athletic girls. The former type of patients have a great deal of fat in the pelvis, and this obstructs the delivery of the child at birth. In these cases, a great deal can be done through diet. These women are usually overfed. They eat too much, and the child is usually large. Then, with the fat in the pelvis, we have a difficult labor, and often a fatality as regards the child. The other type of patients are the young girls who are athletic, play tennis and golf, ride horseback, and think nothing of long walks. In them, the os is rigid, as well as the muscles of the perineum; and the chances are that we have a hard delivery, with severe laceration. These cases can be helped with sitz baths, especially during the later months.

Bronzed Diabetes (Hæmochromatosis).

Report of a Case and Review of the Literature.

GEORGE BLUMER, M.D., NEW HAVEN.

The recognition of a type of diabetes associated with pigmentation of the skin dates back nearly thirty years. In 1882 Hanot and Chauffard described a case under the title of bronzed diabetes with pigmentary hypertrophic cirrhosis, and since then others have been described in Germany, Italy, Holland, Sweden, England and the United States. It has since been recognized that this clinical entity merely represents a phase of the form of pigmentation of the organs and tissues described by von Recklinghausen in 1889 as hæmochromatosis. The number of cases described is as yet so small that it seems worth while to continue placing new ones on record. Following is the history of a case seen last year in which we were fortunately able to secure an autopsy:

B. D., a German blacksmith, a widower of 67, was sent in to the New Haven Hospital by Dr. F. A. Ruickholdt, December 12, 1910, with a diagnosis of diabetic coma.

The patient's family history was negative.

He had had no serious illness as an adult except typhoid fever as a young man. He was not an alcoholic. There was no history of syphilis. His present illness dated from July, 1910, the first symptoms noted being loss of appetite, weakness, loss of weight and great thirst. Later his appetite became ravenous at times. There was polyuria. There was no itching of the skin and no boils. Three days before entrance he became irritable, and his landlady noticed that his breath smelt peculiar. The day before entrance his mind was confused, he did not know day from night and did not know the day of the week. He was very constipated for a few days and became very drowsy. His son and daughter had not noticed any unusual pigmentation of the skin, but they only saw him occasionally.

On examination he was much emaciated. There was a strong odor of acetone on the breath. Air hunger was fairly well marked. The patient

was refractory and somnolent. His hair was thin. His skin was dry and harsh. There was patchy brownish pigmentation of the skin of the forehead. The skin of the hands, forearms and legs showed a uniform, rather dark, grayish brown pigmentation. The lungs were clear except for a few fine moist râles at the bases behind. The heart was slightly enlarged to the left. There was a rather harsh high-pitched, systolic murmur all over the heart. The second aortic sound was slightly accentuated. The pulse was rapid, regular and compressible. The radial was thickened. The abdomen was flat. The liver dullness reached four centimeters below the costal margin in the right midclavicular line. The edge was easily felt, very hard and slightly sensitive. The surface felt slightly irregular. The splenic dullness was increased, and the edge of the spleen could just be felt. The abdomen was otherwise negative. There was no cedema of the shins.

The following day it was noted that there was a petechial eruption over the legs and several suggilations over the arms. The patient gradually failed in spite of treatment and died less than forty-eight hours after entrance.

The association of the diabetes with pigmentation of the skin and the signs of cirrhosis pointed to a diagnosis of so-called "bronzed diabetes," i. e., hæmochromatosis with pigmentary cirrhosis of the liver and pancreas with a resultant pancreatic diabetes.

The autopsy was made by Dr. C. J. Bartlett and I am indebted to him for the use of his notes on the gross and microscopic appearances.

The body was still warm. It was that of a man much emaciated. The body length was 164 cm. Rigor mortis was present in the jaw and beginning in the fingers. The body as a whole was pale. There was beginning post mortem lividity. The back of the hands and forearms showed some purplish discoloration. On the forearms, thighs and knees were cutaneous hemorrhages, varying in size from those smaller than a pin's head to those 2 cm. in diameter. The skin over the tibiæ was roughened and glossy. There was slight oedema of the ankles. The subcutaneous fat over the abdomen was only a few millimeters thick. The abdominal cavity contained about 1000 c.c. of a slightly turbid, serous liquid. The liver extended 5 cm. below the costal margin. The lower edge of the stomach extended 6 cm. below the costal margin. The height of the diaphragm on the right side, fourth interspace; left side, top of the fifth rib. The peritoneal surface of the liver, cæcum, and to a lesser extent other parts of the intestine and mesentery, were studded with minute grayish tubercle-like bodies, particularly numerous in the mesentery. A few old adhesions were found between the transverse colon and liver. Tubercles were also present in the omentum. The lymph nodes in the upper part of the anterior mediastinum were slightly enlarged and brownish colored. There were numerous pleural adhesions on the right side.

The heart weighed 300 grams. The veins underneath the pericardium were somewhat tortuous. On the anterior wall of the pericardium were a few milk spots. The mitral valve was narrowed; it measured 7.5 cm. along the free border. This narrowing was due to general fibrous thickening of cusps. The chordæ tendinea were rather short. The papillary muscles in the left ventricle were rather stout. The aortic cusps were all calcified so that they stood out prominently after opening the aorta. There was no calcification of the root of the aorta. It contained a few small yellowish nodules on the intima. The aortic orifice measured 6.5 cm.; pulmonary, 8 cm.; tricuspid, 12 cm. The myocardium was firm. There was thickening and calcification of the coronary arteries. There were small grayish streaks of connective tissue in the myocardium.

The lower lobe of the right lung crepitated but little. On section the lung was firm and moist; frothy liquid could be squeezed from it. There was some emphysema present. The left lung showed the same condition.

The spleen weighed 210 grams. The capsule was thickened, and there were numerous grayish fibrous plaques on the convex surface. It was firm, red in color, and showed more connective tissue than normal. There was one small grayish-red infarct.

The lymph nodes anterior to the head of pancreas were enlarged and of a reddish-brown color.

The liver weighed 1960 grams. Its surface was irregular, due to two things; first, the minute tubercles already mentioned; second, small irregular, raised portions of liver tissue with connective tissue between. The liver was firm and decidedly yellowish-brown in color.

The pancreas weighed 100 grams. There was considerable fat tissue around it. The fat was mottled with brownish-colored pancreatic tissue. On section, fat was found mixed with pancreatic tissue throughout the organ, which had a very brown color. The pancreatic tissue was small in amount and quite firm.

The retroperitoneal lymph nodes were enlarged.

The left kidney weighed 150 grams. The capsule was not adherent. The surface was smooth and the kidney tissue firm. The cortex was of good thickness and rather grayish-yellow in color. (The right kidney, bladder, etc., taken en masse by Dr. J. I. Butler.) The suprarenals showed nothing of note.

The thoracic aorta showed numerous slightly elevated, yellowish patches on the intima. The abdominal aorta also showed these patches, and at the bifurcation there were areas of calcification.

The mucous membrane of the stomach was rather thin and showed several small grayish tubercle-like elevations. The intestine showed nothing of note.

Anatomical Diagnosis:-General emaciation. Pigmentation of skin; slight œdema of the ankles; subcutaneous hemorrhages; stenosis of

aortic and mitral orifices, insufficiency of mitral (and of aortic?) valve, calcification of coronary arteries and of thoracic aorta; chronic passive congestion and oedema of the lungs; miliary tuberculosis of the peritoneum; chronic splenitis and perisplenitis; brown pigmentation of liver, of pancreas, and of lymph nodes; chronic interstitial hepatitis and pancreatitis; chronic gastritis.

Microscopical Examination: The heart-the most noticeable thing here is the brown pigment in the fibres. This has the color and location commonly seen in brown atrophy of the heart, and is present in quantity corresponding with the marked degree of that condition. The fibres of the myocardium underneath the endocardium are pale staining and show considerable longitudinal fibrillation. This is also seen to a less degree elsewhere. In places there is a slight increase in cellular connective tissue in the heart wall.

The lungs-Edema is indicated by the granular content of the air spaces. In places red blood corpuscles and polymorphonuclear leucocytes are present in small numbers. Large pigment-containing cells free in the spaces are fairly common. The walls of the air spaces are thick, due chiefly to dilation of their capillaries. There appears to have been some degree of chronic passive congestion.

The spleen-The capsule is irregularly thickened by dense connective tissue. The trabeculæ are prominent. The walls of the blood sinuses are rather more distinctly outlined than normal. Occasional large mononuclear cells contain granules of brownish-yellow pigment in their cytoplasm. Chronic perisplenitis, chronic passive congestion, slight pigmentation.

The liver-Sections show marked cirrhosis with very pronounced pigmentation of the tissues. The cirrhosis is of the ordinary portal type. The connective tissue is in general quite compact and shows an apparent decided increase in the bile ducts. But little evidence of atrophy of liver tissue is seen. The pigment is brownish-yellow in color. It occurs both in fine and coarse granules, and is found in abundance in the connective tissue as well as in the liver parenchyma. In the latter the pigment is within the cells and is not limited to any one part of the lobules. At times it is in largest quantity near the center of the lobule, but again the pigmentation may be most marked in the outer part of the lobule, or there may be no regularity in its distribution. Practically all of the liver cells contain pigment, each cell usually having many granules in it. Occasionally a cell will show only a few small granules, but more often the cytoplasm is crowded with the pigment, partly in coarse granules. It is also found in the endothelial cells lining the sinusoids between the columns of liver cells. In the connective tissue the larger collections of pigment appear to lie free between the fibres as collections of coarse granules. Pigment is also common in the cells lining the bile ducts, and is occasionally present in the connective tissue cells and endothelial cells.