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CASE 94.-Age, 19 years. F. W. Family history negative. Hygiene bad. No recent vaccination. First sick May 22, 1899; chill, fever, fast pulse, occipital headache, shooting pains down spine. Head slightly retracted on third or fourth day; reddish spots one-eighth to onequarter inch in diameter on neck, smooth and flat. Pupils dilated. Pulse increasing in rate and becoming irregular; head more retracted; semiconscious; general paralysis and death on 27th. M. C.

CASE 95.-Age, 18 months.

Father died nine months ago; cause unknown. Mother in good health. No history of tuberculosis. Child always in good health. Hygiene bad. Admitted to Children's Hospital May 25, 1899; sudden vomiting, abdominal pain, constipation, temperature 102.8, pulse 140, weak and small, respiration hurried. Small area of dullness lower border left scapula; numerous fine dry râles throughout both lungs with roughened breathing. Digestive, glandular, and integumentary systems negative. Sleep well, but cries as if in pain when moved. No pain on pressure over any part of spine. Head not retracted. Urine negative. May 27, sleeps a great deal; objects to being moved; no appetite; pulse weak and irregular; temperature 100° to 103.8°; 29th, much the same; 31st, about as before, with vacant stare, dilated and fixed pupils; temperature 102°, and chest clearing up; June 2, about the same, except is not sleeping well, cries out as if in pain. Slight retraction of head this morning; no pain along most of spine, but back of neck seems sensitive; temperature has come down. June 6, temperature normal or below, pulse 88 to 120, since May 31. Cross and irritable and cries a great deal, though sleeping and taking nourishment better. Sat up in chair. June 8 walks about, but is weak; eats well. June 9, 4 p. m., temperature 104.7, pulse and respiration irregular, latter as low as 12; irritable, screaming out, stupor. Urine negative. June 11, eyes fixed, opening, and staring; lies on back, hands clenched, feet drawn up slightly; muscles of neck rigid, head drawn slightly to right side; resists extension of leg and force extension produces tremor of head and body; temperature ranging from 99.2 to 104.2. No pain along spine on pressure. June 15 less drawing of head to one side, less stiffness of neck; temperature ranging lower; June 17 to 19, about the same; 21st, eyes open and staring, pupils dilated, head rigidly fixed, hands clenched, twitching of facial muscles and of arms and hands; urine involuntarily passed; 23d, same, except temperature subnormal, feet extended and toes flexed; 25th, vomited food; unconscious, moaning cry; CheyneStokes respiration; 29, evident pain if joints are moved, other conditions same; July 1, urine shows a few pus cells; 3d, pain on pressure over spine; slight convulsive seizure this a. m., a few seconds only; 5th, much the same, with increased muscular rigidity and twitching; 10 p. m., temperature, 104.5; almost clonic convulsions; midnight temperature 105.8, heart tumultuous, head much retracted, legs drawn up and respirations shallow and slowing up. July 6, 1 a. m., temperature 106.5°; 2 a. m., 107.29; 3 a. m., 109.2°, and temperature just before death at 4.30 a. m., 1109.

Autopsy (by Dr. William B. French, ten hours after death).-Body greatly emaciated. Rigor mortis moderate. Abdominal contents normal except slightly enlarged mesenteric glands, and ten or twelve drops of pus in pelvis of each kidney. Gross appearance of kidneys normal. Ureters and bladder normal. Heart normal. Hypostatic congestion of lungs over posterior surfaces; bloody fluid oozed out on section but vesicles contained air. Dura adherent to cranium on either side of great longitudinal fissure, and vessels of dura engorged. Vessels lying in sluci surrounded by slightly opaque fluid, especially on lateral and under surfaces of brain, not, however, so well marked as in several other autopsies. Pons, medulla, and structures forming base of brain covered with moderately thick layer of fibrinolymph extending into left lateral ventricle in small quantity; right ventricle free of iymph; choroid plexus congested and opaque. About ounces of turbid cerebrospinal fluid escaped on opening ventricles and from upper part of spinal canal. Gray matter of cortex and vessels on surface of ventricles injected. Outer surface of dura of cord covered with chocolate-colored exudate of fibrino-lymph entire length, but especially plentiful in upper dorsal portion. The diplococcus intracelInlaris found on blood serum tubes inoculated with cerebro-spinal fluid and in the sediment of a culture tube partly filled with the fluid.

CASE 96.-Age, 3 years.

F. C.

Mother in good health; father. Hygiene very bad. Vaccinated two months ago. First sick May 25, 1899; moderate temperature, pulse slightly hurried, abdominal pain, conscious. About the same on second and third days. On fourth or fifth day became comatose and remained so to end. Left side partly paralyzed; right side in constant motion; neck not rigid but back stiff; pupils normal. No eruption. Bowels and bladder emptied involuntarily. Convulsions beginning several hours before death on June 5.

CASE 97.-Age, about 52 years. F. W.

Family history unknown. Hygiene good. No recent vaccination. Has had gastric catarrh at intervals for a year. Nonspecific ulcer of ankle for two years or

more. First seen evening of May 28, 1899, for retention of urine; morning of 29th first evidence of cerebro-spinal trouble, chilly, temperature 101.2, pulse quick, intense headache, no vomiting, respiration 50, conscious, pupils dilated but reacted, both eyes looking to right, no photophobia. Head drawn back and to right side and neck rigid so that patient could be lifted by hand under occiput without flexing neck. Right arm and leg muscular tremor; general hyperæsthesia. Retention of urine necessitating catheter. Coma eight hours before death on morning of 30th. CASE 98.-Age, 5 months. F. C.

Mother in good health. Hygiene good. Never vaccinated. Had slight cough of unknown duration. Night of May 28, 1899, restless and wakeful. Admitted to Children's Hospital morning of 29th; rectal temperature 103.6, pulse 140, conscious; no herpes nor eruption of any kind. Rectal temperature very irregular, varying from 101° to 106 in four hours. Muscles of arms and legs rigid, spasms of fingers and toes; nystagmus, pupils irregular, reacted, convergent strabismus, no photophobia. Muscles of neck rigid; could tilt child by head without bending neck. General hyperesthesia. Some distension of abdomen. Unconscious twelve hours

before death, on June 1. Vomited once only, twenty-four hours before end.

Autopsy (by Dr. William B. French, June 3, forty-eight hours after death).-Abdominal and thoracic contents normal, except slight hypostatic congestion of lower lobes of lungs and slightly enlarged mesenteric glands. Superficial vessels of brain engorged. A possible deposit of lymph over base of brain and medulla. Chocolatecolored, dirty-looking lymph between dura of cord and pia. Slight effusion of cerebro-spinal fluid at base and in spinal canal. No fluid in lateral ventricles. Vessels of cord injected. Scrapings of exudate on cord failed to show diplococcus intracellularis.

CASE 99.-Age, 5 years. F. W.

Family history good. Hygienic conditions fair. First sick May 30, 1899; chill, fever, vomiting, severe headache; pulse very fast; unconsciousness; constant agitation, throwing arms and body about. Passed into coma six hours before death on June 2.

CASE 100.-Age, 45 years. M. C.

Family history unknown. Patient had been with army in Tampa and the South. Was sick two or three days before doctor was called on June 1, 1899; delirious, intense headache, vomited, pulse 80; head drawn back and muscles of neck rigid; could be tilted up in bed by occiput without flexing head. Difficulty in swallowing. Marked improvement on fifth day, and patient reading paper; at night became unconscious again and remained so until death on seventh day of sickness. CASE 101.-Age, 11 months. F. W.

Family history negative. Hygiene very good. No vaccination. Had been sick two days before doctor called on June 6, 1899; moderate temperature and pulse; slight vomiting, scant herpetic eruption over inner aspect of thighs. Pupils normal. Numerous spasmodic seizures occurred later, especially in upper extremities and in facial muscles. During seizures there was convergent strabismus. Unconsciousness after third day, lasting until death. Temperature varying from 101.5 to 103.5 and pulse following rise and fall of thermometer, until two days before the end when rectal temperature reached 108°, and remained about 107° for twenty-four hours in spite of cold packs; six hours before death fell to subnormal and then to 103.5° at death on June 15,

CASE 102.-Age, 11 months. M. C.

Dispensary patient, Children's Hospital. Mother living. Hygienic conditions bad; crowded alley house. First sick June 8, fever and vomiting; 9th, fever, but no vomiting; convulsive movements of arms and legs, feet extended and toes flexed. Pain on handling. On 10th unconscious, and died 12.15 a. m. of 11th.

Autopsy (by Dr. William B. French, fourteen hours after death).—Body fairly well nourished. Rigor mortis absent. Dura adherent to skull; had to dissect it off; opaque and thickened. On removal of dura the entire convexity of brain found to be covered with an unusually thick, decidedly greenish-yellow purulent lymph, extending forward over surfaces of frontal lobes and to bottom of great longitudinal fissure, passing well back to junction of brain and cerebellum. On the lateral surfaces of the parietal lobes the greenish color of the lymph faded to the ordinary yellow and became thinner. Base covered with fibrino-lymph, following down cord, as far as visible, through foramen magnum. A mass of greenish lymph one-quarter inch in diameter found lying free between pons and cerebellum, the latter also covered more or less with this same greenish lymph. Small quantity of reddish cerebrospinal fluid in ventricles and spinal canal. A dirty looking chocolate-colored exudate between dura and cord as far down as upper lumbar region. Vessels of surface of brain greatly engorged and choroid congested. Blood serum culture, fluid from lateral ventricle, shows fine specimens diplococcus intracellularis, some forming chains of four to six members. Whitish ring at surface of pig-foetus bouillon shows same organism in apparently pure culture, but proved to be mixed on carrying it

CASE 103.-Age, 6 months. F. C.

Mother living. Hygienic conditions bad. Doctor knows that about three months ago another child died of meningitis in same house and that this infant slept on the couch used by the one who died. First saw patient June 9, 1899. Temperature 104, pulse rapid, vomiting a good deal, slight rigidity of neck, pupils contracted, and seemed to have pain in head. Temperature remained high-104 to 105° during sickness, which lasted five days. Attendants said muscular twitchings occurred a while before death, June 14. CASE 104.-Age, 2 years. F. C. Family history unknown. Hygiene poor. Had just recovered from an attack of measles. Said to have been sick eight or ten days when doctor called on June 9, 1899, and found child with high temperature, fast pulse, in delirium, head drawn back and neck rigid, nystagmus, and blotchy eruption on chest half to three-quarters inch in diameter. Improved slightly for six or eight hours, and then relapsed to former condition and died June 10.

CASE 105.-Age, 77 years. F. W.

Family history unkown. Hygiene good. No recent vaccination. First sick June 20, 1899; slight chill, temperature 101, pulse quick, intense headache, no vomiting, pupils normal. Conscious during first three days, finally passing into complete coma. Muscular tremor, rigidity of neck, head drawn back and toward right side; general hyperesthesia at first, followed by anesthesia. Eruption on face and chest, purplish flat spots an eighth of an inch in diameter; no herpes. Pupils dilated toward last; intense photophobia; both eyes turned to right. Conditions gradually grew worse and death occurred June 27.

CASE 106.-Age, 46 years. W. M.

Family history good. Hygiene good. No recent vaccination. First sick July 7, 1899; chill at 1 a. m. At 11 a. m. temperature 104°, pulse 130, body pains intense, vomiting, conscious, pupils contracted. Temperature fell toward evening, but patient became more obtuse, which increased through night. July 8, 8 a. m., head drawn back, muscles of spine rigid, could tilt body by occiput without bending neck, pupils normal, divergent strabismus, unconscious and muttering, difficulty in swallowing. Reddish-brown spots quarter-inch in diameter on arms, chest, and abdomen; intense capillary congestion, producing purplish tinge of skin. Through night of 8th to 9th wholly unconscious, general muscular rigidity, strabismus increased, and pupils almost obliterated by dilalation. Cheyne-Stokes respiration morning of 9th, which continued until death, about 6 p. m.

CASE 107.-Age, 21 months. M. W.

Family history good. Hygiene good. Not vaccinated. Brought in from suburbs of city July 13, 1899, when doctor saw him; had been sick nine or ten days; child in convulsions, totally unconscious, head drawn back and neck sufficiently rigid to tilt patient in bed without flexing head on chest; temperature, 103; pulse, 145; pupils unequal, left dilated more than right; paralysis of right leg and apparently of both arms; unable to swallow; retention of urine; sensitive to pressure to right of lumbar spine. No eruption and no herpes. Convulsions practically continuous. Symptoms gradually increased, and child died in convulsions at 3 a. m. of 16th. Lumbar puncture; afternoon of 13th yielded a few drops of bloody serum, blood probably from tissues of back. Vomiting occurred before child was brought to town: not afterwards. Examination of cultures from fluid or blood serum, agar, pig-foetus bouillon, and bread agar failed to show diplococcus intracellularis. CASE 108.-Age, 19 months. F. W.

Mother well; father is of a nervous make-up and was at one time a drinker. Hygiene fair. Never vaccinated. Child had summer diarrhea a year ago; since then well. Had diarrheal trouble on July 1, 1899; better ou 4th, and then well. On 9th was constipated, temperature 1010, and was better early next day; at 11 a. m. of 10th had what parents described as sinking spell; seemed to become unconscious, blue about mouth, fingers, and toes, and was cold; later in day paralyzed on right side, arm, and leg; ptosis of left lid well marked; pupils equal and of normal size; difficulty in swallowing. On 11th pulso slow, 60 to 70, and intermittent; respiration irregular; semiconscious. 12th, pupils dilated, right larger than left, sluggish to light; complete unconsciousness; almost impossible to swallow; pulse 100, temperature 100.8; Cheyne-Stokes respiration; muscular rigidity of back and neck; could tilt child by occiput with very slight bending of neck. 13th and 14th, increase of pulse rate and respiration; spasmodic movements of left arm and leg, especially when disturbed; no vomiting at any time. 15th, stiffness of right arm and slight opisthotonos; other conditions about the same. 16th, spasmodic movements of left side and right arm; right pupil dilated to twice the size of left one. 17th, lies in stupor; several spasms during night; arms stiff at elbows, especially right, and ankles also stiff; feet extended; fingers flexed. 18th, child has been in partial tonic spasm since 11 p. m. of 17th; wrists flexed; spasms increasing in frequency; pulse difficult to find, temperature 103.8°; left pupil more widely dilated than right; spasms

relaxed by few whiffs of chloroform; feet and hands cold. 19th, stupor; muscles nearly relaxed, though fingers still flexed; temperature 1030, pulse perceptible at times only; at 1 p. m. parents reported that there was a spasmodic general contraction of muscles, with two distressing cries, and death.

CASE 109.-Age, 3 months. M. C.

Parents in good health. Hygiene fair. No vaccination. First saw patient July 13, 1899, at 11 a. m.; temperature 100.5, pulse quick and thready, vomiting, eyes congested, pupils dilated and unequal, right larger than left. Parents stated child had had general convulsions night before, calling doctor. Rigidity of muscles of neck; could tilt body in bed by fingers on occiput without flexing neck; pain on pressure over entire spine; rolling of head from side to side; conscious throughout. No eruption. Died 3.30 p. m. of 13th-same day.

CASE 110.-Age 9 years. M. C.

Family history good. Hygiene poor. Six years ago had a severe diphtheria, resulting in a mastoiditis, operation and partial relief; ear continuing to discharge at intervals since that time. On admission to Children's Hospital, July 17, 1899, very slight swelling over right mastoid; constipated; temperature 100.29, pulse 90; respiration 38, full and regular; severe pain in right ear. July 19, temperature slightly higher; ear paining; 21st, temperature 102.4°, pulse faster; cries out frequently with pain in ear; 22d to 25th, temperature 103.9°, pulse and respiration increased; vomited; pain extending about ear; 27th, about the same; 29th, temperature falling, pulse weak and irregular, respiration labored and insufficient; abdomen retracted; no pain on pressure over spine; no retraction of head nor stiffness of neck muscles; occasional spasmodic movements of feet and hands; 31st, temperature 104.1°, pulse feeble and irregular; restless night; pain in and about ear; August 2, the same; 3d, temperature, 4 p. m., 99.3°, pulse failing, eyes fixed and staring, gasping respirations; convulsive movements hands and feet. Died 7.30 p. m.

Autopsy (by Dr. P. C. Riley, resident physician Children's Hospital, eighteen hours after death).-Lungs, slight hypostatic congestion, and on left side a few pleural adhesions. Abdominal cavity negative. Brain engorged with blood; arteries of pia much distended. A large quantity of clear fluid in ventricles and at base; vessels and nerves surrounded with fibrino-purulent exudate extending laterally along base in a strip about 2 inches wide on either side of pons and medulla, both of which were covered with a tenacious fibrino-purulent lymph. Spinal canal filled with a dirty chocolate-colored purulent exudate which surrounded the cord and membranes and followed the vessels and nerve trunks on either side; vessels of cord engorged. Slides made from this material showed the diplococcus intracellularis.

APPENDIX E.

REPORT ON THE HOUSING OF THE LABORING CLASSES IN THE CITY OF WASHINGTON.

By GEORGE M. KOBER, M. D.

The question of housing the wage earners in cities is one of extreme interest to students of sociology and municipal hygiene, and before considering what has been accomplished in this city it will be of interest to refer briefly to the history of the movement which owes its beginning largely to the labors of members of the Civic Center and of the Woman's Anthropological Society.

The Civic Center committee on housing the people has for its field of work the investigation of the alley houses and slums in this city, with special reference to sanitary and sociological conditions and their effect upon the health and morals of the inhabitants. A preliminary investigation was made by the committee in 1895. In the following winter Mr. George A. Weber, secretary of the committee, prepared a schedule of inquries of which the following is a copy:

SCHEDULE NO. 1.-Housing of the people-Washington, D. C.

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13. Are the alley and yard connected with sewer?
14. Material with which yard and alley are paved,
15. Is there sewer connection with the house?
16. Are the drains in the house properly trapped?

; graded,

and drained

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and drained away from the

17. State whether house has any of the following accessions: Water-closets or box

privies (which),
How many?

How many?
Garbage receptacles,

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Running water,
Ash bins,

18. What is done with waste water, ashes, and garbage?

Bathrooms,

19. Are there any bad odors either within or about the house, and what appear to be the causes?

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