Case of Murine Typhus in London

MEDBRuRNL 9 two minutes, whilst the third collapsed after about six minutes and then appeared unconscious, cold, and with a barely perceptible and irregular radial pulse.No convulsions were observed in any of the patients.The survivor was given 1 ml. of nikethamide subcutaneously, and artificial respiration was applied.She recovered consciousness and was detained for observation.Post-mortem examinations were performed upon the two fatal cases, but nothing of note was discovered except a remark- able and quite unusual degree of flaccidity of the heart, the musculature appearing otherwise normal.In both cases the lungs were extremely congested.At this time the true nature of the accident was not realized and the livers were sent to the Government analyst, who subsequently reported the presence of bismuth therein.Because of this report, the survivor was treated with " ametox " and intravenous salines, but signs of bismuth poisonring rapidly appeared and a blue line was visible on the gums on the third day.Diminution of urinary output occurred almost at once, and complete anuria resulted on the fifth day.Intra- venous sodium sulphate solution caused excretion to recom- mence and increase daily until 16 oz.(450 ml.) was passed on the tenth day, when death occurred.All urine passed after admission contained albumin, red blood corpuscles, and casts.The blood-urea estimations showed a rapid rise to a maximurmi Uof 240 mg. per 100 ml. on the seventh day, falling to 208 mg.on the day of death.Post-mortem examination disclosed marked blue gingivitis.The abdomen contained about a litre of clear pale amber fluid.The liver was enlarged, soft, and covered with recent fibrinous adhesions which anchored it to the surrounding viscera.The kidneys were both very pale and swollen, with fine punctate "aemorrhages on the surface.The lower colon and rectum were inflamed, with small haemorrhagic spots.No other finding of note was discovered.Microscopy of the kidneys revealed 'almost complete destruction of the tubular epithelium, with many granular and fatty casts.The liver showed little histological change, but both kidneys and liver contained quan- tities of extremely finely divided fat throughout the tissue.The relative quantities of bismuth given and demonstrated by the analyst were as follows Mg.Sobi'a per Mg.Bi per kg.Body Weight kg.Liver Case 1 (immediate death) .1340 Case 2 ( ,, ,, ).10 30Case 3 (delayed death) .1123 I wish to record my thanks to the medical officers concerned for the courtesy of access to Case 3 and the clinical notes, to the Government analyst for the chemical estimations, and to the late Director of Medical Services, Gold Coast Colony, for his permission to publish this report..