The valve is not competent (it does not hold water). The chorda tendineæ are thick and the musculi papillares hypertrophied. The other valves are slightly sclerotic, but appear to be competent. The pleura of the right lung is adherent to the chest wall. Each lung weighs 750 grams, and is otherwise normal. The abdominal cavity contains 200 c. c. of serous fluid. Position of organs normal. The intestines are seen to be considerably congested. The liver weighs 1,400 grams. It is dark brown in color and of normal appearance and consistence. The spleen weighs 225 grams and is, to all appearance, normal. The right kidney weighs 175 grams, the left 150. The kidney tissue is, microscopically, normal. The brain weighs 1,400 grams. It is very anæmic. No hemorrhages or any other lesion can be seen externally or on section.

R. C. C.
G. W. S.

CASE 14.
Mitral.

I. B. aged 42 years; nativity, Mississippi; admitted to United States Marine Hospital, Evansville, Ind., February 7, 1898; died February 25, 1898, at 1.25 p. m. History.-On admission complained of shortness of breath and swelling of ankles and feet. Lungs normal; examination of heart disclosed murmus with greatest intensity in mitral area and systolic in time. He continued about the same. Feet and ankles would be larger one day and smaller the next. He died suddenly at 1.25 p. m., February 25, 1898.

Necropsy (twenty and one-half hours after death).—Rigor mortis marked. General anasarca. Body well nourished. Brain appeared to be little softer than usual. Falciform process ossified; otherwise normal; meninges normal. Heart: Hypertrophied; weight, 640 grams. Ante-mortem clots in heart. Pulmonary valves normal. Tricuspid valves thickened along edges and contained calcareous deposits. Aortic valves somewhat thickened. Mitral valves thickened and stiff with calcareous deposits and were incompetent. Aorta dilated and covered with calcareous deposits. Pericardium contained about 100 c. c. fluid, clear and straw colored. Right lung normal; some engorgement; weight, 595 grams. Left lung normal; some engorgement; weight, 590 grams. Some adhesions of pleura on left side. Clear fluid in abdominal cavity. Liver normal; weight, 1,570 grams. Spleen normal; weight, 240 grams. Right kidney enlarged; weight, 205 grams; large and white. Left kidney enlarged; weight, 229 grams; large and white. Stomach, intestines, bladder, and genitals normal.

CASE 15.

Aortic and mitral.

J. H. O.

F. M.; aged 32 years; nativity, New York; admitted to United States Marine Hospital, Cleveland, Ohio, January 18, 1898; died February 27, 1898.

History.-Family history negative. Patient had gonorrhoea several times and syphilis eight years ago. Present attack began three weeks ago with pains in the back and legs and eruption with swelling on the latter. For the past four days he has had pain in the abdomen, most severe over the right iliac region, slight cough, scanty expectoration, appetite fair, bowels regular, no history of rheumatism. Petechiæ are present on both legs and thighs, particularly on the inner surfaces. No enlargement of the joints and no periosteal nodes. Spleen enlarged and tender on pressure. Liver dullness not increased; tenderness at costal margin. Presystolic and systolic murmur, the former best heard at base, the latter transmitted to axilla. Pulmonic seemed sound, accentuated with a sharp ringing tone at closure. Pulse 78, rythmic, regular, and of fair volume. No dyspnoea. Respiratory system negative. Urine, specific gravity 1.017; gives diazo reaction.

January 23, 1898.-He has a rise of temperature each evening of 1° C. or over, and it falls to normal, or one-fifth degree C. above, each morning. Still complains of colicky pains in abdomen.

February 17, 1898.-Patient in about the same condition, temperature higher, and he has had diarrhea for the last two days. Urine still gives the diazo reaction. February 18, 1898.—Discharge of foul-smelling pus from the right ear this morning. He is failing rapidly.

February 27, 1898.-Died at 3.05 p. m. Axillary temperature at death, 41.2° C. Necropsy (twenty-four hours post mortem).-Body emaciated; rigor mortis and post-mortem staining present. Discharge of offensive pus from right ear. Scalp of moderate thickness and aponeurosis normal. Sinuses engorged; dura adherent along vertex; general leptomeningitis most marked on convexity, with effusion of lymph over sulci. Cortex congested, puncta vasculosa numerous; lateral ventricles contain much serum; choroid plexuses swollen and studded with soft granular bodies like tubercle. Glistening points of the same material are seen over and along the blood vessels in the fissum sylvii and along inferior surface of the pons varolii. Third and fourth ventricles normal. Cerebellum softened and shrunken. Motor and sensory ganglia present nothing abnormal. Pus found in the middle ear on right side, with perforation of membrano tympani. Spinal cord not examined. Chest: Pericardium normal. Considerable fluid in sac. Heart large and venous system engorged; chicken-fat clots in both ventricles, and walls fatty. Mitral valve contracted; admits two fingers; leaflets of valves thickened and on margins are numerous vegetations soft and floating free in the blood stream. Left auricle dilated. Semilunar valves of aorta covered with soft fringe-like vegetations, which diminish the caliber of the opening so that it barely admits the tip of the index finger, and one clump of vegetations, oval in shape, almost closes the opening like a ball valve. Wall of ascending aorta thickened and atheromatous. Tricuspid and pulmonary valves free from vegetations. Lungs show hypostatic congestion, contain extensive deposits of carbon, but are otherwise normal. Tubercle bacilli were found in the sputum from this man's spit cup, but the mixture must have been accidental, as the lungs showed no evidence of it. No pleural adhesions found. Abdomen: Liver very large, and superior surface of the right lobe presents a globular enlargement the size of a small apple, which on section presents nothing special except the nutmeg appearance seen throughout the organ. Gall bladder empty, contains no calculi, and is very pale in color. Pancreas normal. Mucus membrane of the stomach congested at cardiac orifice. Small intestines normal, no enlargement of Peyer's patches. Large bowel shows congestion of mucus membrane in the cœcum, and several points of superficial ulceration are noted on the posterior wall. Appendix vermiformis normal. Mesenteric glands slightly enlarged. Spleen large, oval in shape, and marked by numerous lobules, firm throughout, except inferior border, which is softened. Suprarenal capsules and kidneys large. Capsules of kidney nonadherent, cortical substance large in both organs and granular on fracture. Ureters, bladder, and generative organs normal. Microscopic examination of sections of his tissues shows cloudy swelling in the liver and kidneys.

D. A. C.

CASE 16.

Mitral and aortic.-Pericarditis.

A. R.; aged 26 years; nativity, Virginia; admitted to United States Marine Hospital, Memphis, Tenn., March 22, 1898; died May 7, 1898.

History.-Has suffered from periodical attacks of acute rheumatism for past five years or more; has no signs of syphilis and denies infection; was treated in this hospital during January for valvular lesion. On admission patient was very

CASE 19.

Aortic and mitral regurgitation-Bright's disease.

M. A.; aged 31 years: nativity, Cape de Verde Islands: was admitted to the United States Marine Hospital, port of San Francisco, Cal., November 11, 1896, and died December 13, 1897, at 10.10 a. m.

History.-When admitted he complained of having suffered for over a month with pain in his chest, shortness of breath upon exertion; also had a dry cough. Physical examination showed patient to be a well-developed, well-nourished negro, male. On percussion lungs were normal, heart slightly enlarged, liver and spleen normal. Auscultation: Lungs were normal; heart regurgitant; murmurs were heard over the aortic and mitral areas. Under treatment the patient improved for a time, but later compensation failed, followed by general oedema. Paracentesis of the abdomen was performed several times. Finally the heart gradually failed, and the man died at 10 minutes past 10 on the morning of the 13th of December.

Necropsy (four and one-half hours after death).-The body is that of a welldeveloped, well-nourished adult negro, male. Rigor mortis is not well marked. General oedema is very pronounced. The skullcap, brain case, the sinuses and vessels, and the brain are normal. The pia mater over the vertex shows evidences of chronic exudative meningitis. Weight of brain is 1,180 grams. The pericardial sack contains 400 c. c. of a straw-colored fluid; otherwise normal. The heart is hypertrophied generally. The leaflets of the aortic valve are thickened, contracted, and covered with calcareous deposits. The leaflets of the mitral valve are distorted, shrunken, and covered with calcareous deposits. Both valves are incompetent. The walls of the aorta for a distance of 4 centimeters from its origin were thickened and calcareous. Weight of the heart is 620 grams. The parietal and visceral layers of the pleura on the right side show a few adhesions over the base. The same condition is present on the left side. The right lung, upon section, shows evidences of passive congestion; weight, 800 grams. The left lung also shows evidences of passive congestion; weight, 470 grams. The bronchial glands are enlarged. The peritoneal cavity contains 4,000 c. c. of ambercolored fluid. The spleen is normal; weight, 180 grams. The left kidney is congested, calices dilated, and one or two have undergone amyloid degeneration; weight, 190 grams. The right kidney shows the calices to be dilated; weight, 180 grams. The remainder of the genito-urinary organs are normal. The liver is smaller and paler than normal; weight, 550 grams. The walls of the gall bladder are thickened. The remainder of the organs of the digestive tract are normal.

Aortic and mitral-Bright's disease, granular kidney.

M. B.; aged 66 years; nativity, Ireland; admitted to the United States Marine Hospital, Boston, Mass., March 7, 1898; died April 29, 1898, at 5.45 p. m.

History.-When admitted to the hospital patient stated that he had been a free drinker all his life. For some time past he had been failing in strength and suffered with dyspnoea. For three weeks his lower limbs had been swollen, and there had been some suppression of urine. Inspection showed that his lower extremities were very oedematous, pitting deeply on pressure. Physical examination of the heart revealed a murmur at the mitral area and also at the aortic. The former was systolic, the latter diastolic, in time. His urine was measured and amounted to about 500 c. c. in the twenty-four hours. On microscopical

examination epithelial casts, compound granules, and bacteria of decomposition were found. Under treatment urinary secretion increased in amount and the ædema improved, but the heart action gradually grew worse. On the afternoon of April 29, while the nurse was absent from the ward, patient got out of bed to use the commode. While up he became exhausted, face became cyanosed, and he had just been gotten into bed when he died.

Necropsy (fifteen hours after death).—General nourishment good; rigor mortis and post-mortem lividity marked; pupils medium; jugular veins distended and prominent; face cyanosed. The heart weighed 685 grams, and was much enlarged and beefy." The coronary arteries were prominent and very atheromatous. Its pericardial sac contained 50 c. c. of fluid. The pulmonary and tricuspid valves were competent; aortic and mitral valves were incompetent, their segments thickened and containing cartilaginous plates. The left ventricle was greatly hypertrophied, its wall being more than twice as thick as normal. The left lung weighed 490 grams. The right lung weighed 575 grams. Both lungs were deeply pigmented and passively congested to a marked degree, and the right lung was slightly cedematous. Both pleural cavities were filled with fluid, and the left was obliterated posteriorly by firm bands of adhesion, fibrous in character. The peritoneal cavity was distended and filled with fluid. The gastro-intestinal tract was normal throughout. The liver weighed 1,655 grams. On section it showed excessive development of connective tissue, giving it a nutmeg appearance. The gall bladder contained 20 c. c. of bile. The pancreas weighed 125 grams, and was normal. The left kidney weighed 215 grams. The right kidney weighed 190 grams. Both organs were deeply congested and gave evidence of hypertrophic cirrhosis. The urinary bladder, urethra, and prostate were normal. The suprarenal bodies together weighed 16 grams. The spleen weighed 330 grams. It was soft and friable, and was passively congested. The brain weighed 1,420 grams, and was apparently normal. Its membranes were much thickened and were congested.

F. W. U.
H. W. W.

CASE 21.
Aortic and mitral.

C. J., aged 36 years; nativity, Denmark; admitted to the United States Marine Hospital, New Orleans, La., January 27,1898; died June 16, 1898.

History.-Patient says that he had had "slight fevers," and first noticed shortness of breath after he recovered from an attack of fever. Legs have been swollen for the past twelve days. Face pallid; well nourished; has dyspnoea, swelling and oedema of legs. Physical examination showed a mitral regurgitant murmur, and an aortic regurgitant murmur. He obtained some relief from digitalis for a short time. Patient gradually developed some gastric symptoms, then cough, dyspnoea, hæmoptysis, sleeplessness, renal symptoms, pain over cardia, palpitation, irregularity of the pulse, and an ascending anasarca of both feet, legs, and abdomen. Physical signs of hypertrophy, and then dilatation. Murmurs of heart continued and became louder and more distinct. Systolic and diastolic murmur over aortic area, indicating a stenosis, and a mitral regurgitant murmur, which was transmitted so as to be heard over whole chest and posteriorly. Pulse was full, hard tension; the pulse wave would be followed by a sudden fall in fullness. Other physical signs were those of oedema of lungs and hydrothorax. There was an occasional remission of the symptoms from use of stimulants, sedatives, diuretics, and cathartics. He was placed on milk diet and special diet, had frequent steam baths, and rest in bed; occasional dose of morphine.

Necropsy (twelve and one-half hours after death).-Rigor mortis complete. Livores over whole of back and lower extremities and over dependent portions of body. Edema of extremities, abdomen, penis, and scrotum. Abdomen swollen,

weak and suffered from severe dyspnoea on slightest exertion; temperature was subnormal, 36.3, and pulse waterhammer in character; ankles and feet swollen and puffy; some ascitis. His condition improved considerably under general supportive treatment and rest in the recumbent position till about five days before his death, at which time he commenced to suffer acutely from pain in cardiac region, increased dyspnoea and cough, and some increase in ascitic fluid. His temperature during this period would rise to 38.2 every afternoon, becoming subnormal in the morning, about 36.2.

Necropsy (eight hours after death).—Body well nourished; eyelids puffy; feet, ankles, scrotum, and penis cedematous. Abdominal cavity contained about 1,000 c. c. fluid. Liver enlarged, dark and congested, extending to umbilicus; weight, 3,650 grams. Gall bladder nearly empty. Spleen enlarged; weight, 230 grams. Kidneys enlarged and congested, capsules not adherent; right kidney weighed 240 grams; left, 265. Stomach, intestines, and oesophagus normal. Bladder contracted and normal. Right pleural cavity contained 150 grams serum, no adhesions; left cavity obliterated by adhesion over upper lobe. Heart, weight, 420 grams; left cavities enlarged and walls thickened; mitral and aortic valves both incompetent. Pericardial surfaces covered with a shaggy coat of fibrin, giving the appearance of a Turkish bath towel. Brain weight, 1,370 grams; membranes much congested, otherwise normal.

G. M. M.

CASE 17.
Mitral and aortic.

N. B.; aged 38 years; nativity, Wisconsin; admitted to the marine ward of the St. Vincent Hospital, Portland, Oreg., June 17, 1898; died June 26, 1898. History.-He has suffered from two attacks of rheumatic fever in the last five years, the last occurring early in May of this year. There are external signs of syphilis, although this experience is not admitted. About three years ago was operated on for strangulated inguinal hernia of the right oblique variety, a radical cure having been effected. On admission he had dyspnoea, slight oedema of the feet and ankles, irritable stomach, and scant urine. Physical examination: The heart is greatly hypertrophied; apex impulse below and to the outer side of the nipple; the cardiac action is rapid, weak, and arythmical; the sounds are distinguished from each other with difficulty, and murmurs, more musical than rasping, are heard over the apex and below the second right costo-sternal articulation. They are not transmitted over a large area, and there is no arterial pulsation in the superficial vessels. The pulse could hardly be distinguished in the radials. Compensation was somewhat restored by the aid of drug stimulation, and there was a noticeable improvement in his distressed condition, but later on the œdema advanced and dropsical effusions filled the cavities. The patient died in a state of coma.

Necropsy (eleven hours after death).-Body muscular, corpulent, and the limbs oedematous. Rigor mortis not marked. Brain: The cranial bones are thin and very brittle; the veins of the pia mater are engorged; a considerable amount of serum is found in the base; the brain weighs 1,400 grams. Thorax: Right sac contains 150 c. c. serum; right lung weighs 1,020 grams and is congested below and posteriorly. Left sac contains a similar amount of pale yellow fluid; the lung is similarly congested and has a few firm adhesions near the apex posteriorily; it weighs 906 grams. The pericardial sac is distended, occupying a considerable portion of the central chest and encroaches upon the lung to the left; it contains 200 c. c. serum. The heart is greatly hypertrophied, weighing, minus clots, 906 grams; the walls are much thickened and the cavities contain large amounts of post-mortem clots.

The aortic valves are thickened and show a few