CASE 4.

H. P.; aged 35 years; nativity, Cape Verde Islands; was admitted to the United States Marine Hospital, port of San Francisco, Cal., February 16, 1898, and died June 21, 1898.

History.-Patient said that he had night sweats, coughed a great deal, had had a hemorrhage and was losing weight. Physical examination showed that the patient was poorly developed and emaciated; the chest was well formed, the right side was somewhat fuller than the left. Movements were greater on the right side, while vocal fremitus was increased on the left side. Upon percussion, dullness of the right apex and of the entire upper lobe of the left lung, with impaired resonance of the lower, was elicited. Over the anterior area of the upper lobe, extending from the clavicle and the third rib the cracked-pot percussion note was obtained. On auscultation, bronchial breathing and moist râles were heard over the entire upper lobe of the left lung and over the apex of the right lung. Over the anterior surface of the upper left lobe there was amphoric respiration. Heart area was normal. There was an impairment of the systolic mitral sound, but its cause could not be determined. Liver and spleen were normal. Treatment was supportive and symptomatic. The patient had several hemorrhages, which were controlled by Magendie's solution and ergot. He slowly grew weaker until 4.15 p. m. June 21, 1898, when he died.

Necropsy (twenty-four 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 1495 grams. Pericardium normal. Heart normal, although the myocardium is very pale and anæmic. Weight of heart 430 grams. At the base of the right lung and over the whole of the left lung the layers of the pleura are bound down by fibrous adhesions. The right lung is infiltrated throughout with the tubercular product. Weight of lung 1650 grams. In the apex of the left lung a large cavity is seen, while the inferior portion of the upper lobe and the superior portion of the inferior lobe appear normal. The base of the inferior lobe is consolidated and contains several cavites from 1 to 2 cm. in diameter. Weight of left lung 800 grams. The peritoneal cavity is normal. Spleen normal, weight 90 grams. Kidneys normal, weight of right 170 grams; left 250 grams. The remainder of the genito-urinary organs are normal. The liver is normal. Gall bladder distended with bile. Weight of liver 1795 grams. The remainder of the gastro-intestinal tract is normal. The spinal cord was not examined.

R. R. H.

T. B. P.
J. M. G.

CASE 5.

R. S. (colored), aged 32; nativity, Virginia; was admitted to the marine ward, St. Vincent's Hospital, Norfolk, Va., June 22, and died June 28, 1898.

History. This patient had been admitted to the hospital several times previous to the above date suffering from tuberculosis. When admitted, June 22, he stated that his health had lately rapidly failed and that he had had several severe hemorrhages from the lungs. He was greatly emaciated; feet and legs swollen; fever every afternoon; pulse weak and rapid, and breathing very much embarrassed. He gradually grew worse until death.

Necropsy (eighteen hours after death).—Rigor mortis slight. Body emaciated, feet and ankles swollen, brain normal, pericardium congested, and contained a small quantity of purulent fluid; heart in diastole and enlarged, and contained ante and post-mortem clots; no valvular lesions. Both pleura adherent-the right

almost entirely so. Both lungs nodular on external surface, and contained small tubercular masses and pus cavities. Liver large, but apparently healthy. Spleen large nodular, resistent on section. Omentum deficient in fat, but otherwise normal. Kidneys enlarged, mottled in color, and contained small nodules. Intestinal tract normal.

E. E. F.

CASE 6.

J. R.; aged 46 years; nativity, Pennsylvania; admitted to United States Marine Hospital, New Orleans, La., January 27, 1898, with tuberculosis of lungs; died March 19, 1898.

History.-Patient suffers from persistent cough, frequent hæmoptysis and general exhaustion. Previous history.-Present trouble began two years ago, subsequent to an attack of pneumonia, by severe cough and spitting of blood; continued to perform his duties as engineer up to two months ago, when patient was admitted to hospital at Cairo, Ill. Discharged at his own request, slightly improved, but after a short time cough became worse and frequent hemorrhages from the lungs occurred; about eighteen in number last month. Examination shows body emaciated, respirations hurried and weak, chest sunken and narrow, marked dullness over upper part of chest, vocal fremitus increased, råles over both lungs and evidence of consolidation in areas in both lungs. Expectoration profuse, purulent in character; cough severe, considerable dyspnoea; hæmoptysis in variable amount, almost a daily occurrence; considerable nausea and vomiting; general exhaustion. Attempts to control the hemorrhages by morphia, ice applications to chest and breast were made. The cough was decreased some by a squill cough sirup, and the patient became more comfortable. The hemorrhages from the lungs persisted; the irritability of the stomach continued, and the strength of the patient became gradually exhausted until death occurred at 8 p. m. on March 19.

Autopsy (fourteen hours after death.)-Edema of feet and ankles; general emaciation; rigor mortis present; peritoneum normal; intestines free of adhesions; a few enlarged mesenteric glands; stomach and intestines normal; spleen normal, weight, 335 grams. Right kidney normal, weight, 137 grams; left kidney normal, weight, 130 grams; ureters normal. Liver, weight 2,120 grams; capsule of Glisson rather thicker than normal, otherwise liver appears normal; gall bladder and duct normal; bladder contains 75 c.c. urine, normal; brain apparently normal; pleura and pericardium adherent to chest wall. Left pleural cavity contains 400 c.c. of clear serous fluid, pleura thick and rough, visceral pleura studded with tubercles. Lung tissue consolidated at places and tightly adherent to chest wall; crepitation almost disappeared in areas. Right pleura presents the same condition, except there is no serous effusion. Adhesions old and tough. Lung tissue studded with tubercles, scattered over surface and throughout the organ in consolidated areas. Heart normal, except for the pale flabby condition of the muscular substance; weight, 255 grams.

H. H.

CASE 7.

W. P.; aged 38 years; nativity, Alabama; admitted to the Marine Hospital, Cairo, Ill., January 8, 1898; died January 28, 1898.

Clinical history.-Has had a bad cough during the last four months and thinks he has fever continuously; he suffers from dyspnoea on exertion; he expectorates large quantities of purulent matter, containing an unusual number of tubercle bacilli; there has been no hæmoptysis; the appetite is good, but he has lost considerable flesh; there was slight oedema of the feet and ankles; there is dullness over the upper half of both lungs and dry bronchial rales over the entire

chest. The temperature ranged from 38° to 39.2° C. up to the date of his death. On January 28 a congestion of the lower portions of the lungs caused death at 8.30 p. m. The urine contained a trace of albumen.

Necropsy (twenty-four hours after death).-General state of nutrition poor; rigor mortis marked. Brain: Dura mater thickened and opaque; sinuses contained clots, partly fibrinous; the vessels on the surface of the brain were distended with blood. Thorax: Thymus gland not found; large vessels distended with clots, also the cavities of the heart; the cavities were normal and valves competent. The heart walls were of normal thickness and color; they were quite firm. Lungs: The left was firmly adhered to the chest wall, the pleura being thickened by fibrinous deposit. This lung was filled with cheesy nodules and pigmentary deposit; there were two cavities of considerable size-one in the upper, one in the lower lobe. Upon cutting into the lung, thin yellow pus exuded. The right pleura presented a few adhesions, though much less firm than those of the left: the upper lobe was thickly filled with tubercles, and the remainder of the lung presented a few yellowish nodules scattered throughout. The lower portion of the lung, upon which the patient must have chiefly depended for breathing, was of dark red color from congestion. The great vessels, nerve trunks and diaphragm, were apparently normal. Abdomen: The omentum contained little fat and was of dark red color. The kidneys were slightly enlarged, weighing, right, 195 grams; left, 210 grams. There were no macroscopic changes. The adrenals were of normal size and appearance. The bladder and genital organs were normal. The liver was of firm consistence and presented a nutmeg appearance when cut. Weight, 1,875 grams; color, light brown. Spleen: Weight, 60 grams; diameter, 74 by 5 cm. The intestines presented quite a large number of ulcers with thickened edges, most of them of small size with no special relation to Peyer's patches. The mesenteric glands were enlarged and yellowish in color externally. The vermiform appendix was about 12 cm. in length, with mesenteric attachment through its entire length. Its cavity was patulous, but empty.

P. C. K.

CASE 8.

A. E. T.; aged 26 years; nativity, California; admitted to United States Marine Hospital, Stapleton, Staten Island, May 15, 1897; died November 26, 1897.

Previous history.-Was in this hospital about four months ago for inflammation of ethmoidal sinus. Since leaving he has been at work, though he has had fever daily. He coughs a great deal, and has lost about 40 pounds in weight during last year. Now has poor appetite, and his feet swell, especially in the afternoons. Bowels regular; is not vomiting; has had one or two chills recently. Numbers of tubercle bacilli found in his sputum, and the malarial organisms found in his blood (intracorpuscular form). The patient was put on quinine, cod-liver oil and malt, and alcohol, and later on creosote. His chills were finally controlled on the above treatment, but his general condition grew steadily worse. A physical examination made on October 16 showed the left lung throughout its upper portion infiltrated by the tubercular process; the right not so much so. On October 21 he developed considerable cedema about face, legs, and thighs. On the 22d he developed herpes zoster on right side, which occasioned him considerable pain and irritation. On November 21 he began to run high fever in the afternoon, coughed a great deal, and began to vomit and to have profuse night sweats. His strength rapidly failed, and he died at 2.45 a. m. on November 26, 1897.

Necropsy (eight hours after death).-Body of a white man, dark hair and moustache, blue eyes, about 5 feet 10 inches high. Poorly nourished, but not greatly emaciated. Rigor mortis present. Body livid over dependent parts and around ears and face. Calvarium not removed. Thorax: Pericardium contained about 50 c. c. of clear amber fluid. Heart considerably enlarged (weight 520

grams), the enlargement being mainly in left ventricle. Right heart chambers filled with dark fluid blood and clots; left not so much distended. Left auricle in its posterior part contained an organized clot. Mitral valve had one leaflet bound down, leaving valve incompetent. Other valves normal. Fluid in both sides of thorax. Lungs: Both lungs bound down by adhesion. The upper lobes of both lungs thoroughly infiltrated by purulent material, and the lung tissue breaking down into small cavities in several places. Lower portion of both lungs crepitant throughout and showed no evidence of disease. Abdomen: Omentum rather thin and dark. Abdominal cavity contained considerable fluid. Liver enlarged. Spleen enlarged and a very small accessory spleen found. Kidneys: Both kidneys alike; about normal size and somewhat pale; capsule stripped off easily, leaving a pale surface behind. On incision cortex found somewhat less than normal and the whole organ pale; ureters normal. All other organs apparently normal.

CASE 9.

C. H. L.
G. W. S.

J. H.; aged 36 years; nativity, Pennsylvania; admitted to United States marine hospital, Chicago, Ill., August 23, 1897; died November 3, 1897.

History.-About two years ago patient contracted a cold, but never consulted a physician until he presented himself at the outdoor department for relief from a troublesome cough. He was admitted to hospital, and the following noted: Cough is harassing at night and on rising in the morning; frequent night sweats and distressing shortness of breath; appetite is very capricious; expectoration is muco-purulent, at times tinged with blood, and very profuse; steady loss of weight and of strength. Supra and infra clavicular fossæ of both sides sunken. Patient greatly emaciated. Deficient expansion. Vocal fremitus is accentuated at the upper portion of each lung, more marked in the left. Dullness at the apices of both lungs, extending down to the fourth intercostal space on the left. Bronchial breathing and large moist rales at apex of right lung. Bronchial breathing, large moist rales at the apex of the left lung; lower down bronchial breathing and small moist rales on same side. The temperature never exceeded 39.2 C., ranging from 1 to 2 higher at night than in the morning. Tubercle bacilli found in the sputum in great numbers, also staphylococci. Treatment: Patient was put upon nourishing, easily assimilable food. Bowels kept open by laxatives and an occasional enema of warm water. The usual remedies were administered, including carbonates of creosote in increasing doses up to twenty decimeters after each meal. Stimulants when needed. In spite of treatment patient grew steadily weaker and the sputum continued to be loaded with bacilli. Necropsy (twenty hours after death).—Male, 5 feet 7 inches high. Rigor mortis marked. Body pale, thin, and emaciated. Abdominal wall, in iliac region, greenish blue. Hypostatic congestion of shoulders and back. Abdominal organs found in normal relations without adhesions. Mesentery slightly congested, containing several enlarged glands, but free from fat. Small intestine distended with gas and containing a few small lumps of fecal matter. Large intestine empty. Appendix in normal position, but of unusual length, about 17 cm. Stomach slightly distended and contained about 500 c. c. of undigested milk. Liver weighed 1,800 grams; pale, friable, gritty to the knife when cut. Capsule nonadherent. Gall bladder normal, containing small amount of bile. Bile ducts without obstruction. Pancreas normal, weighing 90 grams. Spleen, also normal, weighed 310 grams. Left kidney in normal position, enlarged and congested. At the lower third of the inner border were found a few tubercles; weight, 250 grams. Suprarenal capsule normal; weight, 5 grams. Right kidney weighed 220 grams; relations normal, enlarged, congested; contained a small abscess

about the size of a pea in lower part; capsule easily detached. An adventitious vessel entered inner border 2 cm. below the hilum. Diaphragm normal and without adhesions. Thorax: Pleura of right side adherent to lung and chest wall. Pleura of left side adherent to lung and chest wall throughout its entirety; is very thin and easily torn. Right lung weighed 1,190 grams; considerable hypostatic congestion; apex contained a cavity the size of a hen's egg; walls irregular; body of lung firm and noncrepitant on pressure; studded with miliary tubercles. Left lung weighed 1,010 grams. Its upper three-fifths contained numerous small cavities; the remaining portion was firm, noncrepitant, and studded with miliary tubercles. Heart weighed (after opening) 320 grams; pericardial sac contained 155 c. c. of fluid; right ventricle filled with large antemortem clot; right auricle contained a small ante-mortem clot; heart muscle pale, flabby, without fatty infiltration. Blood vessels normal. Brain weighed 1,360 grams. Dura mater adherent to median fissure 25 cm., posterior to center. Vessels of pia distended.

CASE 10.

J. B. S.

H. B. (colored); aged 25 years; nativity, Louisiana: admitted to the United States Marine Hospital, New Orleans, La., April 4, 1898; died April 4, 1898. History.-Was admitted at 4 p. m. April 4, 1898, and seen at 5.30 p. m. Patient was very weak; had dyspnoea and cough, slight expectoration, purulent in character; pulse very weak and rapid. Was given stimulants in the form of milk punch, but patient continued to lose strength, sinking into collapse, and died the same night. The history of this same patient on previous admission is as follows: Admitted February 16, 1898; discharged February 24, 1898, at his own request. Diagnosis: Tubercle of lung. On admission said he had been sick for the past two months with cough and shortness of breath; never had had a sickness worthy of mention. Examination: Has pectoral cough, expectoration chiefly mucus. Respiratory murmur interrupted and irregular on left side of chest; rales heard over same side. Was discharged improved.

Nocropsy (sixteen and one-half hours after death).—General emaciation; rigor mortis present; pupils slightly dilated; superficial view of abdomen normal; peritoneum of walls normal; few adhesive bands on visceral peritoneum between loops of intestines; all mesenteric glands enlarged, varying in size from a pea to a hazel nut; few scattered tubercles on loops of small intestines noticed opposite attachment of mesentery. Weight of spleen 345 grams. Its surface is markedly tubercular; capsule is adherent. On section the spleen is studded with a mass of tubercles, most of which are beginning to undergo caseous degeneration. Weight of liver 1,740 grams. Color darkened; its surface is smooth, except in few scattered points where tubercles protrude beneath capsule; capsule is easily peeled, being found adherent at points where tubercular growth has begun. On section liver tissue is apparently normal, except for a few scattered points of small tubercular growths. Gall bladder normal. Gall ducts normal. Right kidney weighs 190 grams: pale; surface smooth; capsule nonadherent; on section is pale and anæmic and few small scattered tubercular masses. Left kidney weighs 190 grams; surface smooth, pale; capsule nonadherent; on section apparently normal. Ureters normal. Bladder and urethra normal. Vas deferens, seminal vesicles, and prostate gland apparently normal. Superficial appearance of chest shows protruding ribs and interspaces sunken. Left pleural cavity contains 300 c. c. fluid; surface is roughed from adhesions. Visceral pleura of left lung smooth except where a few adhesions were torn. The surface appears irregular on account of protruding tubercular masses beneath pleura. Weight of left lung 905 grams. On section has tubercular masses, large and small, scattered throughout its tissue, particularly in the upper lobe; right pleura has dense adhesions