The improvement was so gradual and so marked that one is justified in looking upon it as a cure and not a remission.
MALIGNANT MALARIA WITH OBSTRUCTIVE JAUNDICE.
A European sailor from a coasting steamer was admitted on 28th June.
His temperature was 100, conjunctivæ jaundiced, left lobe of liver very tender and constant vomiting; a blood slide showed numerous malignant quotidian parasites. The jaundice became rapidly general and the vomiting very persistent; under hypodermics of morphia the latter symptom subsided, but the patient became delirious and rapidly sank, dying on the 2nd July. The temperature was normal in the morning and 104 in the evening of 29th, normal all day 30th, 105 in the morning and 102 in the evening of 1st.
Post mortem,--Jaundice deeply marked all over. Gall bladder slightly distended but no obstruction could be made out. Brain congested and excess of fluid. Spleen enlarged and soft. Smear from this organ teemed with malarial parasites.
CHRONIC PANCREATITIS JAUNDICE-DEATH.
An engineer was admitted from a steamer on the 30th May, 1901, deeply jaundiced and dying. The only history obtainable was that he had had jaundice for over a year but had been doing his duty up to a few days before his admission. He was deeply jaundiced all over, temperature 101, quick almost uncountable pulse and great dyspnœa. He was put to bed and given stimulants but died a few hours after, passing a large tarry stool just before death.
Post mortem--Gall bladder was much distended and full of bile; intestines full of blood. Pancreas very much enlarged and hard, being about double the average size and weighing eight ounces; head was firmly adherent to the common bile duct and intestines. Section of pancreas was stained and showed a large increase in the connective tissue but no recent hemorrhages.
MALARIA COMA-PREMATURE BIRTH-DEATH.
A Chinese prisoner in about the 8th month of pregnancy was suddenly seized with a fit at the 3 Gaol on 1st June, 1901. When seen she was quite unconscious, with contracted pupils, deep stertorous breathing, insensitive conjunctivæ and small feeble pulse. Under the idea she was suffering from uræmia she was transferred to the Maternity Hospital. On arrival she was in much the same condition, temperature 100, and passing her urine unconsciously. By means of a catheter a specimen was obtained--1015, acid, trace of albumen--3.3% urea. The following day she was slightly better and could be roused by loud shouting and tried to do what she was told (put out tongue, &c.). The urine contained albumen with blood corpuscles and blood casts. Labour came on naturally, the child, however, being dead. On the 3rd the temperature was 103, urine normal, patient again more unconscious--a blood slide showed large numbers of malignant quotidian parasites. Ten grains of quinine hypodermically were given night and morning but without any drop in the temperature which on the 4th went up to 106.8. As the patient was quite unconscious and evidently sinking, lumbar puncture was performed and the tube left in for 48 hours. Under ice packing the temperature fell to normal at midnight. The blood next morning was still full of malaria, though the patient was much better and more easily roused. The quinine was increased to 15 grains twice daily hypodermically and a mixture of Tinct. Ferri XV and Quinine gr. II given every two hours. The patient, however, slowly became more unconscious, the temperature ranging between 101 and 105 till the 7th when she died, temperature 106. Throughout urine and fæces were passed unconsciously.
Post mortem.--Heart and lungs normal save for some old adhesions at right base. Liver cirrhotic, 2¼ lbs.; kidneys normal but much congested; spleen 5 oz.; brain soft and congested but no increase in the fluid either at base or in ventricles; blood smear from spleen teemed with parasites.
INTESTINAL OBSTRUCTION DUE TO STRICTURE OF RECTUM.
A married European female, aged 31, was admitted to hospital on August 21st. She was quite well up to the 20th, when she was seen by a medical man who prescribed a pill (Pil. Hydrarg. grs. III, Pil. Coloc. Co. grs. IV) for vague abdominal pain and vomiting. On admission her temperature was 102.4, with furred tongue, tympanitis and tenderness all over the abdomen, but more especially in the right iliac region; malignant malarial parasites were found in the blood. Her previous medical history was good, though there was a history of an attack of dysentery in 1895 but no abdominal trouble since. The vomiting continued throughout; the rejected matter consisting of green "spinach-like" material and never fæculent. Bowels did not respond to enemata, salines or small repeated doses of calomel. On 24th she was examined under chloroform but nothing definite could be found to account for the symptoms. There was no dulness in the right iliac fossa and nothing was felt per rectum. On 25th her condition was the same and as the tympanitis was distressing and the vomiting continued a small trocar was inserted into the intestines and a quantity of fetid gas escaped with a certain amount of relief. On 26th, as her condition was decidedly worse, laparotomy was performed. The intestines were much congested and distended; there was no appendicitis and no cause was found to account for the distension. She slowly sank and died the same day.
Post mortem.--No peritonitis or appendicitis. Intense enteritis.
The whole of the small intestine and the large intestine as far as the sigmoid flexure were distended and at the lower end of the sigmoid flexure a stricture was found, the intestine being contracted to the size of a goose-quill. On cutting through this constriction it was found to be due to the cicatrisation of a dysenteric ulcer with thickened and indurated edges. There was no tubercular disease anywhere.
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Remarks.—The case is interesting on account of the obscurity of the cause of all the abdominal symptoms. The temperature was accounted for to a certain extent by the presence of malarial parasites (malignant tertian) in the blood. Although the patient was a delicate woman her condition could hardly be attributed to the aperient she had taken. The puncture of the intestine with the smallest trocar in Potain's aspirating case afforded relief and did not induce the slightest local inflammatory trouble.
HEPATIC ABSCESS-OPERATION FOLLOWED BY GUMMA OF THE LIVER-RECOVERY.
A French sailor, 42 years of age, was admitted on June 7th, having been ill 15 days with fever. His temperature on admission was 101; liver much enlarged with distinct fluctuation in front. The abscess was opened, the walls stitched to the skin and a tube inserted. It healed rapidly but the temperature still ran an intermittent course, being normal in the morning and 102 or 103° in the evening. On the 13th, malignant parasites were found in the blood and 5 grains of quinine given every four hours. This brought the fever down to normal in a few days and he soon put on weight and was waiting for a passage home when on July 29th the temperature again rose with parasites in his blood (after he had been out on leave for the first time). There was also a distinct tumour of the liver below the ribs which was hard and not tender on pressure. Notwithstanding quinine every 3 or 4 hours the temperature still continued an irregular course, rising to 100 and occasionally to 103 in the evening. On August 11th, he was aspirated but no pus found. A distinct specific history having been obtained he was put on Potass. Iodid. grs. xv ter die. The temperature almost immediately fell to normal and continued to, and the swelling slowly but markedly disappeared.
He left for Europe on 9th September looking and feeling well, his weight having risen from 8st. to 8st. 7¼ lbs. and without any trace of hepatic enlargement.
INTESTINAL OBSTRUCTION DUE TO PLAGUE-DEATH.
An English boy aged 11 was admitted to hospital on the 9th September. He had been taken ill two days previously with a sharp pain in the abdomen for which a dose of castor oil was prescribed which however only set up vomiting immediately after being taken. On admission his temperature was 102.7, foul tongue and pain in abdomen, chiefly in right iliac fossa where there was a distinct sense of resistance on pressure. His temperature continued between 102 and 104 till the 11th, with great abdominal distension and pain. On this day a papular eruption was seen chiefly on forehead and back of ears. In the evening slight delirium was noticed for the first time. On the 12th the condition was much the same with frequent vomiting (bile and blood), very fœtid breath, epistaxis and abdominal distension, and from this onwards no further action of the bowels occurred. There was dulness in both flanks. The stools were liquid and bile-stained. There was distinct tenderness and dulness in the right iliac fossa where a distinct tumour could now be felt. In the evening the enema contained only a trace of fæces. The morning temperature was 100 and a few malignant malarial parasites were found in the blood. The evening temperature was 101.8 and the pulse varied between 88 and 92. The case became slowly worse, pulse 120 to 180, vomiting, constipation and great distension, and a trace of albumen in the urine till the 14th--8th day of illness--when the temperature rose to 105, and the patient succumbed.
Post mortem.--Small intestine normal. Spleen hard and firm. No appendicitis. Large intestine (cæcum) swollen with hæmorrhagic extravasation into the walls for about 3 inches causing almost complete obstruction. Mesenteric glands swollen and hæmorrhagic. Retroperitoneal extravasation well marked. Slight amount of bloody fluid in abdominal cavity. Spleen and glands full of typical plague bacilli; a culture of which was injected into a guinea pig and produced death with plague bacilli in internal organs.
Remarks.--No idea of plague was ever thought of in diagnosing this case which was looked upon at first as being one of malarial colitis or appendicitis, and the patient was treated accordingly with purges and hypodermics of quinine. Fortunately for various reasons no operation was attempted. Authorities on plague mention the possibility of mistaking the disease for appendicitis but such a case as this is worth recording owing to the very definite tumour and complete obstruction produced.
COMPOUND FRACTURE OF FEMUR-AMPUTATION--DEATH FROM TETANUS.
A European sailor was knocked down by a heavy sea on the 10th December and sustained a compound comminuted fracture of the lower end of the right femur. On arrival here, six days after the accident, the man was brought to hospital. The wound was thoroughly cleaned, some jagged ends of bone removed and an endeavour made to save the limb. As the temperature chart pointed to septic infection, amputation was decided upon, and assisted by Staff Surgeon NOLAN, R.N., and Surgeon WALLIS, R.N., at 11 a.m. on the 20th, the limb was removed. Just previous to the operation the patient complained of stiffness in the jaw muscles and inability to open his mouth. To our regret smears taken from three places in the wound showed tetanus bacilli. The patient stood the shock fairly well and at 1 p.m. was conscious, the spasms short and frequent, and the pulse fairly strong. At 4 p.m. he had a severe spasm which almost raised him off the bed, and died suddenly.
Remarks.--The extreme rarity of tetanus following operations here makes this case worth recording. It is extremely difficult to account for his having been infected on board a ship as the bacillus is generally looked upon as an earth germ and the steamer had not been carrying manure, horses or other animals as cargo. Immediately after the injury everything seems to have been done to keep the wound clean and the limb at rest by means of Carbolic lotion and an improvised splint.