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النشر الإلكتروني

Day of Disease.

Time of

10 11 12 13 14 15 16 17

1897.

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88 ✖

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bi-sulph. 0.30 grams by hypodermic, stimulants of strychnine and whisky by hypodermic. The chills and vomiting and bilious appearance continued for several days until the 11th, when patient showed slight change for the better. Patient began to take fluid nourishment by mouth. The temperature range was chiefly intermittent in character, ranging between 37° C. to 40.2° C., pulse followed variations of temperature, ranging between 92 and 120 per minute. Although the vomiting ceased and patient began taking some fluid nourishment, he remained in partial stupor and was occasionally delirious. Quinine was given in large doses, followed by dilute nitric acid; stimulants were freely administered, yet the depression continued. Malarial organisms were found in the blood on the 6th to 10th, inclusive; none on the 11th and days following.

Necropsy.-Autopsy held one-half hour after death. Very slight rigor in lower jaw. Marked general emaciation. Eyes sunken; sclera yellow. Cheek bones prominent; cheek sunken. Superficial appearance of chest shows marked emaciation. Clavicle, ribs and scapulæ prominent. Abdomen is sunken and hollow in appearance. Two large ulcers in both inguinal regions; the one on right side is 22 cm. long by 10 cm. wide; left side 10 cm. long by 5 cm. wide. Ulcer of penis involves the whole of foreskin and whole length of under surface of penis. On section, the serous membranes have an icteric appearance. The costal cartilage is of a pale yellow hue. The pericardium is apparently normal; contains about normal amount of serous fluid. Heart weighs 250 grams; flabby, small, while its muscular structure is pale and anemic. Valves and cavities apparently normal. Respiratory organs: Right lung collapsed on opening of its pleura. Weight, 465 grams. Surface is darkly pigmented and smooth; crepitates normally. On section some frothy fluid exudes from cut surface. Left lung collapsed on opening of left pleura, except a portion of the upper lobe, which was fastened anteriorly and posteriorly by bands of old adhesions. Weight of left lung, 362 grams. Surface smooth, bluish-gray in color, with numerous small spots of dark pigment; crepitates normally. On section, a very few small, scattered tubercles noticed on cut surface of upper lobe. Section of lower lobe apparently normal. Bronchial lymphatic glands not enlarged. On section, the abdominal walls are very thin, the muscles are anemic, the peritoneum smooth and free from any adhesions. There is a faint yellow hue to the whole intestine. The small intestines appear collapsed, as also the large bowel, on superficial view. The stomach is empty and collapsed; the duodenum seems normal. On making pressure on gall bladder with organs in situ the ducts are patulous and the flow of bile into duodenum is free. Mucous membrane of small intestine for a distance of 50 cm. next to cæcum is normal, not a sign of ulceration. The colon is empty, except the sigmoid and upper third of rectum, which contains fæces. The liver weighs 2,250 grams. Its surface is smooth. On section, is light brown; contains blood and few minute tubercles over cut surface. Gall bladder full; no calculi. Spleen weighs 320 grams; is moderately enlarged; surface is smooth. On section, is dark red in appearance; full of blood. Right kidney weighs 195 grams. On section, has a brownish-yellow appearance. Left kidney weighs 215 grams. On section, is yellowish-brown. Genito-urinary system normal. Other organs normal. Primary cause of death, pernicious malarial fever, algid form. Secondary cause, exhaustion.

R. H. VON E.

TUBERCLE OF LUNGS.

CASE 1.

C. R., aged 60; nativity, Virginia; was admitted to the United States Marine Hospital, Baltimore, Md., November 19, 1895, and died April 13, 1898.

Previous history.-Was admitted to hospital at Norfolk about a month previously, where a diagnosis of tubercle of the lungs was made. At first he had a remittent fever with a temperature of from 39° to 40° C., but this disappeared under the use

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of quin. sulph. Cough was very troublesome, appetite was poor, patient was losing weight fast, and tubercle bacilli were found in the sputum. Physical examination showed less movement in respiration on the left side than on the right; the clavicle was quite prominent. Dullness on percussion on both sides, more marked on the left. Rales heard over entire left side and at apex of the right.

Present history.-Patient in about the condition described above. Cough is very distressing at night, and various remedies were given for the relief of this troublesome symptom, with only temporary effect. From this time on until the 1st of January, 1898, the case ran the usual course of such cases. At this time, however, there began to be noticed an oedema of the legs and scrotum and penis. This subsided at times and returned again. Later on the use of the lower extremities was lost entirely. and the anasarca became general. The urine, too, was but scantily secreted and hot baths were tried, but their beneficial effect was of very brief duration. The usual stimulating and nourishing treatment was given. Patient died of exhaustion.

Necropsy (eighteen hours after death).-Emaciation only moderate in degree. Numerous scars on various parts of the body, chest, and lower extremities. Legs, feet, penis, and scrotum are markedly dematous, and the tissues exude serum on section. Heart appears normal. Right lung shows recent adhesions at the apex, also well organized adhesions to diaphragm and to pericardium. A large cavity was found at the apex, and the upper and middle lobes were full of tubercular nodules. The left lung was collapsed and was no larger than an orange; it was hollowed out into a cavity of about 150 c. c. capacity. Both kidneys were large, pale, and showed signs of fatty degeneration. The stomach and pancreas appeared normal. The liver was smaller than normal and there was a small abnormal process of liver tissue which partly replaced the gastro-hepatic fold of peritoneum. The liver structure was normal in appearance. The spleen was of normal size, but was so friable that it was torn in removal from the body. No other organs were examined.

C. H. G.
G. P.

CASE 2.

A. J.; aged 38 years; nativity, Russia; was admitted to the United States Marine Hospital, port of San Francisco, Cal., September 14, 1897, and died January 24, 1898.

History.—Patient stated that he was ill for six months prior to his entrance into the hospital, and during this time had lost 40 pounds in weight. Complained also of persistent cough, with copious expectoration, night sweats, and shortness of breath. Physical examination: Dullness over the apex of the left lung anteriorly to the second intercostal space: posteriorly, to the fourth dorsal vertebra. The percussion note over the right lung was normal. Upon auscultation moist and sonorous bronchial râles were heard over the whole chest. Examination of the sputum demonstrated the presence of tubercle bacilli. Heart was normal. The treatment was supportive and symptomatic, but, notwithstanding large doses of strychnia and digitalis were given, the patient gradually grew weaker, and died at 6 a. m. January 24, 1898.

Necropsy (five hours after death.)—The body is that of a well-developed, though emaciated, adult white male. Rigor mortis fairly well marked. Encephalon normal. Weight of brain, 1,297 grams. The pericardial sac is normal. The superficial fat of the heart is increased, although the heart muscle and valves are normal; weight, 420 grams. The left pleura is adherent throughout. On the right side there are adhesions at the apex, otherwise the pleura is normal. Upon 10918-7

section, the upper lobe of the left lung shows a cavity occupying the whole of its substance. In the upper part of the lower lobe are two small cavities; the remainder of the left lung is consolidated; weight, 1,400 grams. The apex of the upper lobe of the right lung shows numerous cavities from 1 to 4 cm. in diameter: remainder of apex is consolidated. Throughout the substance of the middle lobe are seen deposits of tubercular tissue, while the lung tissue in the lower lobe is normal; weight, 1,330 grams. The peritoneal cavity is normal.

The spleen is normal; weight, 247 grams. Kidneys enlarged; weight, right, 252 grams. In the upper part of the left a cyst, 2 cm. in diameter is seen; weight, 260 grams. The remainder of the genito-urinary tract is normal. The liver is normal; weight, 2.320 grams. The remainder of the gastro-intestinal organs are normal. The spinal cord was not examined.

R. R. H.
J. M. G.

CASE 3.

M. S.; aged 23 years; colored; nativity, Mississippi; admitted to the United States Marine Hospital, St. Louis, Mo., May 25, 1898; died June 27, 1898.

History-The patient had been sick for two months. He has had cough, dyspnoea, pains in his chest, muco-purulent expectoration, night sweats, fever, no appetite, diarrhea, and great weakness. His brother and sister died of tubercle. Physical examination: Body emaciated, depressions above and below clavicles, marked dullness over whole of right lung, especially the upper lobe, slight dullness over apex of left lung, bronchial breathing over right lung, inspiration quick and harsh, expiration prolonged; breathing the same over left lung, but not so marked; tubercle bacillii very abundant in sputum; a faint murmur heard after the second sound of the heart; an ischio-rectal abscess cavity exists on the right side of the rectum; this cavity has opened externally about an inch from the anus. This case ran the ordinary course of tuberculosis of the lungs and bowels, the end being hastened by the warm weather. He suffered mostly from high fever, rapid pulse, dyspnoea, diarrhea, and great weakness. On June 1, his right foot, leg, and thigh, as high as Poupart's ligament, became swollen, œdematous, and painful along the line of the large vessels. This swelling and pain, however, subsided by the 18th. Patient died at 2 p. m. on the 27th.

Necropsy (twenty-one hours after death).—Height 165 cm. Body greatly emaciated; abdominal wall 14 cm. thick, no fat. Pericardial sac contains 75 c. c. of straw-colored fluid. Heart flabby and soft, 13 by 12 by 6 cm.; tissue pale, small yellow clot extending from right ventricle through pulmonary artery; thickness of right ventricle wall 8 mm., of left ventricle wall 2 cm.; edges of mitral valve slightly thickened, other valves normal; weight of heart 285 grams. Right lung, apex adherent to walls of chest; weight 1,750 grams, 26 by 18 cm; large gangrenous cavity in upper lobe 7 by 5 cm.; rest of upper lobe one mass of ulcerated tubercular tissues; remainder of right lung hard and tissues filled with gray tubercles. Left lung: Weight 900 grams, 24 by 16 cm.; tissue nodular, hard, noncrepitant, filled with tubercles; tissue of lung at border and small portion of apex crepitant, and only a few tubercles present. Spleen: Weight 570 grams, 16 by 13 by 7 cm.; slate color; tissue hard and full of gray nodules the size of a small marble. Left kidney: Weight 150 grams, 11 by 7 by 3 cm.; tissue dark red, pyramids distinct. Right kidney: Weight 175 grams, 12 by 74 by 4 cm.; appearance of tissue same as left kidney. Stomach 22 cm. long by 9 cm. broad; contains 25 c. c. thick, yellowish fluid; mucous membrane grayish-white, covered with mucus of the same color. Mesenteric glands hard and swollen, some as large as a pigeon's egg. Liver: Weight 1800 grams, 28 by 23 by 13 cm.; tissue on section very dark, almost black; 10 c. c. of brown-colored bile in gall bladder.

W. G. S.

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