Autopsy (by Dr. William B. French, six and a half hours after death).-Body much emaciated. Rigor mortis slight. No eruption. Dura thickened and adherent to skull and its vessels engorged. Vessels in sulci turgid. Thick patches of fibrinolymph covering pons, medulla, and base of cerebellum, and extending along vessels on lateral surfaces of middle lobes halfway toward vertex. Cord covered with yellow lymph as far as visible through foramen magnum. Large quantity of slightly turbid cerebro-spinal fluid in subarachnoid space and in lateral ventricles, and small amount of lymph in latter; thick pus-like fluid in fourth ventricle. Not practicable to open spinal canal. Blood-serum culture from cerebro-spinal fluid, forty-eight hours in incubator, shows diplococcus intracellularis.

CASE 70.-Age, 13 years. F.W.

Family history negative. Hygiene good. Vaccinated three or four years ago. Taken slightly sick April 20, 1899, temperature 100. A typical pre-scarlatinal or measles sore throat and characteristic scarlet fever eruption, with history of boon companion then sick with scarlatina. Next day eruption gone, leaving a few petechial spots on inner side of arms and on chest. Throat symptoms increased, making a typical angina, coryza continuing. Temperature 102, pulse 100. Six p. m. of 21st violent vomiting, severe photophobia forbidding examination of pupils; intense headache, conscious; general convulsive movements; apisthotonos, great tenderness over spine. Died quietly two hours later. CASE 71.-Age, 5 years and 9 months. F. W. Family and personal history good. Hygiene poor. No recent vaccination. Sickness began on April 21, 1899, with vomiting; convulsions for two hours, at end of which time child appeared well and wanted to go to school. At end of twenty-four hours convulsions returned, with high temperature, opisthotonos well marked, which later became emprosthotonos. Elbows flexed at right angles, and wrist and fingers forcibly flexed; feet forcibly extended, and muscles of arms and legs rigid. Muscular tremor decided at times. No reflex to conjunctiva; slight convergent strabismus; pupils widely dilated; excessive lachrymal secretion apparently containing air. Slight frothing at month. During last twenty-four hours muscular spasms became general and patient was profoundly comatose. Pulse very rapid, 180 or more. No herpes, but scant purpuric eruption a while before death. Died April 23, at 3 a. m. The doctor has known family since childhood of parents, and excludes complications. A brother of the above case, 4 years old, was seized at same time as his sister, with even more severe symptoms; vomiting, higher temperature, and holding head in both hands as if in great pain; wild delirium, with four convulsions in twenty minutes, followed by slight general rigidity, remaining in this condition fourteen hours. He then dropped into a profound sleep, accompanied with a profuse sweat, lasting ten hours, and awakened apparently well, and is now, four days later, as well as ever except that parents think his mental state is not as good as it was. A sister of the above children, 2 years old, was attacked at 8 a. m. of April 23 with nausea, but not vomiting; moaning and screaming at intervals, and rubbing head apparently as if in pain, which lasted until 2 p. m., when she slept soundly, had profuse sweat and recovery by night. These last two cases had photophobia. There were no complicating diseases. CASE 72.-Age 14 years. M. C.

Family history good, and child's health heretofore good. Hygienic conditions very poor. Seen by doctor on April 24, 1899, and mother stated that child had been sick two weeks with hight emperature, vomiting, marked opisthotonos, eyes crossed; no convulsions. On April 24, doctor found temperature 102.2 and pulse 81, and next day normal temperature. Two herpetic patches well marked on inner surface of right thigh and about sacral region. Persistent opisthotonos; slight convergent strabismus; eyes congested and pupils irregular. Conscious at intervals. On May 13, patient is up and about and practically well. Mental condition good and special senses normal.

CASE 73.-Age, 45 years. M. C.

Family history unknown. Said to be a hard drinker. Hygiene poor. No recent vaccination. Doctor first saw patient April 25, 1899, on third day of disease. Temperature, 102.5; pulse good; pain in head and back. Next day much the same. On fifth day became delirious. Tenderness in cervical region on right side. Would get out of bed at times. Involuntary passage of urine on sixth day and partial paralysis of legs. Some improvement on seventh day, and sent to Washington Asyium Hospital at 3 p. m. Condition on admission: Temperature, 102; pulse, 96; respiration, 56; semiconscious and can be aroused, but is confused on attempting to speak. Muscular tremor of arms. Carpholagia. Photophobia; pupils contracted. No eruption. Tendon reflexes absent. Abdomen disturbed with gas. Muscles of back of neck stiff, so much so that patient can be raised to an angle of 45° by hand on occiput without bending head forward. Tenderness along spine on pressure doubtful, owing to patient's mental condition. Lumbar puncture yielded no tluid. Bled 8 or 9 ounces from right arm. On eighth day temperature had fallen to 99°,

with improvement in mental state, but by tenth day delirium became violent, and patient had to be strapped in bed. Muttered constantly. Muscular twitchings continued. On eleventh day temperature normal, patient quieter, and consciousness returning. Asked questions about straps on hands and feet for first time. Could recall events of three or four years ago, but no recollection of recent incidents. Slept well nights of eleventh and twelth, and mind became much clearer. Muscular twitchings diminished and freer movement of head and less pains. By fifteenth day all symptoms about gone, and patient convalesced steadily. By thirtieth day recovery was complete, except marked loss of weight, and full strength had not returned.

CASE 74.-Age, 3 years and 2 months. M. W.

Never vaccinated. Doctor saw child on May 2, fourth day of sickness, and found slight use of temperature and pulse, with headache. Improved for three or four days and then gradually lost until tenth day, when pulse was 180 or more, axillary temperature 105°, and coma and death on twelfth day. From sixth day occasional muscular tremors; no retraction of head. Pupils dilated on sixth and seventh day. Could swallow to within twenty-fours of death. Skin generally hot and dry, and hands and feet especially so to touch. Some general hyperesthesia. Died May 8. CASE 75.-Age, 7 months. M. W.

Family history good. Hygiene good. First sick April 29, 1899. Said to have had cold legs and arms, probably a chill. Vomiting, general convulsion, temperature 103.5. Conscious two days, then semiconscious. Pupils dilated, eyes rolled up. Slight eruption on left side, left breast, and calves of legs; purplish, flat, oneeighth to one-fourth inch in diameter. Pain on moving child, especially joints. Cry of meningitis. Last two days of sickness well marked opisthotonos; muscles of neck stiff and rigid. Convulsions nearly constant after third day. Bowels normal, urine scant. Died May 7.

CASE 76.-Age, 15 years. M. W.

Family history good. Hygiene fair. No recent vaccination. First sick morning of April 30, 1899, vomiting, chill, high temperature, fast pulse, and immediate delirium. In thirty-six hours temperature reached 1070, and remained high, with delirium, to end. Eruption on feet only. Pupils contracted. No opisthotonos, but muscular contractions general. Tremor on touching patient. Lumbar puncture yielded no fluid. Died at 2 p. m., May 2.

CASE 77.-Age, 56 years. F. C.

Family history unknown. Hygiene poor. First saw patient April 30, 1899. Unconscious vomiting, moderate temperature, slow pulse, dilated pupils, slow stertorous breathing. Said to have had muscular twitchings. Tremor of muscles. Died May 2. CASE 78.-Age, 6 years. F. W.

Father well. Mother has valvular heart lesion. Hygiene good. No recent vaccination. Child had a slight cervical adenitis, and occasional attacks of indigestion, otherwise well. Taken sick at 5 a. m. of April 30, 1899, with vomiting, fast pulse, and fever, vomiting lasting until 3 p. m.; then became violently delirious, throwing herself about in bed and screaming. Opisthotonos, with muscular spasms of feet and hands, especially in the latter. Pupils dilated and eyes rolled upward. Petechial spots on abdomen, and on chest and arms. Died twenty-six hours after beginning of attack.

CASE 79.-Age, 5 years. F. C.

Parents and one other child in good health. Hygiene very bad. Vaccinated two months ago. May 1, 1899, had chill, high temperature, unconsciousness, retraction of head and muscles of neck rigid. Head could not be flexed. Pulse 120. Pupils dilated. Muscular tremors marked. Photophobia decided. Remained unconscious for six hours and became rational on following day. Tenderness over upper dorsal spine. Herpes of lips, and well marked small areas of a purplish eruption, especially on legs. After the second day gradual improvement began and continued to complete recovery by June 4.

CASE 80.-Age, 24 years.

F. W.

Family history good. Hygiene good. Vaccinated in childhood. Arrived in city three or four days before May 1, 1899, when sickness began. Chills, temperature 104; pulse 110; violent occipital headache; slight retraction of head, which became excessive by third or fourth day. Could lift patient by occiput without bending neck, then spasm relaxed under morphia and bromides and patient became comatose for three days with temperature running about 105°, pulse and respiration constantly increasing. On fifth or sixth day purpuric eruption appeared, from onefourth to 1 inch in diameter and was general. On eighth day patient rational for few hours and recognized friends, then deeper coma than at first, lasting until death. A few herpetic spots on cheek. Muscular spasms of legs; general tremor at times. Hyperæsthesia in beginning. Pupils dilated, unequal, reacted to light. Photophobia. Urine diminished, but no albumin. Involuntary passage of urine and bowel contents toward last. Died May 15.

CASE 81.-Age, 10 years. M. C.

Was

Family history good. Hygiene very poor. Vaccinated one year ago. Patient rather delicate all of life and late in walking. Both tibia curved forward. not very bright mentally. Went to school in forenoon of May 5, 1899, well, apparently, and returned at noon with violent headache, abdominal pain, and vomiting. Teacher noticed unsteadiness of gait and of other muscles, at school. Became delirious by evening and remained so until death. Opisthotonos by second day, became extreme later. Tenderness over cervical spine and mild convulsive seizures. Blad der and bowels empty involuntarily. Pupils contracted and fixed; photophobia; eyes rolled upward. Constant talkative delirium. Temperature normal or below. Impossible to get pulse at wrist on account of muscular twitchings. Respirations hurried and weak. No eruption. Death 7 p. m. of May 8, after three and a half days of sickness.

Autopsy (by Dr. William B. French, sixteen hours after death).-Rigor mortis marked, Head large posteriorly. Both tibia curved 24 inches forward of a line between internal condyle and inner malleolus. Bruise on scalp on right side of frontal bone, but bone beneath scalp uninjured. Dura adherent to bone in places. Upper surface of cerebrum for 2 inches along either side of superior longitudinal fissure covered with a great quantity of yellowish fibrinio-lymph extending well anteriorly and following along vessels in sulci laterally. Fissure of Rolando filled with pus and lymph and over convolutions forming fissure. Sella Furcica filled with fibrinio-lymph. Right lateral ventricle contains a quantity of partly cloudy fluid, and vessels of ventricle bathed in lymph anteriorly. Right ventricle the same. Spinal canal opened for 2 inches in lower dorsal region showed dura covered with a dirty looking yellowish lymph. Syringe withdrew apparently pure pus from beneath dura. Cord very soft. Fluid from subarachnoid space, on blood serum showed a dozen small whitish separate colonies of staphylococcus aureus. Lymph from pons showed diplococcus intracellularis, as did also pus from cord.

CASE 82.-Age, 38 years. M. C.

History unknown. Hygienic conditions in locality from which patient came very poor. Admitted to Freedman's Hospital May 6, 1899, 3 p. m., unconscious and apparently in great pain. Said to have had chills on 4th and 5th; temperature 102.4°, pulse 80, on next day 101° to 98, and 90 to 60, respectively. Restless and moaning, and at times complained of intense headache. Urine passed involuntarily on 7th and subsequent day. Profuse perspiration during sickness. In stupor midnight of 7th and until death at 7.30 p.m. of 8th. No autopsy.

CASE 83.-Age, 6 years. F. W.

Family history good. Hygiene fair. Vaccinated four years ago, and again within two months. A healthy child always, except an attack of stomatitis two weeks before present sickness. Exposed to case 87, next door. On May 7, 1899, at night, was seized with high fever, vomiting, and occipital headache. Doctor called on 8th; pulse fast; slight fever; headache; seems prostrated. At night had increased temperature, delirium, vomiting, and more pain in head; 9th, pain extended to shoulders; hyperesthesia marked, especially over abdomen, which is hard and flat; restless and very irritable; photophobia; pupils dilated; some rigidity of neck; vomiting; on 10th, occipital pain; towards morning semi-coma, which continues; eyes sunken: stiffness of cervical spine; May 11, rational; complains of pain in left knee and right instep; head turned to left; epistaxis left side; May 12 to 21, gradual improvement. Is now, 21st, up and doing well, though very anæmic and much emaciated. CASE 81.-Age, 5 years. M. W.

Family history good. Hygiene fair. No recent vaccination. Had typhoid fever a year ago, with complete recovery. First sick, May 9, 1899; temperature 103.5°, fast pulse, vomiting, pronounced chill, headache lasting throughout illness except during last week. Temperature fell, together with pulse, to nearly normal after first few days. Delirium for several days from beginning of sickness, then rational. Herpes labialis, no eruption. At end of nine or ten days such extreme muscular irritability that convulsions were expected at any time, but did not occur. Twitching of facial muscles, head drawn back, neck muscles rigid and painful if moved. No opisthotonos. Convergent strabismus, normal pupils after third week. DeafDied quietly May 21.

ness.

CASE 85.-Age, 2 years. F. W.

Parents and one other child in good health. Annt died of tuberculosis. Hygiene excellent. Patient had bronchitis six or seven months ago, and is just convalescent from measles. Taken sick May 9, 1899, temperature 104, pulse 140, headache and vomiting, conscious. Improved for two or three days, and temperature fell to 99°, remaining at that point for two days, and then gradually rose to 102, but not above. At end of first week pupils nearly normal and reacted, convergent strabismus, photophobia, general muscular tremors, hyperesthesia lasting four days. End of second week, head retracted, almost touching spine, and marked opisthotonos, lasting two days and gradually relaxing. Legs and thighs flexed. Child occasionally rational

about end of third week and seemed better in other ways. June 3 or 4 evident paralysis of throat muscles, and death June 8.

CASE 86.-Age, 15 years. F. W.

Family history good. Hygienic conditions good. Vaccinated years ago. A death five doors away, six weeks prior to this attack, from cerebro-spinal meningitis; case 35. This child had been a constant companion of case 35 for several years, but did not call after 35 became ill. First sick May 11, 1899, complaining of general malaise, and doctor saw her on 13th and found temperature 102, pulse 98, restless, crying out as if in pain. No headache and no vomiting. Pain in back over sacrum; unable to raise either leg; tremor of left hand and arm. Hyperæsthesia of both legs and feet and dreaded to have them touched. On second day, May 14, petechial spots on both feet, especially well marked on great toe and inner malleolus. Condition unchanged for about a week, temperature ranging from 101.2° to 102°, and pulse about 110. Sighing respiration, pain in epigastric region, conscious. Ninth or tenth day, pain in cervical spine, purplish flat spots, half to 14 inches in diameter on both hands, lasting four days. Beginning of second week, rolling of head, partly unconscious, increasing to complete unconsciousness last thirty-six hours of life. Temperature, fourteen hours before the end, 104.6°, pulse 170 or more, respirations 40 to 60 and shallow. During this attack there were no stiffness of muscles of neck, no opisthotonos, no chill, no vomiting, no photophobia, and no double vision. As brain became involved use of legs returned. Died forenoon of May 26, eleven days after active symptoms began.

Autopsy (thirty-six hours after death, by Dr. William B. French).-Body much emaciated; rigor mortis well marked. Vessels of dura and on surface of brain engorged. The whole brain superficially and in its substance intensely congested, small vessels showing bright red. Very little if any lymph at base. An area of thick . fibrinio-lymph on upper surface of brain, extending along either side of longitudinal fissure for about 4 inches and 14 to 2 inches wide, rather more on left hemisphere than on right, and dipping down into fissure. Vessels on lateral surface of brain show slight deposit of lymph about them. Cerebellum free of lymph. Very little cerebro spinal fluid in ventricles or elsewhere. Slight lymph deposit about one of the larger vessels in right lateral ventricle. Diplococcus intracellularis found in colonies on blood serum and in pig foetus bouillon.

CASE 87.-Age, 21 months. M. W.

Family history good. Hygiene fair. Never vaccinated. Lives in adjoining house to case 83, a cousin, who was taken sick four days before this child. Had suppurative otitis with convulsions when 15 months old; is a nursing child, though artificially fed also. May 11, 1899, at 4.30 a. m., had convulsions, temperature 103, fast pulse, vomiting; was conscious; temperature remained high and convulsion repeated toward evening. On 12th, a rash resembling German measles appeared over entire body; 13th, temperature normal at 11 a. m.; at 4 p. m. another convulsion and temperature 103.5°; restless at night; on 14th, child better; 15th, restless; irregular fever; gums over lower canines lanced; 16th, temperature normal morning and evening; fretful; pronounced hyperesthesia; stiffness and tenderness of cervical spine; strabismus; head retracted; said to have had high fever during night; 17th, when child is lifted holds head in fixed position mentioned; twitchings of eyelids and facial muscles. May 18 and 19 about the same; 20th, improving; 21st, can move bead, looks brighter, and is better. By May 26 sufficiently recovered to be up and about; pallor and emaciation marked.

CASE 88.-Age, 33 years. M. W.

Mother in good health; father died of pneumonia ten years ago. Hygiene good. Vaccinated four years ago, but did not "take; was successfully vaccinated in childhood. No recent disease, and patient a magnificent specimen of physical development. Office call on doctor May 13, 1899, sore throat, congestion of pharynx but no deposit, pains in back and limbs, constipated, anorexia, general malaise. Continued at work, and while free of pain was much exhausted. On 18th had Vomiting, severe headache, and was unable to sleep. On morning of 19th doctor was called at 6 o'clock and found patient with intense frontal headache, somewhat delirious, temperature 102, pulse 80. At noon, improved and quite comfortable. Morning of 20th, bowels had moved freely in night from purgative; slept poorly and was restless. Conscious, but evidence of beginning mental hebetude and complained of confused mental state. Pain in cervical muscles; temperature 103, pulse 80°. Comatose condition increased during day, and by 5 p. m. patient could only be aroused with great difficulty, and then no rational answer could be obtained to questions. Face flushed; temperature 102, pulse 80. At noon of 21st, in profound coma, gradually increasing paralysis of left side, twitching of muscles of right side of face; temperature 101, pulse 84. Resistance made to extension of arms. Muscles of neck rigid; could tilt patient up in bed by occiput without flexing neck. No opisthotonos. Pupils normal in size, equal, and react. No apparent photophobia. Urin voided, involuntarily, and scant. Noon of 21st, lumbar puncture yielded 8

ounces of very slightly turbid fluid, containing flocculi of lymph and small oil globules. Died forty hours later, forenoon of 23d. Impossible to secure autopsy. Examination of lymph from fluid showed diplococcus intracellularis-fine speci

mens.

CASE 89.-Age, 15 months. F. W.

Mother in good health; father chronic syphilitic. Two older children well. Hygiene very bad. Patient had a bronchitis April 29, 1899, to May 9. On May 15, early in morning, child had one or two well marked convulsions; temperature 101°, pulse very rapid; conscious. Next day retraction of head, neck muscles rigid, and child could be tilted to an angie of 45 by hand on occiput without bending neck. Paralysis of right hand and leg, extreme general hyperesthesia; pupils dilated, equal, and reacted. Gradual improvement began two days later, and by June 3 child was practically well.

CASE 90.-Age, 49 years. F. C.

Twelve brothers and sisters living; four dead, one of tuberculosis. Admitted to Freedman's Hospital May 14, 1899. Said to have had, two weeks before entry, headache, extreme soreness nape of neck, abdominal pain. Injured back two months before admission. On 14th became unconscious and was brought to hospital. Evening of May 16 temperature 100, pulse 72; 4 p. m. of 17th temperature 104°, and a convulsion; after which it ranged from normal to 1019, and pulse 70 to 100. Generally unconscious. From 4 p. m. of 17th to 10.30 a. m. of 19th six convulsions occurred; some very severe, others milder. Conscious and able to talk at 1.30 p. m. of 19th, and delirium again on 20th. Slight convulsion 10.50 p. m. of 21st, and died 5.35 a. m. 22d. Catherterized throughout attack, and bowels moved involuntarily. No autopsy.

CASE 91.-Age, 7 years. F. W.

Family and personal history good. Hygiene fair. Vaccinated five months ago. May 16, 1899, temperature at 6 a. m. 104, which began to rise at midnight after going to bed apparently perfectly well. Pain in abdomen, ascending to right side of chest, and pain over cervical spine and in occiput. Vomiting at intervals. The following three days, irregular temperature; restless nights; epistaxis on 18th from left side; convergent strabismus; intermittent deafness; muscular spasms of right arm; hyperesthesia, and pain when touched or moved. On 20th, herpes labialis; pale; eyes sunken; very weak; short, coma-like sleep; moist, short cough; physical signs in chest normal; much emaciated; knees drawn up; at noon, pulse 120, temperature 101°. May 21. Last night very restless; cries disturbed neighbors; cephalic cry, especially if disturbed; spasms of right arm and left arm and leg; answers questions; mother thinks there is noticeable deafness; temperature normal during day; pulse 116 to 120; sleeps with lids half closed; restless; post cervical tenderness marked. May 22. Child has improved, and by 26th is convalescing nicely.

CASE 92.-Age, 24 years. M. W.

Parents in good health. Hygiene good. Vaccinated four years ago. First sick morning of May 16, 1899; pain in calf of leg, chill about noon, fainted, no vomiting until evening; fever; pain in arms on removing coat; severe occipital headache. Doctor called morning of 17th; temperature 101, pulse quick, vomiting had ceased, and patient felt more comfortable in spite of restless night. Continued to improve up to noon of 20th; sitting up in bed reading paper, and called for glass of water, and when it was handed to him bit at glass, vomited, and had slight convulsions, twitching of hands and face, unconscious for an hour or more; doctor called, found mental condition sluggish; replies to questions with difficulty, and seems dazed. Urine negative. This state rapidly passed off and by morning of 21st appeared as well as before seizure. Herpes labialis; profuse purpuric-like eruption about oneeighth to one-fourth inch in diameter, plentiful over surface, but especially about elbows and ankles. Some spots seem tender on pressure. Hæmorrhagic condition of gums and nose. Tenderness over cervical spine; no retraction of head. Photophobia during first two days. May 23 temperature and pulse normal, patient perfectly rational and comfortable.

CASE 93.-Age, 13 years.

M. C.

Family history unknown. Hygiene very poor. Vaccinated three months ago. First sick May 17, 1899, with vomiting, pain in occipital region and delirium for two days. Also pain on pressure over spine. Retraction of head and opisthotonos. In five days was much better and in ten days could walk about room. On May 29 had nose bleed, headache, tenderness on pressure back of neck, drowsy, photophobia with normal pupils and conjunctiva injected. Muscles of neck rigid, sufficiently so to tilt child in bed without flexing head. Temperature for several days about 103, then irregular and finally normal, with gradual improvement in symptoms and recovery by July 1. On the thirteenth day of this child's sickness, case 63 died in the same room. The exposure of case 93 had been constant and intimate, occupying the same lounge or bed indifferently.