diagnosis exceedingly difficult. I was inclined to say upon first inspection that there was a sacculated effusion, the result of a previous attack of pleurisy. The dullness, however, was too extensive, and the history which we could obtain was not at all that of pleurisy. The physical signs on the back of the chest, too, were not those of an effusion, unless, indeed, there had been some plastic exudation there.

On the second day after the admission of the patient I thought I noticed a slight impulse at a spot in the left chest. The idea passed through my head that there might be some tuberculous consolidation giving rise to obstruction of a bronchus, thus causing an obstacle to the entrance of the air. On the evening of the second day I found that there had been slight hæmoptysis, and it occurred to me that there might be a tumor pressing on the lung, and so preventing the entrance of air. I noticed a swollen vein crossing the chest and pectoral muscle and joining the mammary vein. This proved to me that there was serious congestion somewhere. On the morning of the third day the man's pulse was very slight, this vein was still more swollen, and there was more hæmoptysis. I then, for the first time, suspected that there was an aneurism of the descending thoracic aorta, which was pressing on the overlying lung, and of which physical signs were muffled by this indurated and intervening lung tissue; that this aneurism was about to ulcerate into the left bronchus, and so gave rise to the slight spitting of blood; and that there had been a very rapid consolidation of the whole lower lobe of the lung on the left side going on, which had produced the coarse, crepitant râles. This diagnosis was made on the third day. On the evening of that day the aneurism burst, and the man died.

To-day I bring before you the results of the post-mortem examination, which prove that my final diagnosis was the true one and reveal to us the post-mortem lesions of a most obscure and remarkable case. At the apex of the right lung was found a collection of cheesy nodules, the results of syphilitic deposit, or catarrhal inflammation. The left lung was enlarged and very solid. There were a number of lumpy, solid clots of blood scattered through the lobes; the rest of the lung tissue was entirely collapsed. The lower lobe was almost black, the result of a combined pneumonia and hæmorrhagic infarction. There was also in this lung some pneumonic inflammation with infiltration. Upon opening the mediastinum, extensive pericardial effusion was brought to light. As there had not been any friction sound heard, this was never suspected during life.

All arteries adjacent to the arch of the aorta were found to be healthy. A large clot was discovered lying in an enlarged part of the arch. As the thoracic aorta was opened downwards extensive clots were passed, and its lower portion was found distended into a large aneurismal sac.

Upon opening the trachea the right bronchus presented an entirely healthy appearance. The walls of the left bronchus, however, were almost entirely sloughed away. The aneurism itself was completely covered by lung tissue.

This case presented a most extraordinary condition. The diagnosis had to be reached by a careful process of exclusion. The aneurism had grown in such an obscure manner as to give rise to no external physical signs. As regarded the rational symptoms, all that could be discovered was that the man had not been entirely well for some six months, and that towards the last he had experienced considerable difficulty in swallowing and suffered from distressing dyspnoea. The aneurism had been too deep seated to affect the pulse or pupils.

In conclusion, let me sum up for you the results and their probable causes. The left lung was entirely collapsed, and the entrance of air into it was finally prevented. This condition had given rise to complete flatness upon percussion and entire absence of respiratory sounds. The gasping respiration had filled the lower lobe with the blood which had found its way into the left bronchus through the ulcerated wall, and this blood had clotted, forming the numerous hæmorrhagic infarctions found at the post-mortem examination. The pressure of these clots had produced numerous spots of local gangrene.

The aneurism itself was located one inch below the origin of the right subclavian artery, and was undoubtedly the result of syphilitic arteritis. The cheesy nodules in the upper lobe of the right lung were due to syphilitic deposits; there was no tubercular disease. I have spoken above of the distinct evidences of pericarditis elicited by the autopsy.

This case is such a remarkable one that I shall present a complete history of its ante-mortem symptoms and post-mortem appearances at the next meeting of the Pathological Society.

OSTEOMALACIA IN A MAN.1

BY CALVIN ELLIS, M. D.,

Professor of Clinical Medicine in Harvard University.

THE patient was a carpenter, fifty years of age, belonging to a healthy family. Though he had a bad cough all winter, he thought nothing of it, and reported that he had not been ill, more than a day or two, for twenty years, until December 10, 1871, when, while in California, after exposure to cold, he had what was called pneumonia, which confined him to his bed for four weeks. The patient's account of the disease, however, did not necessarily indicate pneumonia. Though Read before the Boston Society of Medical Observation, December 3, 1877.

He

there was an initial chill and fever, and dyspnoea was marked, there was neither cough nor expectoration. The other symptoms were loss of appetite, great weakness and fainting. The fever and faintness both disappeared, but the latter was very troublesome while it lasted. There was not much loss of flesh. At the end of a month he left his bed, and, after sitting up two weeks longer in his chamber, went out, but walked with great difficulty and gained nothing, forcing himself to go merely to get the air. The appetite returned, but he did not get well enough to do anything, and continued very weak and unable to walk even a short distance without much fatigue. On May 16, 1872, he started for Boston, by steamer. At first he was able to go to his meals, but, on the fourth morning, while stooping forward to wash his face, something in his back was heard to snap, his room-mate describing the sound as that of a piece of leather when made tense suddenly. This was accompanied by severe pain, and he fell at once. After that he was confined to his bed, as he could not stand if there was the least flexion of the spinal column, though he could if perfectly erect. was carried across the isthmus on a litter placed in a baggage-car, but suffered much from pain in the back and all over. He also had a very hard time on the steamer this side of the isthmus. He had but one dejection for ten or eleven days, and his efforts caused great pain, and were followed by the passage of blood, or, to use his phrase, a "bloody He finally reached New York on June 17th. He remained in New York five weeks, and was then brought to Boston. The bodily health improved immediately. He was able to sit up, however, but a short time, and spoke of "weakness in the bowels," and any exertion caused him to droop at once. He could not move a step without the aid of another person, and then on crutches, and had been able to do this a few days only when he was first seen on August 4th. There was much pain across the middle third of the abdomen, and, while lying in bed, some in the chest, which he considered muscular. When sitting he supported himself on his elbows. His feet were swollen one day "like a pin-cushion," he said, but there was nothing of the kind at the time of the visit, nor afterwards. The back curved outwards while in the sitting posture. Appetite and digestion both good. Tongue clean and pale. Bowels very costive, the dejections being composed of scybala as hard as bullets. Dyspnoea was quite marked. His chief complaints were faintness, dyspnoea, weakness of the bowels, and constipation. He spoke of a "cold-water spittle" rising in the throat and nearly strangling him. The urine was normal in appearance. Pulse 76. The temperature in the axilla below the normal point. There was no obvious paralysis, but he thought there was some diminution of sensation in the anterior part of the thighs. When well, he weighed two hundred pounds, but was much emaciated when seen. No

morbid physical signs over the heart or lungs. To the hand there was decided pulsation in the epigastrium, which he spoke of as trembling. On examination of this region with the stethoscope, there was heard a souffle, probably with the first sound, though at times it seemed to accompany the second. He showed a tendency to lie with the knees drawn up. The weather was excessively hot, and he had some "faint spells." He slept pretty well and did not sweat at night. He was ordered a pill composed of sulphate of iron two grains, aloes one half grain, extract of nux vomica one fourth grain, after each meal.

He was not seen again until September 5th. It was then reported that he continued to gain until he was able to be carried across the street, to his brother's, without injury. He had been troubled only by constipation and by faintness one very hot day. There was still a great secretion of saliva, with some blood, but no cough. It was stated at this visit that he had for a long time had difficulty in raising the right leg to get a stocking on, and he was trying to do this about the last of August, when he suddenly experienced, just above the right ilium, a feeling like that previously reported above the left, as if something gave way, accompanied by considerable pain, but without noise. The pain was still felt. Previous to this he had been able to sit up four or five hours, and could walk to a chair in the room with the aid of crutches or an attendant, but still had the same trouble in holding himself upright. There was no dyspnoea unless the weather was hot. The bowels had been opened every day, but the fæces were very hard and passed with much difficulty. No pulsation was felt in the epigastrium, and nothing unusual was heard by the unaided ear. Appetite excellent. Pulse 89. The aloes were increased to one grain, and an enema was ordered every day if there was no dejection.

When next seen, on September 15th, he spoke of noticing pulsation in the abdomen all the time, more internally than externally, but not perceptible to the touch. He was still troubled by the bloody secretion from the throat, which he was obliged to expectorate frequently in the night. This was noticed only after going to bed, as if it were in some way connected with position. He had not regained the power of standing, even with the help of his hands, and there seemed to be a weakness in the hips. He could, however, support his weight on his hands, while sitting on the bed, and was able to be carried down-stairs on the two previous days. Sneezing caused pain in the back. The appetite continued good. The urine was free. Pulse 92, strong and full. He looked about the same, but thought that he had gained some flesh. Though the dejections were still scybalous they were not the cause of suffering as before. He complained principally of pain in the epigastrium, and want of power over the legs. As a portion of the record was unfortunately lost, it is not known precisely when a change for the

worse took place, but on September 27th the following report was made: He suffered much from the passage of hard scybala, though an injection was given. The pain had become much more severe, and was so much increased by any attempt to move him that he would cry out and say that he could not bear it. Still he refused opiates. He had had high fever from early morning till noon, and did not seem to know any one, but in the afternoon he was better, and recognized his friends. His mind was clear, and he answered questions on being spoken to, though he lay in a dull, heavy state. Respiration good in the front of the chest, which was not examined behind. Pulse 100, very full.

On September 28th, he was reported to have passed a comfortable night without an opiate, which he refused. He was able to help himself somewhat, and to turn upon his right side, complaining only of being tired of lying in one place. He continued to sink, however, and died on the 29th.

One physician told him he had Bright's disease, and as far as can be remembered there were some suspicious appearances in the urine, but if a record were made it was lost.

Autopsy forty hours after death.

Head not examined.

About four ounces of purulent serum in the right pleural cavity. The greater part of the latter, however, was obliterated by old adhesions. The pleural surfaces between the left upper and lower lobes were dull, as from recent inflammation, and at the bottom of the fissure was some concrete pus. The posterior parts of the lower lobes of both lungs were considerably solidified as from oedema, hypostatic congestion, and perhaps some inflammation. Upper lobes oedematous.

Heart large as from general hypertrophy, but no valvular disease. The right side was filled with coagulated blood.

Spleen rather soft.

Liver apparently normal.

Kidneys rather large and succulent. Veins upon the external surface distinct and in groups. Cortical substance and pyramids less distinctly defined than usual, but there was no granulation nor anything especially morbid.

The ribs and sternum were soft and filled with red pulp. The vertebræ, paticularly the lumbar, were sawed and broken down with ease, the bodies and processes being alike involved. They were filled with the same red pulp as the ribs and sternum, which is so characteristic of osteomalacia. In the midst of the diseased parts were some islands of firm bone.

The other bones were not examined.

The difficulty of diagnosis was great. The symptoms pointed very