CASE 14.

Fatty degeneration of kidneys and liver.

J. M. (colored); aged 21 years; nativity, Indiana; admitted to the United States Marine Hospital, Cairo, Ill., March 15, 1898; died March 19, 1898.

History.-Was ill a week before coming to the hospital with diarrhoea and cough. He complained of pain in the left side and has marked dyspnoea. There is a large quantity of frothy sputum, tinged with blood. This, under the microscope does not show the pneumococcus. Physical examination: The lungs give a dull percussion note over their upper portion; more marked in small areas. The left lung on auscultation gives bronchial breath sounds and moist rales. The same signs present on the right side to a less degree. Posteriorly: Dullness especially noted at the apices.

March 17.—Much better to-day; breathing easier; sputum less in quantity. March 18.-Dyspnoea returned; character of sputum the same as on day of admission. The urine contains albumen.

March 19.-Death occurred at 1 p. m.

Necropsy (twenty-one hours after death).—State of nutrition fair. Rigor mortis present. Brain: Weight, 1,375 grams; dura mater thickened and opaque, especially over anterior convolutions and superior longitudinal sinus. This sinus contained a fibrinous clot throughout its entire length. The veins on the surface of the brain were distended with dark-colored blood. Vessels of pia mater very much injected over the entire surface. The lateral sinuses contained dark-colored blood. Lungs: The pleura was covered at some points with yellowish fibrin. There were slight adhesions on both sides between the lung and the diaphragm, the adhesions being easily torn. The edges of the lungs show emphysema. The left lung in its upper portion is consolidated, but rather nodular to the feel. The upper portion of the right is also firm to pressure, but less so than the left. The summits of the apices show healed tubercucar cicatrices. The cut surface of left lung is red in color and sinks in water. Portions of the lower lobe are in a similar condition, but show an earlier stage of the pneumonic process. There is an escape of dark fluid blood from the cut surface upon pressure. In the visceral pleura there were many pin-head spots of a whitish color, apparently tubercular. Right lung: Upper lobe shows pneumonic consolidation; cut suface light colored, exuding serum on pressure: no pus in smaller bronchial tubes of this side; lower lobe crepitates on pressure and shows very little congestion; large bronchial tubes show inflamed mucous surface covered with purulent secretion. Weight of lungs: Right, 750 grams; left, 875 grams. Heart: The vessels on the surface were distended; the right ventricle contained firm fibrinous clots; valves of heart competent: muscular tissue firm; weight of heart, 655 grams. Abdomen: The omentum contained very little fat. Spleen: Weight, 120 grams; surface shriveled; shape, long and narrow; color (cut surface), light red; very little blood. Kidneys: Capsules adherent; surfaces show numerous lines of contraction; almost complete fatty degeneration of cortical portions; the cortical columns of fat extend between the pyramids toward the central portion of the organ; weight, 165 grams each. Liver: Weight, 2,060 grams. The surface presented yellowish patches, corresponding in size to numerous spots shown on cut surface, due to fatty infiltration. The color of the cut surface was light brown. The bladder, genital organs, stomach, intestines, pancreas, and great vessels were of normal appearance.

P. C. K.

CASE 15.

Valvular disease of heart-Mitral regurgitation.

W. E. J.; aged 31 years; nativity, New Jersey; was admitted to the United States Marine Hospital, port of San Francisco, Cal., March 23, 1898, and died April 2, 1898.

History.-Patient was deaf and dumb. He had been ill about three weeks. Had had a cold, which settled on his chest. Physical examination showed that chest was well shaped. Movements were increased on left side; vocal fremitus increased on right side posteriorly. Percussion showed dullness of the middle and lower lobes of the right lung posteriorly. Upon auscultation bronchial breathing was heard over the areas of dullness; moist and sonorous bronchial rales were also present. Heart area was increased downward and to the left; mitral murmur was heard at the apex. Liver and spleen were normal. The abdomen was distended with gas and tenderness was felt upon pressure. The patient refused all medicine; occasionally he could be induced to take some whisky. He gradually grew weaker and died at 7.20 p. m. April 2, 1898.

Necropsy (fifteen hours after death).—The body is that of a well-developed, though slightly emaciated, adult white male. Rigor mortis well marked. Encephalon normal. Weight of brain, 1,410 grams. The pericardium is normal. Heart is hypertrophied; edges of mitral valve are thickened and atheromatous; weight of heart, 740 grams. Both pleural cavities are normal. The right lung upon section shows hypostatic congestion of the lower lobe with area of consolidation not completely cleared in the remaining lobes; weight, 1,170 grams. Left lung upon section shows lower lobe to be in a condition of hypostatic congestion; weight, 800 grams. The peritoneal cavity is normal. Spleen normal; weight, 170 grams. The right kidney is very much contracted; cortex thinned; capsule adherent, and the central pyramids are absent; weight, 80 grams. The same conditions obtain in the left kidney; weight, 80 grams. The remainder of the genito-urinary organs are normal. Liver normal; weight, 2,100 grams. The rest of the gastro-intestinal tract is normal. The spinal cord was not examined. R. R. H.

J. M. G.

CASE 16.

Pericarditis suppurative.

M. L.; aged 34 years; nativity, Norway; was admitted to the United States Marine Hospital, port of San Francisco, Cal., December 31, 1897, and died January 2, 1898.

History.-Patient, while on a prolonged alcoholic debauch, was taken ill Sunday, December 26, 1897. He had a severe chill, followed by fever, with pain in the right side, especially aggravated by coughing. He, however, refused to accept medical relief until brought to the hospital by his friends, who were alarmed at his condition. Physical examination: Upon percussing, dullness was found on both sides of chest, except over upper lobe of right lung. Heart area normal. On auscultation, subcrepitant and moist rales were heard. The heart sounds were apparently normal. Pulse weak and rapid. Sputum tenacious and scanty. In spite of vigorous supportive and stimulating treatment the patient rapidly grew worse and died at 9.10 p. m. January 2. Apparently death was due to failure of respiration, as the pulse remained in fair condition up to a short time before death.

Necropsy (fourteen hours and a half after death).-The body is that of a welldeveloped, well-nourished adult white male. Rigor mortis well marked. Enceph

alon normal. Weight of brain, 1,450 grams. The pericardial sac contains 150 c.c.of creamy pus. The visceral and parietal layers of the pericardium are thickened and infiltrated with fibrin, serum, and pus. Heart is normal; weight, 380 grams. The pleura at base of left lung shows a few adhesions. Elsewhere the parietal and visceral layers of both pleuræ are covered with fibrin, serum, and pus. The left lung upon section shows the lower lobe to be in a condition of red hepatization; upper lobe partly gray and partly red hepatization; weight, 780 grams. The right lung upon section shows lower lobe to be in a state of red hepatization, while the middle and upper lobes are slightly congested; weight, 460 grams. The peritoneal cavity is normal. The spleen is soft and spongy; weight, 250 grams. Kidneys normal; weight, right, 170 grams; left, 180 grams. The remainder of the genito-urinary organs are normal, with the exception of a wellmarked stricture in the spongy portion of the urethra. The liver is normal; weight, 2,300 grams. The intestines are distended with gas. The remainder of the gastro-intestinal tract is normal.

R. R. H.

H. S. M.
J. M. G.

Microscopical report.-Sections made from the consolidated lung show that the air spaces and smaller bronchii are filled with an exudate, which shows signs of degeneration and softening. The white blood cells are granular and do not stain well; no red blood cells may be seen; the pus cells are broken down; joining with the fibrin present, they form conglomerated granular masses which have shrunken away from the walls of the containing air spaces and do not completely fill them. The changes in the walls of the air spaces are slight, and consist only in a swelling of the epithelial cells remaining in situ, alternating with smaller areas where the cells have disappeared. The dilatation of the smaller blood vessels is not marked. The condition of the lung is that, therefore, of gray hepatization, confirming the diagnosis of acute lobar pneumonia.

BRONCHO-PNEUMONIA.

CASE 1.

With abscess and gangrene of the lung.

F. M. C.; aged 19 years; nativity, Maine; admitted to the United States Marine Hospital, Boston, Mass., April 20, 1898; died May 29, 1898.

History.-Two days before admission fell overboard between a log and the dock and, being unable to swim, was nearly drowned. He got much water in his lungs and was revived by artificial respiration. Up to the time of admission he had expectorated clots of blood, and at that time there was tenderness over the ensiform cartilage, and slight jaundice. His bowels were costive throughout. His temperature ran an irregular course, from normal to 39.8°, but with a regular evening rise and morning remission. May 2 a pleuritic friction sound developed on the right side, and a week later on the left also. Friction disappeared from the right side May 7. The other physical signs were those of broncho-pneumonia. The expectoration, at first scanty and blood-streaked, later became purulent, and ten days before his death began to be offensive. From time to time he had coughing spells, which steadily grew more distressing, frequent, and prolonged, the expectoration becoming more and more putrid. It finally became so offensive that he was removed from the ward with the other patients. May 25 he coughed up 300 c. c. of pus, and seemed relieved, his evening temperature going down to normal the next three days. On the 28th another coughing spell brought up 1,000 c. c. of brown, foul pus, but there was extreme

dyspnoea. Passed a very restless night, coughing incessantly and breathing with great difficulty, and on morning of 29th collapsed, but was revived. During this day he coughed up about 500 c. c. of pus of the same character, and dyspnoea increased. Died suddenly at 6.35 p. m. from asphyxia. Appetite good throughout. Necropsy (twenty hours after death).-Post-mortem lividity and rigor mortis marked; general nourishment good. Heart weighed 280 grams; valves competent and presented no lesion; walls normal; right side engorged with black clot; left ventricle contained a firm pink clot, which extended into the ascending aorta; pericardium contained considerable effusion. Nares full of thin, pus-like fluid. Left lung weighed 1,370 grams; upper lobe on section in state of gray hepatization; bronchioles exuded a frothy mucus; lower lobe in a condition of red hepatization, and covered with a tough exudate; adhesions numerous in upper left pleural sack, and some present in lower portion. Right lung weighed 800 grams; upper lobe normal, but bound by a few firm adhesions; the entire middle and lower lobes honeycombed by an abscess, and, for the most part, in a gangrenous condition; large opening from the lung into the pleural sack, the sack containing 1,500 c. c. of vile-smelling, chocolate-colored pus. Stomach normal, containing a little partially digested milk. Intestines empty, slightly congested, and distended with gas; some feces in the sigmoid flexure. Liver weighed 4,000 grams, and was passively engorged. Pancreas weighed 165 grams. Left kidney weighed 250 grams; was composed of three lobes, and slightly congested, capsule stripping off readily. Right kidney weighed 250 grams, slightly congested, capsule stripping off readily. Bladder normal, containing a few grams of urine. Spleen weighed 440 grams, and was congested. Brain, 1,558 grams. and slightly congested.

CASE
Measles.

H. W. W.

J. H. H.; aged 18 years; nativity, Tennessee; was admitted to the United States Marine Hospital, San Francisco, Cal., June 25, and died June 29, 1898. History.-Patient was transferred from the general field hospital, United States Army, at the camp near this hospital, and was a recent arrival from his home. He was admitted to the general field hospital on June 18, 1898, with the then prevailing epidemic of measles. Rash broke out June 24, 1898. Bronchitis appeared early and gradually grew worse. On admission here both sides moved equally on respiration. Crepitant râles heard all over the chest. Pulse 100, weak; respiration, 36, superficial; temperature, 40° C. Patient grew steadily worse in spite of all treatment-quinine, expectorants, stimulants, diaphoretics, diuretics, inhalations of oxygen, and hot baths. Patient died during a coughing spell. The temperature the evening of his death was 38.2 C.; pulse, 70; respiration, 50. The mitral tones were clear, but the others were either drowned by the râles or were so weak that they could not be heard clearly.

Necropsy (five hours after death).-Body that of a well-developed and wellnourished young, white, adult male. The skin of face and neck show large livid blotches, with similar patches of small size scattered over the body, and very large patches on back, evidently measles. Small quantity of frothy mucus found in mouth. Lungs presented a mottled appearance, the colors being blue, gray, and red. Lungs distended. Pericardial sac contained about 45 c. c. of clear straw-colored fluid (serous). Pericardium normal in appearance. Heart normal. Coronary veins filled more in the left heart than in the right heart. Consistence of muscle of left heart slightly harder than normal. Right heart soft and fatty. Color pale red. Heart contracted. Amount of fat in the subpericardial tissue is considerable along the auriculo-ventricular border and the base, slight in interventricular groove. Right heart contained some dark gelatinous blood clots;

also a fibrinous clot extending on one side into the ventricle and on the other into the superior vena-cava for about 15 cm. Small pieces of fibrinous clots were picked out from between the columnæ carneæ. Left heart contained a very dark clot, and also a fibrinous clot extending into the pulmonary vein. Left ventricle contained a very small quantity of dark, clotted blood. A small fibrinous clot 4 cm. long extended into the aorta. The wall of left heart was normal in color and firmly contracted. The wall of the right ventricle was thin and composed mostly of fat. The valves of the heart were all normal. A fibrinous clot was incarcerated between the edges of the mitral valves. When the bronchus was cut a free flow of sero-sanguineous fluid containing pus occurred. Weight, right lung, 927 grams; weight of left lung, 785 grams. On palpitation, the right lung is found to be firm; the superior lobe has an area about 5 mm. in diameter, which is especially firm. On section, the lung appears to be grayish throughout, except in some small places, where it is reddish. Thin, frothy, purulent fluid runs over the cut surface as soon as section is made. There are many points where pus is seen very distinctly collected in areas of 2 mm. in diameter. Both lungs are in about the same condition.

No further examination made.

CASE 3.

T. B. P. J. M. G.

C. K. G.; aged 19 years; nativity, Michigan; was admitted to the United States Marine Hospital, port of San Francisco, Cal., June 23, 1898, and died June 24, 1898. History.-Patient was one of the United States volunteer soldiers then recently massed at this point, and was admitted to the camp (army) hospital June 14, 1898, suffering with the prevailing epidemic of measles. Broncho-pneumonia supervened June 21, 1898, in the evening. On admission patient was extremely cyanotic. Temperature, 39° C.; pulse, 112, weak; respiration, 52, superficial. Patient raises a thick, tenacious mucus. Bronchial breathing very marked over bases of both lungs. A supportive and revulsive treatment of strychnine and digitalis hypodermatically; mustard paste externally; and spirit minde revi, quinine, and whisky was begun, but without appreciable effect except to relieve the distress of the patient. At 9 p. m. respiration was 57 and pulse 122 to the minute. The dyspnoea became more marked until toward morning, when a period of calm ensued, terminating in death at 5.45 a. m., within twelve hours of his reception. Necropsy (eight hours after death).-Body that of a muscular, well-nourished young white man. Rigor mortis marked. Pericardium contains 32 c. c. serous fluid. Heart greatly distended and filled with well-organized blood clots extending into the pulmonary arteries and representing casts of them and of the interspaces of the columnæ carneæ. Valves normal; weight, 340 grams. Pleural cavities dry. Lungs: Right slightly adherent to diaphragm; weight, 770 grams; engorged. On section filled with red blood and small pus foci. Bronchi coated with thick viscid material, and mucous membrane deep red. Left lung, weight 660 grams, and resembling right lung. No further examination was permitted. T. B. P. J. M. G.

ACUTE GASTRITIS. CEREBRAL MENINGITIS.

H. R.; aged 49 years; native of Germany; was admitted to the United States Marine Hospital, Baltimore, Md., February 12, 1898; died February 17, 1898.

History.-Health has always been good until this illness; began drinking heavily February 10, and spree lasted for two days and nights. On admission he had symptoms of acute gastritis; temperature 38.2 C.; complained of severe headache,