DISEASES OF CHILDREN

and expectoration and had lost a stone in weight; he had been radiologically examined, but nothing was found; he had had a holiday at Moss Vale and another at Moree. but grew worse, and would go no more to the country but continue his work as a public servant in Sydney. He had had a second X-ray examination, this time by Dr. H. R. Sear, who found a cavity in the upper lobe of the right lung and slight opacity in the left lung; the patient had then agreed to further rest and had been off duty for four months until April, 1929. At this time he was tall, thin and wan; his weight was eleven stone one and a half pounds when he was fully clad; his pulse rate was 110 per minute, his respirations numbered 22 per minute and his temperature was 100 0 F.; he was languid and his appetite and digestion were poor; there were dulness, bronchial breath sounds and a few rll.1es over the upper half of the right lung, and some, but slighter, signs over the upper lobe of the left lung; he had a little pain and a friction rub; his sputum was pink and contained tubercle bacilli; he was a little hoarse and his vocal cords were a little red and rough; he had a small ischio-rectal abscess. With difficulty he was persuaded to take yet four more months' rest, but he refused to go to the country. He was treated with hypodermic injections of albumose-free tuberculin (T.A.F.), from 0'00001 cubic centimetre up to 0'06 cubic centimetre, and did well till he was upset by his daughter's illness (pneumonia and empyema) and by his mother's death. He then had bovine tuberculin (P.T.), from 0'001 cubic centimetre up to 0'08 cubic centimetre, and did very well, till in 1931 he had regained his lost flesh, weighed over twelve stone and said "he felt better than he had ever been in his life". His legs sometimes ached and he had occasional pleural pains. He did his work regularly except for his annual holiday at Blackheath. In 1932 Dr. George Hamilton kindly examined him for a rodent ulcer of the face and treated him successfully with radium. In August, 1932, he had some diarrhcea, but no tuberculosis of the bowel could be found; his cavity was unhealed but nearly dry. Early in August, 1933, he had vague abdominal pain with diarrhcea and a little vomiting. On August 20 he became worse; he had severe abdominal pain and there was tenderness in the right and also in the left iliac fossa. Dr. Hunter Jamieson saw the patient in consultation and agreed with a tentative diagnosis of abdominal tuberculosis. He was admitted to the Royal North Shore Hospital of Sydney, and on August 22 Dr. Jamieson operated and excised an almost rigid appendix, which in one place appeared gangrenous. The patient sank and on August 25 he died. Post mortem it was found that the appendix had been converted by the growth of epithelium from its mucous wall through the mucosa and other coats into a rigid, brittle tube about five inches long and .half an inch in diameter. There were small metastases in the peritoneum, in the liver and in the lungs; recent non-tuberculous bronchopneumonia was present at the base of the right lung, and early general peritonitis was noted. There was a fibrouswalled cavity of the capacity of about three ounces in the right lung, and in this wall were at one place two small lesions which contained giant cells; otherwise the tuberculosis appeared to be healed. There were old. calcareous nodules in the left lung, but no recent tubercles were found anywhere. Examination of the heart revealed some terminal myocarditis. The honorary histologist reported that an adeno-carcinoma with scirrhous tendency had arisen in the mucosa of the appendix and had infiltrated the whole mucosa and all the coats, and that metastases of this were to be seen in the peritoneum. the liver and the vessels of the lungs.