Necropsy (fifteen hours after death).—Marked post-mortem lividity: rigor mortis slight; greatly emaciated; pupils dilated. Heart weighed 290 grams; pericardial sack contained 10 c. c. of fluid; aortic valves thickened; heart muscle flabby and right side somewhat distended with venous blood. Ascending aorta and arch enormously dilated, walls greatly thickened and inner coat thickly studded with miliary tubercles. Left lung, 1,390 grams; pleural adhesions at apex, posterior, border, and base; crepitant to feel, and studded throughout with miliary tubercles; caseous mass, 4 cm. in diameter, in apex. Right lung, 780 grams; everywhere adherent to thoracic wall; tough on section; a mass of miliary tubercles with caseous masses scattered here and there. Liver, 1,490 grams, miliary tubercles throughout. Spleen, 320 grams, slightly tuberculous; small supernumerary spleen near the hilum. Other abdominal viscera normal. Left kidney, 240 grams; capsule adherent, with tubercular deposit abundant beneath and scattered through the parenchyma. Right kidney, 190 grams, also tuberculous, with densely adherent capsule. Bladder wall thickened, mucous membrane hypertrophied and somewhat congested, and contained a small amount of turbid urine. Left testicle enlarged and contained a quantity of thick pus; 25 c. c. of clear yellow fluid in cavity of tunica vaginalis. Brain membranes pale. Brain, 1,470 grams; abundant tubercular deposit along the longitudinal fissure; serous effusion in the subdural and subarachnoid spaces. H. W. W. CASE 31. A. N.; aged 38 years; nativity, Peru; was admitted to the United States Marine Hospital, port of San Francisco, Cal., December 5, 1897, and died February 10, 1898. History.-Patient had had a sore throat with cough, loss of weight, and pain upon swallowing, for five months. Physical examination showed that the chest movements were equal; vocal fremitus normal. On percussion, slightly impaired resonance of the upper lobes was found, especially of the left. Upon auscultation, inspiratory sounds were harsher and more prolonged than normal and moist bronchial râles were heard. The heart, liver, and spleen were normal. The throat showed evidences of inflammation. On February 9, 1898, a reexamination was made and upon percussion dullness of both apices with impaired resonance of the entire left lung was found. Over the lower lobe of the left lung pleuritic sounds were heard. The sputum was examined repeatedly, but the tubercle bacillus was not found. The treatment was stimulative and symptomatic, but the patient gradually grew weaker and died of inanition at 3.30 p. m. February 10, 1898. Necropsy (nineteen hours after death.)—The body is that of a poorly developed and emaciated adult mulatto male. Rigor mortis well marked. Encephalon normal. Weight of brain 1,580 grams. The pericardium is normal. Heart normal; weight, 250 grams. At the apex of the right lung and the apex and base of the left lung are fibrous adhesions. Otherwise the parietal and visceral layers of both pleuræ are normal. The left lung upon section shows tubercular infiltration of the upper lobe, while the lower lobe is congested and infiltrated, but to a less degree; weight, 910 grams. Right lung is deeply congested, while throughout its substance are seen areas of tubercular infiltration; in the upper lobe are two cavities, one 2 cm., the other 1 cm. in diameter; weight, 770 grams. The peritoneal cavity is normal. Spleen is normal; weight, 130 grams. Left kidney is very small, although all the pyramids are intact; weight, 97 grams. Right kidney shows evidences of an old interstitial nephritis; some of the pyramids are absent; weight, 93 grams. The rest of the genito-urinary organs are normal. Liver is normal; weight, 1,270 grams. Gall bladder distended with bile. The remainder of the gastro-intestinal tract is normal. All organs show evidences of marked anæmia. The spinal cord was not examined. R. R. H. W. M. J. J. M. G. CASE 32. Dilatation of heart, general; emphysema. L. C.; aged 56 years; nativity, Germany; was admitted to the United States Marine Hospital, port of San Francisco, Cal., December 6, 1897, and died February 11. 1898, at 4.30 a. m. History.—On admission the patient complained of weakness, shortness of breath, and of cough with profuse expectoration. Physical examination: Patient was well developed and well nourished. The chest was barrel-shaped; its movements were equal, but deficient. On percussion of chest no dullness was found, but over the greater part of the lung a hyperresonant note could be elicited. On auscultation numerous moist râles were heard. The heart was enlarged downward and to the left, the apex beat being situated 4 cm. to the left of the mammary line in the fifth intercostal space; sounds normal. The liver and spleen were not enlarged. Under treatment his symptoms were temporarily improved, but subsequently grew worse until his death. Necropsy (nine hours after death).—Body is that of a well developed, well nourished adult white male. Rigor mortis is well marked. Encephalon is normal. Weight of brain, 1,420 grams. The pericardial sac contains 300 c. c. of clear finid, but is otherwise normal. The heart is dilated, the right ventricular cavity being nearly double its normal size. The valves are normal. Weight, 410 grams. The parietal and visceral layers of the pleura on the right side of the chest present a few slight adhesions; on the left they are everywhere strongly adherent. The right lung is enlarged, and on section presents the condition of vesicular emphysema. The lower lobe also shows a marked degree of hypostatic congestion. Weight, 1.280 grams. On section of the left lung a cavity 5 cm. in diameter is seen occupying a position in the apex. The entire upper lobe is infiltrated with tubercles. The lower lobe presents the conditions of vesicular emphysema and hypostatic congestion. Weight, 830 grams. The peritoneal cavity is normal. The spleen is normal; weight, 230 grams. On section the right kidney presents the condition of fatty degeneration. The cortex is thicker than normal, and both it and the pyramids are yellow in color. Weight, 270 grams. The left kidney presents the same pathological condition as the right; weight, 230 grams. The genito-urinary tract is otherwise normal. The liver is normal; weight, 2,150 grams. The digestive tract is normal. The spinal cord was not examined. S. W. W. M. J. J. M. G. CASE 33. Stricture of urethra, organic-Inflammation of bladder, acute—Disseminated suppurative nephritis-Inflammation of large intestine-Tubercle of lung, double. P. McD.; aged 26; nativity. Nova Scotia; admitted to United States Marine Hospital, port of Boston, Mass., September 10, 1897; died October 23, 1897. History.-Patient contracted gonorrhoea two years ago, which lasted as gleet to the present time. Three months ago testicles began to swell. Was treated at office for stricture of urethra and retention of urine before he was sent to hospital. On entering he was found to have a stricture just within the meatus urinarius and several deeper ones. Passes very small stream of urine with difficulty. Can not retain urine over one hour. No. 12 sound passed. This was followed by a chill. Later, at every attempt to pass sound, a chill followed, with bloody micturation; and after several days bloody mucous diarrhoea set in, which in spite of treatment, persisted with ten to fifteen stools a day until death. During entire sickness complained of difficulty in passing water, pain in back, and later of dyspnoea. Examination of chest at first was negative. Later revealed dullness at both apices with fine subcrepitant râles over entire front of chest. Heart sounds very faint, but regular. Necrospy (twenty hours after death).-Poorly nourished; rigor mortis slight. Pericardium adherent to chest wall in front. Pericardium and entire anterior mediastinum emphysematous; contained 30 c. c. fluid. Heart wall pale and flabby, otherwise normal; all valves competent and normal except tricuspid, which was slightly enlarged. Left lung weighed 300 grams; was slightly adherent at apex. Upper lobe thickly studded with nodules in state of caseation. Lower lobe markedly congested. Right lung weighed 400 grams; adherent at apex; nodules in state of caseation in all three lobes with marked congestion in lower. Liver weighed 1,460 grams; was congested, friable, and of slightly "nutmeg" appearance. Gall bladder contained 20 c. c. of bile; no stones. Stomach contained 110 c. c. of green chyme. Ruga were well marked. All the glands of the mesentery were enlarged, the largest being the size of a pea and in a state of caseation. Small intestine normal. Large intestine congested and showed elevated nodules on inner surface size of very small pea, possibly tubercles. Kidney: Left weighed 150 grams, congested, dark red, soft, bled freely, pelvis dilated; contained urine and pus; lower part contained large cysts in state of caseation; cortex well marked; capsule not adherent. Right weighed 155 grams; entire pelvis and most of cortex made up of cysts containing pus and detritus; rest of substance studded with smaller cysts in state of caseation. Suprarenal capsules weighed-left, 7 grams; right, 8 grams. Bladder contained 60 c. c. of cloudy urine: was contracted and congested. Urethra: Stricture near meatus and whole caliber of canal much contracted; marked congestion in bulbous portion. Epididymis enlarged and hard. Spleen normal; weighed 150 grams. Brain weighed 1,780 grams and contained small amount of fluid in membranes and ventricles. S. B. G. CASE 34. J. D.; male; aged, 33 years; nativity, Ireland; was admitted to the United States Marine Hospital, Port Townsend, Wash., March 7, 1898; died May 24, 1898. History. The patient was first admitted to the hospital on January 17, 1898, and remained under treatment for tubercle of the lungs until March 5, 1898, when, after violating the rules of the hospital, he remained away without permission. He reported two days later, and, apologizing for his desertion, he was readmitted on account of his serious condition. He stated that he had suffered with a slight cough for the past two and one-half years, which, gradually becoming more pronounced, had been quite severe during the past fifteen months. Shortness of breath had existed for nine months. He had had no night sweats, but the cough was very troublesome, and he expectorated profusely, but no blood at any time. He had lost considerable flesh and was growing much weaker. Upon admission he was suffering from a slight elevation of temperature in the evenings, but had no night sweats; the cough was very severe and large quantities of muco-purulent sputum were expectorated; the pulse was rapid and feeble. An examination showed diminished expansion of both lungs, an increase of vocal fremitus over the upper portion of the chest on both sides, dullness over the upper lobes of both lungs, harsh respiratory murmur in the same locality, and numerous small mucous râles over both the upper and lower lobes of both lungs. The physical signs were sufficient to reveal beyond doubt that the disease was tubercular, but additional evidence was furnished by an examination of the sputum, which showed the presence of great numbers of tubercle bacilli. The course of the disease, after coming to the hospital, was acute, the patient becoming gradually weaker and much emaciated, but at no time having the slightest hemorrhage from the lungs. Creosote was tried in full doses, but was of no benefit. A profuse diarrhea supervened toward the end of the illness, and from this time the patient rapidly lost strength. His death occurred ten days later. Necropsy (twenty hours after death).—External appearances: Body much emaciated; post-mortem lividity slight, and post-mortem rigidity not marked. Thoracic cavity: The pericardium was normal, containing 40 c. c. pale straw-colored serum. The heart muscle was healthy and the valves competent and free from disease, the organ weighing 378 grams. A small ante-mortem clot was found extending from the left ventricle into the aorta. Both pleural cavities were practically obliterated by numerous adhesions between the visceral and parietal layers of the pleuræ. Both lungs showed marked tubercular infiltration throughout their entire structure, but the process was not pronounced in the upper lobes. The right lung weighed 1,021 grams and contained in its apex a cavity 3 cm. wide and 5 cm. long, and many other smaller cavities scattered through its substance. The left lung weighed 832 grams and contained several small cavities in the upper lobe. The larynx presented no evidences of the disease; in fact, there was no inflammation or ulceration of its mucous membrane, but just posterior to the cricoid cartilage and extending behind the trachea as low as the fifth ring was a small cavity containing 7 c. c. of very thick white fluid. A smear from the contents showed a vast number of tubercle bacilli and a few staphylococci. The mucous membrane of the trachea and the bronchial tubes was congested and inflamed. Abdominal cavity: The peritoneum showed no evidences of tubercle and was healthy. The liver had undergone fatty degeneration and was somewhat enlarged, weighing 1.700 grams. The pancreas and spleen were normal; the weight of the former was 57 grams, that of the latter organ 155 grams. The mucous coat of the stomach presented no pathological changes and the greater portion of the small intestine was healthy, but there were a few small tubercular ulcers and some congestion in the lower part of the ileum. The kidneys were enlarged and slightly waxy; the left weighed 297 grams and the right 269 grams. The other portions of the genitourinary tract were normal. LEPROSY-TUBERCULAR. J. C. P. L. A.; aged 25 years; nativity, Hawaii; was admitted to the United States Marine Hospital, port of San Francisco, Cal., November 28, 1893, and died January 26, 1898. History. The patient had been ill five months when he applied for admittance. Illness began as a swelling of the foot, accompanied by pain in the knee. At this time the limb began to atrophy. Two months later paralysis developed in the affected limb. Physical examination showed that the patellar reflexes were normal; ankle clonus was not impaired, and an eruption was seen upon the back and arms. In December, 1893, anesthetic areas were mapped out over the feet and the titial sides of the legs. Upon mixed treatment the patient improved and was discharged January 14, but was readmitted on January 20, 1894. On January 24, 1894, examination showed the left forearm to be swollen slightly, the feet were swollen, tense, and shining. Pain was present in the knees and along the course of the sciatic nerves. Ten days later a deep-seated nodule appeared over the sternocleido-mastoid muscle just below the lobule of the ear. During March brownish blotches developed on the back and a small lump was seen situated just anterior to the internal condyle of the right humerus. In June the blood was examined and large numbers of the lepra bacilli were found. Tubercles developed in one place, disappeared, only to reappear in another. This condition continued until June 30, 1897, when he was unable to leave his bed. At this time tubercles developed in the eyes, the one in the right eye ulcerated and filled the anterior chamber with pus. Paracentisis of the anterior chamber was performed to evacuate the pus, lessen the tension and relieve the pain. Shortly tubercles developed on the face and ears; many ulcerated and discharged pus which had a disagreeable and characteristic odor. Emaciation became very pronounced, the patient growing weaker until January 1, 1898, when he could with difficulty be urged to take food, and died of inanition at 4 a. m. January 26, 1898. Necropsy (eleven hours after death). The body is that of a poorly nourished and greatly emaciated adult, mulatto male. Rigor mortis is well marked. The face is covered with tubercles, unhealed ulcers, and cicatrices; while the ears are masses of ulcerated tubercles. The skin of the neck, trunk, arms, and thighs is normal, but that portion covering the legs is cracked and scaly. The feet are swollen, the toes covered with ulcers, and the nail of the great toe of the right foot is missing. The fingers are greatly swollen, and over the left metacarpo-phalangeal articulation of the middle finger is a large ulcer. The right eye shows obliteration of the anterior chamber, while the left presents a staphyloma of the cornea which causes a bulging of the upper lid. Encephalon is normal. Weight of brain, 1,330 grams. The pericardium is normal. Heart normal; weight, 255 grams. A few adhesions are present at the apex of the left lung, otherwise the parietal and visceral layers of both plueræ are normal. The apex of the left lung is infiltrated with tubercles; the remainder of the lung is normal. Weight, 245 grams. The right lung is normal; weight, 265 grams. The peritoneal cavity is normal. Spleen is normal; weight, 310 grams. Kidneys normal; weight, right, 210 grams; left, 235 grams. The remainder of the genito-urinary tract is normal. The liver is normal; weight, 1,960 grams. The gall bladder was greatly distended with fluid and inspissated bile. The remainder of the gastrointestinal organs are normal. The spinal cord was not examined. All the organs show a large amount of pigment. R. R. H. SCLEROSIS LATERAL AND POSTERIOR COLUMNS SPINAL CORD. C. B.; aged 43 years; nativity, Germany; was admitted to the United States Marine Hospital, port of San Francisco, Cal., May 17, 1895, and died November 14, 1897, at 2 a. m. History.-On entrance the patient complained of weakness in his lower extremities, more marked in the left. He also said that he felt unsteady when walking in the dark or with the eyes shut. He gave a specific history of two years standing. Physical examination showed no atrophy of the lower extremities nor any arias of anesthesia or hyperæsthesia. The reflexes were markedly exaggerated. The pupils were normal. He was given specific treatment for six months without benefit. He gradually grew worse, the paresis of the lower extremities becoming more pronounced and complicated with a spastic condition. During the last year he became bedridden; had involuntary movements of the bowels; incontinence of urine, and an occasional epileptic seizure. He gradually grew weaker until his death. Necropsy (nine hours after death).-The body is that of a well developed, well nourished adult white male. Rigor mortis is well marked. There are areas |