13 



However, in Jaiuiaiy he felt sufficiently improved to leave Manila for 

 Japan, where he remained for about three months. During some of this 

 time he neglected treatment entirely. For the first month he reported 

 himself to be fairly well, but shortly afterwards an acute exacerbation of 

 the djsenteric symptoms appeared and he was compelled to enter a hos- 

 pital. As soon as his condition temporarily improved he returned to 

 Manila. He was seen again by the writer on April 9 ; at this time he was 

 considerably emaciated and his face was drawn. He complained of an 

 aching sensation in the right shoulder. The liver was distinctly palpable 

 for several fingers' breadth below the costal margin. The temperature 

 registered 100° and there was a leucocytosis of 15,000. His pulse counted 

 112. The question of an operation for liver abscess was considered, but was 

 not immediate!}' urged. Owing to the chronic character of the dysentery 

 and the general condition of the patient, it was decided that an attempt 

 should first be made to ameliorate the dysenteric symptoms. Therefore he 

 was again placed upon quinine enemata with occasional doses of Dover's 

 powder and was given, in addition, stimulants with the hope that in a few 

 days his condition might so improve as to warrant an operation. His diet 

 consisted only of liquids. The temperature ranged for the next two days 

 between 100.2° 103.2°. The bowel movements numbered three or four per 

 day and usually contained considerable mucus. On April 12, at 9 a. m., his 

 daily quinine enema was administered. During the day there were two 

 bowel movements, the last at 3 p. m. At 7 p. m., a large intestinal 

 hemorrhage occurred, nearly a pint of fresh blood being passed. At 9 a. m. 

 a second hemorrhage, smaller in amount but of the same character, occurred. 

 At 12.30 a. m. a large amount of dark blood was passed. Morphia was 

 administered hypodermically, and later, ergot. Finally a hot enema of 

 tannic acid was given, but apparently no favorable results were obtained. 

 Between 12.30 and 8 o'clock the next morning there were five small hemor- 

 rhages. At the latter hour the temperature registered 99° and the pulse 

 138. The patient gradually sank. There were no more large hemorrhages 

 from this time up to that of his death, which occurred at 7 a. m. the 

 following morning, but the movements which occurred and were passed into 

 a bedpan, consisted almost entirely of clotted blood. 



At autopsy the large intestine showed extensive ulcerations throughout. 

 The ulcers were as a rule shallow, usually undermined, and with smooth 

 or slightly imeven reddened margins. In the ca»cum deeper ulcerations 

 were present and between these lesions portions of the mucosa were covered 

 with pscudomembrane. Some of the ulcers in the cifcum were gangrenous. 

 The contents of the large bowel consisted of dark-reddish masses of fluid 

 and partially clotted blood, together with some mucus. 



The lower end of the ileum for about 15 centimeters above the valve 

 also showed ulceration. No distinct point from which the hemorrhages 

 arose could be detected any^vhere in the entire intestine. 



There were six abscesses of the liver situated in both the right and left 

 lobes and measuring from .5 to 10 centimeters in diameter. A number of 

 the hepatic veins contained throml)i. 



