m. Patient swallowed and retained a little milk before noon, and took some later in the day; looked much better at 7 p. m., and was quiet and rational; 14th, looks much brighter; is perfectly quiet; no fever; 1.30 grams quinine three times a day. Died suddenly at 10.45 a. m.

Necropsy.-External examination: General nutrition fair. Skin muddy or clay colored. Rigor mortis beginning. No other external evidence of disease. Brain removed; dura mater thickened and opaque along longitudinal sinus and adherent to skull in this locality. The vessels of the pia mater were injected over the entire brain, there being several bright red spots on the convexity, showing slight hemorrhages under the pia. The brain substance was firm throughout on section. Thorax: A slight amount of fluid in pericardial sac. Right auricle, and large veins emptying into it, were much distended with fluid blood. Right ventricle

nearly empty; left ventricle contracted, Weight of heart, 240 grams. Walls of heart rather thin, but of normal color and consistence. Valves normal. Lungs: Right, everywhere adherent to costal pleura and to diaphram; left slightly adherent at a central point anteriorly. Lungs contained considerable pigment. There were no spots of consolidation or congestion. The great vessels and nerve trunks were of normal appearance. Abdomen: External appearance of organs.-The intestines were distended with gas and showed several dark-colored areas, chiefly in the ileum. The liver appeared large and dark colored. The omentum was of darker yellow color than usual, and contained only a small amount of fat. Spleen, 15 cm. by 10 cm. in diameter, of dark-brown color and firm consistence. The kidneys were swelled, the edges of the capsules being retracted on incision. The cut surface of dark-red color, exuding blood on slight pressure. The adrenals were normal. The bladder was contracted, with thickened walls and containing very little urine, rather cloudy in appearance. The mucous lining of the bladder was dark pink in color, apparently much thickened and congested. Organs of generation normal. The liver was large; of dark chocolate color; of firm consistence and friable. Weight, 2,750 grams. The gall bladder was partly filled with thin bile of light-green color. The pancreas was of normal appearance. The intestines were removed, leaving a large number of enlarged lymphatic glands. The cæcum, near the valve, presented two or three ulcers of about 1 cm. in diameter. The ileo-cæcal valve on the side of the ileum was lined with small ulcers and the small intestines for a distance of 15 cm. presented many more of the same character. The dark spots noted above as being seen externally marked the location of the ulcers; none of them were large and none occupied Peyers patches by preference. There were portions of the intestine in this locality showing deep injection of vessels running transversely in the mucous membrane. The vermiform appendix was 13 cm. in length, and contained two grape seeds and several small fæcal concretions. The mucous membrane at this point was thickened and congested. Other parts of the intestine and organs were examined and found normal.

Remarks: The history of this case, the general appearance, including the color of the skin, indicated that the patient was suffering from malarial poisoning, while the presence of the ulcers, though not quite characteristic of typhoid, render it probable that the patient had suffered from typhoid infection also.

PERNICIOUS MALARIAL FEVER (EXHAUSTION).

P.E.K.

J. P. (colored), aged 24 years; nativity, Mississippi; admitted to the United States Marine Hospital, New Orleans, La., June 5, 1898; died June 17, 1898. History.-On admission, complained of ulcers in groin and on penis; also of having chills regularly for the past few months. Examination: Patient weak and emaciated. Eyes yellow and sunken, cheeks hollow, mucous membranes pale and anemic. Examination of inguinal region show large ulcerating surface involving skin and superficial fascia. Penis is swollen and oedematous. The prepuce is adherent to the glans; there is complete phimosis with a pin-hole opening through which patient passes urine. A chancroidal ulcer extends along the whole undersurface of penis. The ulcers on penis were cauterized and an incision made through the swollen prepuce to the glans penis. Glans penis was freed from adhesions, so that patient could now urinate freely.

June 6.-Patient had two chills, one at 3 a. m., the second at 9.30 a. m. Temperature 40.2° C.; vomiting set in, bilious in character, intense prostration, pulse feeble and small, 122 per minute, sclerotics of eyes were yellow, tongue dry, broad, and heavily coated. Examination of blood showed the small intracorpuscular malarial organism in large numbers. The patient was given quin.

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