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of quin. sulph. Cough was very troublesome, appetite was poor, patient was losing weight fast, and tubercle baseilli were found in the sputum. Physical examination showed less movement in respiration on the left side than on the right: the clavicle was quite prominent. Dullness on percussion on both sides, more marked on the left. Rales heard over entire left side and at apex of the right. Present history.—Patient in about the condition described above. Cough is very distressing at night, and various remedies were given for the relief of this troublesome symptom, with only temporary effect. From this time on until the 1st of January, 1898, the case ran the usual course of such cases. At this time, however, there began to be noticed an oedema of the legs and scrotum and penis. This subsided at times and returned again. Later on the use of the lower extremities was lost entirely. and the anasarca became general. The urine, too, was but scantily secreted and hot baths were tried, but their beneficial effect was of very brief duration. The usual stimulating and nourishing treatment was given. Patient died of exhaustion. Necropsy (eighteen hours after death).-Emaciation only moderate in degree. Numerous scars on various parts of the body, chest, and lower extremities. Legs, feet, penis, and scrotum are markedly occlematous, and the tissues exude serum on section. Heart appears normal. Right lung shows recent adhesions at the apex, also well organized adhesions to diaphragm and to pericardium. A large cavity was found at the apex, and the upper and middle lobes were full of tubercular nodules. The left lung was collapsed and was no larger than an orange; it was hollowed out into a cavity of about 150 c.c. capacity. Both kidneys were large, pale, and showed signs of fatty degeneration. The stomach and pancreas appeared normal. The liver was smaller than normal and there was a small abnormal process of liver tissue which partly replaced the gastro-hepatic fold of peritoneum. The liver structure was normal in appearance. The spleen was of normal size, but was so friable that it was torn in removal from the body. No other organs were examined. C. H. G. G. P.
A. J.; aged 38 years; nativity, Russia; was admitted to the United States Marine Hospital, port of San Francisco, Cal., September 14, 1897, and died January 24, 1898.
History.—Patient stated that he was ill for six months prior to his entrance into the hospital, and during this time had lost 40 pounds in weight. Complained also of persistent cough, with copious expectoration, night sweats, and shortness of breath. Physical examination: Dullness over the apex of the left lung anteriorly to the second intercostal space: posteriorly, to the fourth dorsal vertebra. The percussion note over the right lung was normal. Upon auscultation moist and sonorous bronchial rāles were heard over the whole chest. Examination of the sputum demonstrated the presence of tubercle bacilli. Heart was normal. The treatment was supportive and symptomatic, but, notwithstanding large doses of strychnia and digitalis were given, the patient gradually grew weaker, and died at 6 a. m. January 24, 1898.
Necropsy (fire hours after death.)—The body is that of a well-developed, though emaciated. adult white male. Rigor mortisfairly well marked. Encephalon normal. Weight of brain, 1,297 grams. The pericardial sac is normal. The superficial fat of the heart is increased, although the heart muscle and valves are normal: weight. 420 grams. The left pleura is adherent throughout. On the right side there are adhesions at the apex, otherwise the pleura is normal. Upon
section, the upper lobe of the left lung shows a cavity occupying the whole of its substance. In the upper part of the lower lobe are two small cavities; the remainder of the left lung is consolidated; weight, 1,400 grams. The apex of the upper lobe of the right lung shows numerous cavities from 1 to 4 cm. in diameter: remainder of apex is consolidated. Throughout the substance of the middle lobe are seen deposits of tubercular tissue, while the lung tissue in the lower lobe is normal; weight, 1,330 grams. The peritoneal cavity is normal. The spleen is normal; weight, 247 grams. Kidneys enlarged; weight, right, 252 grams. In the upper part of the left a cyst, 2 cm. in diameter is seen; weight. 260 grams. The remainder of the genito-urinary tract is normal. The liver is normal; weight, 2,320 grams. The remainder of the gastro-intestinal organs are
normal. The spinal cord was not examined. R. R. H.
J. M. G. CASE 3.
M. S.; aged 23 years; colored; nativity, Mississippi; admitted to the United States Marine Hospital, St. Louis, Mo., May 25, 1898; died June 27, 1898.
History—The patient had been sick for two months. He has had cough. dyspnoea, pains in his chest, muco-purulent expectoration, night sweats, fever, no appetite, diarrhea, and great weakness. His brother and sister died of tubercle. Physical examination: Body emaciated, depressions above and below clavicles. marked dullness over whole of right lung, especially the upper lobe, slight dullness over apex of left lung, bronchial breathing over right lung, inspiration quick and harsh, expiration prolonged; breathing the same over left lung, but not so marked; tubercle bacillii very abundant in sputum; a faint murmur heard after the second sound of the heart; an ischio-rectal abscess cavity exists on the right side of the rectum; this cavity has opened externally about an inch from the anus. This case ran the ordinary course of tuberculosis of the lungs and bowels, the end being hastened by the warm weather. He suffered mostly from high fever, rapid pulse. dyspnoea, diarrhea, and great weakness. On June 1, his right foot, leg, and thigh, as high as Poupart's ligament, became swollen, oedematous, and painful along the line of the large vessels. This swelling and pain, however, subsided by the 18th. Patient died at 2 p.m. on the 27th.
Necropsy (twenty-one hours after death).-Height 165 cm. Body greatly emaciated; abdominal wall 13 cm. thick, no fat. Pericardial sac contains 75 c.c. of straw-colored fluid. Heart flabby and soft, 13 by 12 by 6 cm.; tissue pale, small yellow clot extending from right ventricle through pulmonary artery; thickness of right ventricle wall 8 mm., of left ventricle wall 2 cm.; edges of mitral valve slightly thickened, other valves normal; weight of heart 285 grams. Right lung, apex adherent to walls of chest; weight 1,750 grams, 26 by 18 cm; large gangrenous cavity in upper lobe 7 by 5 cm.; rest of upper lobe one mass of ulcerated tubercular tissues; remainder of right lung hard and tissues filled with gray tubercles. Left lung: Weight 900 grams, 24 by 16 cm.; tissue nodular, hard, noncrepitant, filled with tubercles; tissue of lung at border and small portion of apex crepitant, and only a few tubercles present. Spleen: Weight 570 grams, 16 by 13 by 7 cm.; slate color; tissue hard and full of gray nodules the size of a small marble. Left kidney: Weight 150 grams, 11 by 7 by 3 cm.; tissue dark red, pyramids distinct. Right kidney: Weight 175 grams, 12 by 74 by 4 cm.; appearance of tissue same as left kidney. Stomach 22 cm. long by 9 cm. broad; contains 25 c. c. thick, yellowish fluid; mucous membrane grayish-white, covered with mucus of the same color. Mesenteric glands hard and swollen, some as large as a pigeon's egg. Liver: Weight 1800 grams, 28 by 23 by 13 cm.; tissue on section very dark, almost black; 10 c.c. of brown-colored bile in gall bladder.
W. G. S.
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 rāles 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 anaemic. 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.
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 haemoptysis 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, rales over both lungs and evidence of consolidation in areasin both lungs. Expectoration profuse, purulent in character; cough severe, considerable dyspnoea; haemoptysis 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.)—GEdema 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.
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 haemoptysis; the appetite is good, but he has lost considerable flesh; there was slight oodema 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 S-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 oedema 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