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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 rāles 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 pleurae. 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 3cm. 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.
J. C. P. LEPROSY-TUBERCULAR.
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 pluerae 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.
H. S. M.
J. M. G.
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 anaesthesia or hyperaesthesia. 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
of superficial sloughing on the outer sides of both hips, and on the inner sides of both knees and ankles. They vary from 4 to 6.5 cm. in diameter. The skullcap, brain case, sinuses, and vessels are normal. There is a chronic meningitis present, especially well marked along the median sulcus. The brain is normal. The pericardium is normal. The heart is dilated: weight, 370 grams. The walls of the ventricular cavity are thinned and the cavity is dilated. The pleurae and lungs are normal. The omentum is normal. The spleen is normal. The kidneys present on section the condition of a chronic diffuse nephritis. They weigh 165 grams each. The genito-urinary tract is otherwise normal. The digestive tract is normal. The spinal cord presents no gross lesions.
H. S. M.
J. M. G.
INFLAMMATION BRAIN MEMBRANES DIFFUSE, ACUTE SEPTIC.
C. J.; aged 32 years; nativity, Norway; was admitted to the United States Marine Hospital, port of San Francisco, Cal., November 27, 1897, and died December 2, 1897, at 2.45 p.m.
History.—On entrance the patient, who was slightly delirious, gave an indefinite history of headache, weakness, and fever for the preceding week. Physical examination: No evidence of any lesions of the viscerae were discovered. His face was flushed, tongue coated, and his breath foul. The abdomen was distended with gas, and there was some rigidity on pressure. The pulse was full and ran 80 per minute. The temperature taken in the axilla was 39 c. There was no facial or local paralysis. During his first night in the hospital he became violently delirious, at times requiring restraint, and at other times he lay in a stupor. A second physical examination made on the third day after his entrance revealed a slight facial paralysis of the right side, some inequality of the pupils, and a thickness of speech. There was also some rigidity of the muscles of the neck and a rise in the surface temperature at the base of the skull. In spite of treatment his temperature remained high, and he steadily grew worse until his death.
Necropsy (twenty-one hours after death).-The body is that of a well developed, well nourished adult white male. Rigor mortis is well marked. The subcutaneous fat is abundant. The skullcap and brain case are normal, presenting no evidence of injury. The sinuses and vessels are normal. The pia mater over the convexity of the brain is injected, and along the larger blood vessels is thickened. The pia at the base of the brain and over the medulla and pons is thickened, injected, and covered with thick creamy pus. The tentorium cerebelli is also bathed in pus. The basal ganglia of the brain are normal with the exception of the pituitary body, which is the seat of an acute suppurative inflammation. The ventricles of the brain are distended with clear fluid. The brain is otherwise normal. The parietal and visceral layers of the pleura on both sides of the chest are everywhere adherent. The lungs present the condition of hypostatic congestion; the right lung weighs 720 grams and the left 750 grams. The pericardium and heart are normal; the heart weighs 350 grams. The omental fat is abnormally developed. The spleen is congested, but is otherwise normal; it weighs 150 grams. The kidneys are normal; the right weighs 170 and the left 190 grams. The genito-urinary tract is normal. The liver is normal; it weighs 1,970 grams. The digestive tract is normal. The spinal cord was not examined.
DEGENERATION CYST OF CEREBELLUM.
D. S.; aged 45 years; nativity, Massachusetts; admitted to United States Marine-Hospital, Cleveland, Ohio, October 6, 1897; died January 14, 1898. History.—Mother dead from heart disease; one brother and one sister dead from tubercle of the lungs. Patient had syphilis eight years ago and pneumonia five years ago. Present trouble dates from March. 1897, when he began to suffer from severe pains in the head, occipital region. The pains are most severe in the morning and during exertion. He has alternating constipation and diarrhea, his gait is celebellar (walks with the feet wide apart) and balances himself with difficulty. The cervical, epitrochlear, inguinal, and femoral lymph glands are enlarged; there is a small umbilical hernia, and circulatory and respiratory systems show nothing abnormal. Owing to the history, the case was considered one of cerebellar tumor, probably syphilitic in its nature and the usual specific treatment was adopted with anodynes for the relief of pain. Slight improvement was noted, but he complained much of his head and at times he became so noisy that he was restrained with difficulty. On November 15 he was much better, and the improvement continued until December 14, when he relapsed. His gait is now markedly cerebellar, stands with his feet wide apart, and if he attempts to walk with his eyes closed he pitches forward. The attacks of severe pain are frequently preceded by a kind of epileptic fit, and if he is about the ward he has to be carried to his bed. He has had a number of epileptiform convulsions recently in which he becomes very rigid, and these are followed by profuse perspiration and total unconsciousness of what has occurred during the seizure. January 10, 1898.-Condition worse for the past few days, great pain in the head, and attacks more frequent. He attempted to throw himself out of the window last night, but remembers nothing of it this morning. Operative measures were considered in this case but abandoned, as it was considered impracticable to reach the seat of the trouble. January 14, 1898.-During the morning ward visit at 9 a.m. he seemed quite rational, free from pain, and stated that he felt much better. At 10 a. m. while the medical officers were engaged in the surgical dressing room a sudden call came from his ward and on hastening there he was found dead in bed. He died without a struggle. Necropsy (three hours after death).-Body fairly nourished; rigor mortis absent; post-mortem lividity on dependent portions of body. Head: Scalp and aponeurosis normal. Calvarium of moderate thickness; parietal eminence on left side very prominent. Slight adhesions over dura on right superior region. superior longitudinal sinus. Pia mater shows venous engorgement over cerebral hemispheres. Brain of average size and lateral ventricles contain considerable serum, choroid plexus on right side enlarged. Cerebral hemispheres and nuclei on cross and lateral section show no deposits of any kind and no softening. Fourth ventricle distended and marked by irregularities in the floor. Calamus scriptorius enlarged and bands stand out in bold relief. Other points of the floor marked by nodules and there is slight softening. The superior surface of the cerebellum was occupied by a cystic tumor which had produced by pressure absorption of the greater part of the superior vermiform process and upper surfaces of both lateral lobes. This tumor pressed directly on the pons and medulla, and was as large as a goose egg. The contents were gelatinous. Spinal cord not examined. Chest: Pleural adhesions on both sides; no effusions; leucomatous patches on visceral layer of pericardium; normal amount of pericardial fluid present. Heart in systole, valves normal, except slight thickening on margins of tricuspid. Slight atheroma in wall of ascending aorta. Lungs crepitant, carbon deposits present, and a puckered cicatrix in each apex. A cretaceous particle the size of a small pea was found in the outer margin of the upper lobe of the right lung. Liver, large; pancreas, normal; spleen enlarged and somewhat softened. Small cyst on outer surface of right kidney, and both have considerable fat in the pelves. Stomach and intestine normal. Bladder distended with urine; walls thin. Microscopic examination of sections of the different tissues shows only slight catarrhal nephritis.
D. A. C.
P. R.; aged 42 years; nativity, Louisiana; admitted to United States Marine Hospital, Louisville, Ky., July 19, 1897, case being transferred from Chattanooga, Tenn.
History.—Six weeks prior to admission to hospital patient suffered a stroke of paralysis affecting left side. The center of speech was also affected to such an extent as to produce ataxic aphasia later in his sickness. Amnesic aphasia partially developed. The case developed no special points of interest, the cerebral hemorrhage being followed by softening, and as this progressed the physical and mental condition became worse; still the man retained considerable intelligence and a reasonable amount of physical ability, up to time of death, notwithstanding the large area of cerebral softening present as shown at necropsy.
Necropsy (fourteen hours after death).-Body of greatly emaciated colored male about 45 years old. Rigor mortis slight, neck quite movable, mouth wide open, eyelids partially closed, front teeth missing. No discharge from nose or mouth. Thorax flat, abdomen retracted. No cicatrices. Scalp divided by incision across from one ear to the other. There are no extravasations of blood or other signs of injury to head present. Skull cap very thick and difficult to remove, bones of skull about 8 mm. thick. The dura mater is everywhere thick and opaque. The vessels of the pia mater, choroid plexus, and the large vessels of the walls of the ventricles were calcified and atheromatous, and although empty they retained their shape, not collapsing at all. The corpus striatum and optic thalamus pale and soft. The white substance of the hemispheres is pale and moist; the ventricles empty. Considerable area of softened, broken-down tissue was found in both the pons and medulla oblongata. Thorax: Left lung adherent, pleural cavity contained about 400 c.c. fluid. Right lung free and very little fluid in cavity. Both lungs were oedematous with some small areas of hypostatic pneumonia in posterior inferior parts. Heart very considerably hypertrophied, about 30 c.c. blood in rightauricle, somewhatsmaller amountin left. Small ante-mortem clot extending into right ventricle. Aortanarrow, itsinner coat hardened and atheromatous. Aortic and mitral valves incompetent; other valves competent. The spleen firm and somewhat wrinkled, at inferior border a cicatrix such as is at times left by a large hemorrhagic infarct was found. Liver of chocolate brown color, tissue on section of bronze color, substance firm. Both kidneys were hard and granular; the left contained an abscess about the size of a hazelnut. The omentum and intestines were normal in appearance, except post-mortem discoloration. Urinary bladder contained about 50 c.c. urine. Weight of organs: Heart, 540 grams; brain, 1,450 grams; liver, 1.170 grams; left lung, 440 grams; right lung, 770 grams; left kidney, 100 grams: right kidney, 110 grams; spleen, 75 grams. The radial and other arteries examined were not atheromatous except as noted. The amount of softening and breaking down of brain tissue about the centers of life were out of all proportion to the clinical phenomena, and in fact would seem to have been incompatible with continued existence.
W. P. MCI.