6 LOUIS A. DUHRING;
on the forehead to the right of the median line the cranium is bare in the form of a rounded area, three-quarters of an inch in diameter ; the skin around is firmly adherent to the tissues beneath, and is not thickened or infiltrated. At the root of the nose extending to the right eyebrow and involving the same is an irregularly-rounded, un- even, firm, fungoid, dark-reddish mass, covered with a dark-red, blackish crust, about two inches in diameter and raised a half-inch. A similar tumor exists on the back of the head just above the occiput, which is distinctly fissured and lobulated and soft.
Commencing on a line with the right ear, occupying the lower temporal, the parotid, and the submaxillary regions, from the cheek to the sterno-cleido-mastoid muscle, is a firm, lobulated, subcutaneous swollen mass covered with slightly movable, reddish, infiltrated skin. At the upper portion of the growth there is a superficial, quarter- dollar-sized ulcer, which is covered with a brownish crust. A similar enlargement but smaller exists on the opposite side of the face at a corresponding point. In the right posterior supra-clavicular region are three hazelnut-sized subcutaneous nodules, freely movable beneath the skin. Two smaller ones are found in the same region on the other side of the neck. No enlarged post-cervical glands. Upon the inner side of the right arm near the axilla is a large, hen's egg- sized, firm, fleshy, reddish-brown, excoriated and crusted, movable tumor. Much to our surprise the tumor of the labium of the vulva has entirely disappeared ; nor can so much as a trace of it be found. The abdomen is flat. Upon incision a half-inch of subcutaneous fat is noted down the median line. Intestines are not distended. Omentum is supplied with a small amount of fat, and is adherent to left side with a single cord-like band. The color of small intestines is dark-red on surface: little or no serum present. The surface of the intestines has iji places a finely granular look, and is dry. The abdominal organs occupy their normal position. The right costal junction is prominent, — more so than the left.
The pleural cavities are very dry, and except a few old adhesions on either side are normal. The left heart is moderately contracted ; right relaxed. Blackish clots are found in right auricle and ventri- cle : the left ventricle is empty. The tricuspid and pulmonary valves are normal. The mitral orifice is also normal in size; the anterior leaflet is thickened but smooth. The aortic leaflets are also thickened at several points along their line of junction, and at one point there is a slight calcareous deposit. Coronary arteries and aorta normal. The color of the heart-muscle is pale ; the tissue is friable ; the walls are of normal thickness ; cavities of normal size.
The lungs are everywhere crepitant. There is a slight amount of fibroid thickening at their apices beneath the pleural adhesions. No nodules are anywhere to be felt or seen in the lung-substance. The glands at root of lungs are not enlarged but are deeply pigmented ; no enlarged glands can be felt from the pleural sac.
The spleen is of usual size, with a slight fibrous depression at one border ; otherwise normal. Supra-renal bodies small and firm ;
