in direction, and just above the lower extremity of the bone. He gave a history of perfect good health previous to the injury. On the evening of October 29, while using the bedpan, he became very much exhausted, dyspnoea set in, and the heart became very weak. In a half hour he died.

Necropsy (fourteen hours after death).—Post-mortem lividity extreme; rigor mortis marked. Pupils medium. Jugular veins distended and prominent. The heart weighed 460 grams. The right heart showed marked fatty degeneration, and the right auricular wall was much thinner than normal. In the anterior wall of the right auricle, near the auriculo-ventricular septum, and just external to the appendix auriculæ, was a perforation the size of a goose quill, and somewhat irregular in shape. The heart muscle was very soft and friable. All the valves were competent, the aortic valves somewhat thickened. The pericardial sac was filled with fluid venous blood. The left lung weighed 620 grams. The right lung weighed 780 grams. Both lungs were of a dark-reddish slate color, and on section showed marked venous congestion, and were filled with bloody froth. The pleuræ were normal. The stomach was distended, and was slightly congested. The intestines were somewhat congested. The liver weighed 1,700 grams. It was dark in color, and on section showed a slight increase of the connective tissue, giving it a nutmeg appearance, and there was also some congestion. The gall bladder contained 15 c. c. of bile and was normal. The pancreas weighed 110 grams and showed no pathological changes. The left kidney weighed 200 grams. The capsule stripped readily; on section, there was slight congestion. The left renal artery divided into two branches-one entering the hilum normally between the ureter and vein; the other branch entered the inner border of the kindey above the hilum and near the apex. The right kidney weighed 198 grams. Its capsule stripped with ease; on section, some congestion was found. The urinary bladder contained 200 c. c. of urine, and its mucosa was markedly congested. The urethra and prostate were normal. The suprarenal bodies showed post-mortem softening. The spleen weighed 230 grams and was somewhat congested. The membranes of the brain weighed 1,370 grams. All its vessels were much congested, and the lateral ventricles contained each about 5 c. c. of bloody

serum.

H. W. W.

CASE 24.

Pericarditis, suppurative.

C. L.; aged, 50 years; nativity, Germany; was admitted to the United States Marine Hospital, port of San Francisco, Cal., January 18, 1898, and died February 3. 1898.

History.-Patient, while on a prolonged alcoholic debauch, contracted a cold, which steadily grew worse. He coughed considerably, especially at night, and for several days prior to his admittance to the hospital had a pain in his right side. Physical examination showed that the chest was well formed; movements were equal on both sides, while vocal fremitus was increased on the right side. Upon percussion, no definite dullness was discovered, although there was a slight impairment of resonance over the lower lobe of the left lung. Over the entire lung area the respiratory murmur was harsh and prolonged upon inspiration, while numerous sibilant and sonorous rales were present. Heart, normal; liver, slightly enlarged in its vertical diameter. On the 25th of January the patient complained of shortness of breath, and upon percussion the area of cardiac dullness was shown to be increased in all directions, and the heart sounds were muffled. A blister was applied over the area of dullness and two large blebs resulted. The patient continued to be dyspnoeic, and on February 1 it was noticed that his legs were swollen. On the 2d, paracentesis of the pericardium

was performed and about 30 c. c. of pus withdrawn. Microscopic examination showed the diplococcus pneumoniæ of Frankel to be present. Strychnia and digitalis were freely given, but the dyspnoea increased, and patient died February 3, 1898, at 9.45 p. m. From the 18th to the 25th of January the patient had a temperature which varied from normal to 38.5° C., but after the 25th the temperature was normal.

Necropsy (sixteen hours after death).—The body is that of a well-developed, well-nourished adult, white male. Rigor mortis well marked. Encephalon normal. Weight of brain 1,250 grams. The pericardial sac contains 300 c. c. of creamy pus. The visceral and parietal layers of the pericardium are thickened and infiltrated with fibrin, serum, and pus, while at the apex there are strong, fibrous adhesions uniting both layers. On section, the peripheral layers of the cardiac muscle are infiltrated with pus for a depth of 3 mm., while the remainder of the muscle is anæmic. The cavities and valves are normal. Weight of heart, 510 grams. The aorta is atheromatous. The pleuræ, at the bases of the right and left lungs, show a few fibrinous adhesions, elsewhere the parietal and visceral layers of both pleurae are normal. The lower lobe of the left lung is congested, otherwise it is normal. Weight, 650 grams. In the most dependent part of the lower lobe of the right lung is a cavity 3 cm. in diameter, while the remainder of the lung shows areas of consolidation from 1 to 4 cm. in diameter. Weight, 900 grams. The peritoneal cavity is normal. Spleen, normal; weight, 250 grams. In the left kidney is seen an increased amount of fat; weight, 270 grams. The right shows evidence of fatty degeneration; weight, 290 grams. The remainder of the genito-urinary organs are normal. The liver is congested; weight, 1.900 grams. The remainder of the gastro-intestinal tract is normal. The spinal cord was not examined.

R. R. H.

W. M. J.
J. M. G.

Microscopical report.-Sections made from the lung show scattered areas where the following changes have taken place in the air spaces and smaller bronchi: The walls of the bronchi are thickened and show a proliferation of the fixed connective tissue cells and an increase of fibrous tissue; the peribronchitic zones show a similar development of new tissue; the air spaces communicating with and near the diseased bronchi show similar changes in their walls; and both bronchi and air spaces are filled with an exudate which is well organized and shows little or no tendency to break down. The condition of the lung, therefore, confirms the diagnosis of broncho-pneumonia.

P. A.; aged 56; nativity, New Hampshire; admitted to the United States Marine Hospital, Mobile, Ala., December 11, 1896, having been transferred from Jacksonville, Fla.; died March 28, 1898.

History.-Suffered no disease until three years ago, when his strength gave way. Then had cough and frequent attacks of dyspnoea, with progressive weakness. Cough increased until he could not do duty. The attacks of dyspnoea became more frequent. The roaring of the aneurism prevented sound sleeping when he lay on the left side. Impulse to subclavian artery simulated an aneurism of that vessel.

Necropsy (six hours after death).-Present: Hospital staff and P. A. Surg. A. C. Smith. Rigor mortis, not complete. Post-mortem lividity, left side of face and posterior third of body. General nourishment, poor. Pupils partially dilated. Pericardial sac contained about 200 c. c. of pale fluid; no adhesions to heart. Heart: Weight (after opening), 700 grams; wall of left ventricle about 20 mm. in thickness, of right ventricle about 12 mm.; endocardium and valves normal. Aorta: Seat of a fusiform aneurism, involving the ascending and transverse portions of the arch; interior of arch showed calcified plates, very firm and partially detached; diameter of center of aneurism about 5 cm. Thoracic and abdominal aorta and other vessels normal, not calcified. Lungs: Both lungs compressed by the fluid in pericardial sac and in the pleural sacs; lungs deeply congested; anterior edge of right lung showed a cicatrix; right pleural cavity contained about 800 c. c. of a dark-colored fluid; masses of loose floculent lymph, floating free; quite a number of very strong adhesions; left cavity contained about 900 c. c. of a pale-yellow liquid: no adhesions. Liver: Capsule very adherent; edges rounded; tissue firm; in color, dark purple, mottled with gray; weight, about 1,400 grams. Gall bladder much distended. Kidneys: Left, weight 140 grams; shrunken; dark; tissue firm; capsule nonadherent. Right, weight 135 grams; shrunken; more purple than left; capsule nonadherent. Spleen: Weight, 300 grams, congested; large cicatrix in capsule near lower end; dark purple; firm. Left clavicle broader than right, apparently flattened, and of dark color on under side of center. Head: Scalp not congested; membranes pale; small amount of fluid. Weight of brain, 1,450 grams; brain substance firm; anæmic; cuts easily; apparently nothing abnormal. Opinion as to cause of death: Death was probably due to a “splinting” of the heart, caused by the effusion in the pleural and pericardial sacs, and to a loss of lung space by compression of the lungs from

same cause.

J. F. A.
R. D. M.

CASE 2.
Arch of aorta.

J. B.; aged 38; nativity, Sweden; admitted to United States Marine Hospital, Chicago, Ill., May 26, 1897; died May 27, 1898.

History. The patient came to hospital complaining of severe pains in chest, neck, and back, a poor appetite, and insomnia. In 1893, four years previous to his entrance to hospital, the patient noticed slight pains in thoracic region. For eighteen months these pains became more severe, but his condition improved after that time until May, 1897, when he again entered the hospital and remained for one month, and left feeling somewhat better. He returned, however, October 21, 1897, and was found to be suffering from an aneurism of the arch of aorta. The patient's condition remained about the same until March 22, 1898, when he was discharged at his own request against advice. During his absence the patient grew worse, and was readmitted April 5, 1898, in a serious condition. The patient was then suffering great pain in head and neck, lips were blue, voice husky, and he breathed with difficulty. Heart was rapid and contractions very weak. Temperature, 36.6 C.; pulse, 90. The patient could only sleep in a sitting posture, with his head between his knees. His condition grew steadily worse, and he became delirious at times, which continued to the end. The treatment consisted of bromides, morphia, iodide of potash, and finally cardiac stimulants, under which he improved slightly.

Necropsy (eighteen hours after death).-Post-mortem rigidity marked. Brain weighed 1,550 grams. Punctiform congestion in tissues. Sinuses were normal. The vessels were congested. Membranes were adherent and congested. Anterior

mediastrium and thymus gland were apparently normal. Pericardium contained no fluid. The heart weighed 300 grams, and was contracted. The wall of the left ventricle was thin, the right much thickened. The bodies of the six cervical vertebræ, and also the first, second, third, and fourth dorsal were found to be eroded, due to pressure of the aneurismal sac. Plura were strongly adherent. Left lung weighed 400 grams and was pale around aneurism. Right lung weighed 1.100 grams and was congested. Great vessels: Arch of aorta had a large dilatation containing large clots of blood nonlaminated. Cavity would contain about 100 c. c. Walls of artery thickened. Nerve trunks were normal; diaphragm was normal. Omentum was thin; otherwise normal. The spleen weighed 200 grams; capsule adherent, tough on section, and congested. Kidneys: The right weighed 170 grams; capsule adherent; cortex normal. The pelvis contained a great deal of fat. Left kidney weighed 250 grams; pelvis contained more fat than right; capsule strongly adherent; suprarenal capsules were normal. The bladder contained about 150 c. c. of dark urine; walls were thickened. Organs of generation were normal. Rectum was normal and contained but little fæcal matter. The duodenum was small in caliber. The stomach was small and congested. Gall ducts patulous. Liver weighed 1,460 grams; capsule was strongly adherent and thickened; otherwise normal. Gall bladder contained about 100 c. c. of bile. Pancreas was normal. Solar plexus apparently normal; mesentery was normal. Small intestines were small in caliber; large intestines contained numerous scybala of fæces. The great vessels were normal.

CASE 3.

H. C. R.
H. W. S.

Fusiform, transverse aorta-Valvular disease, heart aortic, and mitral regurgi

tation.

A. T.; aged 55 years; nativity, Spain; was admitted to the United States Marine Hospital, port of San Francisco, Cal., July 19, 1894, and died March 1, 1898.

History.-Patient was treated for twenty-six days for aneurism of the aorta and aortic incompetency and stenosis. He was discharged at his own request August 6, 1894. He was again admitted for relief of the same complaint August 17, 1894. Physical examination: On inspection of the chest a pulsating area was seen between the second and third ribs to the right of the sternum. The apex beat was seen to be displaced outward, being situated 3 cm. to the left of the mammary line. On percussion no dullness of the lungs was discovered except a small area situated in the middorsal region to the right of the spinous processes of the vertebræ. The heart area was enlarged downward and to the left. On auscultation a bruit both systolic and diastolic in time was heard over the pulsating area, being transmitted downward to the xiphoid appendix. Systolic and diastolic murmurs were heard over the aortic orifice, and over the mitral valve a systolic murmur was heard. The liver and spleen were apparently normal. He was given a systematic course of treatment with potassium iodide, and was confined to bed for some time. He was also put on a diet rich in albuminoids, but with as little liquids as possible. Under this treatment his symptoms were so much ameliorated that at his own request he was discharged improved December 12, 1894. He again sought treatment May 5, 1895, for the same complaint. He was given practically the same treatment as during his previous stay in the hospital. Physical examination at this time revealed no change in his condition. Physical examination: The cardiac area of dullness was enlarged downward and to the left, the apex beat being situated at 4.5 cm. to the left of the mammary line and 5 cm. below the nipple. On auscultation the bruit was heard both on systole and diastole, and

over the aortic valve systolic and diastolic murmurs were heard. There was also a mitral systolic murmur present. At this time the pulsating area noted in the previous physical examination was not found. He remained in fair condition until January, 1898, when it became evident that failure of compensation threatened. At this time physical examination showed that both the bruit and the pulsating area noted in the examination of August 17, 1894, had disappeared. Under stimulation his heart reacted well for a while, but the improvement was temporary, the heart muscle gradually growing weaker until his death.

Necropsy. The body is that of a well-developed, well-nourished. adult white male. Rigor mortis is well marked. The encephalon is normal; weight of brain 147 grams. The pericardium is normal. The heart is enormously hypertrophied; weight, 750 grams. On section the aortic orifice is seen to be dilated and the cusps of the valves thickened and distorted. The mitral orifice is dilated, but the leaflets of the valves are normal. Occupying the entire ascending and transverse portions of the arch of the aorta an aneurism 12 cm. in diameter is seen. On section of the aneurism a well-organized clot is seen adhering to the walls; the thickness of the clot varies from 1 to 2 cm. There is 600 c. c. of clear serous fluid present in the right pleural cavity; the pleuræ on the right side are otherwise normal. The parietal and visceral layers of the pleuræ on the left side of the chest are strongly adherent at the base of the lung. The right lung is normal, except for a wellmarked degree of passive congestion; weight, 1,050 grams. The left lung is slightly collapsed, but is otherwise normal; weight, 450 grams. The spleen is normal; weight, 170 grams. The right kidney is normal; weight, 160 grams. The left kidney is normal; weight, 180 grams. The genito-urinary tract is normal. The liver presents on section a marked degree of fatty degeneration; weight, 1,800 grams. The digestive tract is normal. The spinal cord was not examined.

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

CASE 4.

Thoracic aorta.

P. D.; aged 51 years; nativity, Ireland; admitted to the United States Marine Hospital, Cairo, Ill., June 28, 1897; died December 12, 1897.

History.-Under treatment for rheumatism since March 6, 1897, as an office

patient.

July 27, 1897.-Troublesome cough and expectoration. Has had night sweats and dyspnoea. Some dullness on percussion over apices. Voice hoarse; breath sounds bronchial in character. Heart: Apex beat 2 inches outside nipple and two spaces below; no murmur, but sounds indistinct. Pulse intermits every few beats and of little strength. Patient's weight, 143 pounds.

December 7, 1897.-Expectoration slight; the cough and dyspnoea due to passive congestion of lungs from cardiac trouble. Skin pale; veins distended; pulse frequent and lacking force. Has little or no appetite. Pain in shoulders very troublesome, but phenacetine at night gives some relief. Urine has been examined lately, but shows no trace of albumen.

December 9, 1897.-Apex beat 13 cm. outside nipple and a little downward when patient is lying on back. Apparently separate pulsation over upper part of thorax. This, with the pain felt in back and shoulders, indicative of aneurism, and from the location of greatest intensity of pulsation probably the arch of aorta affected. The radial pulses show a difference in strength; the left weaker