Necropsy (twenty-four hours after death).-The heart was contracted and weighed 300 grams. Valves were normal. The pericardial sac contained 80 cc. of fluid and was normal. The left lung weighed 950 grams and was bound to the thoracic wall by strong bands of adhesion all around, particularly at the apex. The organ was filled with tubercular nodules and contained very little air. The right lung weighed 1,850 grams, and had a large cavity in the upper lobe about 250 cc. capacity, and was infiltrated with nodules and very friable. Some small tuberculous nodules were found on the pleural surface of the diaphragm. The peritoneum was normal, but the mesenteric glands were slightly enlarged. Did not appear to be caseous. The omentum was normal. The stomach was small with walls thickened. The small intestine was smaller in caliber than normal, and contained very little fluid. The large intestine small; the rectum was full of hard fecal matter. The liver weighed 1.850 grams, and was slightly friable; the gall bladder contained 25 cc. of bile, and was normal. The pancreas weighed 120 grams and was normal. The spleen weighed 330 grams; rather friable, with capsule adherent. The left kidney weighed 260 grams; was congested. The right kidney weighed 225 grams. Their capsules were nonadherent. The suprarenal bodies were normal. The urinary bladder contained 100 cc. of urine, and was normal. The testicles were atrophied. Penis normal. The membranes of the brain were congested. The brain weighed 1,410 grams. Blood vessels were distended with blood; otherwise normal. Almost 10 cc. of fluid escaped while removing the brain.

H. C. R. H. W. A.

CASE 18.

J. C.: aged 63 years; nativity, Ireland; admitted to the United States Marine Hospital, Cairo, Ill., March 12, 1898; died March 31, 1898.

Clinical history.-Was treated in this hospital from January 29, 1898, to February 14, 1898, for rheumatism. When admitted this time he complained of feeling very weak and of being unable to eat. He felt chilly, but had no distinct chills. Had not been able to work since leaving the hospital. He occasionally vomits what little food he is able to take. Physical examination: Radial arteries somewhat hard; heart's sounds feeble; no valvular murmur. The lungs give the normal resonance on percussion. Liver: Area of dullness diminished from normal.

March 25.-The same indefinite symptoms continue-the irregular range of temperature, from 37.5 to 39 C., weakness, and inability to take nourishment. There is very slight cough. The patient died March 31.

Necropsy (fifteen hours after death).-Rigor mortis present; no external evidences of disease, except the extreme emaciation. Brain: External surface presents several pacchionian bodies along the superior longitudinal sinus. The dura mater was quite thick and opaque. The subarachnoid space contained an excess of fluid. The brain tissue and sinuses presented a normal appearance. Thorax: The heart was of normal size and appearance; weight, 335 grams; walls, firm; valves competent, but mitral slightly thickened. Great vessels of thorax normal. Lungs: Weight of right, 1,128 grams; left, 1,448 grams. Both of these were firmly adhered to the chest wall at their apices. The upper and middle lobes of the left lung were completely filled with gray tubercular nodules, the lower lobe showing an earlier stage of miliary tuberculosis-small pearly bodies, pin-head size, thickly disseminated. This lobe, though permeable to air, was somewhat congested. The right lung was in a similar condition to that of the lower lobe of the left. The mucous membranes of the bronchial tubes were congested and thickened, but were almost free from pus and mucus. The great vessels, nerve trunks, and diaphragm were apparently normal. Abdomen: The vessels of the

omentum were somewhat injected. The spleen was swollen and purplish in color; weight, 300 grams. Its consistency was soft and the tissue easily torn. The pulp exuded freely on pressure. The kidneys presented under the capsule numerous pearly tubercles, and at one point a calcareous nodule under a surface cicatrix. These organs were of normal size, and presented no other appearance of disease. The adnexa were small and shriveled. The bladder and prostate were normal. There was congenital phimosis with adhesion of the foreskin. A slight stricture was found in the membranous portion of the urethra. The intestines were apparently normal. The stomach contained, near its pyloric orifice, an ulcer with smooth sloping edges, nearly circular in shape, and about 4 cm. in diameter. The mucous surface elsewhere was pale in color, with small areas of injected vessels. The gall bladder was distended with fluid bile. The liver was of light-brown color, rather small in size; weight, 1,800 grams. Other organs normal.

CASE 19.

P. C. K.

A. G.; aged 58; nativity, Canada; admitted to the United States Marine Hospital, Chicago, Ill., October 24, 1895; died April 12, 1898, at 10.45 p. m.

History.-Was admitted first on October 24, 1895, complaining of soreness over the abdomen and in the small of the back. He stated then that two years before he had had a pleural effusion on left side, and had been tapped three times, finally recovering. One year afterwards he commenced to have sharp cutting pains over the kidneys. On examination a diagnosis of floating kidney was made and he was operated on. The right kidney was found floating and was anchored to the muscles of the back with catgut ligatures. The wound healed nicely. The kidneys acted well, and the urine was normal, but the bowels were always constipated. On December 14 the wound was healed, but he still complained of pains in his side, and was very much emaciated. He was very carefully examined at this time-heart, lungs, and liver found to be perfectly normal. Spleen so small that it could not easily be distinguished. He continued in this state for months, taking morphine frequently on account of the pain, which now extended into the right iliac fossa and up into the back, being confined to bed all the time. Then he got a little better, and was up and around the wards for a few weeks. He soon returned to his bed again and slowly grew worse, the pain being with him constantly and the bowels being only moved by purgatives. On September 7, 1897, he was readmitted under the diagnosis of tubercle of the lung. About this time he had an attack of diarrhea, which the history states was the first spontaneous movement he had had in two years. His case ran along like that of all consumptives. Cough and vomiting were very troublesome, a great many remedies being given for the latter. Strong stimulation was given all the time, but morphine was often required. During the last of March and first of April his voice could hardly be heard, and he fell into a dull lethargy and gradually failed up to the date of death.

Necropsy (fifteen hours after death).—Body very much emaciated; weight about 80 pounds; slight post-mortem lividity; rigor mortis marked; pupils equal and slightly dilated; large bedsore over spine in lower scapular region. Heart weighed 280 grams. Pericardium adherent to anterior wall of chest and to lungs, obliterating the anterior mediastium; otherwise normal. Aortic, pulmonary, mitral, and tricuspid valves competent and normal; wall of the right ventrical thin; ventrical dilated. Left ventrical showed excentric hypertrophy; other circulatory vessels normal. Respiratory organs: Nares, larynx, and trachea normal. Lungs: Left bound down to parietal pleura by dense adhesions throughout the entire surface; pleura much thickened; weight of lung, 1,030 grams; almost completely solidified; full of small tubercles. Right bound to parietal pleura, with dense adhesions; weight, 800 grams; very much solidified; full of

small tubercles; not so solid as the left. Abdomen: Peritoneum and omentum normal; stomach much dilated and contained 120 c. c. of greenish fluid; walls, cardiac, and pyloric openings normal; small intestines normal; cæcum and rectum contained a small amount of hardened feces; appendix very small and about 1 inch in length; free from adhesions. Liver: Weight, 5,280 grams; pale yellow in color, very friable, mottled yellow on section, very large, apparent fatty degeneration. Gall bladder distended with bile; duct patulous. Pancreas weighed 77 grams; normal and duct patulous. Kidneys: Left, weight, 160 grams; cortex reddish yellow, showing chronic parenchymatous nephritis; ureter and pelvis normal; no tubercles. Right kidney, weight 150 grams; cortex same as left; ureter and pelvis normal. Suprarenal capsules weighed 6 grams each; normal. Bladder contained about 70 c. c. of fluid; walls thickened. Prostate slightly enlarged; penis showed no scars; testicles atrophied. Spleen weighed 330 grams, pigmented, on section capsule adherent. Nervous system: Head narrow in front; scalp normal; skull of medium thickness. Brain weighed 1,420 grams; vessels, ventricles, and substance apparently normal. Solar plexuses not found. M. H. F. H. W. S.

CASE 20.

J. H.; aged 33 years; nativity, Kentucky; admitted to United States Marine Hospital at Louisville, Ky., October 26, 1897; died February 21, 1898.

History.-Mother died of tubercle. Father killed in battle. One sister living. No brothers or sisters dead. Man says he does not drink to excess. Has had hard and soft chancres as well as gonorrhoea. The patient coughs a great deal, and suffers from dyspnoea. Chest narrow and contracted. The sputa contains bacillus of tubercle. Patient is emaciated; appetite poor. Apex of right lung dull and flat. Creaking-leather sound and tubular breathing. Evidently a cavity in upper part of right lung. He died February 21, 1898. Post-mortem (twelve hours after death).—Body small and emaciated. Rigor mortis. Large cicatrix on left shoulder from burn; also scar from some cause 4 cm. in diameter on lower part of sternum. There were no pathological lesions aside from those usually found in the body of a person dead from pulmonary tubercle. There were a few recent vegetations of valves of heart and an old hemorrhagic infarct in left kidney. The right lung contained several large cavities, and was so bound down by adhesions as to necessitate removal in sections. The pericardial fluid was normal in quantity and appearance. The heart valves were competent. The kidneys were contracted and hard, but not granular, at least their microscopical appearance did not show granulations. The capsules torn off instead of peeling readily. The liver was small and bled on section; its color was a chocolate brown. The brain small, but appeared normal, as were its membranes. Weights of organs: Brain weighed 1,460 grams; heart, 375 grams; left lung, 600 grams; right lung, 1,260, infiltrated with tubercle; liver, 1,740 grams; kidney, left, 190 grams; kidney, right, 195 grams; spleen, small and pale, 150 grams.

W. P. M.

CASE 21.

J. C.; aged 26 years; nativity, Ireland; admitted to United States Marine Hospital. Detroit, Mich., May 26, 1896; died February 13, 1898.

History.-Had been a patient in the hospital before and had gone out much improved, but returned in a worse condition. The history and rational signs made it positive that the disease was tuberculosis infection of both lungs. He continued to improve during the summer. In December he fell from a ladder, sustaining a fracture of the ulna and several contusions. He rapidly recovered from the results of the accident. Later, called attention to a tumor in the groin,

which he said he had had for a long time. An impulse was imparted to the tumor on coughing. The tumor lay below Pouport's ligament, and was diagnosticated femoral hernia.

January 1, 1898.-The tumor has enlarged considerably lately, and he complains that coughing causes him pain in the tumor. There is fluctuation. Aspirated and 75 c. c. of thick, ropy puss withdrawn. Operation: Abscess opened, irrigated, and packed. About 100 c. c. pus in pockets. Pus had burrowed almost to knee. Lying loose in the bottom of the abscess cavity were several pieces of bone the size of the end of the little finger. Two openings were made for drainage. A small opening or sinus was found on the under side of the shaft of the femur leading to exposed bone. The saphenous vein was lying loose in the cavity and was ligated. Chloroform. The patient improved until January 21, when he had a severe diarrhea follow constipation. This condition was never controlled, and he gradually grew worse, dying of exhaustion.

Necropsy (twenty-four hours after death).—Body very thin. Rigor mortis well marked. No discolorations. Calvarium removed. Membranes and brain normal. Heart and great blood vessels normal. Lungs studded throughout with tubercles in different stages of softening. Pleura adherent over bases and apices of both lungs behind; only small cavities. Omentum very thin, and blood vessels can hardly be seen. No enlargement of mesenteric glands. The mucous coat of the stomach quite badly inflamed and covered over with a slimy, blackish mucus. Peritoneum perfectly normal everywhere, showing no protrusions at any point. The liver was somewhat anæmic. The common duct was distended at one point, this socculated portion containing muco-pus. Gall bladder distended above the normal. The fluid seemed normal. The head of the pancreas was much harder than normal. Spleen hard and capsule thickened. Both kidneys enlarged and each undergoing chronic, productive inflammation. Ureters, bladder, great blood vessels, and organs of generation normal. The abscess cavity opened up and thoroughly exposed. A sinus was found running upwards under the sheath of the psoas to the last lumbar vertebra and sacrum. The bodies of the vertebra were destroyed at the junction, and several of the vertebræ were diseased, undergoing necrosis.

J. O. C.
J. G.

CASE 22.

Tubercle of lungs and intestines.

L. C.; aged 42 years; nativity, Georgia; admitted to the United States Marine Hospital, St. Louis, Mo., November 22, 1897; died, January 20, 1898.

History. This admission was the patient's second to this hospital. He was admitted November 8, 1897, under the diagnonis of "tubercle of lung," and, on request, was discharged November 11, unimproved. He was readmitted November 22, 1897, under the same diagnosis. The patient complained of a bad cold, which he contracted several months before, of a bad cough with profuse expectoration, of night sweats, and shortness of breath. There was no history of hæmaptysis. No tubercle bacilli were found in his sputum, though searched for many times. The patient also complained of a continuous pain in the abdomen, which came on about a month before his admission, accompanied by diarrhoea of a moderate degree. Physical examination: The patient is greatly emaciated. There is a sinking in above and below the clavicles. The fingers are clubbed," the scapula "winged." Palpation: The epitrochlear, submental, and post-cervical lymphatic glands are enlarged. Tactile fremitus at the apex of the left lung is greater than is the normal. There is tenderness over the abdomen below the umbilicus. No tumor can be felt. No ascites or tympanites. Percussion: A higher-pitched note is elicited over the apex of the left lung with a tympanitic

area just below this. Auscultation: Vocal fremitus is increased over the apex of the left lung. On ordinary respiration the inspiratory murmur is rough, short, and wavy, the expiratory slightly prolonged and rough over the apex of the left lung. Many râles are heard at the end of inspiration over the whole chest. To the left of the sternum and 4 centimeters below the left clavicle a rough adventitious rhonchus is heard. On forced respiration the inspiratory murmur is very rough, as is also the expiratory, being bronchial in character. After a month the signs and symptoms on the part of the lung were much improved, the râles disappearing and the respiratory murmurs becoming more vescicular in character; but not so the pain in the abdomen and the diarrhoea, palliative measures neither relieving the one nor checking the other for any time. The patient lost 30 pounds in weight while in the hospital, notwithstanding the most nourishing diet and careful treatment. The last two weeks before his death he lost 15 pounds. The patient's condition gradually became worse till at half past 1 o'clock on the evening of January 20, 1898, when, appearing critical, the medical officer in command was summoned, but before anything could be done the patient passed away.

Necropsy (twenty hours after death).-The body is that of a negro, much emaciated, apparently 40 years of age; height, 5 feet 8 inches. The lips are covered with yellow mucus. No foreign material is seen in any of the body orifices. Rigor mortis is well developed. The eyelids are open, the pupils evenly dilated, the corneæ firm and transparent. There having been no symptoms of disease of the brain, it is thought unnecessary to open the cranial cavities. Thorax and abdomen: There is but little subcutaneous fat. The abdominal organs are in their normal positions. The intestines lie very far back. No foreign body is seen in the abdomen. The parts exposed are of a pale color generally, only the small intestines being slightly reddened. The diaphragm on each side reaches the lower border of the fifth rib. Thorax: On the left side there is a very firm adhesion between the base of the lung and the chest wall, the adhesion being 2 cm. thick. The pericardium contains 50 c. c. of a clear fluid. The heart is about the size of a man's fist and is very pale. On the anterior surface of the right ventricle there is a white spot 3 cm. long by 2 wide. The apex is moderately covered with fat. The right auricle contains 25 c. c. of fluid blood, the right ventricle 18 c. c., chiefly black and clotted. The left auricle and ventricle contain a small quantity of clotted blood. The valves are without alteration and are competent. The heart is 15 cm. long by 12 thick by 6 wide, and weighs 350 grams after the blood has been removed. The wall of the left ventricle is 1 cm. thick. The large veins of the neck are moderately distended with blood, the arteries being empty. The lungs seem large, and are of a dark-slate color with reddish mottling. On section, the apex of the left lung contains a large tubercular nodule 1.5 cm. by 2 cm., with numerous smaller nodules around it. Upon cutting this tubercle, its interior is of a black color, dotted with numerous chalky spots. This lung is 23 cm. long by 14 wide by 6 thick, and weighs 435 grams. The right lung is crepitant throughout, presenting no tubercular nodules. It is 23 cm. long, 15 wide, and 8 thick, and weighs 530 grams. The bronchial lymphatic glands are all greatly enlarged and are hard to the touch. On section, they are of a dark color with minute white spots. Abdomen: The spleen is of a dark slate color. It is 14 cm. long, 9 wide, and 5 thick, and weighs 190 grams. On section, it is uniformly red. The left kidney is easily stripped from its capsule. Its anterior surface near the hilum presents a decided bulge, which is firm to the touch. On section, the pyramids are few in number but well defined, one pyramid being contained in this prominence before mentioned. The cortical zone is narrow. This kidney is 13 cm. long, 6 wide, and 4 thick, and weighs 180 grams. The right kidney is 12 cm. long, 7 wide, and 3 thick, and weighs 170 grams. On section it presents nothing notable. The bladder is empty. The stomach is somewhat distended and contains 150 c. c. of 10918- -8