over whole surface; lung does not collapse on opening pleural cavity at any point on account of dense adhesions between the visceral and parietal pleura: dense adhesions also occur between the lobes. Weight of right lung 1,310 grams; normal crepitus entirely absent. On section upper lobe present one large cavity involving the entire lobe. This cavity opens directly into a large bronchus, second branch from trachea. The tubercular abscess cavity is lined by a pyogenic membrane, and contains a slight amount of purulent fluid. The middle lobe presents numerous abscess cavities and large masses. The lower lobe appears

nearly solidified; a few sections of this lobe sink in water, probably from tubercular pneumonia. Pericardium smooth; contains considerable pale, straw-colored fluid. Heart weighs 310 grams; small; pale on surface and on section; valves slightly thickened. Bronchial lymphatic glands all enlarged; tubercular. Pancreas weighs 82 grams; apparently normal on section. Brain weighs 1,240 grams; membranes of brain and brain apparently normal.

R. H. VON E.
S. N.

CASE 11.

J. F.; aged, 34 years; nativity, New York; admitted to United States Marine Hospital, Stapleton, Staten Island, N. Y., April 26, 1897; died December 3, 1897. History.-Complains of sore throat, which he has had several years; has cough of three months' duration. Has lost weight during the last three months. Has been drinking hard for several days and has taken little food during that time. Complains of weakness. An examination of his sputum showed numerous tubercle bacilli. Urine contained a heavy sediment, but no albumen. Patient was put on creosote, but showed no improvement, and steadily lost in weight. The latter part of June he began to have nausea and vomiting. He was put on an easily assimilable and nutritious diet with alcohol, but showed no improvement. On December 3 he had a sharp attack of dyspnoea, which was relieved by morphine. In the afternoon he had another attack and in a few minutes died. Necropsy (seventeen hours after death).-Body of a white man, about 5 feet 8 inches high. Very much emaciated; rigor mortis marked; livid over back; calvarium removed and cranial cavity and contents found normal. Thorax: Heart pericardium contained about 50 c. c. of fluid; heart small and pale; both chambers contained considerable semifluid blood; valves normal. Lungs: Left closely bound down to chest wall; large cavity in the apex, the remainder of the upper portion of the lung infiltrated throughout with pus and contained several small cavities. Right lung not bound down so closely as left; the whole upper lobe infiltrated with pus and breaking down. Lower lobes of both lungs crepitant. Both sides of thorax contained small quantity of fluid. Abdomen: Small quantity of fluid in peritoneal cavity. Omentum long and had a fairly good deposit of fat. Both kidneys alike, normal in size, pale in color, firm to the touch; capsule stripped off, leaving a smooth surface. On section nothing abnormal observed except the paleness of the organ everywhere. Bladder contained about 150 c. c. of muddy urine; its mucous membrane slightly dark in color and its vessels injected in several places. Ureters normal. Spleen enlarged; liver normal; stomach and intestines normal.

C. H. L. G. W. S.

CASE 12.

J. F. G.; aged, 34 years; nativity, New York; admitted to United States Marine Hospital, Stapleton, Staten Island, N. Y., July 23; died November 22, 1897. History.-Was in this hospital three months ago in the tubercular ward; had improved some and felt well enough to go out. He now returns with his pulmonary condition worse; is vomiting a good deal, has diarrhea, coughing some,

profuse night sweats, losing flesh, etc. He was put on an easily assimilable diet, and after his vomiting ceased was given creosote in increasing doses, and some general tonics with alcohol. On this treatment he improved slightly, but in a few days his vomiting and diarrhea returned. From this time on, though he occasionally improved for a while, his tendency was steadily downward. Physical examination made on October 20 showed extensive involvement of left lung with a large cavity in upper lobe, and less extensive involvement of upper part of right lung. The patient's stomach at no time bore his food or medication well, and his treatment consisted mainly of symtomatic remedies, with nourishing food and alcohol. He became comatose on the morning of November 22 and died at 2.30 that afternoon.

Necropsy (sixty-nine hours after death).-Body of a white man, 5 feet 4 inches high; very much emaciated; dark hair, eyes, and mustache. Rigor mortis passed off; livid over dependent parts; cedema around ankles; calvarium not removed. Thorax: Pericardium contained small quantity of clear fluid. Heart rather small and pale, otherwise normal. Lungs: Left, contained a large cavity in upper lobe and the surrounding lung tissue was infiltrated with pus; right also contained a small cavity in upper lobe; both lungs bound closely to chest walls by pleural adhesions. Abdomen: Omentum very thin; cavity contained considerable clear amber fluid. Liver enlarged, hard on section, and gall bladder distended with bile. Spleen soft and pulpy and enlarged to some degree. Kidneys: Left, large (weight, 200 grams) and pale, its capsule stripped off easily, leaving a smooth, very pale (almost white) surface behind, on which could be plainly seen the small vascular circlets; the organ was elastic to the touch and cut clean and hard; the cortex greatly increased, and its pallid, yellowish appearance contrasted strongly with the purple red color of the pyramids; the right in all respects like the above except it was smaller (weight, 175 grams). Bladder contained small quantity of urine. Scattered in various places through the small intestines were several round or oval ulcers on a raised, hardened base. The glands scattered along the mesentery opposite these ulcers, enlarged, and on the outer (peritoneal) surface of the gut covering the ulcers were several collections of small white miliary bodies. Other organs apparently normal.

CASE 13.

C. H. L.
G. W. S.

J. A.; aged 40 years; nativity, Finland; was admitted to the United States Marine Hospital, Boston, Mass., November 13, 1897, and died December 15, 1897. History. He was in the hospital during the month of August, when he had a severe cough, profuse expectoration, the physical signs of tubercle of the lungs, and a diarrhea which could not be controlled. When admitted the second time, on November the 13th, he was much emaciated and completely prostrated. He had an intense racking cough, with very profuse expectoration; a diarrhea so profuse as to average twenty stools in the twenty-four hours; and physical examination revealed dullness, most marked at the apices of the lungs, and some cavernous respiration. Treatment produced but little effect and he rapidly wasted away, marked dyspnoea and delirium setting in a few days before his death.

Necropsy (fourteen hours after death).—Post-mortem lividity slight; rigor mortis moderate; emaciation extreme; pupils contracted. The heart weighed 280 grams. In each ventricular cavity was an ante-mortem clot, that in the right being the larger. All the valves were competent. The pericardial sac contained 22 c. c. of fluid and was normal. The left lung weighed 1,180 grams. There were a few adhesions at the apex of its pleural cavity. The organ was studded throughout with tuberculous nodules. At the apex was a large cavity, while the lower lobe was hypostatically congested and the seat of a large cavity filled with pus.

The right lung weighed 540 grams. Its pleural cavity was obliterated at the apex by adhesions. There was slight cavity formation in the upper lobe, and in the lower lobe there was hypostatic congestion, but less marked than in the other lung. The peritoneum was much congested, and the mesenteric glands were enlarged and indurated, and, on section, were seen to contain broken down caseous material. The small intestine was studded throughout with miliary tubercles, and its mucous surface was the seat of numerous large tuberculous ulcers. The liver weighed 1.420 grams and was normal throughout. The gall bladder was also normal. The pancreas weighed 115 grams and was normal. The left kidney weighed 180 grams; the right kidney weighed 175 grams; neither organ showed evidence of any morbid process. The urinary bladder contained 25 c. c. of urine and was normal. The suprarenal bodies together weighed 16 grams and were filled with tuberculous nodules. The spleen weighed 275 grams and was normal. The membranes of the brain were much congested. The brain weighed 1,510 grams and was normal.

H. W. W.
H. W. A.

CASE 14.

B. C. J.; aged 30 years; nativity, Norway; was admitted to the United States Marine Hospital, port of San Francisco, Cal., August 12, 1897, and died January 17, 1898.

History.-Seventeen months prior to his admission patient caught cold and has been coughing since that time. A week prior to admission he was compelled to go to bed, and the last three days of that time was spitting blood. Physical examination showed the patient to be a well-developed, though somewhat emaciated adult white male. The skin was sallow and upon the chest were seen numerous brown spots. The chest was well formed; the right side moved more than the left. Vocal fremitus was increased on the left side. Upon percussion, dullness was found on the left side, anteriorly as low as the fourth rib, posteriorly as far down as the third dorsal vertebra. The right side was normal except for a very slight dullness over the apex. On auscultation, bronchial breathing and moist rales were heard over the entire upper lobe of the left lung. On the right side, subcrepitant rales were heard over the apex. The heart area of dullness was enlarged downward and to the left. The apex beat was in the fifth intercostal space to the left of the mammary line. No murmurs were heard, but the second sounds, both aortic and pulmonary, were accentuated. The liver and spleen were normal. The sputum was examined and tubercle bacilli were found. Patient was put upon creosote. On the 25th of August he had a severe pulmonary hemorrhage, which was controlled by ice and magendie solution. On the 13th of September a reexamination of the chest was made which showed the dullness of the right apex to have increased, extending down to the second rib anteriorly and the fourth dorsal vertebra posteriorly. Dullness of left lung extended from the fourth rib in front to the fifth dorsal vertebra posteriorly. Pleuritic friction sounds were heard all over the left side of the chest. The patient remained about the same until January 15, when he had a severe pulmonary hemorrhage. He died at 1.07 a. m. January 17, 1898.

Necropsy (ten hours and a half after death).-The body is that of an emaciated adult white male. Rigor mortis is well marked. Encephalon is normal. Weight of brain, 1,295 grams. The pericardium is normal. Heart is normal; weight, 330 grams. Both layers of the pleura on the left side are firmly bound by old adhesions; on the right side the adhesions are more recent. The upper lobe of the left lung presents one large cavity about 8 cm. in diameter. Everywhere the remainder of the lung is infiltrated with the products of the tubercular inflammation. Throughout the lower lobe are many small cavities; weight, 595 grams. Throughout the right lung are present small areas of tubercular infiltration separated

from one another by distances of from one to three centimeters, the intervals being occupied by competent lung tissue; weight, 950 grams. The peritoneal cavity is normal. The spleen is normal; weight, 320 grams. Kidneys normal; weight, right, 170 grams; left, 190 grams. The remainder of the genito-urinary tract is normal. Liver is normal; weight, 2,400 grams. All the other organs of the gastro-intestinal tract are normal. The spinal cord was not examined.

R. R. H.

H

H. S. M.
J. M. G.

CASE 15.

F. H.; aged 24 years; nativity, Finland; admitted to United States Marine Hospital, Stapleton, N. Y., September 8, 1897; died October 15, 1897.

History.-No sickness since childhood; denies venereal troubles; uses tobacco and alcohol in moderation. Has been sick some months with general malaise and vague pains in his chest; began to have a cough in April, 1897, which has continued to present time; expectoration profuse and sometimes bloody; has had pain in throat recently when he swallows, his voice being hoarse. These, with dyspnoea on exertion, are his chief symptoms. He did not lose appetite and has lost very little in weight. Has had no night sweats; bowels are regular; urinates normally; has had a discharge from right ear for several years. Patient's present condition appears fair; has a muddy complexion, clear tongue. Physical examination Is not well nourished; more mobility on left than on right side. Patient somewhat emaciated; vocal fremitus marked on right side; slight dullness right side; breath sounds on left side exaggerated, scarcely heard on right side save in patches; moist rales high up in superior axillary region, right side; a few dry ones near lower end of anterior axillary line. Heart sounds normal. Throat examination shows a badly ulcerated epiglottis. Tubercle bacilli found in the thick purulent sputum. Urine examination negative. Temperature, pulse, and respiration about normal all the time; gradually grew worse. His inability to swallow, thirst, and sleeplessness were his worst symptoms. Although tonics, stimulants, and nourishing food were employed, he gradually failed, and died October 15, 1897, 4 p. m.

Necropsy (twenty hours after death).-Body of a white man about 24 years of age; light hair and eyes, fair skin; very much emaciated. Rigor mortis not present to any marked extent. Body livid over dependent parts. Calvarium not removed. Thorax: Pericardium contained about 100 c. c. clear amber fluid. Right chambers of heart distended, with clots; left contained a considerable quantity of semifluid blood. Organ normal in all respects except that it looked pale. Lungs closely bound down on both sides to chest wall; right contained a large cavity occupying nearly all of the upper lobe; the remainder of the lung substance disorganized; small cavities filled with pus scattered throughout. Left lung also contained a cavity in its apex, but not so large as the one in the right; the remainder of this lung was found in about the same condition as the other. Larynx contained considerable pus over its walls, and the epiglottis was ulcerated to some extent. Abdominal organs apparently normal, except kidneys, which were very dark, and considerable oozing from them took place on section.

G. B.; aged 37 years; nativity, Island of St. Helena; was admitted to the United States Marine Hospital, port of San Francisco, Cal., November 29, 1897, and died December 6, 1897, at 3.30 a. m.

History.-On admission the patient gave a history of a slight cough and night sweats of a year's standing, becoming more marked during the last month. Physical examination: The right side of the chest is smaller than the left and the vocal

fremitus is increased on the left. On percussion dullness was found over the entire surface of the right lung and over the lower lobe of the left lung. On auscultation bronchial breathing was heard over the entire surface of both lungs, and over the apex of the right lung there was an amphoric quality to the respiratory sound. There were numerous moist bronchial rales. The heart was not enlarged, and the sounds, though weak, were normal. The liver and spleen were normal. Tubercle bacilli were found in the sputum. Under treatment the symptoms were somewhat ameliorated, but he rapidly grew weaker until his death.

Necropsy (twenty hours after death).-The body is that of a well-developed, moderately emaciated, adult, white male. Rigor mortis is well marked. The skullcap, brain case, sinuses, and vessels are normal. The meninges are normal, except for a few scattered miliary tubercles on the base of the temporal lobes. The brain is normal. It weighs 1,230 grams. The pericardium is normal. The heart is normal. It weighs 400 grams. The parietal and visceral layers of the pleura on the right side of the chest are covered with miliary tubercles and are everywhere adherent. The parietal and visceral layers of the pleura on the left side of the chest are covered with miliary tubercles. The pleural sac contains 1,200 cc. of blood-stained fluid. The right lung is everywhere tubercular. The upper lobe presents one large cavity occupying the entire substance of the lobe. Throughout the other lobes there are numerous cavities ranging in size from 1 to 3.5 cm. in diameter. The left lung is everywhere tubercular and is consolidated throughout, except for a small cavity 3.5 cm. in diameter at the center of the posterior inferior border of the upper lobe. Both lungs were firmly attached to chest walls and could not be removed except in small fragments. The omentum and peritoneum are thickly covered with miliary tubercles, and they present numerous adhesions. The spleen presents the condition of passive congestion, but is otherwise normal. It weighs 150 grams. The right kidney presents on section the condition of amyloid degeneration, the center pyramids being obliterated. It weighs 150 grams. The left kidney is normal. It weighs 120 grams. The genito-urinary tract is otherwise normal. The liver is normal. It weighs 1,500 grams. The digestive tract is normal. The spinal cord was not examined. S. W. J. M. G.

CASE 17.

R. W. (colored); aged 31; nativity, North Carolina; was admitted to the United States Marine Hospital, Boston, Mass., November 15, 1897, and died February 8, 1898.

During the past summer has Night sweats nearly every night. Eight days ago, after exposure,

History.-Both parents living. Habits good. had a slight cough, and has lost some in weight. Sharp pain in left side. Never spit any blood. was seized with pain in chest, a great deal of coughing, and general prostration. Loss of appetite. Had chilly feelings. Pain in stomach. Bowels not moved for several days. Physical examination: Right side, dullness at apex in front and behind down to sixth rib. Fremitus increased, breathing diminished, voice exaggerated, a few fine rales. Left side nearly normal; has had pain. November 19.-Soft blowing murmur detected at apex. Pulse good, soft, regular. Slight tenderness on deep pressure at McBurney's point. Tongue furred. Appetite poor. Bowels regular and watery.

November 21.-Temperature remains above 38. No pain, little cough, bloody expectoration.

November 26.-Examination of sputum shows presence of tubercle bacilli. February 7.-During the night patient was taken with some cramp, which left him in an exhausted condition. Died 10 a. m., February 8.