Phthisis; its morbid anatomy, etiology, symptomatic events and complications, fatality and prognosis, treatment and physical diagnosis, in a series of clinical studies

Front matter

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TRANSFERRED TO YALE MEDICAL LIBRARY

PHTHISIS:

Preface

This volume is the result of much labor, not only in the careful recording of over six hundred and seventy cases of Phthisis, but in the abstracting, grouping, and analysis of them with reference to practical deductions. Whether the result has any value proportionate to the labor which it has cost must be left for the reader to decide, but the author trusts that the series of clinical studies which the volume embraces will not be without interest and importance for the practitioner. Whether this be so or not, his past experience assures him of kindly consideration on the part of his professional brethren.

New York, October, 1875.

Contents

PA'. I

Introduction ... .17

Chapter I Morbid An A T M T

Chronic phthisis a bilateral disease — The law of parallelism iu acute miliary tuberculosis— Cases in which the right and the left lung were most diseased — Exceptions to the rule that the apex of the lung is first affected — Pulmonary cavities — Displacements of the heart in consequence of loss of the pulmonary substance — The morbid appearances in cases o acute miliary tuberculosis — Cu^es with pleurisy and pleuritic effusion — Phthisis and recent pericarditis — Phthisis and acute pneumonia — Collections of liquefied morbid products — Case of poisoning with aconite, a single and small nodu'e the only evidence of phthisis — Case showing cicatrization eighteen years before death — Relationship of gray granulations and tuberculous exudation — The relative importance of gray granulations when associated with either exudation, liquefied morbid products, or cavities — Perforation of lung and pneumothorax — Coexistence of vesicular emphysema — Pleuritic adhesions — Inter- -litial pneumonia — Enlargement of bronchial glands and obstruction of a primary bronchus — Pulmonary apoplexy — Pulmonary gangrene — Dilatation of bronchial tubes — Diminished volume of lung — Circumscribed congestion in connection with hemoptysis — Morbid appearances of the heart — Morbid appearances in the larynx and trachea — Intestinal ulceration — Disease of the mesenteric glands — Peritonitis — Gastric ulcer — Morbid appearances in the liver, spleen, and kidneys — Thrombosis of the iliac veins — Morbid appearances of the brain

r ir a pt E k ii.

ETIOLOGY.

Influence of age — Evidence therefrom of a constitutional predisposition — Influence of sex — Influence of occupation — Influence of antecedent diseases ; pleurisy, pneumonia, and bronchitis — Haemoptysis — AnteceiMit disea>rs ; intermittent fever, measles, dyspepsia, diarrhoea, rheumatism, perineal fistula, scrofulous affection of

Vlll CONTENTS.

PAGE

the glands of the neck, syphilis, bronchocele, psoriasis, parotiditis, smallpox, typhoid and yellow fever, dysentery, diabetes and Addison's disease — Influence of pregnancy and lactation — Influence of congenital predisposition and hereditary tendency ..... . 48

Chapter III. Symptomatic Events And Complications

Bronchorrhagia preceding and accompanying the development of phthisis — Exciting causes — Dependence on local congestion — Its occurrence without being accompanied or followed by phthisis — Propositions embodying conclusions from clinical studies — Hemorrhage in cavities — Death from bronchial and cavernous hemorrhage — Moral effects of hemorrhage— Relief of pulmonary symptoms an effect in some caBes — Increase of disease after hemorrhage in some cases — Coagulation of blood in the bronchial tubes — Influence of bronchorrhagia on fatality, arrest, tolerance, recovery, and duration — Treatment of bronchorrhagia— Diarrhoea, its significance as respects intestinal lesions, its relations to other complications and to the pulmonary affection, its bearing on prognosis and on the duration of phthisis — Miscellaneous events referable to the digestive system ; epidemic cholera, sporadic cholera, choleraic dysentery, gastric ulcer, peritonitis, pharyngitis — Laryngitis, its frequency and symptoms, its chronological relations to the pulmonary affection, its influence on the fatality and duration of phthisis, the prognosis as regards recovery from the laryngitis and the treatment — Lobar pneumonia as an intercurrent affection in phthisis, its influence on phthisis, its agency in causing death — Circumscribed pneumonia leading to error as regards the amount of phthisical affection — Pleurisy with effusion, its agency in determining death in certain cases, and its influence on the progress of phthisis sometimes salutary — Perforation of lung with pneumothorax, symptoms denoting its occurrence, exciting causes, its occurrence after thoracentesis, the propriety of thoracentesis when the pleural sac becomes filled with liquid, the propriety of this operation when the accumulation of liquid air occasions much dyspnoea, the propriety of a free incision into the chest in phthisis with pneumothorax, cases illustrative of this procedure in perforation following emphysema, chronological relations of perforation to the commencement of phthisis and the subsequent duration of the disease — Pulmonary calculi— Pneumorrhagia and gangrene — Dorso-intercostal neuralgia — Latency of phthisis and the sudden evacuation of collections of liquefied morbid products, "tuberculous abscesses" — Affections of the heart and pericardium — Articular rheumatism — Disease of the kidneys — Thrombosis of the iliao veins — Angular curvature of spine— Cerebral meningitis— Perineal fistula, its significance and influ. ence on the progress of phthisis — Pregnancy, its influence on the progress of phthisis— Clubbed fingers — Rosy complexion . 7 K

CONTENTS. IX

Chapter I Y. Fatality And Prognosis

PAtfE

Acute miliary tuberculosis, the histories of five cases, the duration, and mode of dying — Miliary tubercles without exudation or cavities in fatal cases, death being caused by complications — Acute tuberculosis supervening on phthisis — Abstracts of the histories of forty-four cases of recovery from phthisis — Ratio of recoveries — Amount of the affection in the cases which recovered — Import of age in prognosis — Influence of sex — Do. of family predisposition — Do. of haemoptysis — Do. of chronic laryngitis — Do. of pleurisy with effusion — Do. of perineal fistula— Symptoms denoting tolerance in the cases which recovered — Importance of determination and energy on the part of the patient — Recurrence of phthisis — Abstracts of the histories of thirty-one cases of arrested or non-progressive phthisis — Analysis with reference to the amount of disease and influence of age, sex, family predisposition, haemoptysis, chronic laryngitis, pleurisy with effusion, perineal detain, symptoms denoting tolerance, and duration of the disease — Recurrent attacks — Abstracts of the histories of ten cases of slowly progressing phthisis — Analyses with respect to amount of disease, age, sex, family predisposition, haemoptysis, perineal fistula, symptoms denoting tolerance and duration of the disease — Conclusions drawn from the analyses of the cases of recovery, of arrest, and of slowly progressing phthisis — The duration of the disease, and the complications, events, or circumstances affecting duration and causing death, in fatal cases of phthisis — Case of forty years' duration— Case of twenty years' duration — Case of thirty-one years' duration — Analyses of cases of duration between ten and fifteen years — Do. of cases of a duration between five and ten years — Do. of cases of a duration between three and five years — Do. of cases of a duration between six months and a year — Do. of cases ending within six months — Propositions embodying conclusions drawn from these- analyses ... . 181

CHAPTER V .

TREATMENT.

Treatment of acute miliary tuberculosis — Treatment of fibroid pbtbisis — Review of cases ending in reoovery, cases of arrested or non-progressive, and of slowly-progressing phthisis, for evidence of an intrinsic tendency in phthisis to end favorably — The objects of treatment — Modes of estimating the influence of particular remedies or measures of treatment — Treatment of cases ending in recovery — Abstracts of the histories of fifteen of these cases in which the treatment consisted of hygienic measures — Abstracts of the histories of eight of these cases treated with cod-liver oil, hypophosphites, or alcoholics — Abstracts of the histories of nine of these cases, of which the notes are defective as regards treatment— Summary of results of the study of forty four cases ending in recovery, respecting treatment —

X CONTENTS.

PAOR

Treatment of cases in which the disease was arrested or non-progressive — Abstracts of the histories of six of these cases in which there was neither hygienic nor medicinal treatment — Abstracts of the histories of ten of these cases in which the treatment consisted of hygienic measures — Abstracts of eleven of these cases treated with cod-liver oil, hypophosphites, or alcoholics — Abstracts of the histories of four of these cases, the notes of which are defective as regards treatment — Summary of results of the study of the thirty-one cases of arrested or non-prngressive phthisis, with reference to treatment — Treatment of ten cases of slowly progressing phthisis — Summary of the treatment in these cases — Treatment of fatal cases— Abstracts of the histories of sixteen of these cases in which there was no important hygienic nor medicinal treatment — Analysis of these sixteen cases and comparison with the cases not having had treatment, among those ending in recovery, or arrested, or slowly progressing — Abstracts of the histories of twentytwo fata] cases, the treatment of which consisted of hygienic measures — Analysis of these twenty-two cases — Comparison as respects duration and tolerance with the fatal cases in which there was no treatment — Analysis and comparison of all the cases in the collection in which the treatment consisted of hygienic mejisures -Abstracts of the histories of twenty-four fatal cases, treated mostly with the cod-liver oil — Analysis of these cases, and comparison, as regards duration, with cases receiving hygienic but not medicinal treatment — The usefulness of cod-liver oil shown by improvement and tolerance under its use— Abstracts of the histories of three of the fatal cases treated with the hypophosphites — Abstracts of the histories of three fatal cases treated with alcoholics in large quantity — Treatment,

with the iodide of potassium of case in hospital with syphilitic complications

Cases treated with bloodletting — Abstracts of the histories of four fatal cases, the notes of which are defective as regards medicinal treatment — Account of six cases treated with the chlorate of potassa — Recapitulation of conclusions drawn from the study of fatal cases with respect to treatment — Treatment in cases the histories of which are defective as regards either duration or termination — Abstracts of the histories of eighteen cases in which there was neither hygienic nor medicinal treatment— Analysis of these eighteen cases — Abstracts of the histories of twentytwo cases in which the treatment consisted exclusively, or chiefly, of hygienic measures— Analysis of these twentytwo cases— Comparison of this group of twenty-two cases with the preceding group of eighteen cases— Abstracts of the histories of fifteen cases in private practice, treated with cod-liver oil— Analysis of these fifteen cases— Abstracts of the histories of twenty-nine cases in hospital practice, treated with cod-liver oil— Analysis of thess cases, and comparison with results of the analysis of the fifteen cases in private practice treated with cod-liver oil— Abstracts of the histories of ten cases treated with the hypophosphites— Analysis of these ten cases— Abstracts of the histories of five cases treated with alcoholics given largely— Treatment of a case thirty years ago— Case treated with ih pancreatic emulsion— Summary of the treatment with cod-liver oil. the hypophosphites, and alcoholics— Summary of hygienic treatment— Analysis with re-

CONTENTS. xi

PAOR

ference to temporary change of climate — Influence of particular climates- Relative advantages of different climates— Analysis with reference to change of habits from those more or less sedentary and con6ning within doors, to those involving out-of-door life and activity — Analysis with reference to change of residence, either from the city to the country, or to a different climate — Remarks on the treatment of phthisis — Arsenic — Hypophosphites — Cod-liver oil — Pancreatic emulsion — Alcoholics — Dietetic treatment — Tonics — Change of habits as regards out-of-door life — Injury of over-exercise — Cold bath — Clothing — Change of climate — Travelling — Case illustrative of the influence of change of climate and travelling on horseback — Sea voyages— Expectorants and cough palliatives — Influence of marriage on the disease — Abstracts of the histories of fifteen cases in which men affected with phthisis married — Analysis of these cases — Abstracts of the histories of two cases in which women who were phthisical married — Conclusions . . . 270

Remarks on the treatment or Phthisis . , . 39ft

CHAPTER VI.

PHYSICAL SIGNS AND DIAGNOSIS.

Obstruction of a primary bronchus— Impulse of the aorta or of the pulmonic artery, and displacement of the heart from shrinkage of lung — Requirements for the recognition and interpretntion of the physical 6igns of diseases of the chest — The true method of determining the individuality of signs and their differentiation — The physical conditions in advanced phthisis — Cavernous signs — Signs in phthisis not advanced to the formation of cavities — Signs in incipient phthisis — Intercurrent pneumonia in cases of phthisis — Phthisis in cases of pulmonary emphysema — Signs in arrested or non-progressive phthisis, and after recovery from the disease — Signs in acute miliary tuberculosis— Signs in fibroid phthisis . . 421

ERRATA.

Puge 133, 2d line in paragraph 3, for "anaemia," read uraemia. ' ; 221, in heading of Case 3, for "complete," read comfortable.

PHTHISIS:

SERIES OF CLINICAL STUDIES.

Introduction

The purpose, in the pages which are to follow, is to give the results of clinical studies relating to phthisis. Notwithstanding the pathological distinctions, the nosological subdivisions, and the variety of names which are to be found in recent medical literature, the terms phthisis, pneumonic phthisis, and pulmonary consumption, apply to a well-defined class of cases. In a clinical or practical view, the application of these terms occasions no difficulty nor confusion. Applied without any qualification, they denote a chronic affection. For the most part, the cases which I am about to study are cases of chronic disease. . I shall, however, embrace in my studies some cases of the affection known as acute miliary tuberculosis, and, also, some cases of the form of chronic disease called fibroid phthisis, or cirrhosis of the lung. "With these few exceptions, all the cases belong to a class remarkable for uniformity as regards the character of lesions, together with the symptomatic events and laws which belong to the clinical history. With the disease in its ordinary form, all physicians, from its frequency, are but too familiar.

Of the cases of phthisis which had come under my observation up to the time of entering on these studies, I have preserved notes of a considerable number, namely, six hundred and seventy. These cases were noted during a period of thirty-four years. For twenty-five years I made notes of nearly all the cases which I observed, both in private and in hospital practice ; but for the past nine years my field of clinical observation has been so large, and my professional duties have been so much increased, that the 2

18 INTRODUCTION.

cases of phthisis which I have noted bear but a very small proportion to those observed. Moreover, the number of cases which I had already noted was so large, that I felt a desire to accumulate notes of cases of other diseases rather than to increase my collection of cases of phthisis. This latter consideration affected especially my notes of hospital cases ; hence, of the cases which I have noted, much the larger proportion were in private practice.

My notes present much diversity in minuteness and completeness. For the reasons just stated, those made of late years are comparatively brief. Formerly they were quite full as regards the previous history, together with the symptoms, physical signs, etc., while the cases were under my observation. But a pretty large proportion of the cases were not under my observation during the whole course of the disease, and many were observed for only a short time, the patients not infequently residing at a distance, and, therefore, seen by me only once or twice. With regard to the latter cases, however, I have, in a considerable proportion, obtained information of the subsequent histories.

Notwithstanding the imperfections of many of the histories, the analytical study of so large a collection of cases will, as I cannot but think, lead to results of sufficient value to repay the labor which they will cost. I have entered upon the undertaking with this belief. Examining all the histories and classifying the data which they contain, I shall employ, as far as practicable, the numerical method of investigation with reference to various objects of inquiry, introducing histories to illustrate certain points of interest or importance, and giving abstracts of the cases studied with reference especially to the treatment of the disease. The various pathological questions connected with phthisis, which have of late given rise to much discussion, I do not propose to consider in this work. I shall refer to them only as they are suggested in connection with conclusions to which my studies ma} T lead.

In the prosecution of my studies I shall adopt the following arrangement of topics : First, the morbid anatomy of phthisis ; second, the etiology; third, symptomatic events and complications ; fourth, fatality and prognosis ; fifth, the treatment, and, sixth, the physical signs and diagnosis. These topics, as thus arranged, will be considered in separate chapters.

CHAPTER I.

MORBID ANATOMY.

Chronic phthisis a bilateral disease — The law of parallelism in acute miliary tuberculosis — Cases in which the right and the left lung were most diseased — Exceptions to the rule that the apex of the lung is first affected — Pulmonary cavities — Displacements of the heart in consequence of loss of the pulmonary substance — The morbid appearances in cases of acute miliary tuberculosis — Cases with pleurisy and pleuritic effusion — Phthisis and recent pericarditis — Phthisis and acute pneumonia — Collections of liquefied morbid products — Case of poisoning with aconite, a single small nodule the only evidence of phthisis — Case showing cicatrization eighteen years before death — Relationship of gray granulations and tuberculous exudation — The relative importance of gray granulations when associated with either exudation, liquefied morbid products, or cavities — Perforation of lung and pneumothorax — Coexistence of vesicular emphysema — Pleuritic adhesions — Interstitial pneumonia — Enlargement of bronchial glands and obstruction of a primary bronchus — Pulmonary apoplexy — Pulmonary gangrene — Dilatation of bronchial tubes — Diminished volume of lung — Circumscribed congestion in connection with haemoptysis — Morbid appearances of the heart — Morbid appearances in the larynx and trachea — Intestinal ulceration — Disease of the mesenteric glands — Peritonitis — Gastric ulcer — Morbid appearances in the liver, spleen, and kidneys — Thrombosis of the iliac veins — Morbid appearances of the brain.

My notes embrace an account of the appearances after death in eighty cases. The appearances were not observed and noted with a view to a numerical analysis respecting the presence or absence of lesions in all the different organs and structures of the body. The researches of Louis, published nearly fifty years ago, leave not much to be desired, in this point of view, so far as morbid appearances are ascertained without the aid of the microscope. It is worthy of note that the researches of that conscientious and patient observer in the study of phthisis, as also of typhoid fever, are as valuable to-day as when they were made. He analyzed one hundred and twenty-three cases of phthisis, the histories embracing an account of the appearances after death, not only of the lungs, but of all the organs of the body. In these histories negative, as well as positive, facts were included ; that is, the morbid appearances in different situations were described, and the absence of any morbid appearances was also noted. This was prior to the employment of the microscope in pathological studies. As regards microscopical appearances, the observations of Louis are, of course, defective ; but, as far as they go, the facts developed by his laborious researches can only be invalidated by the occurrence of important changes in the laws of disease. In a large proportion of my cases the post-mortem examination was not complete, but limited to a greater or less number of organs, and in not a few of the cases, the only organs examined were those within the chest. The object which, more than any other, I had in view in my observations relating to the morbid anatomy, was to note the lesions in connection with the physical signs which had been already noted. The histories, moreover, are barren as regards microscopical appearances. With these defects, it remains to be seen how much value my autopsical records have; but, perhaps, considering the large number of cases, the results may repay the labor of the analysis.

Phthisis belongs eminently among the bilateral affections. This is shown by the exceedingly small number of exceptions to the rule that, after" death, both lungs are found to be affected. The morbid appearances in my eighty cases were limited to one side in only two. The facts noted in these two cases are as follows : In one the left lung was entirely free from the disease. The right lung, in the upper and middle lobe, had several cavities which were anfractuous with traversing bands of condensed pulmonary tissue. There were neither granulations, miliary tubercles, nor any exudation. It is, perhaps, probable that, in this case, miliary tubercles had existed in both lungs, and had disappeared from the right lung, leaving no obvious traces of their existence. In the other case, the left lung was healthy. The right lung at the apex had a cavity of the size of a hazlenut, together with a small amount of solidification. Peritonitis from intestinal perforation, numerous large ulcers in the colon and rectum, and a few ulcerations in the small intestine, existed in this case. The liver and the kidneys were fatty, and the mesenteric glands were much enlarged. 1

Although a bilateral affection, phthisis does not exemplify fully the law of symmetry. The two lungs are affected un-

1 Louis found the disease limited to one lung in 7 of 123 cases. In five cases it was limited to the left, and in two to the right, lung.

RELATIVE AFFECTION OF THE TWO LUNGS. 21

equally. To this rule there are very few exceptions. The disparity is evidently owing to the affection being of older date in one lung than in the other. These statements apply to chronic phthisis, but not to the affection known as acute miliary tuberculosis. In a case of the latter affection both lungs were alike crammed with miliary tubercles which were also found in other organs. In a few other cases of the same affection, it is simply noted that both lungs were crammed with granulations or miliary tubercles.

Is the greater amount of disease, in the majority of cases, seated in the right or in the left lung; or, what is an equivalent question, which of the two lungs is oftenest affected primarily? Of 55 cases, in 28 the greater amount of disease was in the right lung, and in 27 cases the left lung was most diseased. Hence, there is no uniform law as regards a greater tendency in either lung to phthisis. The practical bearing of such a law would relate chiefly to diagnosis ; and it is evident that physical signs, when they are of a doubtful character, derive no diagnostic force from their situation on either side of the chest. 1

It is a well-known fact that, as a rule, phthisis is either limited to the upper lobes, or, if it affect the lower lobes, it is greater in extent and more advanced in the former. The primary seat is at or near the apex, and the disease advances from above downward. Three cases only furnished exceptions to the rule. In one of these cases the lungs were adherent on both sides to the walls of the chest, excepting that, on each side, at the base there was a collection of puruloid liquid within the pleural cavity. At the base of the right lung there was a cavity of the size of an English walnut, anfractuous and evidently tuberculous. At the lower part of the left lung were several nodules. There was no affection at the upper part of either lung. In another of these cases the lower lobe of the left lung contained two cavities of the size of a large American walnut. Both lungs, in this case, were crammed with miliary tubercles, which were sufficiently numerous to produce solidification of the upper lobe of the left lung. Of the third case it is simply stated that

1 Of 38 cases analyzed with reference to this point by Louis, the left lung was most affected in 28 and the right lung in 10 ; hence, he concluded that the left more than the right lung is liable to become affected.

there was an affection of the base corresponding to the signs noted during life.

In 62 of 78 cases there were cavities. The cases differed as regards the number of cavities, their size, and their existence in only one lung or in both lungs. It seems hardly worth while to determine numerical facts with respect to these points of difference. This may also be said of other points, such as the flaccidity, or otherwise, of the walls of the cavities, the number and size of the communications with the bronchial tubes, et cetera. An analytical investigation with reference to these details would not be likely to develop anything not sufficiently known already. I shall content myself with citing a few incidental circumstances.

In one case a large cavity, estimated to be of sufficient size to hold half a pint of liquid, contained several loose calcareous masses of irregular shape. Evidently they were too large to pass through the openings into the bronchial tubes, and had not, therefore, been expectorated.

In one case a portion of the upper part of the lower lobe of the right lung projected so as to form a tumor of the size of an American walnut. On section, this proved to be a cavity distended with air. There was a cavity of the apex of the lung as large as a small orange. The remainder of the upper lobe was solidified by recent exudation. A portion of the lower lobe was also solidified, and there were several small cavities in this lobe, in addition to the cavity, the anterior wall of which formed the projecting tumor.

In three cases there was blood within the cavities. In one of these cases there were two cavities at the base of the left lung, each of the size of a large American walnut, and each contained dark liquid blood. Both lungs were crammed with miliary tubercles. The bronchial glands were greatly enlarged ; some hard and smooth on section, others of a cheesy consistence. The right primary bronchus was obstructed by the pressure upon it of one of the enlarged glands. The heart was normal. In another case a cavity of the size of an English walnut, at the summit of the right lung, was partially filled with sano-uinolent serum and darkcoagula. In the remaining case, a cavity at the left summit, of the size of an orange, was filled with

ACUTE MILIARY TUBERCULOSIS. 23

coagulated blood, and also a smaller cavity communicating with the larger. Both cavities contained at least half a pint of coagula. They were much distended with the clots. In the rest of this lobe there were disseminated nodules. A small cavity, together with disseminated nodules, existed at the summit of the right lung.

Several of the cases furnished examples of very great destruction of lung by the formation of cavities. In one case it is noted that the "left lung was much contracted, and presented a series of communicating cavities extending from the apex nearly to the base, the two lobes being firmly united, and the whole lung closely adherent to the thoracic walls."

Displacement of the heart as a result of great destruction, with cavities of the right lung, was observed in two cases. In one of these cases the heart was situated on the right side of the sternum, and the displacement had taken place while the case was under observation. In the other case, the heart was, in like manner, displaced, and the pericardium was attached to the right lung at the site of a cavity of the size of a small orange. The walls of this cavity were flaccid, and, at the situation where it was adherent to the pericardium, they were quite thin. The inner surface of the cavity was rough. This case was of much interest on account of the production within the cavity of a very loud friction-murmur by the heart's action, resembling a pericardial friction-murmur. Reference will be made to the case in connection with the study of the physical signs. There was no pericarditis.

In 16 of 78 cases there were no cavities.

In 5 of these 16 cases the disease was acute miliary tuberculosis. The distinctive anatomical peculiarity of this affection is the presence in both lungs of either gray granulations or miliary tubercles (the latter name being applied after they have undergone a granulo-fatty metamorphosis), in immense numbers, together with their coexistence in other organs, namely, the spleen, liver, etc., without either cavities or solidification from exuded morbid products heretofore known as tuberculous infiltration or yellow tubercle. I shall give an abstract of the notes relatiug to the appearances after death in these five cases.

Case 1. Old pleuritic adhesions existed on both sides. Both lungs were stuffed with granulations. No exudation nor cavities. Nothing is noted of appearances in other organs.

Case 2. There were no pleuritic adhesions. The lungs were crammed with small hard tubercles, not larger than pins' heads. Both lungs were equally crammed. The spleen was enlarged and crammed with tubercles. There were some cheesy masses in this organ. The liver was studded with tubercles, and they were scattered throughout this organ. The peritoneum was studded with tubercles. The mesenteric glands were enlarged. The kidneys were free from tubercles.