At necropsy, with the exception of the joints, little of interest was found outside the thoracic cavity. On the posterior and diaphragmatic surfaces of both lungs fibrous adhesions were present binding the visceral to the parietal pleura. The right lung was moderately voluminous and grey in color over the upper lobe, but had darker red areas over the surface of the lower lobes. Patches of increased consistency were found in the lower part of the upper lobe, in the middle lobe, and at the base. On section there was a slight, red, serous exudate. The surface over the more solid areas was somewhat translucent, grey or light red, and was firm and not friable. The bronchi of the lower lobes were conspicuous, and at the extreme base so dilated as to give almost a honeycombed appearance. From them yellow pus exuded. The left lung was less voluminous and showed some increase in consistency throughout. In the lower lobe this was more uniform, but the upper had a shotty feeling. On section the upper lobe showed many hard or caseous nodules, with occasional patches of grey, gelatinous pneumonia. One small cavity was present about 3 centimeters from the apex. The lower lobe showed no gross evidence of any tuberculous process. Many pseudotubercles projected from the red surface, but from each pus could be expressed exposing the slightly congested wall of a bronchiole. At the extreme base two small cavities filled with yellow pus were present (Fig. [L]).

Sections from the left upper lobe showed, microscopically, both a chronic and acute tuberculous process. Tubercles with a definite wall were present, but there were also large areas of caseation. The tissue between showed interstitial organization with mononuclear infiltration and occasional groups of leucocytes. The bronchial epithelium exhibited no marked change, but the bronchi were filled with pus cells.

Sections from the left lower lobe and from the right lung showed both necrotization and organization. The alveoli contained an exudate, fibrinous, serous, and hemorrhagic, but predominantly leucocytic. There was slight necrotization of alveolar walls in some areas with infiltration of leucocytes in them and in the interstitial tissue. Several sections showed a marked degree of interstitial organization (Fig. [XLVI]). The bronchi were filled with a purulent exudate which sometimes involved the walls to form a peribronchial abscess. The walls of other bronchi showed great thickening with infiltration of both mononuclear cells and leucocytes, and many saccular dilatations were found (Fig. [XII]).

The post-mortem blood culture showed a small, gram-negative, hemoglobinophilic bacillus (B. influenzæ). Cultures from lungs and bronchi yielded hemolytic streptococci, and Staphylococcus aureus was also present in the lung.

Summary.

Of the ninety-five cases included in this report, twelve showed the reparative process in a more or less marked degree. Furthermore, the twelve showing organization had an illness averaging twenty-seven days in duration, whereas for the eighty-three cases in which there was no organization, the period of illness averaged nine days. Thus, it appears that the early fatal termination of the disease in the latter group is responsible for the absence of organization.

With one exception, when organization was encountered, the disease had run a relatively acute course without marked remission until death. In this instance, the fatal outcome was the result of an accident at a time when all the clinical evidence pointed toward a subsidence of the acute disease. The history of this patient is abstracted below, for it may throw light upon possible relapse and upon late, chronic, respiratory changes.

Autopsy No. 163.

A white male, aged 35 years, was admitted to the New Haven Hospital on December 5, 1918, complaining of “cough, pain in the chest, and headache.” For six days he had had fever, chills, and severe frontal headache, and for three days pains in the chest. He had also had “coryza” and epistaxis. The family and past histories were unimportant.

The physical examination showed a well developed and well nourished male, who was slightly jaundiced and markedly prostrated. The conjunctivæ were injected. The heart, abdomen, extremities, and right lung were negative. In a small area outside the left nipple and extending into the axilla, tubular breathing and subcrepitant râles were heard, but no definite signs of consolidation were made out. The physical signs remained the same during the eight-day stay in the hospital. At entrance his temperature was 102.8°F. In twelve hours it fell to 100°F., then rose to 103°F., where it stayed for twenty-four hours, falling by lysis and remaining normal for the three last days. On his eighth day in the hospital, the patient suddenly collapsed and died within fifteen minutes.