Sessional_Paper_1902 — Page 836

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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 tempe- rature 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 even- ing. 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 terdie. 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. 74lbs. 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°, 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 on wards 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 130, vomiting, constipation and great distension, and a trace (26) 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 saline 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 fairy 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 record- ing. 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.

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