diseased, nor was the cæcum. The gangrenous small intestine was perforated in several places, through which the contents passed (partly) into a cavity or abscess with softened walls, eroded posteriorly, and giving exit to the purulent fæcal fluid noted as draining upward and softening the liver. The mucosa of small intestine was very generally ulcerated. Whilst there is room for doubt, the autopsy rather strengthens the antemortem diagnosis of enteric perforating ulcer, with plastic protection and limitation of the suppurative process, and, finally, septic exhaustion and death.

CASE 7.

R. C.; aged 18 years; nativity, Arkansas; negro; admitted to the United States Marine Hospital, Memphis, Tenn., March 22; died March 26, 1895.

History. The patient had apparently been taken sick six days before his admission to the hospital. At the time of admission he had symptoms pointing toward enteric fever, but not distinctive of it. There was mental confusion, which became later maniacal delirium, and this was succeeded in turn by a dull and partly comatose condition, which ended in death. The day before death the patient's temperature went down to normal, and rose only slightly thereafter. The course of the disease was rapid and peculiar, and the diagnosis was in doubt. There were no symptoms of meningitis except the delirium.

Necropsy (seven hours after death).-The examination was made by Dr. William Krauss, of Memphis, Tenn. No post-mortem lividity; rigor mortis strongly marked; general nourishment fair; pupils somewhat dilated. The heart weighed 243 grams. The pericardial sac contained about 25 c. c. of clear serum. All the valves of the heart were competent. The bronchial lymph glands were enlarged but soft. The left lung weighed 381 grams. It was extensively adherent to the chest wall, the pleural cavity being almost obliterated. A number of tubercular nodules were found in the apex of this lung. There was considerable hypostatic congestion. The right lung weighed 417 grams. Its pleural cavity was free of adhesion. It was affected with hypostatic congestion and oedema. No tubercle was found in it. The peritoneal cavity contained no effused liquid. The mesenteric vessels were congested, and the glands were much enlarged but soft. The lower portion of the ileum was opened, and its mucous membrane was examined. Peyer's patches were found to be affected, some having merely the "shaven beard" appearance, while in others there were inflamed and swollen spots which were ready to break down into ulcers. The diagnosis of enteric fever in an early stage was thus confirmed. On the lower border of the left lobe of the liver was found a small patch of tissue having the appearance of being in the state of amyloid degeneration. The surface of the liver was mottled in color; its weight was 1,825 grams. The left kidney weighed 199 grams; its capsule was slightly adherent. The right kidney weighed 193 grams. The tissue of the renal cortex was normal in appearance, except for being unusually pale. The spleen was large, and weighed 597 grams. Its tissue contained occasional minute cheesy foci having the appearance of miliary tubercle. The cranium was opened and the meninges of the brain were examined. They were congested and the perivascular and the arachnoid lymph spaces were well filled, there being evidently some serous effusion. The convolutions of the brain were somewhat flattened. There was no appearance of meningitis in any part.

CASE 8.

A. C. S.

P. V.; aged 28 years; nativity, Norway; admitted to marine ward, Cleveland City Hospital, June 19; died June 23, 1895.

History.-Patient had been sick, but kept at work for ten or twelve days before his admission to hospital on the 19th with enteric fever. General condition appeared good, with no untoward symptoms until the 23d, when symptoms of heart failure suddenly appeared-cyanosis (very rapid and weak heart action)—and he died about three hours after the onset.

Necropsy (fifteen hours after death).-Post-mortem lividity and rigor mortis very marked; general nourishment good; pupils equal and dilated. Heart: Weight, 320 grams, felt flabby, without the firm texture of a normal heart. Incision of its walls showed them to be somewhat thinner than normal, and the muscular texture had a muddy look, all indicating degeneration. Lungs: Weight of right lung, 630 grams; left lung, 655 grams; both normal, except for some passive congestion, apparently recent, and more marked in lower lobes; no oedema. Liver: Weight, 2,450 grams; enlarged and some degeneration apparent microscopically. Spleen: Weight, 470 grams—about double the normal size, very dark in color, congested, and very friable. Gastro-intestinal tract: Examination of small intestines showed Peyer's patches to be very much involved, several being from 4 to 5 inches in length; ulceration very extensive, and in two or three places had eroded all the coats of the bowel except the peritoneum; ileum very much congested throughout, the remainder of the bowel being normal. Mesenteric glands were very much involved, appeared in large masses, individual glands being much enlarged, and all soft and pulpy in consistence. Kidneys: Weight of each, 202 grams; normal, except for some passive congestion. Nervous system not examined.

CASE 9.

Intestinal perforation.

E. P.

C. II. W.; aged 21 years; nativity, England; admitted to United States Marine Hospital San Francisco, Cal., September 22, died October 3, 1894, at 4.15 o'clock p. m. History.—On admittance complained of weakness, pain over sternum, and coughing. He had been ill nine days and looked very anæmic. Urine was loaded with albumen. A diagnosis of acute nephritis was made. There was no diminution of appetite, and the bowels were regular. Patient was a British seaman on a sailing vessel which had reached this port after a long voyage; illness began the day after anchor was cast; the patient had not been ashore During period of treatment in hospital the morning temperature was 39° C., reaching nearly 40° C. in the evening. Patient lay in a semistupor, only partially rousing to take food. On the morning of the 1st of October he was seized with sudden and violent pain in the abdomen. The temperature dropped to normal, but during the day arose to 39° C. Tympanitis developed; the pain continued; the pulse became small and wiry, and death occurred the following day.

Necropsy (seventeen hours after death).-Purplish discoloration of skin and rigor mortis; heart normal; slight passive congestion of the lungs. The peritoneum exhibited an intense grade of inflammation and contained a slight purulent exudate. Liver normal; spleen was soft and pultaceous, and weighed 260 grams. Both kidneys were slightly swollen, and were reddened and inflamed along the tubules. The lower 3 feet of the ileum contained numerous necrotic or ulcerated areas in the seat of Peyer's patches. One patch showed several ulcers, divided by septa of mucous membrane. Some of the ulcers were quite superficial; others involved both submucosa and muscularis. One of the ulcers had perforated, causing peritonitis. The ulcers were irregularly crescentic in outline. Other organs not examined.

CASE 10.

J. S.; aged 19 years; admitted to United States Marine Hospital, Baltimore, Md., December 26, 1894; died January 2, 1895.

Clinical history.-Illness began with headache and severe pains all over the body six days before admission to hospital. Two days later patient had a chill, accompanied by severe diarrhea. Had ten evacuations first day and complained of severe headache and pain in abdomen. Diarrhoea continued, but there were no further chills. On admission to hospital December 26, 1894, temperature 40.4 C.; pulse, 84; diarrhea quite marked, greenish color. The temperature during time in hospital

ranged from 38° C. to 40.6° C., and the pulse from 84 to 125. Diarrhea continued. There was wakefulness, but no delirium. Medication had little effect. Temperature was reduced by cold baths. On the afternoon of January 2, 1895, all the symptoms grew suddenly worse. Marked tympanites set in; pulse became very rapid and weak; surface of body was bathed in cold perspiration. There was marked pain in abdomen, evidencing rupture of bowel and consequent collapse. Death occurred at 9.30 p. m., January 2, 1895.

Necropsy (ten hours after death).-Body well nourished; livores well marked on back and neck; abdomen much distended. Heart: Weight, 270 grams; valves normal and healthy; ante-mortem clot in left ventricle entangled in the chorda tendineæ. Lungs were not removed; section made in situ; normal except some slight congestion. Stomach very much distended, containing gas and partially digested milk. Jejunum: Vessels were congested with some enlargement of the solitary glands. Ileum: In upper part the glands (solitary and Peyer's) were enlarged, with here and there a patch of beginning ulceration; lower down the glands showed extensive ulceration, some being destroyed down to the peritoneal covering, others elevated 1.75 cm. above the lumen of the bowel. Near the ileocæcal valve they had nearly closed the lumen of the bowel, here being thickly congregated. In this situation (15 cm. from the valve) a large ulcer (10 by 5 cm.) had broken down in the center, perforating the bowel and forming an aperture about 1.75 cm. in diameter. Through this opening some fecal matter (semisolid) had found its way into the peritoneal sac. The whole intestinal canal was filled with a light-yellow fluid containing small lumps of partly digested milk. Large intestine was to all appearances normal. All the mesenteric glands were enlarged and stood out like beans. Spleen: Weight, 630 grams; very large, soft, and pultaceous; very dark. Liver and kidneys apparently

normal.

CASE 11.

Perforation.

S. N.

A. T.; aged 38 years; nativity, Norway; admitted to marine ward, St. Francis Xavier Infirmary, Charleston, S. C., July 10, 1894; died July 22, 1894.

History.-Had been ill for eight days before admission with fever, constant headache, and slight diarrhea; had been exposed to malaria. Quinine in full doses was given for two days but did not control temperature, which rose to 40.5° C. in spite of cold bathing. Guaiacol (2 c. c.) was rubbed into skin of abdomen and temperature fell. This was repeated at first every four hours, but later the dose was diminished to 1 c. c. twice a day. This sufficed to control temperature and no symptom of cardiac depression was observed. Profuse sweating occurred one hour after each dose. This was accompanied once by a slight rigor. Diarrhea persisted, but there was no iliac tenderness until July 17. Patient's condition was very favorable until the 21st, when he was seized with severe pain in the right iliac region. Pain and tenderness quickly spread to the entire abdomen, which did not, however, become tympanitic at any time. The temperature rose, the pulse became rapid and feeble, the face became livid and anxious, and death occurred within twenty-four hours after the occurrence of perforation.

Necropsy (seven hours after death).—Rigor mortis present; body well nourished and muscular. Thorax: There were a few recent adhesions in both pleural sacs. The lungs were congested and dark in color, but crepitant throughout. The heart muscle was rather soft but otherwise normal. Abdomen: There was no tympanitis. On opening the cavity the peritoneum, both visceral and parietal, was of a dark, livid color. The intestines were covered with recent exudate. A very small perforation was found in the ileum about 25 cm. from the ileocæcal valve. The ileum was opened and the agminate and solitary glands found to be enlarged, showing the "shaven beard" appearance. Only three small ulcers were found, but these were

very deep, with sharply cut edges. One of them had perforated the bowel, and the others had reached the peritoneal coat. The spleen was large, dark, and soft. The other organs were apparently normal. The brain was not examined.

CASE 12.

H. W.; aged 25 years; nativity, Sweden; admitted to the marine ward, German Hospital, Philadelphia, Pa., July 9; died July 12, 1894.

History.-Was in an extremely weak condition when admitted, giving a history of having been taken sick about ten days before with vomiting and diarrhoea. After the first day of the disease he had a chill and then became very weak. Physical examination revealed slight dullness over the base of the left lung, and a diagnosis of beginning pneumonia was thought to be appropriate, but a positive diagnosis was not made until more diagnostic symptoms were present. On July 11 he passed a bloody stool, and on the morning of July 12 he passed another. During the afternoon of the same day he had several more bloody stools, also passed some bloody urine and vomited some blood. He sank rapidly and died 4.15 p. m. His temperature on admission was 40° C., after which it varied from 38.3 C. to 40° C. After he had passed the first bloody stool enteric fever was suspected, but in the absence of any more positive symptoms the diagnosis was doubtful.

Necropsy (twelve hours after death).—External appearances: Body well nourished; post-mortem lividity marked; rigor mortis slight. Thoracic cavity: There was no exudation in pleural cavities. Edema was present at the posterior part of both lungs, and small hemorrhages were also found in these organs. The heart was pale and flabby, the fibers standing apart (acute myocarditis), otherwise normal. Abdom inal cavity: Spleen was twice its normal size, the lymphoid elements being distinet; liver slightly enlarged, pale and cloudy; kidneys enlarged, cortex fatty; pancreas normal. Intestines: There was considerable bloody liquid in the colon. About a dozen ulcerated Peyer's patches were found in the lower ileum. Localized peritonitis opposite ulcers (slight). Mesenteric glands enlarged considerably. Slight hemorrhagic injection in bladder and also in mucosa of the stomach.

INTERMITTENT FEVER (PERNICIOUS).

Chronic interstitial nephritis.

J. F. M.; aged 47 years; nativity, New York; admitted to marine ward, St. Francis Xavier Infirmary, Charleston, S. C., November 16; died November 23, 1894.

History.-Patient had had chills and fever for five days; had been exposed to malaria for a long time. When admitted temperature was but little above normal. There was constant nausea, with vomiting of bilious matter. Occasional hiccough was an annoying symptom. The skin was of a dark-brown hue. The day after admission he passed 30 c. c. of highly albuminous urine. Four days later he passed about 50 c. c. of urine involuntarily. This was all the urine passed during eight days. The temperature after the third day became subnormal. Examination of the blood showed the presence of the plasmodium in considerable numbers. There was much deformity and destruction of red corpuscles. There was a slight systolic murmur at the apex of the heart and decided accentuation of the second sound ove the aortic valves. The radial arteries were rigid. Suppression of urine continged in spite of treatment; patient became delirions, and finally comatose before death. Necropsy (nineteen hours after death).—Rigor mortis; body bronzed; subcutaneous fat slightly bile-stained; abdominal muscles of a slaty hue. The lungs were pale, moderate hypostatic congestion, otherwise normal; there were no pleuritic adhe sions. Pericardium normal; considerable amount of fat beneath visceral pericardium. There was marked hypertrophy of the left ventricle, and irregular thickening and atheromatous patches in tricuspid and mitral valves; these valves slightly incompetent; aortic valves competent, but atheromatous; atheromatous patches in

intima of ascending aorta. Heart cavities contained decolorized clots adherent to valves. The liver was slightly enlarged, firm, and contained a considerable quantity of blood; there were a few patches showing fatty change on the surface, and large portions of the organ were of a deep slate color; other portions normal in appearance. Spleen very small and abnormally firm. The fibrous trabeculae were very prominent on section; color normal. Both kidneys showed typical fibroid degeneration in an advanced stage. The organs were very small and firm and the cortex very thin; portions of cortex were torn off with the capsule; portions of both organs were pigmented. The bladder contained about 50 c. c. of urine. Other organs apparently normal. Brain not examined.

SECONDARY SYPHILIS-ABSCESS IN LARYNX.

CASE 1.

L.A; aged 40 years; nativity, Ireland; admitted to United States Marine Hospital at San Francisco, Cal., on August 2, and died August 31, 1894, at 12.30 o'clock a. m. History.-On admittance patient complained of syphilitic lesions as follows: Several large tubercular syphilides on scalp, forehead, trunk, arms, and legs. A large part of lower lip had ulcerated away. There was a specific pharyngitis, which had destroyed the anterior and posterior pillars of the pharynx and most of the mucous membrane lining the superior and middle constrictors of the pharynx. There were also evidences of obstruction in the larynx, which interfered with inspiration, but which could not be seen with the laryngoscope. Patient gave a history of laryngeal troubles for previous four years. The initial specific lesion was contracted during sexual intercourse four months before entrance to hospital. The eruption on the skin and ulceration of lip yielded promptly to antisyphilitic medication, but the pharyngeal and laryngeal condition grew worse. Large quantities of pus were produced in the larynx. The patient became anemic from rejection of food on account of pain occasioned by swallowing, and also partial inability to swallow because of destruction of muscles concerned in deglutition. Oxygenation was interfered with by laryngeal obstruction. Death was caused by combination of above factors.

Necropsy (fourteen hours after death).—Body poorly nourished; post-mortem rigidity and lividity. Present condition of pharynx was as noted in the history. The epiglottis was curled up in its long axis so as to resemble the longitudinal section of a hollow cylinder, and also pulled backward from cicatricial contraction of the aryteno-epiglottidian folds. Between the folds were several enlarged glands. The ventricle of the larynx on the right side was occupied by a bulging pus sac springing from the necrotic calcified wall of the larynx. The mucous lining of the pus sac was thickened and indurated, and an opening into the ventricle existed in its lower part. The trachea and larger branches of the bronchi exhibited a mild grade of inflammation. Pleural surfaces at apex of left lung were adherent. The extreme apex of the lung was broken down into tough, curdy layers. Lower and middle lobes of right lung in a state of hypostatic congestion. The other viscera were normal.

CASE 2.

Gummata of brain.

T. O.; aged 36 years; nativity, Pennsylvania; was admitted to the marine ward, German Hospital, Philadelphia, Pa., May 18; died July 8, 1894.

History.-Gave a history of having had epileptic attacks. These always began in the left hand, and after involving the left side of the body extended to the right side. On June 4 he was discharged as improved, having had no attacks while in the hospital. Four days later he was readmitted, giving history of having had several seizures during the period between his discharge and readmission. June 14 he had an attack, which was observed by the nurse, which began in the left hand