Cere heard most distinctly at apex. Precordial dullness markedly increased. Cyanosis also present. Patient very nervous and unable to retain anything on stomach but milk. Was given 10 drops of digitalis three times a day, also morphia to control cardiac asthma, from which the patient suffered severely at times. He continued to grow steadily worse, and died at 4 p. m., May 19, 1898. Necropsy (three hours after death).-Post-mortem rigidity well marked. bellum markedly congested; weight, 1,568 grams. Left lung adherent to chest wall, anteriorly and posteriorly; weight, 512 grams. Right lung normal; weight, 704 grams. Pericardium contained about 250 c. c. of fluid. Heart: Left ventricle very much hypertrophied, right ventricle also so to a slight degree. Mitral and aortic valves thickened, incompetent, and covered with vegetations. Liver showed cirrhotic changes; weight, 1,632 grams. Kidneys: Right, weight, 166 grams; left, weight, 208 grams. Both kidneys contained old cicatrices, probably syphilitic. Other organs normal. C. B. R. CASE 5. Pneumonia (lobar). H. T. (colored seaman); age, 31; nativity, Virginia; was admitted to the United States Marine Hospital, Cincinnati, Ohio, March 14, 1898; died March 26, 1898. History.-Patient was admitted to hospital complaining of chills and fever and feeling badly all over. Had been having chills and fever for about a week before applying for admission, the paroxysms occurring every other day. On March 21 the patient developed signs of pneumonia, the right middle and lower lobes being affected. Temperature, 40.1; respirations, 50; pulse, 120. Cough severe and expectoration rusty. Patient was given supportive treatment but gradually grew worse, being delirious for two days before death, which occurred March 26, 1898, at 2.15 a. m. Necropsy (nine hours after death).-Dura slightly adherent; pia somewhat injected. Brain normal; weight, 1,475 grams. Lungs: Left lung very much retracted and contained a number of old tubercular deposits; weight, 640 grams. Right lung adherent to chest wall anteriorly and posteriorly and in a state of red hepitization, also contained several tubercular deposits which had become organized; weight, 608 grams. Pleura contained about 500 c. c. of fluid. Balance of organs found to be in a normal state. CASE 6. C. B. R. Rupture of aortic valves—Malarial fever. E. J.; aged 21; nativity, Finland; admitted to the marine ward, German Hospital, Philadelphia, Pa., October 23, and died October 28, 1897, at 10 p. m. History.-Family history is excellent. Denies the use of tobacco or alcohol; also denies venereal disease. Before the present illness he does not remember ever having been sick. About three weeks ago he commenced to feel badly; shortly after this he had a chill, which was soon followed by a fever and sweat. He had pains in the lumbar region, in the legs, and a severe headache. His appetite remained good throughout. The above paroxysms were repeated at intervals of a few days (two) for about a week, when his vessel put in at a port where there was a marine medical officer. Here he received some medicine and was somewhat benefited, but soon after he became worse. On admission to hospital he was very weak-almost unable to walk without assistance. The knee jerks was absent. Tongue somewhat coated, broad, and flabby. Spleen extended to costal margin. Lungs were normal throughout. Heart was overacting, with an especially loud second sound, best heard at the second right costal cartilage. Pupils reacted to light and accommodation. Was unable to approximate the fingers of one hand with those of the other. Necropsy (twelve hours after death).-He was 5 feet 8 inches in height. Postmortem lividity was slight; rigor mortis was especially marked, being broken up with the greatest difficulty. The pupils were slightly dilated. The body was not much emaciated, the general nourishment being good. The heart weighed 290 grams after opening, was soft and flabby, but no macroscopical evidence of fatty degeneration. The pericardial sac was normal and contained a small amount of serum. By the hydrostatic test the aortic valves were found to be incompetent, the cause of which upon opening was found to be two small rents or tears in one of the leaflets. One was transverse immediately below the "line of contact:" the other one was a longitudinal tear near the margin of the leaflet. The appearance of the tears would indicate that they were quite recent. The mitral, pulmonary, and tricuspid valves were found to be competent. The right ventricle held 93 c. c. of water; the thickness of the wall of the right ventricle was found to be to that of the left ventricle as 1 to 3. The wall of the left ventricle was, as far as macroscopical examination showed, normal, and the cavity held 93 c. c. of fluid. The thoracic aorta was found to have very small atheromatous spots (about 1 mm.), especially at points where the artery gave off branches. The abdominal aorta was found to be perfectly normal throughout its entire course. There was nothing abnormal observed as regarded the other arteries and veins. The nares and larynx appeared normal, except that they were filled with mucus. In the middle lobe of the right lung small areas of hypostatic congestion were found; also in the lower part of the upper left lobe posteriorly. The left lung weighed 460 grams. The pleural cavity contained a normal amount of serum and had no adhesions anywhere. The right lung weighed 520 grams; the pleural cavity was normal, without the slightest evidence of adhesions. The organs on inspection were found in their normal position; the serum was clear, transparent, and of a light straw color. The peritoneum was found normal. The tongue was heavily coated with a whitish fur. The pharynx was found to contain somewhat more than the normal amount of mucus, but otherwise was in a normal condition. The oesophagus contained a small amount of food which had regurgitated from the stomach; it was unobstructed throughout. The stomach contained a small amount of partially digested milk; also one quinine tablet, which was undissolved. The antrum pylori was found to be somewhat indistinct and difficult to make out; the proximal constriction of the pyloric end did not appear to be present. The inside diameter of the pylorus was 1.2 cm. The inside diameter of the cardiac orifice was 2.5 cm. The small intestine was normal, and when water was put in it under pressure it took 20 pounds to rupture it; the interior upon opening was found to be in good condition. The large intestine was nearly free from feces, but much distended with gas. The appendix was 12.5 cm. in length. The rectum was normal. The liver was much enlarged, very dark in appearance, and deeply congested; weight of liver, 2,090 grams. The gall bladder and ducts were found patulous, the gall bladder being distended with normal bile. The pancreas was very friable, but otherwise normal; weight, 150 grams. The left kidney was slightly congested; weight, 175 grams. The right kidney was somewhat more congested, but otherwise normal; weight, 170 grams. The pelvis and ureters were patulous. The bladder was well distended with urine, but otherwise normal. The prostate gland was not enlarged; the urethra had no strictures. The right and left suprarenal capsules appeared much smaller than normal, and weighed 10 grams each. The spleen was much enlarged 10918-10 and extended to the costal margin; it was deeply congested; weight, 350 grams. Head and scalp were to all appearances normal, the skull being of about an average thickness. The membranes of the brain were normal. The brain was in good condition and weighed 1,450 grams. The spinal canal was not examined, because the body was nearly normal in every other respect and the cause of death was well established. There was no microscopic examination of any of the tissues. The cause of death seemed to be clear, especially in view of the clinical history of the case. Two days before his death, after being nearly exhausted from the effect of an untreated malaria, he walked to the hospital (at least 2 miles). The extra strain to which his heart was put caused the tears in the leaflet of the aortic valve. A partial acute dilatation followed. This, with his general exhaustion, was the cause of his speedy death. CASE 7. Mitral-Chronic pleurisy. F. I. A. B.; aged 23 years; nativity, Nova Scotia; was admitted to the United States Marine Hospital, Boston, Mass., March 18, 1898; died April 22, 1898, at 1 a. m. History.-When admitted to the hospital patient gave a history of a prolonged attack of rheumatism during the previous summer, and of a sickness he called "grippe" only two months since, and from which he had not yet recovered. Physical examination revealed a loud systolic mitral heart murmur. The apex beat was displaced downward and to the left of the nipple. Over the right lung was complete flatness, vocal fremitus and voice sounds absent. The only other symptoms obtainable were debility, dyspnoea on exertion, and some sore throat, with a temperature of 38° C., which, however, became normal in a few days and remained so. There was no development of any marked symptoms other than increasing weakness and more forcible and irregular heart action, with weak pulse, until the morning previous to his death, when they became very pronounced, and dyspnoea set in. A brief period of unconsciousness preceded death. Necropsy (ten hours after death).—General nourishment good; post-mortem lividity and rigor mortis slight; pupils dilated. The heart weighed 470 grams. Its pericardial sac contained 25 c. c. of fluid. The aortic, pulmonary, and tricuspid valves were competent. The mitral valve was incompetent and its cusps were shortened, thickened, and bound down by adhesions. The left ventricle was much hypertrophied. The left lung weighed 1,270 grams. It was deeply congested. At its apex was a small tubercular deposit; posteriorly there was some solidification, while at the base it was slightly oedematous. The pleural cavity was normal. The right lung weighed 600 grams. It was compressed and carnified, and on section was deep red in color, and showed complete solidification. It gave no crepitation whatever. The pleural cavity contained 1,076 c. c. of fluid, which deposited a thick white sediment on standing. The pleura was greatly thickened, and was covered with a thick deposit of fibrin, giving it a shaggy appearance. At the apex posteriorly were a few bands of adhesion. The gastro-intestinal tract was normal throughout. The liver weighed 2,020 grams. On section it presented evidence of slight passive congestion. The gall bladder was empty. The pancreas weighed 100 grams and was normal. The left kidney weighed 175 grams and was normal. The right kidney weighed 160 grams. At its upper extremity was a large urinary cyst containing about 3 c. c. of urine, and on its anterior surface there were several smaller ones. On section the medullary portion was seen to be slightly congested. The urinary bladder, urethra, and prostate were normal. The suprarenal bodies weighed each 35 grams, being unusually large. The spleen weighed 235 grams and was normal. The brain weighed 1,350 grams and was apparently normal. The membranes of the brain were much congested. F. W. U. H. W. W. CASE 8. Mitral (congenital diminution in caliber of the colon.) M. S.; aged 42 years; nativity, District of Columbia; was admitted to the United States Marine Hospital, Port Townsend, Wash., May 17, 1898; died June 1, 1898. History.-Upon admission to hospital the following history was elicited. He stated that he had never suffered from rheumatism, but had been very dissipated for the past twenty years, drinking a pint or quart of whisky almost every day, in fact all he could obtain. During the same period he had used tobacco excessively. His system had long resisted the abuse, and his health had been good until two years ago, when he first noticed some shortness of breath on exertion. Instead of now stopping his dissipated habits, he consumed even greater quantities of alcoholic beverages, and only ceased using them two weeks before his admission, when he became so ill that he was completely prostrated, and had to quit work and apply for treatment. When the patient came under observation he was suffering severely from cardiac asthma, the attacks of shortness of breath causing the sensation of impending dissolution. The paroxysms recurred several times during the day and usually lasted one or two hours. He did not suffer any pain except that incident to the feeling of suffocation. The pulse was quick and small. Upon examination the apex beat was seen markedly displaced downward and to the left; percussion showed considerable hypertrophy of the heart, especially the left ventricle, and auscultation revealed a loud, blowing murmur over the apex; this replaced the first sound of the heart and was transmitted to the left axilla. A diagnosis of insufficiency of the mitral valve was made. The physical signs over the other valves were negative. Examination of the lungs showed the presence of some oedema of the lower lobes, and the patient expectorated some frothy sputum containing small quantities of blood. His legs were much swollen. He was placed on full doses of digitalis, and under its use the pulse became slower, fuller, and less compressible, but the dyspnoea was not benefited. Small doses of morphine and atropine were administered when the paroxysms were especially severe, and a dose given hypodermatically always promptly relieved the attack and insured the patient several hours of sleep and comparative ease. In fact it was the only medication that seemed to be of much value for the distressing dyspnoea. The patient was kept at rest and cautioned about making any exertion. His condition remained about the same until the morning of June 1, when, disobeying instructions, he walked to the water closet, a distance of about 15 feet from his bed, and in doing so fell to the floor and expired in a few seconds. Necropsy (twelve hours after death).—External appearances: Body fairly well nourished, the lower extremities œdematous; rigor mortis marked, and postmortem lividity slight. Thoracic cavity: The pericardium was normal and contained only a small quantity of fluid. The heart was much enlarged, weighing 635 grams, and was distended with semicoagulated blood. The wall of the left ventricle was much hypertrophied, being 3 cm. thick; the cusps of the mitral valve were slightly diseased and the valve was incompetent. The aortic valves were normal, but the aorta showed numerous atheromatous deposits. The valves in the right side of the heart were normal and the wall of this ventricle was not much thickened. The left pleural cavity was practically obliterated by old adhesions, which, however, were more pronounced over the upper than the lower lobe of the lung on this side. The right pleura was normal. Both lungs were œdematous, but showed no other evidences of disease; the right weighed 785 grams and the left 650 grams. The larynx and trachea presented no evidences of disease. Abdominal cavity: The vermiform appendix was free and normal. The most interesting thing noted in connection with the examination of the viscera in this cavity was the remarkably small size of the colon, which only measured 2.5 cm. in diameter, the sigmoid flexure being only 2 cm. in breadth, while the hepatic and splenic flexures of this portion of the alimentary tract did not measure more than 3 cm. in width. The cœcum was of normal size, but the diminished caliber of the colon existed at its commencement and continued throughout the entire length. The rectum was one-third smaller than normal. Some adhesions existed between the spleen and splenic flexure of the colon, and also between the gut and the abdominal wall in this locality. These evidently produced no constriction of the intestine, and the patient suffered no inconvenience from the diminished caliber of the colon. This condition was no doubt congenital. The band-like arrangement of the longitudinal muscular fibers was maintained until about the middle of the descending portion, when this was lost and these fibers formed a continuous outer covering, this coat being quite thick in the sigmoid, where the muscular tissue had been largely replaced by fibrous tissue. The stomach and small intestines were normal, and the mucous membrane of the large intestine showed no pathological changes. The liver had undergone fatty degeneration, both the external and cut surfaces being quite yellow. There were also numerous minute depressions on the external surface and the lobules were quite well marked. The organ weighed 1,765 grams. The spleen weighed 135 grams and was normal. The pancreas weighed 65 grams and exhibited no pathological changes. The kidneys were somewhat larger than normal and showed several depressions on their outer surface, which on section were found to consist largely of connective tissue, as of an old cicatrix. The left kidney weighed 225 grams and the right 185 grams. The ureters, bladder, and urethra were normal. J. C. P. CASE 9. Mitral regurgitation-General dropsy. C. B.; aged 56 years; nativity, Sweden; was admitted to the United States Marine Hospital, port of San Francisco, Cal., February 14, 1898; died March 1, 1898. History.-Patient was treated in this hospital for mitral insufficiency, but was discharged at his own request January 28, 1898. At that time the heart had not fully compensated. He returned February 14, 1898. He was dyspnoic, his limbs were swollen, and his abdomen distended with fluid. Upon examination lungs were found to be normal. The heart dullness was increased to the left anterior axillary border. The apex beat was diffuse and upon auscultation a systolic murmur was heard at the apex. The patient was dyspnoic while at rest, his legs were swollen, and his abdomen was distended with fluid. Patient was put on milk diet with infusion of digitalis, and morning doses of epsom salts. The oedema increased. The scrotum was so swollen and painful that it was tapped and about a pint of fluid withdrawn. The patient died suddenly March 1, 1898, at 1.40 p. m. Necropsy (twenty-three hours after death).—The body is that of a well-developed and markedly cedematous adult, white, male; rigor mortis well marked. The lower extremities, abdomen, and scrotum are greatly swollen. The face and neck are cyanotic. A part of the glans penis is absent, the prepuce being adherent to the part remaining. Encephalon is normal; weight of brain, 1,450 grams. The pericardial sac contains 75 c. c. of serous fluid. Heart is greatly dilated. The aortic valves are normal. There is a marked thickening of the edges of the mitral valve. Weight of heart, 870 grams. The pleura at the base of the left lung shows a few adhesions, while on the right side the adhesions are general. The left pleura contains 250 c. c. of serous fluid. Both lungs are in a condition of hypostatic congestion. Weight of left, 680 grams; of right, 940 grams. The peritoneal cavity |