The peritoneum was found shiny, smooth, and transparent. The tongue was coated brownish white. Pharynx normal. The oesophagus was patulous throughout, and presented no gross lesions. The stomach was found nearly empty, a few small curds of milk and about 2 c. c. of yellowish-green liquid were observed. The pyloric orifice was about 2 cm. in diameter. The cardiac orifice was about 3 cm. in diameter. The small intestine in the ileum contained three ulcers which were oval, long axis being situated transversely, and on the side of the mesenteric attachment the edges were hard and infiltrated, and in these were found several small tubercles. The appendix vermiformis was found deeply congested at the distal portion. On opening the appendix at the distal portion an ulcer was seen, which had for its base nothing more apparently than the serous coat of the perotoneum. The edges of the ulcer were hard, much thickened, and much infiltrated. In the sigmoid flexure an ulcer appeared which was about the same in character as the ones described in the ileum. The base of the ulcer involved the muscular coat. The rectum was found patulous. The liver weighed 1,800 grams; was chocolate red in color, and on section revealed nothing abnormal. The gall bladder and ducts were found patulous, no stones being found. The mucous coat of the gall bladder was somewhat roughened. The pancreas weighed 110 grams, was soft in character. The left kidney weighed 160 grams; nothing abnormal could be detected macroscopically. The right kidney weighed 170 grams, and was found normal on section. The pelvis and ureters were found patulous throughout. The bladder appeared much larger than normal, and contained about 150 c. c. of urine. The prostate gland was not found enlarged. The membranous portion of the urethra was congested. The left suprarenal body weighed 9 grams. The right suprarenal body was triangular in form, and weighed 7 grams. The scalp was well covered by a good growth of shortly cropped hair. The forehead was rather low. The skull was very thick. The membranes of the brain were normal, and the brain weighed 1,380 grams. The spinal canal cord and membranes were not examined.

F. I.

CASE 27.

Acute tuberculosis.

I. H. (colored), aged 33 years; nativity, Tennessee; admitted to the United States Marine Hospital at New Orleans, La., August 13, 1897; died, April 21, 1898.

History.-On admission had an ulcer of penis and bubo of right groin. The ulcer was of five months' duration, the bubo was suppurating and had ruptured, leaving an angry looking ulcerating surface. There was also a chancroid of corona of five months' duration and beginning suppurating gland of groin. This was incised and dressings applied to the ulcers. On the 17th of August patient first complained of tenderness over the bladder, passed urine frequently, accompanied with straining; temperature 38.4°; pain continued at neck of bladder and along the urethra. Has continual desire to urinate. No sudden stoppage of urine and no gravel. Milk diet and dieretics given. Several days after this patient passed some muddy looking urine, followed by 50 c. c. of pus. Felt perfectly relieved after this. Irrigation of bladder begun and continued with good effect, many symptoms disappearing. Examination of urethra shows stricture about 3 inches from meatus, tight, annular, moderate calibre and not thick. Examination per rectum showed some tenderness around neck of bladder and prostate; there was also a small inflamed external pile. By the end of the month the ulcers were healing, the pain and tenderness of bladder had disappeared, no straining on micturition, makes urine regularly, and can hold bladder full without discomfort. Urinary analysis: Acid reaction; specific gravity, 1.009; color, amber; slight amount of albumen. The short period of relief was soon followed

by the onset of pain, referred to left inguinal region and back, a “pinching sensation" at seat of stricture, and tenderness in upper part of rectum. There is a distinct mass, palpable through abdominal walls, adherent to rectum or lower end of colon. Pressure of this causes pain that "shoots through" to the back. Straining at stool, and blood in small quantity. Milk diet, rest in bed, and cathartics. After several days a further examination showed some hard tumor in left inguinal region; no fluctuation; tender. The mass extends as high up as level of umbilicus and within 2 c. m. of median line; from there to the left occupying the left lumbar and inguinal regions. The mass is irregular, very little or no movement; on pressure causes pain in rectum to anus. Has considerable pain with full bladder in morning or before passing urine, and the pain disappeared immediately after micturition. Examination of urine: Amber color, considerable sediment of pus, acid reaction, specific gravity, 1.012. Stricture was dilated; bladder explored with negative results. Bladder not tender at all. Provisional diagnosis: Pyelitis is made, with idea that the ureter had become stopped up with pus and suddenly gave way. Opiates given to relieve pain. Sounds passed daily, 16.017, English. Milk diet; rest in bed; salol .6 gm., three times a day. Improved daily: less pus in urine; no pain on micturition; gaining strength.

October 27.-While having a normal movement of bowels noticed "warm blood trickling" from urethra, 4 c. c., then when he urinated had a pain at seat of stricture, and an attempt to urinate caused some pain at the point of stricture which "seemed to be swollen and prevented urine from coming out"; after fifteen minutes urine ran freely. The same symptoms continued, with an occasional clot appearing in urine. The clot caused a temporary obstruction to passage of urine. November 8.-No evidence of tumor; tenderness remains on deep pressure in region between kidney and bladder. Bladder washed out. Toward last of washings, like the last of urinating, the water is muddy with pus, and inclines one to the belief that patient has had an abscess at neck of bladder either in prostate or infravesicular. As usual, however, no tenesmus and but little tenderness exists. Amount of urine in twenty-four hours, 1,500 c. c.

November 20.-Has been improving daily. Complains of shortness of breath; no cough; pain in muscles of back. During the month of December, 1897, continued about the same. Still passing some blood and some pus in urine; has no difficulty in micturating, except when a clot stretches the urethra. Has occasional chills. Temperature range between 38° and 40° during last three weeks of month. Quinine had no influence on temperature. During the month of January the fever continued about the same. Had pain in left lumbar region most of time. Treatment: Attention given to all emunctories and symptomatic. He continued about the same during February, with slight improvement. March examination: A No. 16 English sound passed; some roughness and tightness at prostate, no urethral stricture apparent; bladder contracted; holds at most 140 c. c.; some granular detritus washed out; passes urine frequently, twenty-five times during the night, attended with more or less straining; no pus forced out. Examination per rectum shows enlarged prostate, chiefly middle and left lobes involved. Developed some diarrhea during this month. Temperature was variable, ranging between 37 in the morning and 39 to 39.5° during the evening. During April complained of continuous pain in penis, about 2 inches behind meatus, frequent micturition, every fifteen minutes, tenderness over bladder and left inguinal region. Diarrhea became troublesome, fever increasing; had irregular chills. Rapid emaciation followed; the patient grew weaker daily. During the last week the temperature did not rise above normal, he was in a collapsed state, pulse imperceptible, a cadaveric odor about his body developed, and he finally died of exhaustion.

Necropsy (fifteen hours after death).-Rigor mortis in legs, face, and shoulders. General emaciation. Livores over left shoulder and back. Pupils slightly

dilated. Superficial appearance of chest shows marked emaciation, intercostal spaces sunken. Pericardial sac apparently normal. The heart weighs 370 grams; small and pale and is rigidly contracted. Left ventricle is empty. Its walls are markedly thickened. Right ventricle contains some dark blood and a large buffy clot. Valves apparently normal. Respiratory organs: Nares contained a clot of blood from recent hemorrhage. Left lung weighs 440 grams. Its surface grayish, and presents patches of extravasated blood scattered over its posterior surface. It crepitates normally. On section, the lung appears to be filled with a pale red, frothy liquid. Numerous miliary tubercles are scattered over the whole cut surface in both lobes. Right lung weighs 480 grams. Few adhesions at apex and at the base to the diaphragm. Its surface is grayish white and has scattered black pigmented spots. On section, a frothy fluid oozes from all points. Numerous miliary tubercles are scattered over the whole cut surfaces in all three lobes. Pleural surfaces smooth and glistening, and normal except at points where adhesions occurred on right side. Bronchial lymphatic glands at root of both lungs were enlarged and tubercular. Superficial view of abdomen reveals nothing abnormal. Peritoneum smooth and glistening and in general appearance normal. There are a few peritoneal adhesions to the surface of the spleen. Stomach appears small and collapsed. Small intestines empty. Large bowel slightly distended. Sigmoid colon and rectum contain fecal matter. Liver weighs 2,250 grams, large and dark red in color. Its surface is irregular and markedly tubercular. On section, liver presents disseminated miliary tubercles, many of which are beginning to undergo caseous degeneration. Lymphatic glands in region of transverse fissure gastro-hepaticomentum are tubercular. Gall bladder and gall ducts normal. Pancreas weighs 60 grams, apparently normal. Spleen is very much enlarged, its surface appears nodular from aggregated tubercles. On section, presents disseminated miliary tubercles. Its weight is 855 grams. The lymphatic glands of the spleen occupying its hilum were all much enlarged from tubercular infiltration.

Left kidney weighs 180 grams. Its surface is smooth and slightly pigmented. On section, appears pale and anemic, and shows few scattered tubercles. Right kidney weighs 210 grams. Surface is markedly tubercular, at some points undergoing cheesy degeneration. On section, presents numerous disseminated tubercles, varying in size from a pea to a walnut, the larger ones containing pus on section. Lymphatic glands in abdomen and pelvis are all enlarged-apparently tubercular. Right supra-renal capsule weighs 15 grams. A tubercular mass involves this capsule, so that very little normal tissue is seen. Left supra-renal capsule weighs 2 grams; appears normal. Ureters apparently normal. Bladder contains about 100 c.c. of urine. The bladder walls are much thickened. The mucous membrane of bladder shows numerous ulcerated spots covering its whole surface. At the upper left angle of bladder is seen an opening which may be traced to be continuous with a suppurating tract. This tract courses over the iliopectineal line close to left sacro-iliac synchondrosis, over the upper surface of psoas muscle to level of second lumbar vertebra. The peritoneum and fascia covering the psoas muscle separates the tract from the abdominal cavity. Opening into the tract at its origin in the pelvis is a large suppurating mass, which seems to be a tubercular abscess of the prostatic gland. The prostate gland and both seminal vesicles are tubercular. The entire left epididymis was tubercular. At globus major was a large tubercular abscess. Left testicle also tubercular. Right epididymis felt thick and hard. Right testicle apparently normal. Brain apparently normal; weight, 1,379 grams. Primary cause of death, general acute tuberculosis. Secondary cause, exhaustion.

R. VON E.

H. R. C.

CASE 28.

General acute tuberculosis.

J. G.; aged 48 years; nativity, Ohio; admitted to United States Marine Hospital, New Orleans, La., September 16, 1897; died April 28, 1898.

History.-On admission complained of pain, sudden and cutting pain in side. and back; first occurred one week before admission; has had no chill, not much cough, and had had a similar pain on left side two months ago. Appetite poor, no nausea or vomiting, constipated, skin clear of eruption; vaccinated on admission. Temperature 38.5° C. Examination shows inflammation of left lung, increased fremitus, dullness, increased vocal resonance, and crackling rales with diminished respiration on left side over upper lobe; along base of right lung some pleuritic friction, roughening, otherwise negative. Father died of severe and chronic cough, and lost a great deal of flesh. One sister has same complaint. Patient developed an irregular remittent fever, maximum temperature being 39.2° C. Cough continued, expectoration variable, being sometimes very free and streaked with blood, pain continuous in chest; crackling rales heard over whole left lung, dullness, and decreased respiratory murmur, which became afterwards increased. Tongue continually coated, appetite very poor, bowels became loose, stools diarrhæal, circulation poor, irregular chills, and night sweats; general weakness and emaciation soon developed. Death due to exhaustion.

Necropsy (one hour and ten minntes after death).-Rigor mortis in lower jaw, Marked general emaciation. Pupils of medium size. Superficial appearance of chest shows considerable emaciation, ribs standing out prominently. Pericardium apparently normal; contains about 100 c. c. of pale straw-colored fluid. Heart weighs 360 grams; flabby; fat over the right ventricular wall, apex, and part of surface of left ventricle. On section the left ventricle contains blood and clots, dark in color. The right ventricle contains very little blood. Valves apparently normal. Respiratory organs: Nares and larynx normal. Left lung weighs 705 grams. Its surface is rough and torn from separation of the adhesions, which were so thick that there was great difficulty in the removal of the lung. Numerous openings leading into small and large cavities may be seen over the whole surface. On section the whole lung appears diseased from diffuse miliary tubercles. Also numerous small suppurating cavities, lined by tubercles which have ruptured and others about to ulcerate, may be seen scattered over the cut surface. The largest cavity was at the apex, which involved nearly the whole lobe. Right lung weighs 700 grams. Superficial surface appears darkly pigmented; feels nodular to the touch. On section the cut surface presents numerous miliary tubercles. Considerable pale-red frothy fluid exuded from the cut surface in middle and lower lobes. The pleural surface on right side was smooth, except at points where adhesions occurred on the posterior surface and over the diaphragm. Bronchial lymphatic glands of both lungs were tubercular. Those at root of left lung were much the larger. Superficial view of abdomen shows nothing abnormal. On section the abdominal walls are very thin; the muscles are anæmic and pale; no subperitoneal fat visible on section in median line. Peritoneum apparently normal. Stomach normal. Small and large bowel normal. The mesenteric glands high up in the abdomen, and those in the lumbar region were enlarged and tubercular. Liver weighs 1.490 grams. External surface smooth, dark red in color. On section it presents scattered minute tubercles. Lymphatic glands in gastro-hepatic omentum feel shotty. Spleen weighs 320 grams. External surface apparently normal. On section numerous scattered minute tubercles are seen over whole of cut surface. Left kidney weighs 185 grams. Its surface presents few tubercles under the capsule. On section there are some scattered tuberculous nodules throughout the tissue. Right kidney

Ureters apparently

Its walls are thick.

weighs 175 grams. Few tubercular nodules seen on section. normal. Bladder contains about 100 c. c. of clear urine. The prostate gland seems normal. The seminal vesicles are much enlarged and tubercular. The seminal duct is large. The tunica vaginalis on left side is adherent to the testicle. The left testicle on section shows a large tubercle abscess. The right testicle is apparently normal. Brain weighs 1,355 grams. Its membranes and tissue are apparently normal. Primary cause of death, general tuberculosis; secondary cause of death, exhaustion.

R. VON E.

H. R. C.

CASE 29.

Tubercle of lungs and brain.

J. S.; aged 35 years; nativity, Maine; admitted to the United States Marine Hospital, Boston, Mass., May 21, 1898; died June 27, 1898.

History.-On admission to the hospital gave history of intermittent chills and fever with sweats every third day. Tongue coated, appetite poor, bowels constipated. Temperature 38° C. For a week he had a slight evening temperature and said he felt pretty well. May 31 he had a chill, followed by a temperature of 40, which gradually declined, reaching normal in three days. Next it began to rise, and in two days reached 40°, and ranged between 38° and 40° till his death. June 2 he had a profuse hemorrhage from his lungs, another on the 3d, and two on the 4th. Had small hemorrhages every day till June 1. Sputum did not show the tubercle bacillus till June 10. Urine smoky. Died June 27.

Necropsy (twenty-one hours after death).—Post-mortem lividity marked and rigor mortis slight; general nutrition fair; pupils normal. Heart weighed 375 grams and was flabby; valves competent. Left lung weighed 1,475 grams; lower lobe nodular and upper crepitant to the feel; caseous masses in upper lobe and miliary tubercles throughout; left pleural cavity contained 1,000 c. c. of fluid with adhesions at the apex. Right lung weighed 1,300 grams; upper lobe nodular; miliary tubercles throughout; bronchioles filled with frothy mucus. Stomach contained a little chyme. Intestines empty and distended with gas; a small quantity of feces in the sigmoid flexure. Liver weighed 1,650 grams and was pale. Pancreas weighed 45 grams. Right and left kidneys each weighed 200 grams and were normal. Bladder was empty. Spleen weighed 220 grams. Dura mater was congested and there was some serous effusion in the subdural space. Brain weighed 1,450 grams; deposit of miliary tubercles along the longitudinal fissure.

CASE 30.
Tubercle (general).

H. W. W.

H. A.; aged 47 years; nativity, Finland; admitted to the United States Marine Hospital, Boston, Mass., May 17, 1898; died June 9, 1898.

History.-Had been previously treated during winter of 1898 for enteric fever, and was in this hospital from March 19, to April 20, 1898, with an aortic insufficiency; he left the hospital on his own request, his condition being improved. On reentrance there was emaciation, anorexia, and weakness. Physical examination showed infiltration of right lung, limited respiration on right side, and aortic murmur. After temporary improvement patient began to decline steadily. Alternate constipation and diarrhoea; May 22, left testicle swollen and painful, but subsided under treatment; at same time slight urethral discharge, but patient firmly denied gonorrhoeal history; June 4, suppression of urine, catheter being used till death. Death easy on June 9, at 8 p. m.