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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-mortern 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 faeces. 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.
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 onsection. 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 cascum, near the valve, presented two or three ulcers of about 1 cm. in diameter. The ileo-caocal 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 faecal 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.
P. E. K. PERNICIOUS MALARIAL FEVER (EXHAUSTION).
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.
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 intermittentin 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 scapula 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 cascum is normal, not a sign of ulceration. The colon is empty, except the sigmoid and upper third of rectum, which contains faeces. 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.
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