The Johns Hopkins Medical Journal 33 (1922)

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Contents

The Johns Hopkins Medical Journal - Volume 33 (1922)

https://archive.org/details/johnshopkinsmedi33john

The Johns Hopkins Medical Journal 33 (1922)

The Johns Hopkins Hospital Bulletin


Vol XXXIII — No. 371

BALTIMORE, JANUARY, 1922

Contents - January

  • Secondaiy Aiunuia of Infants. A Study of So-Called Infantile Splenic Anemia or Anemia Infantum PseiidoleuKemica. By Frank A. Evaxs and William M. Happ
  • Pregnancy and Labor in Young Primipar*. (Illustrated.) Bv .JoHx W. Harris
  • The Protective Power of Serum in Pernicious Anemia and Other Conditions Against Hemolysis by Saponin and by Sodium Oleate. By Ehka H. ZiXLK, Hallik M. Clark and Frank A. Evans
  • The Establishment of Collateral Circulation Following Ligation of the Thoracic Duct. (Illustrated.) By Fereinand C. Lee . . . .
  • Studies on Experimental Rickets. XV. The Effect of Starvation on the Healing of Rickets. (Illustrated.) By E. V. McCoLLUM, Nina Sim.monds, P. G. Shipley and E. A. Park


PREGNANCY AND LABOR IN YOUNG PRIMIPAR

By John W. Harris {From the Department oj Obstetrics, The Johns Hopkins Hospital and University)


In spite of the fact that most text-books of obstetrics contain little infonuation upon the subject, there is a prevalent opinion that pregnancy and labor are attended by greater danger in young girls than in older women. Williams ' differs from this view and states that labor in the girl of 16 or less is no more serious than in the women of more mature years. In order to test the correctness of this view I have collected and analyzed all labors in girls of 16 years of age or less which have occurred in the obstetrical service of The Johns Hopkins Hospital.

Vamier ' has compared the average duration of labor in 100 primiparce of less than 20 years of age with that in a similar number of patients between the ages of 20 and 30.


He found the average duration was 13 hours, 5 minutes in the former as compared with 13 hours, 28 minutes in the latter. In all of the patients in Ixith groups the pelvis was normal and the child presented by the vertex.

Gache,' of Buenos Aires, analyzed 91 cases of labor occurring in girls between the .ages of 13 and 16. In 84 patients the pelvis was normal. Of the 91 patients, 78 were delivered spontaneously and 13 by operative measures. He estimated that the average duration of labor was 24 hours and that the children averaged 3039 grams in weight, and concluded that, so far as he could ascertain, the age of the patient is practically a matter of indifference.


Bondj' ' has reported 69 labors between the ages of 14 and 16, of wliich 12 resulted in the birth of premature children. In the 57 patients delivered at term he believed that labor was prolonged in 19 instances.

From the first 10,000 admissions to the obstetrical service of The Johns Hopkins Hospital I have collected the details of 500 labors occurring in girls between the ages of 13 and 16 inclusive. Since most of the abortions are admitted to the gynecological service, the few that appear in our records have not been considered, as they would give no accurate picture of the frequency of this complication.

Table 1 presents an analysis of the age at which delivery took place in each of the two races, and shows that there are more than twice as many blacks as whites in the series. As less than 45 per cent of all patients admitted to the service are blacks, this unusual predominance of colored young priniiparffi may be regarded as an index of the incidence of precocious sexual relations in that race.

TABLE 1


Age


White


Black


Total



12



2


2



13


1


6


7



14


IS


28


46



1^


45


95


140



16


96


209


305


Total .


160


340


500


Pelvis. — In every patient in the series the pelvis was measured both externally and internally and the results are shown in Tables 2 and 3.

In the 160 white patients contracted pelves were noted in 21, a percentage of 13.12. The generally contracted and the funnel were the most frequent types noted, making up 16 of the 21 cases.

Williams," in a series of 1313 wloite women, irrespective of age, found that the incidence of contracted pelvis was 13.33 per cent, and stated that the funnel and the generally contracted were the two types most frequently encountered, the two making up 125 of his 175 cases. On comparing our figures with his, it is seen that the incidence of contracted pelvis is practically the same in both series, and that the types of pelvic contraction most frequently noted were identical. In other words, the white girl of 13 to 16 years of age has as large a pelvis as her older sister.

In the 340 blacks in our series the incidence of pelvic contraction was 60.58 per cent. The two most frequent types encountered were the generally contracted and the generally contracted rhachitic, the two making up 140 of our 206 cases. Williams' found 312 contracted pelves in 902 colored women of all ages, a percentage of 40.93. Of these the generally contracted and the generally contracted rhacliitic made up 258 of his 312 cases. Thus it is seen that in colored young


primiparas contractions of the pelvis occur 50 per cent times more frequently than in colored women of more mature years. This is to be expected when it is remembered that casual observation seems to indicate that the black woman in Baltimore reaches physical maturity later than does the white. Our figures are in accord with those of Williams that the two types of contracted pelves most frequently noted in the black are the generally contracted and the generally contracted rhachitic.

Abnormal Pregnancy. — Table 4 shows the complications of pregnancy met with in the series of 500 cases.

TABLE 2

Classification of Pelves in 160 White Young Peimipaii«;



Normal pelves


Contracted pelves



Age


Generally contracted


Simple flat


Funnel


Gen. cont. funnel


Total cont. pelves


Total


13 14 15 16


1 14 37

87


1 5 3





2 2 3


1 1

1



4 S 9


1 18 45 96


Total.


139


9


2


7


3


21


160


TABLE 3 Classification of Pelves in 340 Black Yotjnq Fbimifaba^




Contracted pelves




TS

Age


Normal pelves



tc



1



§1


s


is

^ >


Total





s


gti


5'-s


c


S3



go,





c


m


a


b


b.


a



H



12



2


2


2


13



3



3








6


6


14


8


11



4


°


2


3



20


28


15


41


16



16


1


9


12



54


95


16


85


51


1


34


1


12


24


1


124


209


Total.


134


83


1


57


2


23


39


1


206


340


TABLE 4 Abnormal Pregnancies



Zj


a


« 



5






es


"S


•-* 6



^







e




z


« 



H


s


H


White


2


9


1


1






13


Black


8


7



25


1


1


1


43


Total


10


16


1


26


1


1


1


56


At first glance it appears that there was an abnormally high incidence of preeclamptic toxaemia and eclampsia, 10


14


[Xo. 371


of the former and 16 of the latter. However, five of the eases of the former and 14 of the latter v^ere not treated in the prenatal clinic but were referred to the service because of the existence of the disease. Consequently, no such incidence of these complications should be expected to obtain in the average run of young primipariB.

It is noted that there were 26 cases of syphilis in the series, 25 being in black women and 1 in white. This is a much lower incidence of the diseai?e than that reported from this clinic by Williams.' The discrepancy can be explained not only on the grounds that in the young girl syphilis would not be expected to be present so frequently, but also because of the fact that more than half of the patients in the series passed through our hands before the introduction of the routine Wassermann determination and, therefore, it may be assumed that many cases of infection escaped detection.

Premature Labor. — Of the entire series of 500 cases 58, or 11.6 per cent, terminated in premature labor. When divided according to race, it is seen that this termination occurred in 17 of the 160 whites and in 41 of the 340 blacks, an incidence of 10.52 and 12.05 per cent, respectively.

In the majority of cases in both races the cause of premature termination could not be determined. In the blacks syphilis was the most important ascertainable etiological factor, and it seems safe to surmise that, had the more recent methods of diagnosis been applied throughout the series, many of the cases classified as undetermined would have shown that syphilis was the causative factor.

TABLE 5 Prematuke Labors





m


M fi



1




1


s



H


White .


11


1


2



2


1





17


Black..


24


11


1


2


1



1


1


41


Total . .


35


12


3


2


3


1


1


1


58


Duration of Labor. — Of the 442 patients delivered at term the duration of labor was accurately recorded in 430 — 138 whites and 292 blacks. The 12 remaining patients were delivered by Coesarean section or accoueliement force before the cervix had become fully dilated.

Tables 6 and 7 show the average duration of term labor in the two races. From Table 6 it is seen that the average duration of labor for the entire series of 138 white girls is 15 hours, 44 minutes. However, when the pelvis is normal the average falls to 15 hours, 10 minutes ; on the other hand, when the pelvis is contracted, labor is 4 hours, 43 minutes, longer than when it is normal.

The average duration of labor in the 292 blacks is 16 hours, 40 minutes. This increase may be assumed to be due to the greater frequency of contracted pelves in that race; as, when the pelvis is normal, the average duration is 14 hours, 40


minutes, as compared with an average of 18 hours, 7 minutes, when the pelvis is contracted.

It is usually stated that the average duration of labor in primiparffi, irrespective of age, is 18 hours. G. Veit ' places it at 20 hours. Accepting the lower figure as correct, it is seen that the young primipara has a labor shorter by 2 hours, 16 minutes in the white and 1 hour, 20 minutes in the black race.

TABLE 6 Average Duration of Labor — White


Age


Total


Normal pelvis


Contracted pelvis


No. cases


Average duration


No. eases


Average duration


^•— jd^atr,


13 14 15 16


1 15 40 82


lOh. 12m. 20h. 02m. 15h. 1.5m. 15h. 16m.


1

11 33 76 .


lOh. 12m. 18h. 48m. 15h. 27m. 14h. 35m.


4 231i. 24m. 7 |14h. 15m. 6 24h. 06m.


Total


1.38


15h. 44m.


121


1.5h. lOra.


17 19h. 52m.


TABLE 7 A^•ERAGE Duration op Labor — Black



Total


Normal pelvis


Contracted pelvis



No. cases


Average duration


No. cases


Average duration


NO- cases 1 ,^J-^f„


12 13 14 15 16


2

5

25

82 178


18h. 03m. 17h. 20m. 191i. 44m. 16h. 48m. lOh. 09m.




8

39



181i. 50m. 131i. 53ra. 14h. 43m.


5 17

43 103


18h. 03m. ITli. 20m. 20h. 10m. 19h. 27m. 17h. 15m.


Total


292


16h. 40m.


122 141). 40ra.


170 ISh. 07m.


ilorc precise information as to the duration of labor may be gained by the " modal " method. This is shown in Tables 8 and 9. The shaded blocks represent the total number of term labors divided into groups of two hours each, while the lines represent the labors occurring in patients with normal pelves. Inspection of these tables shows that in both races the most frequent duration of labor in the entire series, as well as in those with normal pelves, is between 10 and 12 hours. Unfortunately, no comparable statistics concerning the duration of labor in older women are available, but it is not believed that they would show a shorter duration tlian that observed in young primipane.

It is interesting to note that, in spite of the much higher incidence of contracted pelvis in the blacks, the most frequent duration of labor is the same as for the whites. The explanation is, as will be shown later, that the babies of the former are smaller, and, tlierefore, are less likely to be disproportionate to the size of the pelvis.



Delivery. — Of the 448 deliveries at term, 379 were spontaneous and 63 were operative, an incidence of 85.74 and 14.36 per cent respectively. Of the latter 18 were in whites and 45 in blacks. Notwithstanding the apparently greater frequency of operative interference in the blacks, the determination of the percentage frequency shows that the incidence is approximately the same in both races, being 12.95 per cent for the whites and 14.85 per cent for the blacks.

TABLE 8


YOUnS WHITE PRIMIPARAE



rJI...


cviAi , i;^ 1 1 1 n


£2 ^6 30 3a 3d 4a 46 M 34 56 6e 66 70

Houes


TABLE 9


voty/vs Bu\a< pmiPAgAC



u_n

34 J8 -JZ 46 50 54 56 6^ 66 10 Ti IS di Sf HOURS


Opemfions. — The types of operations are shown in Table 10. While the incidence of pelvic contraction was 60.58 per cent in the blacks, only 17 of the 45 operations were done because of pelvic dystocia. Of these, 10 were Cesarean sections, 4 pubiotomies and 3 craniotomies. In the whites only two operations were necessitated by the pelvis, one Caesarean section and one high forceps.

Weight of the Child. — In casting about for an explanation for the relatively short labor in very young primipars it seemed possible that it might be afforded by the smaller size of the children. Accordingly the material was studied from


that point of view. Tables 11 and 13 show the average weight of the children in both races. In the series of 143 whites delivered at term the average weight of the children was 3181 grams. When classified according to the pelvis of the mother, the average in the 126 patients with normal pelves was 3200 grams, while in the 17 with contracted pelves it was 3045 grams, a difference of 155 grams in favor of the child bom of a motlier with a normal pelvis. The average weight of

TABLE 10 Operations •



S



o.


i.


•og




1




"5




^


3


.a


•^ o



« c


1


J3


3-I

-art


3




s


n


>


o


&<


o



1




S


^




3 rt


ii'O


S


^



H


>>


6


•<


Q ®


S"


£


o


White


3


2


i


2



1


1


13


Black


3


4


4


1


4


1


1


18


Total


6


6


S


3


4


2


2


31


on the third day after the the spontaneous delivery of a term child. The other three patients were delivered of premature children, one by manual dilatation of the cervix and version and extraction because of prolonged labor and intrapartum infection. She died suddenly two hours later, with a clinical diagnosis of hemorrhage and shock, but the findings at autopsy were negative. Of the other patients one died on the fifth day of the puerperium from streptococcus peritonitis and the other on the tenth day from pyelonephritis which had existed for weeks before delivery.


Fcetal Mortality. — Of the 442 deliveries at term, 31 children were stillborn or died within the first two week.s of life, a percentage of 7.0. The causes of death are shown in Table 13.

Conclusions

Based upon the study of the 500 patients comprised in this report, it seems permissible to conclude that pregnancy and labor are attended by no gi-eater danger in the young primipara than in the older woman. On the other hand, the duration of labor is actually shorter. As our figures show that the size of the children is not inferior to that noted in older women, and that abnormal pelves occur quite as frequently, this result must be attributed to the greater elasticity of the soft parts. Consequently, speaking from a purely obstetrical point of view, the ages under consideration appear to be the optimum time for the occun-ence of the first labor.

BIBLIOGRAPHY

1. Williams, J. Whitridge: Text-book of Obstetrics. D. Appleton and Co., 1917, 250.

2. Varnier : Combien de temps dure I'accouchement. L'Obstetrique journaliere, 1900, 174-181.

3. Gache : La grossesse et raccouchement chez les primipares de 13, 14, 15, et 16 ans. Annales de gyn. et d'obst., 1904, n. s., 1, 723-736.

4. Bendy: Die Geburt in den Entwicklungsjahren. Ztschr. f. Geb. u. Gyn., 1911, LXIX, 213-246.

5. Williams, J. Whitridge: The Funnel Pelvis. Am. Journ. Obst., 1911, LXIV, 106-124.

6. Idem: The Significance of Syphilis in Prenatal Care and in the Causation of Foetal Death. Johns Hopkins Hosp. Bulletin, 1920, XXXI, No. 351, 141-145.

7. Veit: Beitrage zur geburtshiilflichen Statistik. Monatsschr. f. Geburtsh., 1S54, V, 344-381 ; 1855, VI, 101-132.

8. Riggs: A Comparative Study of White and Negro Pelves, etc. Johns Hopkins Hopsital Reports, 1904, XII, 421-454.




THE ESTABLISHMENT OF COLLATERAL'CIRCULATION FOLLOWING LIGATION OF THE THORACIC DUCT

By Ferdinand C. Lee (From the Anatomical Laboratory oj The Johns Hopkins University)


The general physiology of the lymphatic system has been studied from various angles. The discovery of the lymphatic system by Asellius^ in 1627 was due to an observation correlating digestion with the activity of lymphatic vessels. Clinical pathological findings stimulated individuals to wound the thoracic duct in the chest and study the subsequent phenomena (Lower'); while others (Flandrin," Colin *) ligated the thoracic duct in thetneck and observed the influence of this procedure on the animal economy. Later when the knowledge of chemistry became advanced, thoracic duct fistulse were made with a view toward studying the fluid in the duct under ordinary conditions and as modified by the digestion of various foods, e. g., fats. Again, through the work of Heidenhain' and Starling," the effects of lymphagogues of various classes were investigated. Finally, the thoracic duct was studied in regard to its power of supplying blood cells, chiefly small h-mphocytes, to the blood stream (Biedl and v. Decastello ') .

In this report an attempt has been made to review the literature of the experimental ligation of the thoracic duct, and also to give a description of a new method for ligating that vessel.

Review of Literature

Probably the first one to attempt the ligation of the thoracic duct was Duverney' in 1675. He ligated the subclavian vein near the entrance of the duct, in some cases applying the ligature proximally and in others distally to the entrance. The dogs lived for a fortnight.

Sixteen years later in 1691, Flandrin,' a well-known veterinarian of his time, chose to repeat the work of Duverney, but preferred the horse, since he considered the lymph vessels in the smaller animals as too inconstant in their location. In the first experiment the animal died at the end of three days ; subsequent dissection showed nothing of particular interest. In the second case a young horse was used. It experienced no ill effects immediately following the operation, nor in the subsequent 15 days during which it was allowed to live. " Perfect suppuration" took place in the wound, and with the possible exception of a distension of the thoracic duct at its point of ligation, the autopsy revealed no marked difference


in the appearance of the lymphatics. Similar results were obtained with 10 more horses; the majority of the animals were killed 15 days following ligation, and the only abnormal finding was a distension of the thoracic duct at its point of ligation, with occasional extension of this distension down into the chest. One animal was kept for two and a half months after operation, and at autopsy showed a cicatrized thoracic duct. It is also interesting to note that Flandrin was among the first to introduce a cannida into the thoracic duct for the purpose of studying the properties of the lymph. He concluded that the lymph reaches the blood-stream through other channels than the thoracic duct.

In 1798 Sir Astley Cooper" reported the results of some experimental work involving the ligation of the thoracic duct in dogs. He was stimulated to undertake the experiments because he had observed three cases of obstruction to the thoracic duct in man. In two of these cases he found evidence of collateral circulation ; in the third case no such evidence was found. In the first experiment the dog died 48 hours after the duct had been tied; dissection showed the viscera obscured by an effusion of chyle; particularly was tliis the case with the pancreas and the kidney; a small quantity of chyle had extravasated into the peritoneal cavity; the lacteals were empty; the thoracic duct was twice its normal size. These findings Cooper explained on the basis of a ruptured cisterna chyli. The second experiment was a great deal like the first, only the dog lived 3 days longer. The autopsy findings were the same; the cisterna chyli had burst and the extravasation had hidden entirely the aorta and the vena cava. In a third experiment the thoracic duct was cut and allowed to drain into the tissues; the animal died on the fourth day; dissection showed a pouch of lymph in the wound. These experiments were repeated always with the same results; no animal survived the tenth day. In one case Cooper noticed that a branch of the thoracic duct went over to the right trunk; also that the amount of extravasation bore a direct relation to the amount of food which the animal had just previously taken. Cooper did not give any evidence, e. g., by injections, to support his belief that the cisterna had ruptured.


22


[No. 371


The only other investigator besides Cooper to report rupture of the cisterna chyli following ligation was Mayer." Contrariwise, Eogers " observed no ill effects from ligation.

In 1821, Magendie " reported the exp€rinients which Dupuytren made on several horses. Dupuytren ligated the thoracic duct in the neck, and obsei^ved that some animals died at the end of five to six days ; while others did not seem to be affected by the operation. Subsequent injections showed that in the animals that died there was a complete obstruction of the thoracic duet; whereas, in those that survived — and one case was allowed to go for six weeks — a collateral circulation was always demonstrable. Accordingly, it was argued that the death of those animals that lived only five to six days, and in which the duct was tied, was due to the deprivation of nourishment furnished via the thoracic duct; and the only reason that the other animals lived longer was because collaterals to the thoracic duct had formed and had thus transmitted the necessary food substances to the blood stream.

Leuret and Lassaigne " tied the thoracic duct in the neck of a dog and found that the animal lived perfectly well, even gained weight. At the end of 58 days it was sacrificed at the height of digestion; dissection showed that the canal had been satisfactorily ligated. The only findings of importance were that the duct, the cisterna and the mesenteric lymphatics contained a small amount of chyle; and that the mesenteric veins seemed larger than normal. They believed that the chyle took an abnormal course to reach the blood, and tliat tliis path was from the cisterna chyli to the portal vein. They proved this assertion to their own satisfaction when they ligated the portal vein and found blood in the cisterna chyli and at the conunencement of the thoracic duct. They also found that when the blood and chyle were taken from the thoracic duct and allowed to stand, two distinct clots were formed : the one, red, remained below ; while the other, pink, evidently chylous, remained above.

Colin ^ in 1873 reviewed briefly and analyzed to some extent the work of the above mentioned investigators and then related liis own experiences with ligations of the thoracic duct in various animals. All ligations seem to have been done in the neck. His first experiment was on a bull. The animal made an uneventful recovery and was sacrificed at the end of six or seven weeks when it was found that the thoracic duct was obliterated to the extent of five or six centimeters below the point of ligation, but that collaterals had formed at this point and had extended to the regular entrance of the thoracic duct into the veins. He repeated these experiments on two cows, taking care to include in his ligations all branches of the thoracic duct, and found at the end of 24 hours that there was a marked distension of the lymphatic system, as well as an extensive extravasation into the mesentery. He believed that the animals would have died from the operation if they had been kept long enough. On a bull 18 months old ligation resulted in death at the end of nine days ; lymph did not reach the veins. After the completion of these oljservations on these large animals he made use of dogs for further experiments. One dog died from chylothorax on the dav


following the operation. Two other dogs died at the end of 20 and 25 days respectively, having refused food for almost the entire time. In both cases the thoracic duct was thickened and obliterated at its upper end and injections did not reach the veins. These animals " died the death of starvation." Colin concluded that ligation of the thoracic duct was not always followed by the same results. In those cases in which the duct was double, or anastomosed with the right thoracic duct, lymph reached the blood stream, and the animal recovered ; whereas, if the duct were single and when ligation had been complete, death resulted promptly. He called the attention of future investigators to the fact that the entrance of the thoracic duct into the veins is so variable that in some cases it is absolutely impossible to prevent the lymph and chyle from reaching the blood stream.

However, Schmidt-Miihlheim " devised an operation which seemed to take care of all possible variations of the entrance of the thoracic duct into the veins. The problem which Ludwig gave Schmidt-iliihlheim was to establish whether the digestion products of albumen reached the blood stream via the thoracic duct or not. From this it can be readily seen what an exaggerated importance physiologists up to that time attached to the thoracic duct. He used dogs for his experiments and operated without an atesthetic or curare. He must be credited, however, with using strict aseptic technique during the operation, and, accordingly, ranks among the first to observe aseptic measures on experimental animals in the solution of biochemical problems. The operation consisted in isolating and tying off successively, on the right side as well as on the left, the v. jugularis externa, v. jugularis interna, v. axillaris and v. anonyma. Also the two thoracic ducts, right and left, were cut between ligatures. The operation did not affect the general condition of the animals in any particular; but since they were sacrificed at the end of six or seven days, no report of the effect of long continued ligation of the thoracic duct on the health of the animal is available. The complete occlusion of the entrance of the thoracic duct into the veins of the neck was demonstrated immediately after death by the injection of Berlin blue into the cisterna chyli at a pressiire of 40-50 mm. of mercury; this was followed by dissection of the duct to the point of ligation. Again, the superior vena cava was also opened and a search made for evidence of the dye. Only those cases in which complete obstruction had been established were considered satisfactory; and following careful chemical analysis SchmidtJ\liihlheim concluded that in complete obstruction to the chyle-flow into the blood vascular system, the digestion and absorption of albumens, as well as tlieir conversion into urinary products, are the same as when the chyle is unobstructed in its passage to the blood stream. Tliis result was an advance in the field of physiological chemistry.

The autopsy findings in these exj^erimental dogs differed particularly in one essential respect from the observations of Cooper.' Cooper, it will be remembered, found rupture of the cisterna chyli follomng ligation with extensive extravasations ; however, he failed to verify the rupture by injections.


January, I'Jg-a]


?;j


Schmidt-JIuhlheim, on the other hand, convinced himself by injecting directly into the cisterna with a solution o£ Berlin blue at a pre-ssure of 40-50 mm. of mercury, and keeping this pressure up for hours that, in spite of wide extravasation, the cisterna chyli was intact; in no case was any dye found in the perivascular tissue. Marked distension of the lymphatics, chiefly abdominal, as well a.s enlargement of the lymph glands, was observed constantly. Also, it was noted, that a retrograde injection of the large hnnphatic trunks emptying into the cisterna was possible to the extent of 3-4 cm., because the valves had l)ecome incompetent ; particularly was this true of lymphatics coming from the liver. On the contrary, a retrograde injection of smaller lymphatics was never possible. He added that the mucosa of the intestine always had a normal appearance.

In 1883 Boegehold '" reviewed the important work clone on the thoracic duct. He reviewed not only the anatomy with its numerous variations, the physiologv', the pathology, and clinical features involving the thoracic duct, but also gave an account of the experimental work done on the thoracic duct, adding the results of some of his own experiments. He was interest-ed in studying the effects of wounds of the thoracic duct, and to that end cut the thoracic duct partially or entirely in the chest of dogs. He found that cutting about one-quarter of the periphery of the duct led to fibrin formation and clotting at the damaged area ; cutting completely across the duct caused ehylothorax and death ; wounding the duct slightly, after it had been tied off effectually in the neck according to the method of Schmidt-Miihlheim, resulted at the end of three days in a small amount of fibrin fonnation at the point of injury. Accordingly, he argued that absolute integrity of the thoracic duct was not essential to life. This was shown also by a number of clinical cases that suffered no apparent ill effects from complete obstruction to the duct. Also it seemed as if collaterals were rapidly develoi>ed subsequent to obstruction; but no proof of this was given.

A new departure in ligation of the thoracic duct was effected in 1898 by Stiiler." This author, after referring in uncomplimentary terms to the hypothesis of v. Schwerdt " regarding the pathology of Morbus basedowii with respect to the formation of subcutaneous collateral lymphatics, gave the results of his experimental work on the ligation of the duct in rabbits. Under aseptic precautions and ether anesthesia he ligated the thoracic duct high in the abdominal cavity, just below the diaphragm. Four experiments in all were made. In the first case the aorta was damaged and the animal bled to death ; in the second case the diaphragm was ruptured at operation and the animal later died of peritonitis. The fourth animal also died of peritonitis. The third animal, however, survived and gained weight. A piece of the supposed thoracic duct removed at the time of operation showed microscopically that it actually belonged to the thoracic duct. The author intended to report later the findings in this animal, l)ut no subsequent record is available.

Lucibelli " published the results of his work on the effects of ligation of the thoracic duct. He used two large dogs as


his subjects and gave them milk four or five hours before the operation as an aid in identifying the duct. With chloroform or Richet's solution as anesthetics and with sterile precautions, the operation was performed in the left side of the neck. In the first dog the operative wound became infected and continued to discharge pus for from 20 to 25 days after operation. At the end of this time the dog ceased losing weight and began to gain; his general condition also improved. At the end of two montlis from the time of operation the animal was in fair condition and the various examinations of the different body fluids were made. These examinations were very elaborate and included a complete urine analysis, isotonicity of the blood, red, white and differential blood counts. As a control for these findings an entirely different dog of the same weight, Init living under the same conditions, was used. The first dog gradually became worse and died 3 months and 11 days after the operation. Autopsy showed a spleen five times normal size, mesenteric glands hypertrophied, glands of neck large, large heart, liver and pancreas. However, no injections were made to see whether the ligation in the neck was complete. The second dog did not have any post-operative infection. At the end of three months the same extensive examinations of the urine and blood were made, and immediately thereafter the dog was killed. Autopsy showed no loss of weight as in the previous case; slight engorgement of lymph glands; spleen four times normal size ; small amount of fluid in pleural cavities ; nothing unusual otherwise was observed. There also followed an exhaustive description of the histological findings of the tissues removed from the two animals. From these data, Lucibelli concluded that complete ligation of the thoracic duct caused death in the dog; that partial ligation caused little disturbance because collateral lymphatics established themselves soon; that complete ligation caused changes in all the organs and impaired their secretory function; that changes in the histological picture were due to the toxicity of stagnant lymph ; and that of various causes for cedema, change in the lymphatics was one.

The most recent work on the lymphatic system that involved ligation of the thoracic duct, is that by Bunting and Huston." These authors, in considering the fato of the lymphocyte, resorted to Mgation of the left thoracic duct and jugular vein just before the duct entered, and in some experiments the neck lymphatic tranks on the right side were also tied. All their work was done on the rabbit. They found that this procedure, coupled with splenectomy, produced a marked but temporary decrease in the absolute number of lymphocytes in the circulating blood. They also noted the numerous anomalies of the thoracic duct, and in one case observed anastomosing lymphatic vessels leading through the thymus to the right side.

In the foregoing brief review of the literature regarding the ligation of the thoracic duct as it affects the general economy of the animal, it can be seen that a gradual change in the opinion concerning the importance of the thoracic duct has taken place. At first it was held that ligation of the duct was fatal because the necessary alimentary juices no longer


24


[No. 371


reached the blood stream (Cooper"). Then it was argued that only those cases in which the ligation was complete were fatal; whereas, when all the branches of the thoracic duct were not included in the ligation and chyle could thus get into the blood stream, the animal survived (Magendie '^). Finally, it was believed, even complete ligation of the duct had no evil effect on the animal (Leuret and Lassaigne," Schmidt-Miihlheim ") .

Discussion of Litekatuke

In considering the literature quoted above, it is evident that no conclusive work has been done on the question regarding the effects on the animal of complete ligation of the thoracic duct and its branches, as well as noting the effects of such a ligation after a comparatively long period of time. Duvemey' obviously accomplished nothing with the ligations of the subclavian vein either proximal or distal to the entrance of the thoracic duct. Flandrin' anticipated Leuret and Lassaigne" by 30 years; yet he gave no evidence to support the complete ligation of the duct. Sir Astley Cooper ° and Mayer" claimed that ligation of the thoracic duct is lethal. Cooper claimed that rupture of the cisterna chyli accounted for the extreme extravasations ; however, Schmidt-^Miihlheim " showed by injections that with similar extravasations the cisterna was not ruptured. Indeed Cooper did not describe the rupture to any extent, but considered it a matter of fact. Magendie" believed that death of the animal at the end of 5 or 6 days was due to the effects of the ligation and nothing else. In all probability these deaths were due to infection. Again, Magendie used injections to trace out the lymphatic paths, and in this respect his work was better than that of many investigators who worked a hundred years later. Leuret and Lassaigne on the basis of one experiment found that Ligation had no evil consequences. However, they operated only on one side of the neck, satisfied themselves by dissection without the aid of previous injection that the duct really was tied off; postulated that the chyle took a different course, namely, from the cisterna chyli to the portal vein, and proved this again to their own satisfaction, by simply ligating the portal vein and finding, as a result, some blood in the cisterna chyli. Colin ' after numerous experiments on various domestic animals came to the same conclusion as ^Magendie ^ 50 years before. In his first animal he obviously did not get all the branches of the duct in the neck successfully ligated. In the case of the two dogs that lived respectively 30 and 25 days after operation, infection was also probably the cause of death, since the animals refused all food and behaved so differently from other dogs in which the duct was really tied without infection. In this respect the careful work of Schmidt-Miihlheim " is noteworthy. Up to this time all operative work had been done without antiseptic or aseptic precautions, and although " perfect suppuration " took place, nevertheless, this very fact vitiated practically the entire experiment. Schmidt-Miihlheim made the first serious attempt to prevent the chyle from reaching the blood stream ; and furthermore, he used injections to make sure that the ligations were complete. It would have


been interesting to know what would have taken place if the animals had been kept longer than seven days. Unfortunately, all the animals were sacrificed within a week from the time of operation. However, to tie off practically the entire superior vena cava is a considerable operation and a great shock to the animal; nevertheless, the animals recovered from the operation very satisfactorily. Even this operation would not necessarily always shut off the chyle from the blood stream, since it is possible that branches of the thoracic duct could enter the axillary vein distally to the point of ligation and eventually reach the heart through the collateral venous circulation which obviously would be established. The advantages of this operative procedure were at once recognized and frequently used by biochemists (Munk and Friedenthal "°) . Boegehold " also stated that ligation of the thoracic duct exerted no deleterious effect on the animal, basing his argument on clinical cases as well as on the result of his last experiment, in which he ligated the thoracic ducts according to the method of Schmidt-Miihlheim. In this animal he made a small injury to the duet, and three days after this found a small clot at the site of injury. Here the same objections can be raised as were advanced with Schmidt-Miihlheim; besides this, injection of the lymphatics was not made to ascertain whether the ligation was complete. The experiments of Stiller " are as novel as they are inconclusive. All that can be gathered from his work is that a complete ligation of the thoracic duct was attempted in the abdomen; that a large lymphatic trunk, probably the thoracic duct, was ligated; thdt the animal recovered and gained weight; and that the subsequent findings in the animal were promised but are not available. Lucibelli " tried to determine what effects ligation of the duct would have on the animal economy, particularly when studied several months after the operation. His animals were killed at the end of three months, which is the longest time any animals with ligated thoracic ducts were ever allowed to survive. Unfortunately, his work is not without serious objections. In the first place he ligated the duct on one side of the neck only, although previous work, particularly that of Selimidt-Miihlheim," had showTi how frequent it was that branches of the thoracic duct went to the right side, and how essential it was to ligate not only the thoracic duct on one side, but also to ligate the large veins in the base of the neck on both sides, as well as to ligate the right thoracic duct. That the dog is no exception in having many anomalies in the entrance of the thoracic duct into the veins was previously emphasized by Kuft'erath."^ In the second place, one of the two animals had a postoperative infection lasting nearly a month. This infection alone discounted the value of the results obtained by careful chemical analysis of the urine and blood. Again, he used as controls, not the same animal before operation, but preferred an entirely dilferent dog of about the same weight as tlie experimental animal and kept under the same conditions. Also, judging from the urinaiy findings, the first animal had what LucibeUi called a chronic interstitial nephritis. Accordingly, no animal with a kidney lesion, even though the thoracic duct be securely tied, could be compared


Jandaky, 1933]


25


with a normal animal, particularly in so I'ar as the urinary findings are concerned. The presence of the infection vitiated also all conclusions regarding the histological changes purported to be consequent to a thoracic duct ligation. There is, furthermore, no evidence supported by post-mortem procedures to substantiate the conviction that the ligations were successful ; and the absence of confirmatory examination alone makes the whole work faulty. It is needless to discuss the authoi-'s contention that his two experiments support the view that oedema is due to stagnant lymph formation. Finally, in the work of Bunting and Huston " there was no evidence to support the belief that the thoracic duct was completely ligated. Their work did show that the rabbit is also no exception to the general rule which holds that the entrance of the thoracic duct into the veins of the neck may be extremely varied.

Before proceeding to the experimental work, it may be added that numerous investigators (Kunkel, Fleischl," Kufferath,'* Harley," Josue,"' Wertlieimer and Lepage,'" Davis and Carlson") also ligated the thoracic duct and studied the effect of simultaneous ligation of the biliary duct, or subsequent changes in the number of lymphocj'tes in the blood. None of these authors operated in a way to preclude all possibility of anomalous collateral circulation, nor did all inject their specimens post-mortem to be sure of the course of the lymph.

The Russian literature also contains reports of work done on the ligation of the thoracic duct. Some of the work is experimental (Khlopin^), in which the absorption of fats was studied; others (Yitlin^°), reported a case of injury to the duct, and reviewed the literature on other cases of injury to the duct. It is interesting to note that Vitlin ^° and Temkin '° took the same case from the clinic of Professor Better in Berlin as a stimulus for their respective articles.

At the suggestion of Dr. Cunningham, and with his frequent advice, experiments were undertaken to determine what effect on the general economy of the animal ligation of the thoracic duet would have ; also what collateral circulation, if any, would be established. It is a pleasure to thank Dr. Sabin and Dr. Cunningham for their interest and help during this investigation.

Experimental Eesults

In all the experimental work the cat was used exclusively, chiefly because it is a convenient and very satisfactory laboratory animal, and also because the lymphatics of the cat have been described to a considerable extent. The animals were for the most part yoiing adult male cats, seemingly in good health. Food was withheld for 24 hours before the operation which was performed under ether anesthesia and with strict aseptic precautions. During the operation, the animal received the benefit of hot-water bottles and after operation it was placed in a wann cage. All the animals were weighed immediately before the operation and at various times after the operation.

Operative Procedures. — At first, attempts were made to ligate the thoracic duct in the neck. In these cases the animals were fed cream five hours before operation in order to make


the duct more conspicuous; at times this advantage was heightened by adding Scharlach R to the cream. Several of these operations were successful in so far as injections from below showed that the duct had been effectively ligated. But it was soon evident that this procedure clid not produce enough positive results to make it reliable for work which required absolute ligation of the duct, for frequently the duct had numerous entrances into the veins of the neck, and it was not possible to operate without feeling doubtful about the ligation of all the branches.

Accordingly it was decided to try to ligate the duct high up in the chest, before all the anomalous branches were given off. Because of the consequent pneumothorax following opening of the chest, intratracheal ether was given. A calibrated No. 13 F soft rui)ber catheter with accessory openings at its end was inserted into the trachea. Air for the apparatus was supplied by a foot bellows which was connected to a mercury safety valve adjusted to 20 mm. of mercury, and led over ether in. a WouLfe bottle, which was further provided with a by-pass direct to the catheter. With this apparatus all gradations from pure air to heavily saturated ether vapor could be administered at physiological pressures. The operation consisted in going into the second or third intercostal space, spreading the ribs apart, isolating the carotid artery and vagus nerve, inclosing as much of the surrounding tissue as possible in a ligature, and closing the cavity. This operation also was not successful, because isolation of the vagus nerve and carotid artery was often difficrdt, and besides branches of the duct to the right side were completely missed by this undertaking.

The Operation. — Finally it was decided to operate lower down in the chest, and this procedure gave the desired results. The animal was placed on its right side, with the left front leg drawn a little upward and forward. The left side of the chest was shaved over an area extending from the third to the tenth intercostal spaces, and from the midline in the back to the parasternal line. Iodine technique to the skin was employed. A transverse incision about 4.5 cm. long was made over the sixth or seventh intercostal space, extending forward from a point about 4 cm. from the midline of the back. Dissection was carried down to the latissimus dorsi muscle, the fibers of which were split longitudinally. By palpation the desired intercostal space was detemiined and dissection was carried down through the serratus muscle to the superior border of the rib bounding the inferior portion of the intercostal space ; this was done to avoid damaging the intercostal vessels which course superiorly. One was sure of good exposure when it was necessary to cut a few lateral fibers of the sacrospinal muscle. The intercostal muscles were then severed along the superior border of the rib, care being taken to cut to a uniform depth. After the pleura was reached, the tip of a pair of blunt-pointed scissors was thrust into the pleural cavity and the opening enlarged. A small pair of self-retaining rib retractors were inserted and the opening widened to about 3 cm. The lungs collapsed considerably and did not interfere with further work, particularly when the intratracheal pressure was kept low.


26


[No. 371


The thoracic duct was usually not seen because it contained no chyle. The adventitia over the anterior surface of the aorta was grasped with forceps and dra^-n slightly toward the opening. The adventitia inferior to the forceps was then carefully dissected from about the aorta as much as possible and an aneurysm needle with a fine silk thread was passed around the aorta ; this thread served as a traction suture on the aorta. A right-angled aneurysm needle was then inserted from the left to the right side of the aorta and under it, and turned through an angle of 180°, so that the point rested on the right side of the vertebral eolumu near the midline. The point was allowed to pass along the vertebral column to the left side until it appeared at the sympathetic chain. The tissues included in this ligature were the thoracic duct and sometimes the azygos vein. The aneun'sm needle was then passed under the aorta from its right to its left side, the tissues of the previous ligature were again included, but chiefly was it desired to get the tissue between the vertebral column and the esophagus. Sometimes it was necessary to include more tissue about the esophagus in a third ligature ; the ligation was thus completed. The ribs were approximated with a double medium silk suture; interrupted sutui'es for the muscle; the usual subcuticular stitch for closure. N"o dressing was applied but the iodinized area was carefully washed with ether to avoid any iodine irritation with consequent damage to the incisions. The entire operation from incision to closure did not take more than half an hour.

Post-Operative. — The animals made a satisfactorj' recovery following operation. They frequently ate on the day after operation. There was no evidence of diarrhoea, cedema or respiratory distress; slight abdominal tenderness was frequently obsened. The animals were weighed at intervals following the ligation ; the results were not unifonn. Some of the animals gained weight, some lost, whereas the one wHch was sacrificed 66 days following the operation, and showed absolute ligation of the duct, evidenced little change in weight. On a series of animals leucocyte counts and differential blood counts were made to study chiefly the lymphocyte change following the operation. This work will be reported later.

The cats were sacrificed from 24 hours to 77 days after ligation. Under ether anesthesia the abdomen was opened and the mesenteric lymphatics of the small intestine were injected vrith a saturated aqueous solution of Berlin blue. The ordinary hypodermic syringe with a Xo. 28 needle was found to be preferable to larger Record syringes, since the pressure of injection could be regulated better. The chief point in injecting the mesenteric IjTnphatics was to avoid any possible injection of veins, for if the dye reached the blood stream other than through lymphatico-venous communications, the experiment would be inconclusive. Thus, if the sul)serous layer or muscular coats of the intestines were injected, then the dye could possibly enter the veins as well as the lymphatics. The same objection held for the mesenteric IjTuph gland, since a direct injection of a lymph gland would also entail the possibility of .striking veins as well as lymphatics. During the injection of the last cubic centimeters of the dye.


the animal was killed, and the injection was continued until the ventricle stopped beating. This was done to insure a sufficient amount of dye at the Ij'mphatico-venous communications. The blue pigment was usually seen in the lungs after the chest was opened and the course of the injection with respect to the thoracic duct studied. Frequently the animal died during the course of the injection from a pulmonary embolus caiised by the injected material. Material for sections was cut from various organs ; .the remainder of the animal, except the head and extremities, was fixed in formalin and saved for further dissection.

Types of Collateral Circulation Focxd after Ligation of Duct

As a result of these dissections, two general types of collateral circulation were established. The one type consisted of a collateral circulation to the right thoracic duct, the other tj^pe comprised those cases in which the lymph entered the azygos vein or its branches.

The first type is illustrated- by Fig. 1 which shows the collateral circulation established to the right thoracic duct. It may thus be justly said that tliis case illustrates absolute ligation of the thoracic duct and the periaortic lym])hatic plexus. The animal from which the figure was drawn was sacrificed one week after operation. The structures of interest were taken out en bloc, dehydrated and cleared in oil of wintergreen. Attention is called to the absolute ligation of all lymph drainage to the left side of the neck. Below the point of ligation is a small but significant lymphatic plexus supplied by a large branch coming off from the thoracic duct. From the superior aspect of this plexus a small branch is seen to course on the azygos vein to a small gland at the mouth of the subclavian vein, and from there two trunks finally join and empty into the junction of the jugulo-cephalic trunk and the internal jugular vein.

Attention is also called to the general appearance of the abdominal lymphatic vessels soon after ligation of the thoracic duct. An cedema developed about the large lymphatic vessels, particularly around the cisterna chyli and its large trunks. This a?dema depended in its appearance on the nature of the fluid in the lymphatics. If these were laden with chyle, the cfidema was chylous in nature; if no chyle were present, the perivascular tissues were bathed in a limpid, slightly yellowtinged, clear fluid which seemed to contain small fatty droplets. In no case did this cedema resemble ascites to any degree. Likewise, the cisterna chyli was never found ruptiired. This cedema in some animals became well established at the end of 24 hours, and persisted for one week, as was shown in a case in which a marked constriction, but not occlusion, of the thoracic duct was secured.

The lymph glands imderwent marked hypertrophy. They had a fatty appearance, and showed the small follicles on the surface. They were very oedematous, and on section a considerable amount of clear, colorless fluid escaped. The increase in the size of lymph glands was more impressive in regious where they were ordinarily small and scarce, e. g., between


January, 192-2]


27


the large mesenteric gland and the small intestine. Occasionally, glands of the size of almonds were seen in this region. In no case did the spleen seem larger than normal. The thoracic duct above the point of ligation was iisually small and contracted.

In none of the dis.sections was the vagus nei-ve included in the ligature; occasionally, the left sympathetic chain was taken. Nor did the pigment reach the lungs via the direct lymphatic communication between the lungs and the cistema ehyli ( Cunningham " ) .

The second type of collateral circulation is shown in Fig. 2, which was drawn from a specimen in which the subject was sacrificed 66 days after ligation. The thoracic duct with the entire lymphatic plexus was ligated. The azygos vein was included in the ligature and thus precluded any collateral vessel developing, as illustrated in Fig. 1. It is seen that an extensive lymphatic plexus has developed at the cistema chyli and the azygos vein. Specimens of the contents of the azygos vein removed near the lymphatico-venous junction as well as a little further along the course of the vein, and examined under the microscope, revealed the Berlin blue pigment.

In one animal that was sacrificed three weeks after complete ligation, the lymphatico-venous connection was in the ninth left intercostal vein just before the latter entered the azygos vein. The communicating vessel took a tortuous path, commencing at a point on the thoracic duct at the level of the entrance of the ninth intercostal vein into the azygos vein, turned inferiorly and extended 7 mm. along the left side of the aorta, giving off small branches which entered the walls of tb-at vessel ; made several small shai-p turns and extended about 4 mm. superiorly and laterally ; then went medially and slightly inferiorly, making an acute angle with the ninth intercostal vein which it entered about 6 mm. from its junction with the azygos vein. This communicating vessel was almost the size of the intercostal vein, and was undoubtedly taking over the function of the thoracic duet.

In another case, a lymphatico-venous communication probably existed between a branch of one of the left lumbar veins and the cistema chyli, since the blue pigment was found in the distal part of the lumbar vein, but in much greater quantity at the entrance of the lumbar vein into the inferior vena cava. As the connection was not actually seen, the absoluteness of the jmiction cannot be claimed.

Eetrogeade Injection of Lymphatics Before entering into the discussion of the above findings, attention is called to the retrograde injection of lymphatics as found in the majority of the dissections. In studying the lymphatic distribution in embryoe by the injection method, advantage is constantly taken of the fact that specimens up to 5 cm. in length have the valves in their lymphatic vessels incompletely developed or entirely absent, and accordingly allow extensive retrograde injection of their lymphatic vessels (Sabin,"'°° Heuer," Cunningham"). In observing the relation of lymphatic vessels to connective tissue in pig foetuses by means of injections, MacCallum "^ noticed that the valves were


not very competent. In the adult, retrograde injections of lymph vessels entering the cistema chyli and regional visceral lymph glands have been described by Schmidt-Miihlheim " and Bartels." While injecting the mesenteric lymphatics, as above described, frequently one could see contributing branches of the vessel which was being injected centripetally gradually sufl'er retrograde injection through the successive dilatation of the intervalvular segments and the incompetence of their respective valves. In several cases such retrograde injections were carried to the subserous coat of the small intestine; while other cases showed a retrograde injection through the lymph glands draining the kidney with the afferent lymphatics injected as far as the hilum of that organ. Likewise, injections of small lymphatic vessels in the adventitia of the aorta and of vessels on the surface of the psoas muscle have been seen. Again, the large lymphatic plexus draining the liver and gall-bladder has been observed in a markedly dilated though uninjected state. In no case, however, have the parenchymatous lymphatic vessels been filled; and this in spite of the fact that these vessels are supposed to have either no or only a few valves (Bartels,°° p. 71). The problem seems to lie in emptying lymphatic capillaries before injections are made; this condition may possibly be achieved by introducing hypertonic solutions into the blood stream, thus emptying the lymphatic capillaries and allowing the injection mass to enter. Waldeyer,^' in 1867, called the attention of pathologists to the possibility of retrograde lymphatic transport of metastases.

Discussion

A new method has thus been described for ligating the thoracic duct. While ligations of the duct have been performed in the neck and in the abdominal cavity by other workers, no attempts, it seems, have been made to secure ligation in the chest, although the duct has been wounded frequently in that cavity for experimental purposes (Boegehold "). The operation can be performed without extensive dissection and without ligation of large veins (Schmidt-Miililheim ") ; it can be performed speedily and with a considerable guarantee of success. The method has provided experimental animals with absolute ligation that have lived apparently unaffected as long as 66 days after the operation. This period of survival of the animal in this study may be compared to the report of Lucibelli, in which it was stated that the longest period of survival after ligation of the duct was three months and eleven days, but in this work of Lucibelli there is much reason to believe that the ligation was not absolute. However, from the above experimental results, one can conclude that the integrity of the thoracic duct is not essential to the life of the animal.

Furthermore, the method of injecting the mesenteric lymphatics avoids all possibility of injecting the venous system inadvertently, and has provided excellent examples of retrograde injections of the lymphatic vessels. Naturally, previous ligation of the thoracic duct may have played a considerable role in facilitating these injections.

It is interesting to note to what extent the present knowledge of the embryology of the lymphatic system may be util


28


[No. 371


ized to explain the experimental findings. However, although it is not the purpose of this article to enter into the discussion of the various views regarding the origin of the lymphatic system (Huntington,'* Sabin,'" McClure," Lewis," Pensa"), it can be stated that at one time in embiyonic life a large lymphatic plexus exists extending from the veins at the base of the neck on either side, down around the aorta, and terminating in the cisterna chyli ; also, that the lower part of the embryonic thoracic duct is bila,tcrally sjTiimetrical. The


branch leading from this plexus to the right thoracic duct may also be considered a part of the embryonic plexus; the fact that it enters a gland first before proceeding to the veins suggests that it was originally one of the smaller and more remote portions of the plexus. In another animal which was sacrificed 77 days after ligation, this small connecting vessel had a counterpart in two huge trunks, each of which was almost the size of a normal thoracic duct; the corresponding gland was also markedly enlarged. This response of embryological


Superior vena ca\/


Juqulo-cephalic

trunk


Subclavian vein


7)h. Intercostal vein


Azyqos vein



Internal jugular vein.

Inferior thyroid vein. Common juqular vein. Subclavian vein Lett innominate vein.


Superior vena cava.


Point of ligation


Point ot ligation.



Lumbar vein


Entrance of lymptiatic into az,yqos vein.

Riqhf lumbar lymph node


Cisterna ctiyli.


Cisterna chyli


Fig. 1.


origin of the thoracic duet in the pig has been described by Baetjer." With these embiyological data as a basis, Davis" described and explained various types of thoracic duct anomalies, and it is interesting to note to what extent Fig. 1 fits in with some of the schematic representations of embryonic lymph channels that he depicted. Thus the small plexus developed below the point of ligation may well represent a portion of the embryological lymphatic plexus which normally does not function, but which, in response to the ligation, may have been forced to enlarge and dilate. Again, the small


Renal arfer_y. Fig. 2.

non-functioning lymphatic capillaries in a physiological capacity, if true, recalls in a measure the important work of Krogh " in relation to blood capillaries.

On the other hand, it is impossible to explain with our present knowledge of embryology, the connection between the thoracic duct and azygos vein, as illustrated in Fig. 2. It seems as if the earliest stages in the development of lymphatic vessels are as yet unknown. The recent work of Sabin ** on the development of blood vessels would suggest that the ditferentiation of angioblasts as well as the sprouting of the vascular


Januakt, 1923]


29


endothelium could lead to the formation of lymphatics at other places along the venous system than from the anterior cardinal veins or from the veins of the Wolffian body. Thus, they could arise from the azygos vein, form a plexus with those lymphatic vessels arising from veins at the usual places, and gradually become small and functionless "until physiological exigencies, produced, for example, by ligation of the thoracic duct, caused them to enlarge and function. Again, that large venous network in the early embryo which is associated with the azygos vein and which later disappears may be a factor in producing this lymphatico-venous connection.

E. E. Clark, in the dascription of a very curious anomaly of the thoracic duct, considered the embryology of the lymphatic system in the explanation of the condition. Likewise, clinical cases of lymphatico-venous fistulse have been discussed on this basis (Halsted"').

Again, the establishment of collateral lymphatic circulation may occur through the regeneration of lymphatics. However, the studies in the regeneration of lymphatics have not been extensive enougli, nor do they carry the necessary conviction (Meyer ") . As much as one is inclined to believe in the regeneration of lymphatics — and this could easily explain the result as illustrated in Fig. 1 — nevertheless, the necessary experimental proof seems lacking.

Since several cases of lymphatico-venous communications have been found (see Fig. 2), the subject of these connections is brought up for consideration. A host of writers (see Bartels "), as early as 1G62, had described unusual lymphaticovenous connections; and numerous other investigators have attempted to disprove the evidence. Boddaert," in 1899, described in the rabbit a connection of the thoracic duct with the azygos vein. Leaf " in 1900 maintained that the azygos vein received many lymphatic vessels. However, Bartels,^' in 1909, questioned the correctness of any such lymphatico-venous communications. More recent work had thrown new light on the subject. Silvester'" described the presence of permanent communications between the lymphatic and the venous systems at the level of the renal veins in adult South American monkeys; Baum " described cases where vasa efferentia of lymph glands emptied directly into veins; Job""' reported lymphatic conununications with the inferior vena cava, ileolumbar, renal and portal veins in rats. It seems, then, well established that the lymph does not necessarily have to enter the venous system at the base of the neck.

The presence, then, of these lymphatico-venous connections enters into the problem of fat absorption. The entire anatomy of the chyliferous portion of the lymphatic system suggests that the newly absorbed fat avoids direct entrance into the liver. Biochemists, even with refined methods for determining fats in body fluids (Bloor""), can recover from the thoracic duct only 60-70 per cent of the previously ingested food fats, but they are at a loss to explain the disposal of the remaining 30-40 per cent. Munk and Friedenthal ^ found that the blood fat increased after the thoracic duct had been tied. D'Errico " maintained that the percentage of fat in the portal vein was normally greater than that in the jugular vein, also that.


following ligation of the thoracic duet, the fat content of the portal vein with respect to the solid residue decreased but still remained higher than that of the jugular vein. He also believed that ligation of the duct accentuated lymphaticovenous communications. It is obvious that lymphatico-venous connections have been a generally unrecognized factor in all these studies of fat absorption involving ligation of the thoracic duct; and consequently these investigations are open to criticism.

Albrecht v. Ilaller, Albin and Hebenstreit are reported by Boegehold " to have seen the thoracic empty into the azygos vein. Wutzer,"* while demonstrating the course of the thoracic duct in the body of a woman 37 years old, noticed that there were three connections between the duct and the azygos vein; also, that above these connections, the duct became attenuated and fibrotic. This case seems to show that in regard to this lymphatico-venous connection there is an analogous relationship between the human subject and the laboratory animal.

However, in spite of this analogy, one cannot claim with absolute siirety that ligation of the thoracic duct in the human subject would prove equally inocuous. Yet it is clear, from the current surgical text-books as well as from the individual reports of injury to the thoracic duct, that there is no accepted method of treatment. Usually one of the four procedures is employed when the duct is injured : (1) Eepair of the wounded duct and provision for subsequent ligation if necessary; ( Gushing "'); (3) tamponade; (3) ligation of the vessel or (4) implantation of the severed duct into a vein (Harrison °). Convalescence is the rule. Gushing considered that in case of ligation of the thoracic duct the lymph current would be reversed, and finally all the lymph would be taken up by the right thoracic duct — a postulate supported in a measure by these experiments. A record of numerous clinical cases involving injury to the thoracic duct with a discussion of their treatment has been given by Zesas." " However, it is very questionable whether all the injuries to the thoracic dact really constituted injuries to the main trunk. Large lymphatic vessels from the head and neck often join the duct before its entrance into the vein and may be mistaken for the duct itself. Again, the presence of chyle does not guarantee the vessel to be the main trunk, because there frequently are several branches of the duct before its entrance into the veins.

In short, then, with the aid of the above experimental data, treatment of thoracic duct injuries would resolve itself into: 1, Eepair of the injury if possible ; or, 2, ligation. There is every reason to believe that similar treatment would apply to injury of other large and important lymph vessels ; e. g., the intestinal trunk.

Summary

After reviewing the literature on the experimental ligation of the thoracic duct, an intra-thoracic method has been described for complete ligation of the thoracic duct in the cat. It seems that the integrity of the thoracic duct is not essential to the life of the animal. In some cases in which the ligation was absolute, collateral lymph circulation was established to the right thoracic duct; while in other cases which showed


30


[No. 371


complete ligation, lympliatico-venous connections were found to exist between the thoracic duct and the azygos vein. The embryology of the lymphatic system may explain partly, but not entirely, these findings which also have a bearing on studies of fat absorption as well as on the clinical aspect of injuries to the thoracic duct.

BIBLIOGRAPHY

1. Asellius, G.: De lactibus sive lacteis venis Quarto Vasorum Mesaraicorum genera Novo Invento Gasparis Aselli Cremonensis Anatomici Ticinensis Dissertatio, Mediolani, 1627. Quoted from Bartels.°°

2. Lower: Tractatus de corde, item de motu, colore et transfusipne sanguinis et de chyli in eum transitu. Leyden. Editio sexta. MDCCXXVIII. Quoted from Schmidt-MuhUieim."

3. Flandrin: Experiences sur I'absorption des vaisseaux lymphatiques dans les animaux. Jour, de med., 1791, LXXXVII, 221.

4. Colin, G.: Traite de physiologie comparee des animaux. Deuxieme edit., Paris, 1873, II, 238.

5. Heidenhain, R.: Versuche und Fragen zur Lehre von der Lymphbildung. Arch. d. gesamm. Physiol., 1891, 209.

6. Starling, E.: The Influence of Mechanical Factors on Lymph Production. Jour, of Physiol., 1894, XVI, 224.

7. Biedl and v. Decastello : Ueber Aenderungen des Blutbildes nach Unterbrechung des Lymphzuflusses. Pfliigers Arch., 1901, LXXXVI, 259.

8. Duverney: Memoires de I'Academie des sciences, 1675. (Quoted from Colin.)

9. Cooper, Sir Astley: Three Instances of Obstruction of the Thoracic Duct, with some Experiments showing the Effects of Tying that Vessel. Medical Records and Researches selected from the papers of a private medical association. London, 1798, 86.

10. Mayer: (See Nockher: Dissertation: De Morbis Ductus Thoracici. Bonn, 1831, 35).

11. Rogers: Salzb. raed.-chir. Zeit., 1823, I, 112. (Quoted from Nockher.")

12. Magendie: Memoire sur le mecanisme de I'absorption chez les animaux a sang rouge et chaud. Jour, de Physiol., 1821, I, 21.

13. Leuret et Lassaigne : Recherches physiologiques et cliniques pour servir a I'histoire de la digestion. Paris, 1825, 178.

14. Schmidt-MUhlheim, A.: Gelangt das Verdaute Eiweiss durch den Brustgang ins Blut? Arch. f. Anat. u. Physiol. (Physiol. Abth.), 1877, 549.

15. Boegehold, E.: Ueber die Verletzung des Ductus Thoracicus. Arch. f. Chir., 1883, LXXX, 443.

16. Stiller: Die intraabdominale Ligatur des Ductus thoracicus beim Kaninchcn. Zugleich eine Kritik der Arbeit von Schwerdt ueber Morbus Basedowii. Cor.-Bl. d. allg. artzl. Ver. v. Thiiringen, 1898, XXVII, 412.

17. (a) V. Schwerdt: Der Morbus Basedowii, ibid., 365. (b) Idem: Erwidenmg auf die Arbeit des Herm Dr. Stiller. Ohrdruff: "Die intraabdominale Ligatur des Ductus thoracicus beim Kaninchen." ibid., 416.

18. Lucibelli, C: Sugli effetti dell' allaciatura del condotto toracico. N. Riv. Clin. Terap., NapoU, 1902, V, 401.

19. Bunting, C. H., and Huston, John: Fate of the lymphocyte. Jour, of Exper. Med., 1921, XXXIII, 593.

20. Munk and Friedenthal : Ueber die Resorption der Nahrungsfette und den wcchselnden Fettgehalt des Blutes nach Unterbindung des Ductus thoracicus. Zentralbl. f. Physiol., 1901, XV, 297.

21. Kufferath: Ueber die Abwesenheit der Gallensiiuren im Blute nach dem Verschluss des Gallen und des Milchbrustganges. Arch. f. Anat. u. Physiol. (Physiol. Abth.), 1880, 92.

22. Kunkel: Ber. d. Gesellsch. d. Wissensch. in Leipzig, 1873. (See Harley.")

23. V. Fleischl: Ibid., 1874. (See Harley.")

24. Harley, V.: Leber und Galle wahrend dauemden Verschlusses von Gallen- und Brustgang. Arch. f. Anat. u. Physiol. (Physiol. Abth.). 1893, 291.

25. Josue, A.: Ligature du canal thoracique; presence de microbes dans le bout inferieur, tandis que le sang est aseptique. Compt. rend. Soc. de biol., Paris, 1895, S. 10, II, 25.

26. 'Wertheimer and Lepage: Sur les effets de la ligature simultanee du canal choledoque et du canal thoracique. Jour, de physiol. et de path, gen, 1899,1,259.

27. Davis, B.F., and Carlson, A. J.: Contributions to the Physiology of the Lymph. IX. Notes on the leucocytes in the neck, lymph, thoracic lymph, and blood of normal dogs. Am. Jour. Physiol., 1909, XXV, 173.

28. Khlopin, N.: (On the influence of hgating the thoracic duct in dogs upon the assimilation of fats.) St. Petersburg, 1892.

29. Vitlin, I.: (Injuries to the thoracic duct in cases of chylothorax and chylous ascites in connection with anatomical and experimental data on the chyhferous system.) Ivharkov. Med. Jour., 1909, VII, 87.

30. Temkin, S.: Dissertation: Zur Frage iiber die Verletzung des Milchbrustganges (Ductus thoracicus) and die Fiille von Chylothorax und Ascites chylosa im Zusammenhang mit dem anatomischen und experimentellen Angaben ilber das Chylusgefiisssystem. Berlin, 1909.

31. Cunningham, R. S.: On the development of the lymphatics of the lungs of the embryo pig. Contrib. Embryol. (Carnegie Inst.), Wash., 1916, IV, 47.

32. Sabin, F. R.: On the origin of the lymphatic system from the veins and the development of the lymph hearts and thoracic duct in the pig. Am. Jour. Anat., 1902, I, 367.

33. Sabin, F. R.: On the development of the superficial lymphatics in the skin of the pig. Amer. Jour. Anat., 1904, III, 183.

34. Heuer, G. J.: The development of the lymphatics in the small intestine of the pig. Amer. Jour. Anat., 1909, IX, 91.

35. MacCallum, W. G.: Die Beziehung der Lymphgefasse zum Bindegewebe. Arch. f. Anat. u. Phys. (Anat. Abth.), 1902, 273.

36. Bartels, P.: Das Lymphgefiisssystem, in v. Bardeleben: Handbuch der .\natomie des Mensehen, Bd. III. Abt. IV, 69.

37. Waldeyer, W.: Ueber die Entwicklung der Carcinome. Virchows Arch., 1887, XLI, 470.

38. Huntington, G. S.: The anatomy and development of the systemic lymphatic vessels in the domestic cat. Phila., 1911. (Wistar Inst. Anat. & Biol., Phila., Memoirs, No. 1.)

39. Sabin, F. R.: Der Ursprung und die Entwickelung des Lymphgefasssystems. Ergebnisse der Anatomie und Entwickelungsgeschichte, 1913, XXI, 1.

40. McClure, C. F. W.: The development of the thoracic and right lymphatic duets in the domestic cat (Felis domestica). Anat. Anz., 1908, XXXII, 534.

41. Lewis. F. T.: The development of the lymphatic sj'stem in rabbits. Am. Jour. Anat., 1906, V, 95.

42. Pensa, A.: Studio suUa morfologia e sulla topografia della cisterna chili e del ductus thoracicus nell' uomo ed in mammiferi. Richerche di anat. norm. d. r. Univ. di Roma, 1908, XFV, 1.

43. Baetjer, W. A.: On the origin of the mesenteric sac and thoracic duct in the embryo pig. Amer. Jour. Anat., 1908, VIII, 303.

44. Davis, H. K.: A statistical study of the thoracic duct in man. Am. Jour. Anat., 1915, XVII, 211.

45. Krogh, A.: The supply of oxj'gen to the tissues and the regulation of the capillary circulation. Jour. Physiol., 1919, LII, 457.

46. Sabin, F. R.: Studies on the origin of blood-vessels and of red blood corpuscles as seen in the living blastoderm of chicks during the second day of incubation. Contrib. Embryol. (Carnegie Inst.), Wash., IX, 213.

47. Clark, E. R.: An anomaly of the thoracic duct with a bearing on the embr\'ology of the lymphatic s>'stem. Contrib. Embrj'ol. (Carnegie Inst.), 'Wash., 1915, II, 45.

48. Halsted, W. S. : Congenital arterio-venous and lyinphaticovenous fistulae. Unique clinical and experimental observations. Contrib. Med. and Biol. Research. Ded. to Sir Wm. Osier, 1919, 1, 560.

49. Meyer, A. W.: An experimental study on the recurrence of lymphatic glands and the regeneration of lymphatic vessels in the dog. Johns Hopkins Hosp. Bull., 1906, XVII, 185.

50. Boddaert, R.: Etude sur une communication exceptionelle entre le canal thoracique et la veine azygos chez le lapin. Ann. de la Soc. de med. de Gand, 1899, LXXVIII, 123.

51. Leaf, C. H.: On the relation of blood to lymphatic vessels. Lancet, 1900, I, 606.

52. Silvester, C. F.: On the presence of permanent communications between the lymphatic and venous sj'stem at the level of the renal veins in adult South American monkeys. Am. Jour. Anat., 1912, XII, 447.

53. Baum, H.: Konnen Lymphgefasse direkt in Venen einmiinden? Anat. Anz., 1911, CXL, 593.

54. Job, T. T. : The adult anatomy of the Ij'mphatic sj'stem in the common rat (Epimys norvegicus). Anat. Record, 1915, IX, 447.

55. Idem: Lymphatico-venous communications in the common rat and their significance. Am. Jour. Anat., 1918, XXIV, 487.

56. Bloor, W. R.: Fat assimilation. Jour. Bio-Chem., 1916, XXIV, 447.

57. d'Errico, G.: Contributo alio studio delle vie di assorbimento del grasso alimentare. Arch, di fisiol., 1907, FV, 513.

58. Wutzer, C. W.: Einmiindung des LKictus thoracicus in die Vena azygos. Mviller's Arch., 1834, 311.

59. Gushing, H.: Operative wounds of the thoracic duct. Report of a case with suture of the duct. Ann. Surg., 1898, XXVII, 719.

60. Harrison, E.: On the treatment of wounds of the thoracic duct. Brit. Jour. Surg., 1917, IV, 304.

61. Zesas, D. G.: Die operativ enstandene Verletzungen des Ductus thoracisus. Ihre Bedeutung. Ihre Behandlung. Deutsche Ztschr. f. Chir., 1911-12, CXIII, 197.

62. Idem: Die nicht operativ enstandene Verletzungen des Ductus thoracicus. Ibid., 1912, CXV, 49.


STUDIES ON EXPERIMENTAL RICKETS XV. THE EFFECT OF STARVATION ON THE HEALING OF RICKETS

By E. V. McCoLLUM and Nina Simjionds Department of Chemical Hygiene, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore

and

P. G. Shipley and E. A. Park,

Department of Pediatrics, The Johns Hopkins University, Baltimore


We have shown elsewhere ^ that certain types of faulty diets induce bone changes identical with those seen in rickets in human beings. Cod-liver oil exerts a pronounced effect in preventing the development of these changes, or, once they are established, tends to cause the bones to return toward a normal condition.

The most effective way which we have found to demonstrate the therapeutic value of cod-liver oil is through the application of our " line test," which has been fully described in another paper. Young rats are restricted to our diet ( Lot 3143) which has the following compo.«ition for a period of 35-40 days.

Lot 3143

Wheat 33.0

Maize 33.0

Gelatin 15.0

Wheat gluten 15.0

NaCl 10

CaCOs 3.0

Any other diet having identical dietary properties would serve the same purpose.

This diet contains proteins of good quality and in great abundance (about 33 per cent), and about twice the calcium necessary for optimal growth and nutrition. It is, however, low in fat-soluble A and below the optimum in its content of phosphorus. One hundred grams contains 0.3019 grams of phosphorus.


If young rats are fed on this diet they develop a condition of the skeleton which is identical with the most severe rickets seen in the child. In the bones of these animals (Fig. 1) the cartilage is overgrown and abnormally persistent. The shaftward margin of the cartilage is irregular and the cartilage is invaded by blood vessels from the shaft of the bone. Lime salts are not deposited in the cartilage, so that no zone of provisional calcification is formed. A wide zone of tissue is formed between the cartilage and the shaft proper of the bone. This is made up of blood vessels, connective tissue and marrow elements, and of cartilage cells in all stages of degeneration, reversion, and of metaplasia into osteoid tissue. This is the rachitic metaphysis. The cortex of the shaft of the bone and the trabeculae of the spongiosa are surrounded by wide zones of osteoid tissue (uncalcified bone). No signs of abnormal resorption of bone tissue are to be found. These bones are very soft and at autopsy the animals show deformities of the skeleton which we have discussed in detail in a preceding communication.'

When a young rat has been restricted for 35-40 days to this diet, experience has shown that the cartilage and adjacent portion of the metaphysis in the long bones will be entirely free from calcium salts. If now cod-liver oil is administered to the amount of 3 per cent of the diet, calcium salts are deposited in the cartilage on the epiphyseal side of the metaphysis. This amounts to the reappearance of the provisional zone of calcification. From the work of Schmorl and others we know this phenomenon to be the beginning of the healing of the lesion. The deposited salts appear in longitudinal sections


32


[No. 371


of the bone as a fine line crossing the proliferative zone of the epiphyseal cartilage transversely.

We have found that the administration of cod-liver oil to the amount of 2 per cent of the diet causes the line of calcification to appear in the cartilage within five days.

We have recently observed that when young rats with rickets are made to fast for periods of three to five days (distilled water only being oifered). liealing begins in exactly the same way as it does when suitable amounts of cod-liver oil are administered.

Ten animals, as indicated in Table I, were fed on our diet No. 3143. At the expiration of tlie preparatory period they were placed in special cages and starved for 3-5 days.* They were then killed with chloroform and autopsied. The long bones were bisected longitudinally, immersed in a 1 per cent solution of silver nitrate, and examined under the microscope after exposure to light for the presence of a newly deposited provisional zone of calcification. The results of this gross examination were checked by the study of celloidin or frozen sections.

TABLE I Data DESCEn'xmi; op Rats Employed for Showino the Effects op

Fasting on the Initution of the Healing Process in Rickets


Number of rats


Age in days when put on diet


Days on diet


Age in days at death


Days

starved


Sex


Weight at death


1183


60


70


130


5


d


82


1221


4.i


64


109


5*


d


87


1341


45


49


94


2*


9


101


1345


55


49


104


3*


9


85


1358'


60


55


115


3*


d


125


1364


65


30


95


3<^


d


80


1365


65


30


95


3*


9


80


1366


65


30


95


3


9


68


1368


60


35


95


3


9


75


1369


60


35


95


3


9


75


Found dead on the morning of the day indicated. The results of starvation were controlled by the examination of animals which had been raised in the same cages on diet No 3143 at the same time, but had not been staiTed.j Not one of the starved animals failed to show reformation of the provisional zone of calcification, and other evidences of the healing of the rachitic process. None of the controls had a vestige of calcium in the cartilage or metaphysis.

Since we have found that even on diet No. 3143 rats wliich were exposed daily to sunlight in the summer from the begin

The cages employed for the fasting rats had wide mesh wire bottoms, so that the feces passed through, and it was impossible for the animals to cat their stools. No bedding of any kind was available for the rats to eat.

t We have sections from the bones of nearly 100 animals which were maintained on diet No. 3143 under the same conditions as our test animals. These served as an additional control for the test.


ning of the experiment did not develop rickets,' three methods are now known of inducing the deposition of calcium salts in the cartilage of the bones of rachitic rats, viz., through starvation, exposure to light, and through the administration of cod-liver oil.

It is difficult to think of any single explanation for the common effect produced by cod-liver oil, sunlight and starvation on the skeleton of the rat rendered rachitic by means of a faulty diet. The possibility has been suggested that the effect of codliver oil may be attributable to physical force of one kind or another. This view we have discussed more fully in another place. But even if the effect of cod-liver oil should be the result of a physical force rather than a chemical reaction it does not follow that one could generalize regarding the other vitamins and accept the view that they necessarily act in an analogous manner. The analogy between the effects on the body of vitamin preparations and of the hormones is so striking that we are not justified in hastily abandoning the view that the vitamins are organic substances. Two at least of the hormones, thyroxin and adrenalin, are definite organic compounds.

Starvation causes healing of the rickets in a rat just as do cod-liver oil and sunlight, and the mechanism of the deposition of calcium salts in the proliferative cartilage may be the same. But cod-liver oil and sunlight improve the general condition of the animal. This is indicated by increased growth, longevity, muscular activity, storage of fat, and sexual potency. Starvation, on the other hand, causes the death of the rat in a few days. Its effects on the animal are favorable only in that they cause the healing of rickets. The mode of action of the three agents must be entirely different. It seems necessary to think that sunlight and cod-liver oil act by enabling the cells to carry on, even when their food supply is unfavorable. In other words, they aid the organism to adapt itself to an adverse environment. Starvation, on the other hand, must produce healing of the rickets at the expense of other body tissues. We cannot disprove at present the possibility that the cell functions more effectively when it is relieved of the load which a faultj' diet imposes on it. However, during starvation certain tissues are destroyed for the upkeep of the supply of nutriment for those whose integrity must be safe-guarded to preserve life.

We have shown that the administration of cod-liver oil is followed by healing of rickets in rats even when they are receiving a diet with a faulty calcium-phosphate ratio. It may be that during the disintegration of protoplasm, which is consequent upon stan^ation, some substance is liberated which permits the animal to readjust the salt ratio within itself. But although it is possible that starvation liberates from the tissues an organic factor or factors, such as are in cod-liver oil, it is not necessary to account for healing in this way. Providing calcium and phosphorus are present in the proper proportions, normal calcification of the skeleton will occur. When the defects in the diet are such as they happen to bo in the diet which we employed in these experiments (diet No. 3143), it would only be necessaiy for phosphorus to be liberated into the blood stream from disintegrated protoplasm (muscle for ex


THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1922



Fig. 1.- -l>lH.iM,,,iri animal whicli li:nl n i fication of tin ciniili


i|ili of -d >\'(.-tiun friuii tlie rachitic rd diet No. 3143. There is no calciil cartihige or of the metaphysis.



Fig. 2.— Photomicrograph .-^howiii:: ;i,i i . -lurination ol a pre \i?ional zone of calcification (Ca) in the bone of a rachitic aniiiu which had been star\-ed for .5 days.


Januaey, 1922]


33


ample) in order to cause calcium deposition to occur in the cartilage. Animals on diet No. 3143, like rachitic children, have much less than the normal amount of phosphorus in the circulating blood. The administration of cod-liver oil or radiation from the mercury vapor quartz lamp causes the phosphorus in the blood to rise and it is not improbable that the healing of rickets which results from starvation is the immediate result of an equivalent increase of this element in the circulating blood. Just as soon as the load of a defective diet is removed and the body is forced to draw on its own tissues for maintenance of life and function, stored foodstuffs are released into the blood stream as the result of a process of selective tissue decomposition.

These experiments furnish the first anatomical proof of the beneficial effect of starvation on the animal body. The good effects of fasting are given a new meaning, because the organism is able to adapt itself to pathogenic distortions of normal metabolic ratios when the burden of carrying on exogenous metabolism is removed. Since the starving body is capable of readjusting abnormal relations within itself it is easy to understand the benefit derived by a diabetic from occasional hunger daySj and why it is that the wasted athreptic infant does not develop rickets.


Eickets has certain of the characteristics of a deficiency disease because a certain substance contained in cod-liver oil and elsewhere corrects an anatomical condition which develops when the calcium and phosphorus in the diet are present in wrong proportions. Yet rickets has a feature entirely distinct from beri-beri, scun'v, and xerophthalmia. The relation between two inorganic elements determines the extent of the animals' need for the organic factor wliich cod-liver oil furnishes. No such relationship between a vitamin and any other food substance has been clearly demonstrated in any other condition.

BIBLIOGRAPHY

1. E. V. McCollum, Nina Simmonds, P. G. Shipley, and E. A. Park. Studies on Experimental Rickets. VIII. The Production of Rickets by Diets low in Phosphorus and Fat-soluble A. Jour. Biol. Chem., 1921, XLVII, 507.

2. P. G. Shipley, E. A. Park, E. V. McCollum, Nina Simmonds, and H. T. Parsons. Studies on Experimental Rickets. II. The Effect of Cod-Liver Oil Administered to Rats with Experimental Rickets. Jour. Biol. Chem., 1921, XLV, 343.

3. E. A. Park, G. F. Powers, P. G. Shipley, E. V. McColhim, and Nina Simmonds. Studies on Experimental Rickets. XIV. The Prevention of the Development of Rickets in Rats by Sunhght. Jour. Amer. Med. Asso., 1921.


NOTES AND NEWS


Dr. Joseph Akerman is Associate Professor of Obstetrics in the Medical Department of the University of Georgia, Augusta, Ga.

Dr. John H. Baird is Associate in Surgery, The Medical College of Virgmia, Richmond, Va.; also Associate in Oral Surgery at the same institution.

Dr. Stanhope Bayne-Jones is Associate Professor of Bacteriology and Pathology, The Johns Hopkins Medical School.

Dr. Smiley Blanton is Professor of Mental Hygiene, University of Wisconsin, and Attending Specialist at U. S. Public Health Service Hospital No. 37, Waukesha, Wis.

Dr. E. Bates Block is now Professor of Neurology and Psychiatry, Medical Department, Emory University.

Dr. IMontague L. Boj'd is Urologist to the Georgia Baptist Hospital, Atlanta, to the Grady City Hospital, Atlanta, and to the Wesley Memorial Hospital, Atlanta.

Dr. Eveleth W. Bridgman is Associate in Clinical Medicine, Johns Hopkins Medical School, Assistant Visiting Physician, Johns Hopkins Hospital, and Dispensary Physician, Johns Hopkins Hospital.

Dr. N. Worth Brown is Visiting Physician to the Toledo Hospital, Toledo, Ohio.

Dr. Nathaniel H. Brush is Attending Neuro-Psychiatrist to the Santa Barbara Cottage Hospital, Santa Barbara, Cal.; and Chief of the Neuro-Psychiatric Service in the Out-Patient Department of the same Hospital.

Dr. C. Sidney Burwell, formerly of the Massachusetts General Hospital, is Resident Physician at The Johns Hopkins Hospital, and Instructor in Medicine in The Johns Hopkins Medical School.

Dr. George L. Carrington is on the surgical service of the house staff of the New Haven Hospital, New Haven, Conn.

Dr. David W. Carter, Jr., is Visiting Physician, B.iylor Hospital, Dallas, Texas, Visiting Physician, Parkland Hospital, Dallas, and Associate Professor of Medicine, Baylor University College of Medicine.


Dr. Howard L. Cecil is to be associated this year with Baylor Hospital and University, Dallas, Texas.

Dr. Malvern B. Clopton is now holding the following positions: Visiting Surgeon, St. Luke's Hospital, St. Louis; Associate Surgeon, St. Louis Children's Hospital, St. Louis; Assistant Surgeon, Barnes Hospital, St. Louis; and Associate in Clinical Surgery, Washington University Medical School, St. Louis.

Dr. Frank D. Conroy is Resident of the Contagious Department of the Cincinnati General Hospital, and Instructor in the College of Medicine of the University of Cincinnati.

Dr. Ernest K. Cullen is Attending Gynecologist, Harper Hospital, Detroit, and Professor and Director of the Department of Gynecology, Detroit College of Medicine and Surgery.

Dr. Edward C. Davidson is at present on the staff of the surgical department of the Heniy Ford Hospital.

Dr. Wilburt C. Davison is Assistant Dispensary Pediatrician, Johns Hopkins Hospital.

Dr. Clyde L. Deming is an Assistant Professor in Surgery, in charge of the Urological Sei-vice, at Yale University.

Dr. Alphonse R. Dochez is Associate Professor of Medicine, College of Physicians and Surgeons, Columbia University, and Visiting Physician, Presbyterian Hospital, New York City.

Dr. John C. Donaldson is Assistant Professor of Anatomy, School of Medicine, University of Pittsburgh.

Dr. Roger G. Doughty is a Fellow at the Cleveland Clinic, Cleveland, Ohio.

Dr. Edgar E. Duncan is Resident at the Woman's Hospital, Baltimore.

Dr. Ethel C. Dunham is Instructor in Pediatrics in the Yale University Medical School, New Haven.

Dr. William C. Duffy is Resident Surgeon, New Haven Hospital, and Instructor in Surgery, Yale University.


34


[No. 371


Dr. Franklin G. Ebaugh is Assistant Physician, New Jersey State Hospital, Trenton, also Visiting Psychiatrist, State Home for Boys, Jamesbury, N. J.

Dr. Arthur B. Emmons, 2d, is Director of the Harvard Mercantile Health Work and Instructor in the Practice of Industrial Medicine, Harvard Medical School.

Dr. Augustus R. Felty is Assistant in Medicine, Columbia University — Presbyterian Hospital, New York City.

Dr. Morris Flexner is Instructor in Clinical Microscopy in the Medical Department of the University of Louisville.

Dr. James C. Fox, Jr., is Assistant in Medicine, Yale University School of Medicine, and member of the staff of the New Haven Hospital.

Dr. Thomas O. Gamble is Associate Visiting Obstetrician, Albany Hospital, and Dispensary Obstetrician, South End Dispensary, Albany, N. Y.

Dr. Hildegarde C. Germann is teaching Anatomy and Physiology in the Blessing Ho.spital Training School for Nurses in Quincy, Illinois. Dr. Germann is also in practice in Quincy.

Dr. Herbert Z. GifBn is Chief of Section in Division of Medicine in the Majo Clinic, Professor of Medicine on the Mayo Foundation for Medical Education and Research, Graduate School, University of Minnesota.

Dr. Calvin H. Goddard is now an Assistant Director, in charge of the Out-Patient Department, Johns Hopkins Hospital.

Dr. Emil Goetsch is Professor of Surgery, at the Long Island College Hospital, and Surgeon-in-Chief, Long Island College Hospital, Brooklyn, N. Y.

Dr. L. W. Gorham is Clinical Professor of Medicine, Albany Medical College, and Assistant Attending Physician, Albany Hospital.

Dr. Jacob P. Greenhill is Chief Resident of the Chicago Lying-in Hospital, and Demonstrator in Operative Obstetrics at the Northwestern Medical School, Chicago.

Dr. Cb'de G. Guthrie is Chief of the Medical Service, Johns Hopkins Hospital Dispensary, Associate Physician, Johns Hopkins Hospital, and Associate Professor of Medicine, Johns Hopkins Medical School.

Dr. Margaret I. Handy is Junior Chief in Pediatrics at the Delaware Hospital, Wilmington, Del.

Dr. Edward M. Hanrahan, Jr., is now Assistant Resident Surgeon, Union Memorial Hospital, Baltimore.

Dr. George Harrop is Resident Physician at the Presbyterian Hospital, New York City, and Instructor in Medicine at Columbia University.

Dr. R. F. Hastreiter is on the staff of the Clara Barton Hospital, Los Angeles, Cal.

Dr. David K. Henderson is now Phy.sician-Superintendent of the Royal As>-lum, Gartnavel, Glasgow, Scotland.

Dr. William H. Higgins is Associate in Medicine, Medical College of Virginia.

Dr. Frank Hinman is Visiting Urologist, San Francisco City and County Hospital; Urologist, University of California Hospital; Assistant Clinical Professor of Urology, University of California Medical School.

Dr. A. D. Hirschfelder is Professor and Director of Pharmacology, University of Minnesota, Minneapolis.

Dr. James M. Hitzrot is Associate Attending First Surgical Division, New York Hospital, New York City; Professor of Clinical Surgery at Cornell Medical School, New York City.

Dr. Walter R. Holmes is Associate in Gynecology, Emoiy University, Atlanta, Assistant Visiting Surgeon, Georgia Baptist Hospital, Atlanta, and Assistant Visiting Surgeon, Piedmont Hospital, Atlanta.

Dr. John G. Huck is now Assistant in Medicine, Johns Hopkins Hospital, and Instructor in Medicine, Johns Hopkins Medical School.


Dr. Henry T. Hutchins is Surgeon, Massachusetts Women's Hospital, Boston, and Consulting Gynecologist, Memorial Hospital, Pawtucket, R. I.

Dr. Albert Keidel is Associate in Clinical Medicine, and Physician in Charge, Syphilis Department, John Hopkins Medical School.

Dr. Norman M. Keith is at present Assistant Professor of Medicine of the University of Minnesota (Mayo Foundation), Rochester, Minn.

Dr. Ferdinand C. Lee is Instructor in Anatomy, Johns Hopkins Medical School.

Dr. Charles S. Levy is Chief Surgical Resident at the Hebrew Hospital, Baltimore.

Dr. D. S. Lewis is Assistant Physician at the Royal Victoria Hospital, Montreal.

Dr. Frederick H. Linthicum is now in private practice in Los Angeles, Cal.

Di'. Hans Lisser is Assistant Clinical Professor in the Department of Medicine, University of California Medical School, and Chief of the Ductless Gland Clinic, University of Cahfornia Out-Patient Department, San Francisco, Cal.

Dr. Herbert M. Little is Assistant Professor in Obstetrics and Lecturer in Gynecology, McGill University, Montreal, and Associate Gynecologist, Montreal General' Hospital, and Obstetrician, Montreal Maternity.

Dr. Arthur J. Lomas is now Superintendent of the University Hospital, Iowa City, Iowa.

Dr. David R. Lyman, who has been Medical Superintendent of Gaylord Farm Sanatorium for some time, is now Clinical Lecturer on Tuberculosis, Yale Medical School.

Dr. Irving P. Lyon is Associate Professor of Medicine, University of Buffalo, Attending Physician to the Buffalo General Hospital, the Buffalo City Hospital, the Diagnostic Clinic (Buffalo City Hospitals and Dispensaries), and Consulting Physician to the New York State In.stitute for the Study of Malignant Diseases.

Dr. L. K. McCafferty is Clinical Assistant, Skin and Sj'philis, Vanderbilt Chnic, Columbia University, and Assistant in the OutPatient Department, Skin and Sj'philis, Presbyterian Hospital, New York City.

Dr. William S. McCann, formerly of the Russell Sage Institute, Bellevue Hospital, is now Associate Physician, Johns Hopkins Hospital.

Dr. James C. McClelland is Demonstrator in Surgery in the Toronto General Hospital, which also includes an appointment on the Univeisity of Toronto Staff.

Dr. William B. McClure is Junior .attending Pediatrist, Evanston Hospital, Evanston, Illinois, Assistant Attending Physician, The Children's Memorial Hospital, Chicago, Assistant Director, The Otho S. .A.. Sprague Memorial Institute, Laboratory of the Children's Memorial Hospital, Chicago, and is doing graduate teaching in the Children's Memorial Hospital.

Dr. Albert McCown is engaged in private practice in Tacoma, Washington.

Dr. Ralph H. Major is Professor of Internal Medicine at the University of Kansas, Rosedale, Kans.

Dr. Verne R. Mason is engaged in private practice in Los Angeles, Cal.

Dr. Kenneth F. Maxcy is Assistant Surgeon in the Regular Corps of the Service, and stationed at Field Headquarters, Memphis, Tenn.

Dr. Milo K. Miller holds the position of Pediatrician, in The Clinic, and Visiting Physician, Children's Free Dispensaiy, South Bend, Ind.

Dr. Joseph E. Moore is Instructor in Clinical Medicine, Johns Hopkins Medical School, Baltimore.


January, 1923]


35


Di'. Hugh J. Morgan is now Assistant Resident Physician at the Hospital of The Rockefeller Institute for Medical Research, New York City.

Dr. I. William Nachlas is at present Assistant in Orthopedic Surgery, Johns Hopkins Medical School, Assistant Dispensar>' Orthopedist, Johns Hopkins Hospital, Adjunct in Orthopedic Surgery, Hebrew Hospital, and Orthopedic Surgeon, Robert Garrett Hospital, Baltimore, Md.

Dr. Patrick I. Nixon is Gynecologist, Robert B. Green Memorial Hospital, San Antonio, Texas.

Dr. Charles C. Noms is Assistant Gynecologist to the Hospital of the University of Pennsj'lvania, Gynecologist and Obstetrician to the Philadelphia General Hospital, Gynecolgical and Obstetrical Radiologist to the Philadelphia General Hospital, Gynecologist to the Children's Hospital, Philadelphia, and Gynecologist and Obstetrician to the Henr\- Phipps Institute, Philadelphia.

Dr. Edward Novak is Dispensary Physician, Johns Hopkins Hospital, and Attending Phj'sician, South Baltimore General Hospital.

Dr. John R. Oliver is Assistant Dispensaiy Psychiatrist, Phipps Clinic, Johns Hopkins Hospital. Chief Medical Officer to the Supreme Bench of Baltimore City, Lecturer on Medical Jurisprudence at the Law School of the University of Marjdand, and Associate Editor of the Journal of the American Institute of Criminal Law and Criminology.

Dr. John K. Ormond is Assistant Surgeon-in-Chief at the Henry Ford Hospital. Detroit, Mich.

Dr. Walter W. Palmer is now Bard Professor of Medicine, College of Ph.vsicians and Surgeons, Columbia University, and Director of Medicine of the Presbyterian Hospital, New York City.

Dr. Katherine Pardee is engaged in post-graduate study as Fellow in Internal Medicine on the Mayo Foundation at Rochester, Minnesota.

Dr. Kenneth A. PlielpS is Instructor in Oto-Larj'ngology and Ophthalmology, at the University of Minnesota, Minneapolis.

Dr. Winthrop M. Phelps is taking a combined house-officership in orthopedics in Boston — in the Children's Hospital until May, 1922. and in the Massachusetts General Hospital from Maj- to November, 1922.

Dr. Lawrence Post is Chnical Assistant in Ophthalmology, Washmgton Universitj- Medical School, and instructor in specially arranged post-graduate courses.

Dr. Mary Putnam is Dispensary Physician at the Children's Hospital, Boston, Massachusetts.

Dr. Arnold R. Rich, who has a leave of absence for one year, is Associate in Pathology, Johns Hopkins Medical School, Baltimore.

Dr. G. Canby Robinson is Acting Professor of Medicine, Johns Hopkins Medical School, Baltimore, and Acting Physician-in-Chief, Johns Hopkins Hospital.

Dr. Stephen Rushmore is Visiting Obstetrician, Evangeline Booth Hospital, Consulting Gynecologist, Symmes Arlington Hospital, Associate Professor of Gynecology, Tufts College Medical School, Boston, Mass,

Dr, S, W. Schaefer is an Instructor in the Colorado School of Tuberculosis in Colorado Springs, Colo.

Dr. Ralph B. Seem, was granted in April, 1921, one year's leave of absence from the Albert Billings Memorial Hospital, University of Chicago, to be Acting Superintendent of the Union Peking Memorial College Hospital, Peking, China,

Dr, Albert B. Siewers is Assistant in Neuropsychiatry in the Medical School, Syracuse University and in the Syracuse Free Dispensary.

Dr. J. Morris Slemons is engaged in private practice in Los Angeles, California.

Dr. Joseph T. Smith, Jr., is Associate in Obstetrics and Instructor in Gynecology, Western Reserve University, Meilical School, Cleveland.


Dr. Walter R. Steiner is Visiting Physician, The Hartford Hospital, and Consulting Physician, The Manchester Memorial Hospital, the New Britain General Hospital, the Bristol Hospital, and the Middlesex Hospital (Middletown), and Lecturer on Medicine, Kennedy School of Missions, Hartford Theological Seminary, Hartford, Conn.

Dr. Heniy A. Stephenson is Assistant Clinical Professor of Obstetrics and Gynecology, Stanford University, San Francisco.

Dr. A. Raj'mond Stevens is Clinical Professor of Genito-Urinary Surgery, New York University, New York City.

Dr. Emerson L. Stone is Assistant in Obstetrics and Gynecology, Yale Medical School, and Assistant Resident in Obstetrics and Gynecology, New Haven Hospital, New Haven, Conn,

Dr, William S. Thayer is now Visiting Physician, Private Wards, Johns Hopkins Hospital.

Dr. Thomas H. Thomason is Assistant in Surgeiy, Johnson and Beall's Hospital, Fort Worth, Texas.

Dr. Clara M. Thompson is at present engaged in a rotating interneship at the New York Infirmary for Women and Children New York City.

Dr. Martillus H. Todd is at present Chief Surgeon of the plant of the United States Coal and Coke Company at Lynch Mines, Kentucky.

Dr. Margaret Tyler is Instructor in Obstetrics and Gynecology in the Y'ale Medical School, New Haven, Corm.

Dr. Karl H. Van Norman is Superintendent of the Charles T. Miller Hospital, St. Paul, Minnesota, having assumed his duties on December 1.

Dr. Allen Voshell is now connected with the University of Virginia Medical School, and the University Hospital, University, Va., with the titles of Adjunct-Professor of Surgery in charge of Orthopedics, and Orthopedist to the University Hospital.

Dr. Leslie T. Webster is Assistant in the Division of Pathology an<l Bacteriology. Rockefeller Institute for Medical Research.

Dr. Winford O. Wilder is Consulting Urologist at the Mercy Hosjiital, Springfield, Mass., and at the Cooley Dickinson Hospital, Northampton, Mass.

Dr. Lawson Wilkins is Assistant Dispensary Physician, Harriet Lane Dispensary, Johns Hopkins Hospital, and practicing Pediatrician in Baltimore.

Dr. Le Grand Woolley is Obstetrician, Junior Staff, Dr. W. H. Groves, L.T. S. Hospital. Salt Lake City, and Instructor in Gross Anatomy, University of mah Medical School, Salt Lake City, Utah.

Dr. Paul G. Woolley is Director of the Laboratories of the Herman Kiefer Hospital. Detroit, and Associate Professor of Pathology in the Detroit College of Medicine and Surgen,', Detroit.


NOTES ON NEW BOOKS

The Principles and Practice oj Medicine. 9th Edition. By the late Sir Willum Osub and Thomas McCrae, M. D. (New York and London: Appleton and Company, 1920.) Osier's Principles and Practice of Medicine has stood out for so many years as a remarkably concise and accurate presentation of the facts of internal diseases that comment on the basic characteristics of the book is .superfluous. One is ever anew impressed by the genius which has gathered into brief sections the essential matter of a broad and ill-defined domain. Sir William always took great interest in the book — in a sense his magnvmi opus — and expressed the desire and hope that its existence might be continued. In the preface to the ninth edition Dr. McCrae outhnes the more immediate purpose of the present revision which adds to the previous material the recent discoveries and advances in medicine. The engaging descriptions, however, of the natural history of disease will always be the most valuable feature of the book. A., L. B,


3G


[No. 371


THE JOHNS HOPKINS HOSPITAL REPORTS


VOLUUE I. 423 pa^es, 99 plates.

VOLUME II. 670 pages, with 28 plates and figures.

VOLUME III. 766 pages, with 69 plates and figures.

VOLUME IV. 604 pages, 33 charts and Illustrations.

VOLUME V. 480 pages, with 32 charts and illustrations.

The Malarlnl Fevers of Baltimore. By W. S. Thaieb, M. D., and

J. Hewetson. M. D. A Study of some Fatal Cases of Malaria. By Lewellts P. Barker. M. B.

Studies in Typhoid Fever. By William Osleb, M. D., with additional papers by G. Blumeb, M. D., Simon Flexner. M. D.. Walter Keed, M. D., and H. C. Parsons. M. D.

VOLUME VI. 414 pages, with 79 plates and figures.

VOLUME VII. 637 pages with illustrations.

VOLUME VIII. 652 pages with illustrations.

VOLUME IX. 1060 pages, 66 plates and 210 other illustrations.

Contributions to the Science of Medicine, Dedicated by his Pupils to William Henrt Welch, on the twenty-fifth

anniversary of his Doctorate. This volume contains 38 separate

papers. VOLUME X. 616 pages, 12 plates and 26 charts. VOLUME XI, 666 pages, with 38 charts and illustrations. VOLUME XII. 548 pages, ^2 plates and other illustrations. VOLUME XIII. 605 pages, with 6 plates, 201 figures, and 1 colored chart. VOLUME XIV. 632 pages, with 97 figures.

VOLUME XV. 642 pages, with 87 illustrations.

Twelve papers on pneumonia. By Des. Chatard. Fabtan, Emerson,

Marshall, McCrae, Steiner, Howard and Hanes. A Study of Diarrhoea in Children. J. H. Mason Knox, Jr., M. D., and

Edwin H. Schorer, M. D. Skin Transplantation. By John Staigb Davis. M. D. Epidemic Cerebrospinal Meningitis and Serum Therapy at The Johns

Hopkins Hospital. By Frank J. Sladen, M. D.

VOLUME XVI. 670 pages with 161 figures.

Studies in the Experimental Production of Tuberculosis In the Genitourinary Organs. By George Walker. M. D.

The Effect on Breeding of the Removal of the Prostate Gland or of the Vesiculce Scminales. or of Both ; together with Observations on the Condition of the Testes after such Operations on White Rats, By George Walker, M. D.

Scalping Accidents. By John Staige Davis, M. D.

Obstruction of the Inferior Vena Cava with a Report of Eighteen Cases. By J. Hall Pleasants. M. D.

Physiological and Pharmacological Studies on Cardiac Tonicity In Mammals. By Percival Douglas Cameron, M. D.

VOLUME XVII. 586 pages with 21 plates and 136 figures.

Free Thrombi and Ball Thrombi in the Heart. By Joseph H. Hewitt,

M. D. Benzol as a Leucotoxin. By Lawrence Selling, M. D. Primary Carcinoma of the Liver. By Milton C. Winternitz, M, D. The Statistical Experience Data of The Johns Hopkins Hospital, Baltimore,

Md., 1892-1911. Bv Frederick L. Hoffman. LL. D., P. S. S. The Origin and Development of the Lymphatic System. By Florence R.

Sarin. M. D. The Nuclei Tuberls Laterales and the So-called Ganglion Optlcum Basale.

Bv Edward P. Malone, M. D. Venous Thrombosis During Myocardial Insufficiency. By Frank J. Sladen.

M. D., and Milton C. Winternitz, M. D. Leukaemia of the Fowl : Spontaneous and Experimental. By Haret C.

SCHMEISSER, M. D.

VOLUME XVIII. 446 pages with 124 figures.

Fasciculus I. A Study of a Toxic Substance of the Pancreas. By B. W. Goodpasture,

M. D,, and George Clark, M. D. Old Age in Relation to Cell-overgrowth and Cancer. By B. W. GooD PASTDRE, M. D., and G. B. Wislocki, M. D. The Effect of Removal of the Spleen Upon Metabolism In Dogs; Preliminary Report. By J. H. King. M. D. The Effect of Removal of the Spleen Upon Blood Transfusion. By J. H.

King, M. D.. B. M. Bernheim. M. D.. and A. T. Jones, M. D. Studies on Parathyroid Tetany. By D. Wright Wilson, M. D.. Thornton

Stearns, M. D., J. H. Jannby, Jr., M. D., and Madge DeG. Thhelow,

M. D. Some Observations on the Effect of Feeding Glands of Internal Secretion

to Chicks. By M. C. Winternitz. M. D. Spontaneous and Experimental Leukaemia In the Fowl. By H. C

Schmeisser, M. D. Studies on the Relation of Fowl Typhoid to Leukaemia of the Fowl. By

M. C. Winternitz, M. D.. and II. C. Schmeisser. M. D. Hyaline Degeneration of the Islands of Langerhans In Pancreatic Diabetes.

Bv M. C. Winternitz. M. D. Generalized Miliary Tuberculosis Resulting from Extension of a Tubercular

Pericarditis Into the Right Auricle. By M. C. Winternitz, M. D.


Acute Suppurative Hypophysitis as a Complication of Purulent Sphenoidal

Sinusitis. By T. R. BoGGS. M. D., and M. C. Winternitz, M. D. A Case of Pulmonary Moniliasis in the United States. By T. R. BoGOS,

M. D., and .M. C. PiNCOi Fs, .M. D. Gauchers Disease (A Report of Two Cases In Infancy). By J. H. M.

Knox, M. D., H. R. Wahl, M. D., and H. C. Schmeisser, M. D. A Fatal Case of Multiple Primary Carcinomata. By E. D. Plass, M. D. Congenital Obliteration of the Bile-ducts. By James B. Holmes. M. D. Multiple Abscesses of the Brain in Infancy. By James B. Holmes. M. D. Gastric Carcinoma in a Woman of Twenty-six Tears. By R. G. Hdssei

M. D. Subdiaphragmatic Abscess with Rupture Into the Peritoneal Cavity Pol

lowing Induced I'neumothorax for Pulmonary Hsemorrhage. By R, G

HussEV, M. D. Heart Block Caused by Gumma of the Septum. By E. W. Briogema

M. D., and H. C. Schmeisser, .M. D. Analysis of Autopsy Records.

A. The Johns Hopkins Hospital. (Table Showing Percentage of

Autopsies. I

B. The City Hospitals, Bay View. (Table Showing Percentage of

Autopsies.) " The Monday Conferences."

Clinical Representatives on the Staff of the Department of Pathology. Donation.

Fasciculus II. The ROIe of the Autopsy in the Medicine of To-day. By M. C. Winternitz,

M. D, Experimental Nephropathy in the Dog. Lesions Produced by Injection

of B. bronchisepticus Into the Renal Artery. By M. C. Winternitz,

M. D.. and William C. Quinby, .M. D. Mesarteritis of the Pulmonary Artery. By M. C. Wintebnitz, M. D., and

H. C. Schmeisser. M. D. A Clinical and Pathological Study of Two Cases of Miliary Tuberculosis of

the Choroid. By Robert L. Randolph, M. D., and H. C. Schmeisseb,

M. D. The Blood-vessels of the Heart Valves. By Stanhope Bayne-Jones, M. D. Equilibria In Precipitin Reactions. By Stanhope Batne-Jones, M. D. Carcinoma of the Pleura with Hypertrophic Osteoarthropathy. Report of

a Case with a Description of the Histology of the Bone Lesion. By

Stanhope Bayne-Jones. M. D. The Interrelation of the Surviving Heart and Pancreas of the Dog in Sugar

Metabolism. By .Admont H. Clark, M. D. Congenital Atresia of the Esophagus with Tracheo-Esophageal Fistula

Associated with Fused Kidney. A Case Report and A Summary of the

Literature on Congenital Anomalies of the Esophagus. By E. D.

Plass. M. D. Ectopia Cordis, with a Report of a Case In a Fifteen-Month-Old Infant.

By James B. Holmes, M. D. Studies in the Mechanism of Absorption from the Colon. By Samuel

(ioLDSCiiMiDT. M. D., and A. B. Dayton. M. D. Report of Two Fatal Cases Following Percy's T/ow Heat Treatment of

Carcinoma of the Uterus. By V. N. Leonard, M. D., and A. B. Daytor,

M. D. The Relationship in Typhoid Between Splenic Infarcts and Perltonltl*

tinassociated with Intestinal Perforation. By A. B. Dayton. M. D. Left Duodenal Hernia. By A. B. Dayton. M. D.

Histological as Related to Physiological and Chemical Differences In Certain Muscles of the Cat. By H. Hays Biili.akd, M. D. A Method of Clearing Frozen Sections. By H. Hays Bollard. M. D. On the Occurrence and Significance of Fat in the Muscle Fibers of the

.\trlo- Ventricular System. By H. Hays Bollard, M. D. Studies on the Metabolism of Cells in vitro. 1. The Toxicity of a -Amino

Acids for Embyonic Chicken Cells. By Montrose T. Borrows, M. D.,

and Clarence A. Neymann, M. D. The Significance of the Lunula of the Nail. By Montrose T. Borrows,

M. D. The Oxygen Pressure Necessary for Tissue Activity. By Montrose

Burrows, M. D.

The Functional Relation of Intercellular Substances in the Body to Certain Structures In the Egg Cell and Unicellular Organisms. By

Montrose T. Borrows. M. D. Studies on the Growth of Cells in vitro. The Cultivation of Bladder and

Prostate Tumors Outside the Body. By Montrose T. Borrows, M. D..

J. Edward Burns, M. D.. and TosHio SrzoKL, M. D. The Study of a Small Outbreak of Poliomyelitis In an Apartment House,

Occurring in the Course of on Epidemic in a Large City. By Montbose

T. Borrows, M. D.. and Edwards A. Park. M. D. Papilloma of the I^arvux. Report of a Case Treated with Radium with

Resultant Chronic Diffuse Thyroiditis. By William C. Doffy, M. D. Analysis of Autopsy Records. Autopsy Statistics.

(a) Bay View.

(h) Johns Hopkins Hospital. Report of the Photographic Department. General Improvements, Donations.

VOLUME XIX. 358 pages with 29 plates. The Structure of Normal Fibers of Purkinje In the .\dult H

Their Pathological Alteration in Syphilitic M

STT.icnT. M. D.. and T. Wingate Todd. M. D. The Operative Story of Goitre. The Author's Operation

Halsted, M. D. Study of Arteriovenous Fistula with

Cai-landee. M. D.

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CONTENTS

  • Immunological Reactions of Bence-Jones Proteins. I. Differences Between Bence-Jones Proteins and Human Serum Proteins. (Illustrated.) By S. Batxe-.Joves and D. Wkight Wilson'
  • Yaws. An Analysis of 1046 Cases in tlie Dominican Republic. (Illustrated.) By W. L. MOS.S and G. H. Bigelow
  • Studies on a Case of Chromic Acid Xephritis. (Illustrated.) By Ralph H. Major
  • Adaptation of Bacteria to Growth on Human Mucous Membranes with Special Reference to the Throat Flora of Infants. By Arthur L. Bloomfield
  • Dermoid Cysts of the Ovary. A Report of Four Cases. (Illustrated.) By Karl H. Martzloff

Titles of Papers Appearing During the Year 1931, Elsewhere than in the Bulletin', by the Present and Former Members of The Johns Hopkins Hospital and Medical School Staff


IMMUNOLOGICAL REACTIONS OF BENCE-JONES PROTEINS

I. DIFFERENCES BETWEEN BENCE-JONES PROTEINS AND HUMAN SERUM PROTEINS

By S. Batne-Jones and D. Weight Wilson (From the Department of Pathology aiid Bacteriology and of Physiological Chemistry, The Johns Hopkins University, Baltimore)


In a previous paper/ presenting a preliminary account of our study of the immunological reactions of Bence-Jones proteins, we have reported that by the use of the precipitin, complement-fixation and anaphylactic reactions we have been able to show that differences exist between the so-called BenceJones protein and the proteins of human serum, and also between preparations of Bence-Jones protein from various sources. While the specimens of Bence-Jones protein which we studied were all typical as regards their phases of coagulation and solution by heat in an acid medium, they differed considerably in their physical properties and in their immunological reactions. These differences were indeed so great that we were forced to regard the so-called " Bence-Jones body " as a group of similar, but not identical, substances, and to refer to the group as the Bence-Jones proteins. One of these I)roteins (No. 4) crystallized spontaneously in the urine of the patient who excreted it. This property permitted purification of the substance by recrystallization. An account of this patient (E) with a description of the protein has been published by Walters ' from the Mayo Clinic, where the patient was under observation on the service of Dr. Eowntree. The other specimens of Bence-Jones proteins used by us were


isolated from urine by various methods of precipitation. They will be described in detail in our paper dealing with their specific immunological differences. In the present report, we shall give the evidence in support of the contention that it is possible by the use of immunological methods to differentiate Bence-Jones proteins from the proteins of human serum.

With the more frequent use of purified proteins in immunological studies, an increasing number of them are being found to possess individual antigenic specificity. It has been known for a long time that the proteins of the lens of the eye and of spermatozoa have this characteristic, and more recently Wells and Osborne,' using purified vegetable proteins. Woods * using the pigment from the uveal tract, and Dale and Dakin " with crystalline albumin from the eggs of hen and duck, have established the fact that chemical composition, rather than biological origin, is the ba.sis of tlie specificity of these substances. The chemical and physical peculiarities of Bence-Jones proteins and their absence from the blood and urine of normal persons have conveyed the obvious suggestion that it might be possible by immunological studies to draw a distinction between the blood-proteins and Bence-Jones proteins. This phase of the question has occupied the attention of a number of investi


38


[No. 372


gators. The results, however, of the experiments of all except two students of this problem have been reported as indicative of an identity rather than a difference between these proteins. ' ' ° From accounts of the way in which the experiments were conducted, and from the results of our work, it seems that the uncritical use of mixtures of proteins has led to these equivocal results. The most notorious example of this is the work of Abderhalden and Rostoski,' which has influenced many of the subsequent immunological studies of Bence-Jones proteins and the opinions iipon the nature of Bence-Jones proteinuria. The patient studied by Abderhalden had chronic nephritis as well as multiple myelomata. As a consequence of the two diseases he excreted in his urine Bence-Jones protein and proteins which Cameron and Wells," in studies of the urine in nephritis, have shown to be identical with the proteins of human serum. Abderhalden injected the whole urine of this patient into a rabbit, and obtained an immune senmi which precipitated both Bence-Jones protein and human serum. In drawing his conclusions, however, he neglected the possibility that he was dealing with a mixture, and developed his ideas about the identity of Bence-Jones protein and serum proteins as if he had been using single pure antigens. It now seems probable that unless a Bence-Jones protein can be separated from urine by crystallization, and purified by recrystallization, it is impossible to separate it by any method of fractional precipitation from other proteins which are usually present with it in the urine.

The investigators who have succeeded in finding immunological differences between Bence-Jones proteins and serum proteins are Massini " and Hektoen.^' By means of the complement-fixation test, Massini was able to show that an antiserum to the preparation used by him fixed complement in the presence of higher dilutions of the Bence-Jones protein than of human serum. Hektoen's recently published preliminary note reports that by absorption of precipitins specific reactions can be obtained which sharply differentiate Benoe-Jones proteins from the proteins of human serum, even when mixed antigens are iised.

Reports of Experiments

In our experiments to discover, if possible, immunological differences between Bence-Jones proteins and the proteins of liuman serum, we used precipitin and complement-fixation reactions with the sera of rabbits immunized to human serum and to several preparations of Bence-Jones proteins, and anaphylactic reactions of guinea-pigs sensitized to these substances.

PRECIPITIN REACTIONS

The preeipitin-sera were prepared as follows :

Anti-human senim. Rabbit No. 161 immunized to human serum by 7 intravenous injections at intervals of 2 to 6 days. The first dose was 0.5 c. c, the last 12 c. c. of serum. Ten days after the last injection, the animal was bled, when its serum gave a precipitate with a 1-1000 dilution of human serum.

Anti-Bence-Jones protein sera: Rabbit No. 144 was immunized to the crj'stalhne Bence-Jones protein (No. 4) by six intravenous injec


tions of a 1 per cent solution of No. 4 at intervals of 4 to 6 days. The first dose was 2 c. c, the last 20 c. c. Ten days after the last injection, when the rabbit's serum caused a precipitate in a 1-1,000,000 dilution of a 4 per cent solution of No. 4. the animal was bled.

Rabbit No. 153 was injected intravenously at intervals of 4 to 6 days with amounts of a 0.5 per cent solution of Dr. J. Ro.senbloom's preparation of Bence-Jones protein increasing from 3 c. c. to 20 c. c. Six days after the fifth injection, the rabbit was bled. Precipitin titer 1-100,000 (antigen dilution).

Rabbit No. 189 was immunized to a preparation of Bence-Jones protein designated as " Simpson," given us by Dr. C. G. Guthrie. After 8 injections of amounts of 2-6 c. c. of a 2 per cent solution of this protein, at intervals of 3 to 5 days, the precipitin titer of this animal was 1-2000 (antigen dilution).

Rabbit No. 195 was immunized to a preparation of Bence-Jones protein denoted as " Farrel." and given to us by Dr. C. G. Guthrie. At intervals of six days, 1 c. c, 5 e. c, and 7 c. c. of a 3 per cent solution of this protein were injected intra\-enously. Five days after the last injection, when the animal was bled, the titer of the serum was 1-8000 (antigen dilution).

With the exception of No. 4, which was the crystalline BenceJoues protein, the other Bence-Jones proteins were non TABLE I Precipitin Reactio.ns


Antihuman serum 161. Precipitation with antigen


Human serum

Bence-Jones protein (4 per

cent solution). No. 4 (crystalline)

No. 1

Coag. No. 2

Coag. R. urine

R. urine

Taylor

Farrel

Simpson (2 per cent)

Dine

Dine urine

X

X urine

Rosenbloom



Dilution <


t antigen



1-10


1-100


++++


+ + +


+ +






+ +





++


+



++


+



++


+


+



+


++


+


+



+


++


+


++


+



+++


++


+


+


+


0,


crystalline, and had been isolated from urine by various methods of precipitation.

The precipitin tests were done in clean sterile tubes, witli clear solutions of the sera and antigens. False results due to bacterial growth were eliminated. The antigens, in various dilutions, were layered upon the anti-sera, and the first reading was made by noting the presence or absence of precipitate at the plane of junction of the two fluids one hour after their apposition. The fluids were then mixed, placed in the incu


February, 1923]


39


bator at 3'i° C. for 24 hours, and a second reading taken of the sediment in the bottom of the tubes. The controls, which are omitted from the following tables, were made by mixing equal amounts of each component with normal salt solution and incubating these mixtures with the series of tests. Wlien precipitate occurred in the controls, the corresponding tests were discarded or repeated with fresh solutions. In the tables, the signs indicate the amount of precipitate formed ; denoting no precipitate, + + + + a very heavy precipitate. The results of the precipitin reactions with antihuman serum arc summarized in Table I.

The advantage gained from the use of a pure crystalline protein is at once apparent from the data presented in Table I. The antiserum to lumian serum proteins does not precipitate the crystalline ] reparation of Bence-Jones protein. On tlie other hand, antihuman serum forms a precipitate with all noncrystalline Bence-Jones proteins which have been salted-out

TABLE II Precipitin Reactions



Precipitation with


Dilution of antigen




1-10 1-100


1-1000


1-2000


1-100,000


144. Anti-BenceJones, No. 4.


Bence-Jones. No.4

(4 per cent). Human serum. ..




-1- \+++


•H--H


-h-(--H


-(--t--h



153. Anti-BenceJones, Rosenbloom.


Bence-Jones, Rosenbloom (4 per cent).




+ + + + ++


-f-H-l-t--l--f


-H--I -f


+



189. Anti-BenceJones, Simpson.


Bence-Jones,

Simpson (2 per

cent). Human serum...


+ +


+


-1--)


-t




195. Anti-BenceJones, Parrel.


Bence-Jones,

Farrel (4 per

cent). Human serum...


-I- + -H -t

-I-I--I--1--H- +

++ +


-i-f







or otherwise precipitated from urine. With the whole urine from patients with multiple myelomata, containing presumably more protein identical with the proteins of serum, the precipitation by antihuman sermn is greater than with the fractions of these urines containing the Bence-Jones protein.

In Table II are summaries of precipitin reactions with human serum, antisera to several preparations of Bence-Jones proteins and their homologous antigens.

From Table II it is seen that a very potent antiserum to the crystalline Bence-Jones protein does not precipitate human serum, while the antisera to the other less pure preparations of Bence-Jones proteins give "cross-reactions," precipitating both their homologous antigens and human serum.

As Hektoen " has pointed out, the method of absorption of precipitins can be used, when mixtures of proteins are unavoidable, to demonstrate differences between serum proteins and Bence-Jones proteins. There is, however, much to be learned about this method before the results obtained witli it can be correctly interpreted."' " In its use, we encountered a number of difficulties. In the first place, precipitating sera, such as those used by us, are no longer active when diluted more than 1 to 20, or 1 to 40. This places a narrow limit upon the


applicability of the metliod, as it may be necessary during the process of absorption to dilute the serum beyond its effective jirecipitin-concentration. When dilution of the serum is avoided, the so-called " prozone " may interfere with the formation of a precipitate during the phase of absorption. In many mixtures of undiluted serum and a concentrated solution of its protein antigen no precipitate occurs, yet when the mixture is diluted, the precipitate appears. In this case, of course, neither the antigen nor antibody is removable by centrifugation, and the delayed precipitation due to the first reaction often occurs when salt solution or the diluted antigens to be tested are added subsequently. It may be that the hydrogen-ion concentration of the fluids is a factor of prime importance in the precipitin reaction. A concentration of hydrogen-ions in the region of the isoelectric point of serum globulin may permit a precipitin reaction to progress to completion even in mixtures of undiluted immune serum and concentrated solutions of proteins. We have not investigated this point thoroughly. The results, however, of our experiments with the absorption of precipitins are unequivocal when the " ring-test " is used, readings of the precipitate at the junction of serum and antigen solutions being taken within one or two hours after the one has been layered upon the other. When allowed to stand for 18 hours or more, a slow precipitation

TABLE III Ab-sorption op Precipitins


Anti-BenceJones, Farrel, 105.


Human serum


Human serum

Bence-Jones.

No. 4. Simpson

Farrel

Human serum

Bence-Jones,

No, 4, Simpson

Farrel

Human serum

Bence-Jones,

No. 4. Simpson

Farrel

Human serum

Bence-Jones,

No. 4. Simpson

Fari^l

Bence-Jones,

Farrel. Human serum,

Bence-Jones,

Farrel. Human serum.


Dilution of antigen


s


o

g


-^


'-'


-1


-t


-1


-t

± -1-4

-l-l




+++


++





often occurs in all sera, including the controls, showing that the original reaction had not been complete but was continuing under the conditions permitted by the subsequent dilution.


40


[No. 373


The technic used in absorbing the precipitins was as follows : With precautions to prevent bacterial growth in the tubes,

1 c. c. of antiserum was mixed with 1 c. c. of a 2 or 4 per cent solution of a Bence-Joues protein. This mixture was incubated at 37° C. for 24 hours, placed in the ice-chest for 18 hours and then centrif uged until clear. The usual series of tests and controls were then made with this absorbed serum, diluted one to two as a consequence of the addition to it of an equal quantity of the antigen for the phase of absorption. A control to determine the effect of simple dilution and manipulation upon the antiserum was made by carrying a mixture of equal parts of immune serum and salt solution through the stages of incubation and absorption.

Antihuman serum No. 161 was absorbed in this manner with 4 per cent solutions of the crystalline Bence-Jones protein, and the Farrel preparation of Bence-Jones protein, and with a

2 per cent solution of the Simpson Bence-Jones protein. To show the effect of the reversal of this procedure, an antiserum to the Earrel specimen of Bence-Jones protein was absorbed with human serum. The results of these absorption tests are summarized iu Table III.

Several of the experiments summarized in Table III show again that antihuman serum does not precipitate the crystaUine preparation of Bence-Jones protein (Ko. 4) and, further, that this Bence-Jones protein does not absorb precipitin from antihuman serum. The data demonstrate that by absorption of antihuman serum with certain preparations of Bence-Jones proteins it is possible to remove from this immune servmi the precipitin responsible for the flocculatiou with solutions of these preparations, while only shghtly lowering the titer of the serum for its homologous antigen, human serum. Confirmation of the result is obtained when an antiserum to one of these preparations of Bence-Jones protein (Farrel) is absorbed with human serum. The conclusion seems inevitable that some of these non-crystalline preparations of Bence-Jones proteins contain traces of human serum proteins, while, in this respect, the crj'stalline Bence-Jones protein acts as a single antigen.

COMPLEMEXT-FIXATION RF.ACTIONS

For the complement-fixation reactions antihuman sermn was tested against the various Bence-Jones proteins, and antisera to the crystalline and Rosenbloom Bence-Jones proteins were tested against human serum. Preliminary titrations were made with all sera and solutions of the proteins to determine their anticomplementary action, and in the tests the anticomplementary controls contained twice the amount which did not inhibit hemolysis. This required the«use of sera diluted one to two, and 1 to 20 dilutions of the solutions of Bence-Jones proteins. These dilutions, as has been pointed out, are just on the limit of effective concentration of precipitin. The results of the complement-fixation tests, therefore, indicate broad relationships, as closer interactions are lost through the dilution. In the tests, 0.25 c. c. was the tmit volume of each component used. The usual antisheep amboceptor, with a titer of 1 to 3200, and guinea-pig serum as complement were employed. After the mixtures of antiserum, protein solution


and complement were made, they were incubated in the waterbath at 37° C. for one hour. At the end of that time, three units of amboceptor were added, the 2.5 per cent suspension of sheep cells placed in the tubes, and all returned to the waterbath. Readings were taken at the end of one hour, or when all the proper controls had cleared. The results of these tests are collected in Table IV, in which -|- -|- -I- -f indicates complete fixation (absence of hemolysis), and lesser degrees of fixation by proportionally fewer -|- signs.

The complement fixation reaction, according to this method, combines a differentiation based upon dilution of the antisera and antigens with the differences due to fixative power of

TABLE IV Complement Fixation Reactioxs


Serum


Antigen


Cone.


Dilut.


Result


Anti-human serum, Ifil. Diluted 1-2.


Human serum

Benee-Jonos protein:



1-40


++++



Xo. 4


i%


1-20




Xo. 1


4%


1-20




Coag. R. urine


4%


1-20






1 20


+ -1+




Tavlor


4% 4% 2%


1 20




1 20



Simpson


1-20




4% 4% i% 4%


1-20




X


1 20





1 20


+++ ++++



A n t i - Bence - Jones, Xo. 4. Serum 144. Diluted 1-2.


Bence-Jones, Xo. 4. . . Human serum


1-20

1-20


A n t i - Banee - Jones, Rosenbloom. Serum 153. Diluted 1-2.


Bence-Jones, Rosenbloom. Human serum


4%


1-20 1-20


++++



specific precipitates. Its effect, therefore, is to indicate only broad relationships. The results thus obtained, as presented in Table IV, confirm the results of the precipitin reactions in showing immunological distinctions between Bence-Jones proteins and the proteins of human serum.

AXAPHTLACTIC REACTIOXS

Anaphylactic reactions were studied upon the guinea-pig as a whole and on excised uterine horns of young virgin guineapigs. The animals in this series were actively sensitized, except where otherwise stated, by an intravenous injection of 0.25 c. c. of human serum or of a 4 per cent solution of a Bence-Jones protein. After an interval of approximately three weeks, the animals were tested by an intra jugular injection of serum or Bence-Jones protein. The data of these experiments are presented in Table V.


February, 1922]


41


Anaphylactic reactions with the crystalline Bence-Jones protein were not as sharp as we desired, as it was difficult actively to sensitize guinea-pigs to this preparation. Both large and small doses of the crystalline protein were given on the first intravenous injection, and the animals were tested by a second intravenous injection of larger amounts after intervals of 18 to 27 days. With one series, fairly satisfactory results were obtained. The guinea-pigs of this lot received as the sensitizing dose injected intravenously 0.25 c. c. of a 4 per cent solution of the crystalline Bence-Jones protein (No. 4) on January 27, 1921. On February 14, 21 days later, an intravenous injection of 1 c. c. of the 4 per cent solution of No. 4 produced a severe but not fatal shock, in guinea-pig No. 396. None of 10 guinea-pigs thus sensitized to Bence-Jones protein No. 4 showed any reaction to human serum.

TABLE V Anaphylactic Reactions


Human e Human e


Sensitizing dose


1 0.26 c. 1 0.25 c.


Beiice - Jones, Rosen bloom prep. 1.5 c. c, 17c sol.

Bence-Jones, Taylor's prep. 1 c. c. 1.5% sol


Human serum O.aS <

Hence -- Jones No.

. c. 0.57c sol. 10 minutes later : 2 <

human serum

pcrit.


Bence - Jones

. c. 17c sol. 10 minutes latei human serun


18 days

IS days 27 days 18 days 18 days


Intoxicating dose


ntri


No.


Bence - Jones, Kosenbloom prep. 1 c. c. 49'o sol.

Bence-Jones, Taylor'f prep, 1 c. c. 4% sol.

Human serum 0.25 c. e.


Human serum 0.25 c- c. Human serum 0.25 c. c


Typical anaphyla Death, one mir No reaction.


The anaphylactic reactions summarized in Table V and in the above paragraph demonstrate a complete difference between the crystalline Bence-Jones protein and the proteins of human serimi. On the other hand, guinea-pigs sensitized to human serum were also sensitive, though in less degree, to the Rosenbloom and Taylor preparations of Bence-Jones proteins, and guinea-pigs sensitized to these Bence-Jones proteins and to Bence-Jones protein No. 1 were extremely hypersensitive to human serum. From tlie results of the precipitin reactions, we are led to assume, in explanation of the crossed anapliylactic shocks, that the non-cry.stalline preparations of Bence-Jones proteins (No. 1, Taylor and Rosenbloom) contain traces of human serum proteins. These traces of serum proteins are sufficient to sensitize the animal to human serum, so that when a large amount of human serum is administered in the second injection, fatal anaphylactic shock occurs. Their content of serum proteins, however, is too small to produce a fatal reaction when they are injected in the amounts used by us into guinea-pigs primarily sensitized to human serum.


An analysis of these preparations of Bence-Jones proteins was permitted by the graphs obtained by the Schultz-Dale method." The a])paratus and solutions used in our studies of the anaphylactic reactions of isolated uterine muscle were essentially those described by Dale. Virgin guinea-pigs, sensitized to human serum or Bence-Jones proteins, were killed by a blow on the head about three weeks after the first injection. The uterus was removed, one horn was attached to the lever of a kymograph, and this strip of smooth muscle was then submerged in Ringer-Locke solution. The bath, 50 c. c. of RingerLocke solution, was kept at 37-38° C, and was supplied cou


Fk. 1. — Uterus of guinea-pig Xo. 1. Passively sensitized to Bence-Jones protein No. 4 by injection of 1 c. c. serum 144 into peritoneal cavity. Killed 18 hours later.

At A : 1 c. c. human serum.

At B: 1 c. c. 3% sol. Bence-Jones protein No. 4.

At C: 1 c. c. 3% sol. Bence-Jones protein No. 4.

tinuously with oxygen. Tracings of the movements of the strip of uterus were recorded on a smoked drum.

It was found more satisfactory passively to sensitize guineapigs to the crystalline Bence-Jones protein. This was easily accomplished by injecting intraperitoneally 1 c. c. of the serum of rabbit No. 144, which had been immunized to this BenceJones protein. The precipitin titer of this serum was 1 to 1,000,000, in terms of dilution of the antigen. Eighteen hours later, these guinea-pigs were found by tests to be hypersensitive to Bence-Jones protein No. 4.


-12


[No. 372


Kepresentative graphs, Figs. 1, 2 and 3, illustrate the results of some of the anaphylactic reactions with the isolated smooth muscle of the uterine horns of sensitized guinea-pigs. From Fig. 1 it is seen that the uterus of a guinea-pig sensitized to the crystalline Bence-Jones protein No. 4 did not react to human serum, and Fig. 2 shows that the uterus of a guinea-pig sensitized to human serum was not affected by the solution of this crystalline protein. Fig. 3 is of especial interest, as it is analogous to experiments on the absorption of antibodies. The uterus used in this test was from a guinea-pig actively sensitized to Eosenbloom's non-cry.-tnlliuo preparation of Bence


FiG. 2. — Uterus of guinea-pig No. 378, sensitized to human serum.

At A: 1 c. c. 4% sol. Bence-Joncs pi-otein No. 4. At B: 1 c. c. himian serum. At C: 1 c. c. hvmian serum.

Jones protein. When treated with a solution of this BenceJones protein, a contraction occurred. A subsequent application of the same protein failed to cause a contraction, showing that the muscle was desensitized to that antigen. It, however, remained hypersensitive to himian serum, as shown by the next phase of the curve, which records the contraction produced by the addition of human serum to the bath. After this second contraction, the uterus was specifically desensitized also to human serum. This analysis permits the definite conclusion that the Eosenbloom preparation of Bence-Jones protein is a mixture of a Bence-Jones protein and human serum proteins.


SUMMAEY AND CONCLUSIONS

In tlie possession of a crystalline Bence-Jones protein we had at our disposal an ideal substance for immunological studies. By crystallization, it could be freed from possible traces of serum proteins and thus permitted the use of a purified preparation to obviate the confused results which vitiate many immunological experiments. Its quality as an antigen was easily established, and the reactions dependent upon its antibodies were unequivocal. In contrast to this, tlie non-ci v.~tal


FiG. 3. — Uterus of guinea-pig sensitized to Bence-Jones protein (Rosenbloom).

At A: 1 c.c. 4% sol. Bence-Jones protein (Rosenbloom).

At B: 1 c. c. same solution.'

At C : 0.5 c. c. himian senun.

At D: 0.5 c. c. human serum.

line preparations of Bence-Jones proteiu.s, precipitated from the urine by fractionation with salts or heat, gave the " cross " reactions usually obtained with mixed antigens. Comparisons between the Bence-Jones proteins and the proteins of normal human serum were made by the use of precipitin, complementfixation and anaphylactic reactions. The precipitin reactions were extended by the method of the absorption of antibodies and the anaphylactic reactions were submitted to analysis by the Schultz-Dale method of the graphic record of the contrac


February, 1922]


43


tion of smooth muscle. The results of all these experiments were in accord, and allow the following conclusions to be drawn :

1. Tlie crystalline Bence- Jones protein acts as a single antigen.

3. The non-crystalline preparations of Bence-Jones proteins, isolated from the urine by salting-out or other precipitation methods, contain traces of serum proteins.

3. The Bence-Jones proteins are immunologically different from the proteins of normal human serum.

4. These differences between proteins from the same animal are further evidence in support of the conception that the specificity of proteins is not dependent upon their biological origin, but due to their chemical constitution.

BIBLIOGRAPHY

1. Bayne-Jones, S., and Wilson, D. W.: Proc. Soc. Exp. Biol, and Med., 1921, XVIII, 220-222.


2. Walters, W.: J. Am. Med. Assn., 1921, LXXVI, 641-645.

3. Wells, H. G., and Osborne, T. B.: J. Infect. Dis., 1913, XII, 341-358.

4. Woods, A. C: Tr. Sect. Opth. Am. Med. Assn., 1917, 133-161.

5. Dakin, H. D., and Dale, H. H.: Biochem. J., 1919, XIII, 248-257.

6. Abderhalden, E., and Rostoski, 0.: Ztschr. f. physiolog. Chem., 1905, XLVI, 125-135.

7. Rostoski : Munch, med. Wchnschr., 1902, XLIX, 740.

S. Boggs, T. R., and Guthrie, C. G.: Am. J. Med. Sci., 1912, CXLIV, 803-814.

9. Hopkins, F. G., and Savory-, H.: J. Physiol., 1911, XLII, 189-250.

10. Cameron, A. L., and Wells, H. G.: Arch. Int. Med., 1915, XV, 746-753.

11. Massini, R.: Deutsch. Arch. f. klin. Med., 1911, CIV, 29-43.

12. Hektoen, L.: J. Am. Med. Assn., 1921, LXXVI, 929.

13. Friedberger, E., and Jarre, H.: Ztschr. f. Immunitatsforsch. u. exper. Therap., 1920, Orig., XXX, 351.

14. Krumwiede, C, and Cooper, G. M.: J. Immunol., 1920, V, 547-562.

15. Dale, H. H.: J. Pharmacol, and Exper. Ther., 1912, IV, 167-223.


YAWS

AN ANALYSIS OF 1046 CASES IN THE DOMINICAN REPUBLIC

By W. L. Moss, Assistant Professor of Preventive Medicine and Hygiene, Harvard Medical School

AND G. H. BiGELOW,

Instructor in Preventive Medicine and Hygiene, Harvard Medical School


Hi.sTORicAL Sketch of Santo Domingo The island occupied by the Republics of Santo Domingo and Haiti is the second largest of the West Indian group lying between Cuba and Jamaica on the west and Porto Eico on the east. It lies between the 17th and 20th parallels of north latitude and between the 68th and 74th meridians.

Its 28,249 square miles of area are diversified by almost every variety of topography; fair and fertile valleys, broad savannahs, towering mountains, sinister desert. The northern half or two-thirds of the island is traversed by two almost unbroken mountain ranges, the Monte Christi and the Cibao or Cordillera, between which stretches from the sea on the west to Samana Bay on the east a beautiful valley, the " Vega Real," the eastern half of which is well watered and wonderfully fertile. It is in this valley and on the lower slopes of the adjacent mountains that most of the cacao and tobacco grow, which, with sugar, make up the chief exports of the island. Indeed the cacao crop of Santo Domingo is said to be the third largest of any country of tlie world. The southeastern part of the island is occupied by a broad coastal plain extending back from the Caribbean as much as 50 miles. This is occupied by broad savannahs, well watered and covered with a luxuriant growth of grass which would furnish excellent pasturage for vast herds of cattle. It is here that the great sugar estates are located which produce the largest single


article of commerce of the island. Coffee is grown commercially to some extent in the mountains of the southwestern part of Santo Domingo toward the Haitian border.

Tropical fruits — bananas, plantains, pine-apples, cocoanuts, oranges, lemons, limes, mangoes, aguacartes, bread-fruit — -flourish. Birds of brilliant plumage rival the gorgeous tropical flora in beauty. The fauna is curiously limited in some respects, the largest native mammal on the island being the agouti, a shy little beast somewhat resembling the guinea-pig in appearance and about the size of a rabbit.

The heat of the tropics is tempered along the coast by sea breezes, and by the altitude of the mountains in the interior, the highest peak, Loma Tina, rising 10,200 feet above sea level.

The commercial life of the island centers in the various ports scattered along the coast — Monte Christi, Puerto Plata, Samana, Sanchez, La Romana, Maccoris, Santo Domingo City and Barahona. The number of inhabitants in these towns varies from a few hundred in the smaller up to about 25,000 in Santo Domingo City, the capital.

The population of Santo Domingo, wliich occupies the eastern three-fourths of the island, is estimated at between 700,000 and 800,000 inhabitants, while Haiti, occupying the western fourth of the island, has a population of about two and a half million. Haiti is known as the Black Republic,


44


[No. 372


and takes pride iu this appellation as indicating pure blood. Tlie language is French. Santo Domingo, ou the other hand, does not boast of its negro blood, although it is probable that considerably more than 75 per cent of the population possess it. In the larger towns, e.specially on the coast, there is a small white population, which shades down through all gradations of color to pure black. Few whites live in the interior, except in the occasional inland towns, the largest of which is Santiago de los Caballeros, a flourishing city of about 20,000 inhabitants, beautifully situated in the Vega Real. The language of Santo Domingo is Spanish.

Life in the interior is simple and furnishes little incentive for industry. The requirements for shelter and clothing are simply met and nature furnishes an adequate and healthful diet, with little exaction beyond the effort required to take it.

Perhaps few of us realize or remember the important part played by this obscure island in the history of Western civilization. Discovered on December 6, 1492, by Christopher Columbus, its present capital, Santo Domingo City, is the oldest existing European settlement in the Western Hemisphere. At the time Columbus landed and took possession of the island iu the name of the King and Queen of Spain, calling it La Espaiiola, the native population consisted of Arawak Indians, estimated at between two and three million souls. Columbus described them as a mild and peaceful race, characterized by their sweetness of temper, the men of hideous visage but the women comely. They offered little resistance to the Spanish occupation, and their land was given by the King of Spain in huge grants to his favorites, who, attracted by the glowing descriptions of the wealth and beauty of the country, came over iu large numbers, built palaces and cathedrals, set up a vice-regal court and lived in an extravagance which almost rivaled that of the court of Spain.

Tlie Indians were easily subjugated, quickly reduced to a state of slavery, and under Spanish tyranny and cruelty were soon exterminated. The appalling rapidity with which this took place may be appreciated from the estimates of the population in the succeeding years. The two or three millions of Indians present in 1492 were reduced in a period of 15 years to 60,000 by 1507, and had been further reduced to 14,000 by 1514. Enrique, the surviving caique, was so enraged by the treachery of the Spaniards, which had led to the capture and execution of Queen Anacaona, that he fled with a small band of followers to the fastnesses of the mountains, where he successfully resisted all efforts to capture him. In 1533 the remaining Indians, 600 in number, under this chief were given lands and established at Boya, a small village within five miles of the camp at which the work we are to report was done.

With the Indians practically exterminated, the land with all its wealth of resources was of little value to its new possessors. To make it again profitable, the African slave trade was instituted as early as 1508. The cruelty and abuses practiced on the Indians were repeated on the Africans, and doubtless would have been attended by the same result, but for the fact that, as they were killed or died off, fresh impor


tations were brought in. With the decline of the Spanish power the greatest bliglit to tlie existence of the slaves was removed, and under climatic aud economic conditions, which were for the most part favorable, they multiplied so that the present population of Santo Domingo consists largely of descendants of the African slaves with a greater or less admixture of Spanish blood.

Although the liistory of the island abounds in interest we may not attempt even a brief sketch of it in this paper. In passing one may recall that it was from Santo Domingo that Cortez, Balboa, Pizarro and De Soto set out to make their brilliant explorations and discoveries. It was the rendezvous for many of the pirate craft that preyed on the British, Dutcli and French commerce with the new world. Here the term " fillibuster " originated. The long speedy boats used in this piracy were called fly-bote or freibote, and their crews were known as freiboters, freebooters or fillibusters. The British and French united to retaliate against the Spanish pirates and established a base on St. Christopher and later on the island of Tortuga, Just north of Santo Domingo, where they were Joined by the Dntch. In addition to their operations on the water, they made frequent incursions into the northern part of Santo Domingo for the purpose of killing the cattle. Those who engaged in this pursuit came to be known as buccaneers, from boucan, the spit on which they cooked their meat.

From Tortuga the French gaiued a permanent foothold on the western end of the island, the part now occupied by Haiti.

Recall that the entire island has been at one time under Spanish rule, that the Dutch and British have each gained a foothold on the island, that eventually independence from France and Spain was gained, and the Republics of Haiti and Santo Domingo were established, that each of these young republics at one time or another gained possession of the entire island, and that these various changes were not effected without blood-shed. Indeed, the history of the island from the time of its discovery by Columbus in 1492 up to its military occupation by the United States in 1916 has been one of external war and internal revolution. Even in the short history of the republics, the list of presidents is of wearying length, the common way of removing a president being by assassination, and of establishing a new government, by revolution.

The result of this constant state of turmoil was that the resources of the island remained undeveloped, the people impoverished ; a relatively large national debt was acquired, lawlessness prevailed, education and sanitation were sadly neglected.

Even in the few years during which the United States Military Government has been iu control, splendid progress has been made in bettering these conditions. Peace has been maintained, law and order prevail, schools have been established, agriculture has been fostered, highways (one of the greatest essentials to the development of the country) constructed, and great progress has been made in sanitation. The credit for this work is due to the splendid group of U. S. Naval officers, who have been in charge of the military


Februaey, 1923]


45


government. The customs have been collected and not only have the expenses of this work been paid for, but the national debt which amounted to approximately $30,0()0.000.00 in 1907 has been reduced by about half.*

At the request of the military government of the Dominican Republic the School of Tropical Medicine, Harvard University, sent a commission consisting of Drs. A. W. Sellards, W. L. Moss and G. H. Bigelow to Santo Domingo during the summer of 1920 to study yaws. The results of the observations made are herewitli presented in abstract.

Ci.ixicAL DESCRirxiox OF Yaws

As the disease is strictly limited to tropical and subtropical countries, it may be unfamiliar to many physicians who have not been in the tropics; lience a l)rief introductory description of yaws is given. f

Synonyms. — Framboesia tropica, yaws, buba, pian, etc.

Definition. — A tropical specific infectious and contagious disease caused by Treponema perteuue ©astellani and characterized by a framboesiform granulomatous eruption.

Dislrihittion. — West Indies, Central America, northern part of South America, Africa, Malay Peninsula, Siam, Ceylon, parts of China. It is said never to occur in the mountains and cold districts and rarely above an elevation of 800 feet.

Etiology. — The Treponema pertenue, first observed by Castellani in 1905, is now accepted as the etiological agent of the disease. There has been much discussion concerning the question of the identity of yaws and syphilis, and while some observers still maintain their unity, the evidence at hand seems sufficient to establish them as two separate diseases. Charlouis, as early as 1882, successfully inoculated yaws in a syphihtic patient, and syphilis in a patient infected with yaws. That yaws patients are not immune against syphilis is further indicated by the observations of Powell and Nichols and of others, who have described cases of syphilis supervemng on yaws.

Incubation Perioit. — Castellani gives the incubation period as from two to four weeks. Paulet, in 1848, inoculated 14 negroes with the secretions from framba?sic granulomata, and all developed yaws in from 10 to 20 days. In monkeys and other animals, experimentally inoculated with yaws, the incubation period varied from 16 to 92 days.

Symptomatology. — Tlie course of the disease, like tliat cif sypliilis, may be divided into a primary, secondary, and tertiary stage. Some authors add a fourth stage (paraframboesial affections), but it is questionable whether the observations on wliich this additional stage is postulated are reliable.


For thi> hi.stoiy of Santo Domingo the reader is referred to two fascinating books: "Santo Domingo — A Country with a Future," by Otto Schocnrich; and "Santo Domingo, Past and Present," by Hazzard; both unfortunately out of print. Free use has been made of these and of the Encyclopedia Bntannica in the brief historical note here given.

t This description is taken largely from the chapter on Framboesia Tropica, Manual of Tropical Diseases. Castellani and Chalmers, Third Edition, Wm, Wood & Co., 1920.


Primary Stage. — Incubation period two to four weeks, characterized by malaise, rheumatic pains, headache, sometimes irregular fever. The primary lesion (motlier yaw, madre buba) appears as a papule, which after a week becomes moist, and develops a yellow secretion. A crust may form, which on removal reveals, an ulcer witli a granulomatous base. The primary lesion may heal before, but usually persists until after the secondary eruption has appeared.

Secondary Stage. — The secondary stage begins in from one to three months after the primary lesion, and is characterized by a general eruption of granulomata over the body. It is preceded by malaise, headache, severe pains in the muscles, joints and bones. In some cases there may be fever of an intermittent type. The granulomata appear first as minute papules, which increase in size to an average diameter of about one centimeter. They may coalesce, become secondarily infected, and form large ulcerating areas. In the majority of cases — witliin three to six months in children, and six to twelve months in adults — the granulomata dry up, shrink, and disapjiear. In some cases the granulomatous eruption may continue for several years, new crops of nodules appearing from time to time in succession. The granulomata generally undergo involution witliin from two to four months, leaving behind, as a rule, some change in pigmentation. At times secondary ulceration occurs, leading to deeper scars, and occasionally the granulomata take the form of a circinate eruption.

The granulomata frequ-ently occur on the soles of the feet, less often on the palms of the hands, with a resulting condition closely resembling the syphilitic psoriasis palmaris and plantaris.

The alimentary, respiratory, excretory, and central nervous systems are rarely involved. The joints are frequently swollen and painful. Lesions of the mucosa are rare. Castellani and Chalmers have not observed alopecia, but state that various groups of lymphatic glands are found enlarged. There may be a moderate degree of ansemia of secondary type and an increase in the large mononuclears. The Wassermann reaction is positive in the great majority of recent cases, but is fairly often negative in old cases.

Tertiary Stage. — The disease often terminates with the secondary stage. Sometimes the secondary and tertiary stages merge, or there may be an interval of years between them.

The characteristic lesions of the tertiary stage are gummatous-like nodules and deep ulcerative processes, frequently resulting in great deformity. The bones are quite commonly implicated, but visceral lesions are rare or absent. Castellani and Chalmers think that Gangosa, an ulcerative condition of the palate, nose, and pharynx, is in reality a tertiary manifestation of yaws.

Histopatliology. — In the frandicrsic papules the surface epithelium is greatly thickened and numerous elongated downgrowths are seen. In patches the epithelial cells are swollen, vacuolated and degenerating. Circumscribed areas contain polymorphonuclear leucocytes. The layers near the corium are almost normal, but the corium itself is oedematous. There


46


[No. 372


is a diffuse cellular infiltration consisting of polj'morphonuclear leucocytes, large and small mononuclears, eosinophiles, plasma cells, mast cells, connective-tissue cells and some estravasated erythrocytes. Treponemata are present in the granulomata.

Treatment. — Brodin in 1910 tried antimony. " Castellani's "Yaws Mixture" contains tartar emetic, potassium iodide, sodium salicylate, and sodium bicarbonate. Salvarsan was first used by Nichols in the experimental disease in monkeys, and by Strong in the treatment of the disease in man. The cure of yaws with salvarsan or neo-salvarsan is one of the most striking examples of specific therapy that medicine presents.

The malady does not appear to be hereditary. The course of the disease is chronic, resulting in serious disability and much suffering in a majority of cases. The mortality from yaws is not high, and death, when it occurs, is usually due to secondary infections.

The Authors' Obsekvations In discussing the cases observed by us in Santo Domingo the following abbreviations are used for convenience of reference. If the reader will take a moment to familiarize himself with these, the understanding of what follows will be facilitated :

M. Madre buba, mother yaw, primary lesion. B'. Florid secondary eruption of granulomata. Eaj'ly secondary stage.

B. Sparse recurring secondary granulomata. Late secondary stage.

C. Clavus. Late lesions on the soles. Late secondary stage. P. Palmar lesions. Late lesions on tlie palms. Late secondary stage.

G. " Gomma." Tertiary stage.

H. History of yaws. No active lesions present. Quiescent.

PEIMAEY STAGE

We observed 64 eases in which a primary lesion was present. sometimes alone, oftener in combination with other manifestations of the disease. Briefly these cases may be presented in the following tabular form :


Diagnosis No. of cases

M 15

MB' 25

MB'C 13

MB 6

MBC 5


The extremes of age in this group of cases were 7 months and 60 years. The duration of the madre at the time of observation varied from one month to six years, and the size varied from 1 to 7 cm. with an average diameter of about 2.5 cm. Of the 15 cases in the above group which presented a madre buba as the only active lesion, five showed healed scars of secondary granulomata ; thus there were only 10 cases which


(rage age

6.6


Average durat in mos.

2.3


8.5


7.3


11.6


4.1


24.2


19.0


10.


175



had not progressed beyond the primary stage. In 54 cases, or 84 per cent, of our series, the madre persisted after the appearance of secondary lesions.

Location of Primary Lesion. — In 969 cases the location of the madre was determined either by liistory, observation of the lesion, or scar (in 635 cases, or 71 per cent, the scar was present). In 18 additional cases the patients stated that they had had no madre but that multiple granulomata had appeared simultaneously over the body. In two cases the patients claimed to have had two mad res simultaneously.


T.\BLE Showing Location of Madre

Cases

Lower extremities 803

Upper extremities 80

Head 39

Trunk 37

Genitalia 10

969


The primary lesion occurred on the right side of the body in 425 cases and on the left side in 468 cases. In the remaining cases, the site was noted as knee, ankle, etc., but the side of the body was not recorded.

These figures have been analyzed to determine if the site of the madre might throw any light on the mode of transmission of the disease. In this connection it is to be remembered that we are dealing with a bare-footed and bai'e-legged population, that even the adults arc scantily clothed, that the upper extremities are almost as much exposed as the lower, and that children of both sexes usually wear no clothing until they are about five years of age.

Sexual Transmission. — Sexual transmission as a common method may be excluded because of the fact that in only 1 per cent of our series was the primary lesion on the genitalia. Of these 10 individuals, 6 were males, 4 females, and 5 were under 8 years of age. Moreover, in 25 per cent of all the eases in our series the infection occurred before the fifth year of life.

Hereditary Transmission. — We saw no evidence of hereditary transmission in any case.

Insect Transmission. — We think that transmission by the bites of the common flying insects, such as flies, mosquitoes, etc., may be excluded on the basis of the distribution of the primary lesion ; in the great majority of cases, the madre occurred on the lower extremities, whereas the face and upper extremities are equally exposed to the bites of these insects.

The preponderance of the primai-y lesion on the lower extremities as compared with the trunk would likewise seem ta exclude transmission by the bites of such non-flying insects as lice, fleas, bed-bugs, and the like.

The fact that in such a large majority of cases (S3 per cent) the primary lesion occurred on the lower extremities led to a further analysis of these eases. The result is sho^vn in the


February, 1922]


47


following tabulation, and for comparison the figures for the upper extremities are given :

Cases Cases

Buttocks 13 Shouldeis 6

Thighs 30 Upper arms 4

Knees 55 Elbows 16

Legs 201 Forearms 17

Ankles 258 Wrists 8

Feet 240 Hands .' 25


Total


803


Total


It -will be noticed that the frequency with which the primary lesion is found on the various parts of the lower extremities increases strikingly as one approaches the ground. This suggests that if the disease is transmitted by the bites of insects, we should tliink of some non-flying insect which remains on or i near the ground, and does not normally prey on man or even 5 desire to domicile with him ; such as ants, ground spiders, and the like.

The possibility tluit trauma provided tlie poital of entry for the trei^onema has been suggested. The greater frequency of the primary lesion on the exposed parts of the body fits in with such an hypothesis. It seems probable also that in a bare-footed population the lower extremities would be the most frequently traumatized part of the body, and that the frequency of minor injuries would inci-ease as one progressed down the extremity. Examination of the preceding tal)le 1 shows that the frequency with which the madre occurs on the various parts of the lower extremities increases as one descends toward the foot.

Man, being a forward-going animal, is apt to get most of his knocks from in front; accordingly, we have analyzed the primary lesions occurring on the knees, legs and ankles with reference to their occurrence on the anterior, external, internal and posterior surfaces.

As far as our records showed this data, the results are set forth in the following table:

Anterior K.Ntei

Knees 18 S

Legs 107 35

Ankles 25 7£

In the case of the knees and legs it is shown that the anterior

\r surface leads by a large majority, the external surface comes

next, followed by the internal surface, while the posterior

surface finishes a poor last. This probably corresponds closely

to the exposure to minor traumata.

In regard to the ankle the circmnstances are different. Owing to its conformation the malleoli are about equally exposed to injury, while the anterior surface of the ankle is protected by the projecting foot which receives on its dorsum tlie injuries which would otherwise go to the ankle. This corresponds with the frequency of the madre on the various parts of the ankle, and with the fact that in the case of the foot, the primary lesion was found on the dorsum in a great majority of eases.


nternal


Poste


6


4


19


12


84


13


It appears probable from our observation, tlierefore, that trauma, frequently minor in character, usually determines the site of the primary lesion in yaws. This is entirely compatible with the view that the disease may be transmitted by direct contact, or that insects, flies, etc., may be vectors of the virus.

SECONDARY STAGE

Florid Secondary Stage. — In our series there were 144 patients who presented themselves during the florid secondary stage of the disease. In 38 of these the primary lesion was still present and in 37 the late lesions of the soles, known as clavus, had made their appeai'ance.

Briefly summarized these eases are presented in tlie following table :

Flohiu Secondary Stage


Diagnosis


No. of cases


Mg.


A vs. iluration


No. of cases with fresli Rraiiulomata < soles" palm


MB' .


. 25


8.5 yrs.


7.3 mos.


2 1


MB'C


. 13


11.6 "


4.1 "


7 1


B' ....


. 82


8.8 "


12.3 "


6


B'C ..


. 24


12.9 "


30.4 '


9 2


144 24 (16.67c) 4(2.8%)

Exclusive of tlie 38 still showing the primary lesion and previously analyzed, the youngest patient in this group was 1 year and the oldest 50 years.

While clavus may develop very early in the disease, witness the 13 MB'C cases with an average duration of 4.1 months, as a rule it does not develop until the disease has lasted more than a year. The average duration in the 82 patients who presented only secondary granulomata was 12.3 months, whereas the average duration of the cases which showed clavus in addition to the florid secondary eruption was 30.4 months. The greater frequency of granulomata on the soles as compared with the palms is indicated by their presence in the former situation in 16.6 per cent of this group as against 2.8 per cent in the latter situation.

From our observation and the histories we obtained, we are led to believe that, in the disease as it occurs in Santo Domingo, practically all of the patients, sooner or later, develop granulomata on the soles and become the victims of the painful condition wliich they designate as clavus.

The secondary eruption, as we saw it, corresponds closely to the text-book description as given by Castellani and Chahners. The individual granuloma does not difl'er materially in appearance from the primary lesion except tliat it usually does not become so large and seems less apt to undergo as deep ulceration. In our notes we described the earliest stage observed by us, as a small papule 1 to 2 mm. in, diameter, gray in color, and surrounded by a narrow zone of hyperemia. These papules increase rapidly in size to an average diameter of about 1 cm. and are usually elevated 0.5 to 0.75 cm. above the skin. The surface of the granuloma is covered with minute


48


[No. 372


bosses which give it a raspbern-like appearance from whicli the disease takes the name framba'sia (Figs. 4, 5, 6, and 8). In the early stage the granulomata are of a pearly gray color ; later they are apt to become covered by a thin yellow crust. After a few weeks or months retrogressive changes take place ; the lesions turn dark, often black in color, shrink in size, the surface becomes checkered, and after a time all that remains is a black crust, which on falling may leave no scar; more frequently pigmentary changes persist, which maj' consist of increased pigmentation, apigmentation or an apigmented area surrounded by a zone of increased pigmentation.

At no stage of the granulomata was vesiculation noted. They may go through their entire existence without ulceration, but more frequently they become secondarily infected, and consequently more or less deeply ulcerated. During the florid secondary eruption there may be hundreds of granulomata over the body, and no part of the cutaneous surface, from the croxvn of the head to the soles of the feet, is exempt from invasion. They show a special predilection for the muco-cutaneous borders — nostrils, mouth, genitalia, anus, and moist surfaces — axills, internatal region, between the upper thighs and popliteal spaces (Figs. 7 and 8). The mucous membranes are said to be rarely involved and we saw but one such case in our series, a single granuloma on the vermilion surface of the lower lip. We observed no ca.se of alopecia except as the result of iilcerative processes involving the scalp. One patient presented the typical circinate arrangement of the lesions on the face, which strikingly suggested the Indian war-paint appearimce (Fig. 12).

Usually there was no complaint of pain in consequence of granulomata on the body except in cases in which they were situated on the bearing surfaces of the feet, on the pahns of the hands or when extensively ulcerated.

Arthritis (Fig. 22) and dactylitis were fairly common, although they usually occurred later than the florid secondary stage of the disease. The knee-joints were involved most commonly, the elbows next in frequency. Usually a single joint was affected. The swelling was sometimes considerable and in one instance as much as 200 c. e. of shghtly turbid, straw-colored fluiil was aspirated from a knee-joint. This fluid was witlniut evident effect when injected into the peritoneal cavity of a guinea-pig. The dactylitis took the form of tlie usual spindle-shaped fingers, generally a single disit, sometimes several, being involved.

Lale Secondary Stage. — There were 190 cases in the series that were considered to be in the late secondary stage of the disease. The patients had passed through the florid secondary eruption as evidenced by the numerous scars of previous granulomata. Many of them had doubtless been entirely free from active lesions for variable lengths of time after which one or more recurrent granulomata had appeared. It is evident from the histories obtained that the disease may undergo an apparent spontaneous cure, but sooner or later granulomata reappear in a majority of cases and successive crops, consisting usually of only a few lesions, continue to make their appearance, with


free intervals between for many years. Briefly tabulated these cases may be presented as follows :


Late Secondary St.vje


niagnosii

MB .. MBC . B .... BC ... BCP .


. 6 . 5 . 60 .106 . 13


AvK.

242°yis. 10.0 ' 9.3 ••

16.5 " 20 5 '


19 mo.s. 172 " 29.6 " 5.4 VIS. 11.3


Total.. 190


No. of cases with

[rf-sh granulomata on

soles palms

2 1

1 1

16 1

69 1

10 4

98(51.6%) 8(42%)


Of the 190 patients in this group, 60 had as their only active manifestation of the disease a few secondary granulomata. 106 had grajiulomata plus elavus lesions and 13 had, in addition to the above, palmar lesions. Eleven cases which have already been analyzed with the madre cases are included here, as they appear to have been in a late secondary stage of the disease in spite of the persistence of the primary lesions.

The extremes of age in this group are 1 and 75 years; and while the former figure shows that a late secondary stage may be reached not only early in life but comparatively early in the disease, the average age in this group indicates that this is exceptional, and both the average age and average duration of the disease at the time of observation point to the chronicity of the secondary stage of the disease.

Clatus. — Perhaps the most curious and interesting effects of the disease are the late lesions which occur on the soles of the feet and it is to these that much of the pain and disability is due. We have adopted the term " Clavus " used by the natives, because it seems an appropriate one, although they use it to designate conditions of the soles long after anything suggesting a " Nail " has disappeared.

In a previous section attention has been called to the frequency with which secondary granulomata appear on the soles. Those occurring in this situation do not differ materially in appearance from granulomata seen elsewhere on the body (Fig. 13). They are perhaps more frequently secondarily infected, and are apt to ulcerate, probably as a result of the fact that the natives seldom protect them by any sort of dressing and continue to hobble about even when the feet appear to be in a shocking condition.

If the granuloma on the sole heals without ulceration, as it shrinks, it separates from the surrounding epidermis and becomes cireumvallate. The hard, dry black core must act like a foreign body beneath the foot and it is the " nail " which led to the use of the term clavus. Finally, the core drops out leaving the "nail hole," a circular opening 0.75 to 1 cm. in diameter with sharp-cut edges which descend vertically 2 or 3 cm. to a flat base.

Usually both soles are about equally involved, although rarely cases are encountered in which only one sole is affected (Fig. 15). The number of granulomata on each sole may vary from only a few to 20 or 30. Irregular erosion, the result of attrition of the epidermis intervening between the " nail holes " may account for the remarkable moth-eaten ai)])earauce


February, 1923]


49


of the soles which many of the old claviis cases present (Figs. 14, 17 and 18).

Under the designation " clavus " the natives include conditions difl'ering from those just described and which are not so readily explained as the result of pre-existing granulomata. Not infrequently the soles presented a condition which is aptly described by the term honey-combed. The entire sole, or, in some cases only the bearing surface, was filled with pits 0.5 cm. or less in diameter, conical in shape and extending to a depth of 2 or 3 mm. These pits are as closely and regularly set as the cells of a honey-comb, and no such number or distribution of fresh granulomata was observed as would suggest that each pit could represent the site of a previous tumor.

In otlrer cases the epidermis of the entire sole or a large part of it was greatly thickened, black, and dead-looking.

The natives applied the term clavus indiscriminately to any of the conditions just described. Pain was the characteristic common to all. Like the granulomata elsewhere on the body, the clavus lesions would clear up spontaneously in time, only to recur again and again throughout many years.

Occasionally a condition of the soles was seen to which the natives apply the name " Eajadura," which means a fissure or crack. The fissures, 2 to 3 cm. long and 2 to 3 mm. deep, are usually arranged vertically about the periphery of the heel. More rarely they occurred in the sole beneath the instep or ball of the foot, where they might attain a length of 6 or 8 cm., reaching to a considerable depth and, like tlio.se of the heel, cause much pain. We gained the impression that these fissures were also due to yaws, and for this reason have included in our analysis the relatively small number of cases encountered with clavus, although the term " Rajadura " is more descriptive.

Before proceeding to the analysis of the clavus cases it may be well to state that we have not included in this category ajiy cases which presented fresh granulomata as the only lesions of the soles. We have reserved the tenn clavus to designate only the late effects of the infection on the soles, and think that these should be regarded as belonging to the late secondary stage of the disease. It may be of interest to give here a description of the changes which took place in the clavus cases following the administration of neo-salvarsan leading to their cure. A statistical statement of the result of the treatment in all cases will be given in a later section of this paper, but the results obtained by treatment furnished corroborative evidence that these several different lesions were properly considered as a manifestation of yaws.

We were prepared to expect the improvement which resulted from the Tise of neo-salvarsan in the cases with fresh granulomata, whether they were situated on the soles or elsewhere on the body, but it seemed rather too much to expect that these old "moth-eaten," dilapidated soles would be rejuvenated by a few injections of any drug. The first few patients were given an injection more as a placebo on account of their importunity and the long distances that some of them had come, rather than with any expectation that they would be benefited. When these patients came back at the end of a week, however, their feet


not showing the least improvement in appearance, we received with surprise and incredulity the statement that they were cured of pain and when they adduced, in support of their claim, tiie statement that, whereas they had been obliged to come on horse the first time, they were able to return on foot, we were encouraged to try treatment on other cases. In the end clavus comprised the largest and in certain respects the most important group of cases that were presented for treatment.

A week after the first injection of neo-salvarsan there was, as a rule, no objective change in the feet, but almost without exception the patients affirmed that the pain was either greatly ameliorated or entirely gone. The injections were usually given at from seven to ten day intervals. About a week after the second injection, the old dead epidermis loosens up about the edges of the clavus holes, erosions and fissures, and begins to desquamate. This process goes forward rapidly until within a week or two after the second injection all the old epidermis has been shed, exposing healthy pink skin.

The followintr table summarizes the clavus cases :


Diagnosis


\o. of


AvB. Xge


.\vg. duration


Right


Sole affecte Left


1

Both


MB'C ....


.. 13


11.6 yrs.


4.1 mos.


8


11


6


MBC ....


.. 5


10. "


17.2 "


4


4


3


B'C


. . 24


12.9 "


30.4 "


21


23


20


BC


..106


16.5 "


5.4 yrs.


94


92


80


BCP


.. 13


20.5 "


11.3 "


11


13


11


C


..327


21.6 "


9. "


299


291


266


c+*


.. 41


29,4 "


12.9 "


33


35


27


cp


.. .50


32.7 "


1S.7 "


45


47


42


In 3 of the 579 cla\'us cases no note was made as to which sole was involved. It is ai>parent, however, that the right and the left sole are affected with equal frequency, and that in a uiajority of cases both soles are implicated (79 per cent in the above series).

Although we have seen clavus in an infant of one year, attention is called to the fact that the average age of the largest group in this series, the 327 patients who had clavus only, was 21.6 years, and that the average duration f of the disease in this group at the time they presented themselves for treatment was 9 years.

Palmar Lesions. — l\'rlia])s (•(irrespondiiig' to the clavus lesions, though not so definitely dependent upon granulomata, are the painful keratoses and fissures which, late in the disease, appear on the palms of the hands. There is sometimes more or less erosion of the epidermis and frequently an inability to open the hand fully and extend the fingers. This is apparently due to a certain amount of contraction of the hard, dry keratosed surface.


The group of 41 cases designated as C-f- had in addition to clavus some other condition which apparently was not dependent on the yaws infection. In a majority of cases the additional affection consisted of chronic leg ulcers.

t Wherever average duration is given in this paper it refers to the duration since the first appearance of the primary lesion and not to the duration of any particular stage, unless so specified.


50


[No. 372


The condition is usually painful, though less so than clavus, and interferes ^\-ith manual labor. It is a much rarer lesion than clavus, and appears to develop in older individuals and later in the disease, though it seems to be equally amenable to treatment.

In our series this condition was met with 68 times, but only five of these patients had palmar lesions (exclusive of scars) as the only effect present. These 68 cases are briefly summarized in the accompanying table :

No. of Averas** Average

Diagnosis cases age duration

BCP 13 20.5 yrs. 11.3 yrs.

CP 50 32.7 " 18.7 "

B 5 25. " 14. "

It is rather striking that of the cases presenting a single manifestation of yaws, clavus forms the largest group, 327 cases, while those showing palmar lesions (other than fresh granulomata) constitute the smallest group — five cases. It is also striking in the above simimary of the palmar cases, that those associated with clavus as the only other lesion form the largest number — 50 out of 68 cases.

It is interesting that the average duration of the disease in the CP group, 18.7 years, is the longest of any group of the entire series, not excepting those in the tertiary stage of the disease.

Studded Lesions. — In a number of cases we observed nodular skin lesions which we believe to be a manifestation of yaws (Fig. 20). The earliest stage of these nodules was either not observed or else was not recognized as the beginning of lesions which in a later stage of their develojiment became quite familiar to us. Apparently, these lesions may occur on any part of the body, although we never observed them on the head or face. The forearms and legs were the commonest sites in the cases which we observed. The thighs and trunk were frequently implicated and lesions starting on the dorsum of the foot and extending on to the plantar surface were noted.

A typical picture of the condition as observed by us may be described as follows: The individual lesion consists of a moderately hard skin nodule, 1 cm. in diameter, elevated 3 to 4 mm.-, not painful, unaccompanied by itching and without striking pigmentary changes until after regression, when increase of pigment may mark its former site-. These nodules are thickly studded and regularly set over an area 8 to 10 cm. in diameter. The size of the area involved increases 'by an advancing margin consisting of an almost unbroken }ow of nodules. As this peripheral advance occurs, healing takes place in the center of the area. If the nodules do not ulcerate this retrogression is accompanied by desquamation of the epithelium. The nodules gradually flatten out and finally disappear, leaving no trace, or more often a circular area of increa.sed pigmentation.

In no case were the nodules observed to pass tlirough a vesicular stage, but they frequently underwent ulcerative changes varying from very superficial ulceration involving only the individual nodules to extensive and deep ulceration which sometimes became confluent over large areas of the body and


extended to the subcutaneous tissues. The degree and character of the resultant scarring probably depends upon the depth to which the ulceration had extended. Sometimes there remains only an increase of pigmentation, as mentioned above ; sometimes the skin over the entire area involved wa.s left thin and crinkly and in patterns like those which form on the surface of hot chocolate which has been thoroughly boiled and allowed to stand awhile. Again, where the ulceration has extended to a greater depth there may result complete leucoderma and sometimes painful keloid (Fig. 21).

We have called these lesions " studded " for the lack of a more descriptive term. The area involved, when small, is usually circular, but as it increases in size it is apt to become elliptical or more often it approaches a rectangular shape but with rounded corners. If situated on an extremity, the long diameter of the area coincides with the axis of the limb. Seldom does it completely encircle an extremity even when large areas are involved.

We regret that we had no opportiuiity of studying these lesions histologically. They do not in the least resemble the primary and secondary granulomata. We do not know if they should be considered a late secondary manifestation of the disease or if they belong to the tertiary stage.

We have notes on 37 cases, the youngest patient exhibiting these lesions being 5 years of age and the oldest 80 years. The average age in this group was 28.8 years, which comes next in length to the gomma group (29.3 years). The average duration of the disease (yaws) in this group was 13.5 years with the extremes of duration 5 months and 39 years. This average duration is exceeded only by the P, G, and CP groups.

Our belief that these skin lesions are a manifestation of yaws is based on the fact that they were observed only in patients who gave a liistory of yaws, or who had other recognized yaws lesions, and on the observation that they apparently responded specifically to neo-salvarsan therapy.

We are inclined to regard them as a late secondary manifestation of tlie disease.

Tertiary Stage

The impression gained from a fairly close study of over a thousand cases leaves no doubt in our minds that yaws and sj'philis are separate diseases. Exclusive of the evidence contained in the literature of inoculation experiments, the occurrence of yaws and syphilis in the same patient, the difference in the response of the two diseases to mercury, the possibility of reinoculation in yaws, the localization of the disease to the tropics and below certain altitudes, the grounds afforded by our ovni experience on which we base our opinion are as follows : Syphilis is universally recognized as a venereal disease, the primary lesion is, in the vast majority of cases, located on the genitalia and even in the cases not contracted through sexual intercourse, in which the primary lesion is extra-genital, the course of the disease is in no way modified by the method of inoculation or the unusual seat of the chancre. Yaws, as we have already pointed out, can be excluded from the category of venereal diseases by the fact that in a series of approximately


February, 1922]


51


a thousand cases the primary lesion was located on the genitalia in only 1 per cent and infection took place in 35 per cent before the fifth year of life. Moreover, the primary lesion in yaws differs distinctly in appearance from chancre, even when the latter is extragenitally located, the madre buba, as a rule, being larger, the surface rougher ; moreover, in no case was there the hardness sometimes present and usually considered characteristic of the syphilitic lesion.

In no case did we observe any evidence or obtain any history of hereditary transmission of the disease.

The duration of the madie buba and the high percentage of cases in which it persists after the onset of the secondary stage of the disease (84 per cent in our group of 64 madre cases) is contrary to what is observed in syphilis.

Wlien we come to consider the secondary stages of the two diseases we find more striking contrasts and more especially do we note the remarkable pleomorphism of the secondary lesions of syphilis and the faithful monotony of the secondary granulomata of yaws. The versatile Spirocheta pallida may occasionally produce a counterfeit yaws but never did we observe a yaws patient in the secondary stage of the disease who failed to show either typical granulomata or scars which we felt sure were the marks of typical granulomata. Even the secondary infections and ulcerations which may result do not disguise the nature of the lesions.

Although Castellani and Chalmers say that " occasionally, peeling, whitish patches may be seen on the pahns of the hands and soles of the feet closely resembling the syphilitic psoriasis palmaris and plantaris " we have never observed in syphilis anything resembling the clavus and palmar lesions which we have described as occurring in yaws. On the other hand, none of the yaws cases which we observed presented such characteristic secondary manifestations of syphilis as the macular skin rash, mucous patches and alopecia.

In the tertiary stage of the disease the absence of visceral involvement especially of the heart, blood vessels, liver and kidneys is in striking contrast with the frequency of their involvement in syphilis. Moreover, in a series of over a thousand cases in which the average duration for the entire series was 20.3 years and 79 of which were in the tertiary stage, none showed any evidence of central nervous system involvement. We do not wish to attach undue significance to the absence of central nervous system lesions in this series of cases because the relative immunity of the colored race to such involvement in syphilis is well known.

Finally, the marked difference in the response of yaws and syphilis to neo-salvarsan is a not ujiimportant point in favor of the duality of the two diseases. We have seen the lesions of a patient in the florid secondary stage of the disease melt away completely after a single injection of 0.6 gm. of neo-salvarsan. Indeed the cure of yaws by this agent is the most dramatic therapeutic performance that we have ever witnessed.

But although a decision between syphilis and yaws in the primary and secondary stages was arrived at with little difiiculty, there were cases presenting tertiary lesion in which we found it impossible to make the differential diagnosis (Figs.


23, 24, and 29). There were patients with periosteal thickenings of the long bones ; especially of the tibia, radius and ulna. There were those with typical spindle-shaped swellings of one or more fingers, and others with the bridge of the nose destroyed and -with perforation of the hard and soft palate (the condition known as gangosa) . There were cases in which old ulcerative processes had led to loss of substance of the cranial and other bones. Some of the patients who had an eye that had ulcerated out, and some in whom the nose was almost completely destroyed or fingers or toes had been lost, suggested the ravage of leprosy. Whether these results were due to syphilis or yaws we are unable to state positively. The patients themselves applied the term " Gomma " to all tertiary lesions and stoutly maintained that they were due to the latter disease " yaws."

There were other patients exhibiting tertiary manifestations which bore no resemblance to syphilis as we see it in the United States to-day. These included extensive skin ulcerations, great enlargement and deformity of the hands and especially of the legs and feet.

As previously mentioned, pain in the joints and often an effusion was a frequent complaint in the secondary stage. Many of the tertiary cases showed arthritic enlargement and partial or complete fixation.

That those cases, objectively indistinguishable from syphilis, were actually yaws, we must, of course, leave unsettled. In favor of the view that they were yaws are the following facts :

The patients themselves, who are familiar with both diseases, maintained that the condition from which they were suffering was yaws. Practically all of this group denied liaving had syphilis (this denial deserves some consideration, because little or no shame attaches to venereal infection among the natives) . There were 79 individuals in the " Gomma " group and of these 67 were able to give the location of the primary lesions. Corroborative evidence of the correctness of their statements as to the location of the primary lesion was furnished by a scar in 34 cases. In only two of the 67 cases was the location of tlie primary sore at all a usual one for a chancre, the upper lip in one case and perineum in the other.

Summary of the Gomma Cases

No. of Average age Duration in years

Diagnosis cases in years Extremes Average Extremes

G 67 29.3 3-85 16.3 7/12-59

MG n

BG 3

BCG 2 ^ 252 7-60 9.7 1-40

CG 5

CPG 1 J

The youngest patient in the entire gomma group was 3 years, the oldest 85 years. The average age for the entire group, as well as the duration of the disease at the time of observation, was greater, as would be expected, than in any other group with the exception of the cases with palmar lesions. The extremes both of age and duration are strikingly far apart.

It is of interest that in one case the primary lesion persisted after tertiary manifestations had made their appearance.


52


[No. 373


That the disease may progress to the tertiary stage in a comparatively short time is shown by the fact that in 10, or 7.9 per cent, of the gomma cases the disea.se had existed 2 years or less at the time of observation.

Latent Yaws

We have inehided in our series 127 individuals who had no active lesions of yaws at the time they were observed but who gave a history of having had the disease and who, in most cases, exhibited confirmatory evidence in the way of scars. Brief histories were taken and examinations made of all these cases, inasmuch as they furnished certain statistical data of some interest. Moreover, being impressed with the chronicity of the disease, the frequent recurrence of active lesions after longer or shorter periods of latency, with the doubt in our minds that spontaneous cure occurred in any considerable proportion of the cases, and at the earnest solicitation of these individuals many of whom would say " I had clavus last month and I will have it again next month " or " I have a breaking out of the buba every year," we made a practice of giving one or more injections of neo-salvarsan to patients in whose cases the history and examination satisfied us that they probably had liad yaws.

The 137 cases which come under this lieading may be tabulated as follows :


Diagnosis

H

H-f

H ulceration


21.2 22.9 27.6


' Extremei

1-80 2-62 10-80


Duration in years Average K.\trenies

8.8 yrs. 2/12-50

10.2 " 6/12-45

10.6 " 3/12-59


Of the cases in this group those designated H were without active lesions of any disease, but gave a satisfactory history of having had yaws. Under H-f- we have grouped those individuals who, in addition to giving a history of having had yaws, had symptoms or signs of some other disease such as various skin eruptions, pains in various parts of the body, extensive scarring and other manifestations. One man gave a history of chancre and had a scar on the prepuce. The H ulceration group comprise 45 eases which in addition to a history of yaws showed active ulceration on some part of the body, usiiaUy old leg ulcers, which we could not definitely identify as yaws, and in most cases believed to be due to some other condition.

It seems not unlikely that this group of 137 individuals must have included many sufferers from latent yaws who, had they been left untreated, sooner or later would have again developed active lesions and not only suffered the disability arising from the disease themselves, but would also have become active agents in the spread of the disease. The statistics of this group seem to lend weight to this view. The average age in this group (33.8 yrs.) is lower than the average age of various other groups which showed active lesions, e. g., groups MB, C-|-, CP, P, G, and G-I-. Moreover, the average duration in this group (9.7 j'ears) is shorter than that in several groups showing active lesions, e. g., C-f, CP, P and G.


Indeed in 33, or 36 per cent, of these 137 cases the primary lesion had developed within 2 years prior to the time they applied for treatment. It seems highly probable that some of th^se 33 patients may have been in a free interval between the primary and secondary stages of the disease and that the majority of them were in a latent period following the early secondary eruption.

With a very limited time in which to work among a given population and with the object of accomplishing as much as possible toward eradicating the disease from the locality in which we were stationed, we think the policy of treating patients who gave a history of having had the disease, even though without active lesions at the time, is fully justified.

Gexeral Remaeks The epUrocldear ghinds were noted in 886 cases and were found to be palpably enlarged in 519, or 58.5 per cent; they varied in size from a grain of wheat to 1 or 3 cm. in diameter. Sometimes two or three glands. 1 cm. in diameter, were found in the epitrochlear region.

The femoral glands were noted in 131 cases and found enlarged in 100 per cent of the cases noted. In a majority of cases the femoral glands formed a visible ovoid swelling in Scarpa's triangle frequently attaining a width of 3 or 4 cm. and a length of 5 or 6 cm. It seems probable that the enlargement of this group of glands may have been due to the frequent pyogenic infections on the feet and legs that occur in a barefoot population.

The spleen was noted in 216 cases and found enlarged in 58, or 36.8 per cent. Malaria is common among the natives and may account for the large percentage of cases with splenic tumor.

The Wa.ssermann test was made in 91 cases and found strongly positive in 78 cases (85.7 per cent), moderately positive in 4 cases, weakly positive in 1 case and negative in 8 ca.ses. The 8 eases with negative Wassermann reactions were distributed with reference to diagnosis as follows :

2 cases diagnosed B

1 " '^ c+

1 " " SL

1 " " H

1 " " H-f

1 " " G

1 " " G+

The Wassermann test was repeated in a iew case^ after one or two treatments, the interval between the two tests being not over a few weeks. In no case did the result of the second test differ from that of the first. If it had been possible to perform the test at a longer interval after treatment, the results might have been different.

Thus it will be seen that in the small number of cases in which we have data on the Was.sermann reaction the negative reactions all occurred in the late secondary stage, the tertiary stage, or in patients who had no active lesions but who gave a history of yaws.


Febkuary, 1922]


53


Sequen^ce and Duration of the Various Stages of Yaws III the discussion of this entire series of cases we have tried to take up the various distinctive manifestations of the disease in the order of their development. In so chronic a disease as yaws it was obviously impossible, in the limited time at our disposal, to observe a single case from the appearance of the madre buba, tlu'ough the various stages, to the final deformity produced by the gummatous lesions. Moreover, it is apparent from the preceding sections that there is much overlapping of the various stages, many patients presenting two or even three different manifestations of the disease at the same time. In one case the madre buba persisted after the tertiary lesions had developed. Indeed, not being able to observe the sequence of events, we were often ignorant as to what it had been. We believe, however, that a statistical study of the data collected enables us to unravel this tangle. Accordingly, we have tabulated those cases that presented only a single manifestation of the disease, arranging them according to the average age of each group. The table also shows the extremes of age as well as the average and extremes of duration for each group.

No. of Aire Duration

Diagnosis cases Averatre Kxtremes .U-erage Extremes

M 15 6.6 yis. 9/12-12 yrs. 2,3 mos. 1/12-7/12 yrs.

B' 82 8.8 • li-50 ' 12.3 " 1/12-7 "

B 60 9.3 •• 1-42 29.6 " 4/12-17 "

C 327 21.6 " 3-68 ' 9 yr.s. 4/12-58 "

H 127 23.8 " 1-80 " 9.7 " 2/12-59 "

P 5 25 " 15-45 ' 14 " 10-19 "

SL 37 28.8 " 5-80 " 13.5 " 5/12-39 "

G 67 293 " 3-85 " 16.3 " 7/12-59 "


720


This series comprises 780 cases and the number included in a majority of tlie groups is large enough to give averages that are probably fairly reliable. It seems to us that this arrangement according to average ages probably indicates the sequence in which the various lesions develop. Confirmatory evidence in support of the correctness of this view is furnished by the fact that the average duration of the disease, at the time of observation, in the various groups, with one exception (Studded Lesions) follows the same orderly progression as do the ages. The fact that the extremes of age and duration in each group may vary widely does not, in our opinion, invalidate the deduction which we have just made.

We have attempted to use the data contained in the above table to answer certain other questions. It will be noted that the average ages and average durations are given as of the date of observation, and in the case of duration this does not represent the actual average duration of the disease or any particular stage of it. To illustrate : A patient in the primary stage of the disease may hiive given a history of having had the madre buba 2 months at the time he applied for treatment; it is quite possible that this lesion would, without interference, have persisted for another 2 months. Thus in that particular case the duration of the primary lesion would have been 4 months. If our reasoning is correct, the actual average duration of the madre buba may be estimated by determining


the average duration of the lesions at the time of observation in a sufficiently large number of uuselected cases under natural conditions and multiplying this average by two. Thus, in our series of madre cases, the average duration at the time of observation was 2.3 months, and if 15 cases were a sufficiently large number for generalization, we could say that the actual average duration of the madre stage of yaws is 4.6 months.

Furthermore, if one stage supervened promptly on the termination of the preceding stage, we could in turn calculate the actual average duration of each of the manifestations in the above series. For example, we would arrive at the average duration of the B' lesions by multiplying 12.3 months by 2 and subtracting the average duration of the madre stage. Thus we would find 20 months as the average duration of the florid secondary stage of the disease. The difficulty about applying such simple mathematical calculations to a disease like yaws is that there may be an interval free from active lesions and symptoms between the various stages of the disease, on the one hand, and, on the other hand, a considerable overlapping of the stages. This difficulty could have been overcome if it had been possible for us to obtain accurate histories of the date of onset of each stage of the disease. This we did not attempt, owing to the ignorance of a majority of tlie patients and the limited time at out disposal.

Although we obtained a history of tlie primary lesion persisting for 6 years in one case and saw patients with a florid secondary eruption', in one case 3 years, in another 7 years and in still another case 19 years after the onset of the disease, if we may accept the history given by these patients, it seems probable that the average duration of the florid secondary eruption is less than 2 years and that the late secondary lesions, especially clavus, may recur throughout a long period which, while frequently much longer, averages about 16 years and that in some cases patients may live to extreme old age, 85 years in one case in our series, with tertiary lesions.

Result of Treatment

Neo-salvarsan was used in the treatment of the cases here reported. The drug was dissolved in freshly distilled water in the proportion of 0.1 gm. to 2 c. c. and injected within 30 to 45 minutes after being put in solution. The intravenous method was used in all cases except for young children with V ins difficult of access, these patients receiving the injections intra-muscularly in the buttock. The dose varied from 0.075 gr. for an infant under 1 year of age to 0.6 gm. for a fully developed adult. Intermediate doses were given in proportion to age and body weight. While reactions were frequent, including chill, fever, headache and general malaise, we observed no permanent ill efl'ects and in none of the patients who received the intramuscular injections did we observe abscess formation which reached the surface, althougli some of them showed a painful brawny swelling.

It should be remembered that we were working under field conditions with no facilities for hospitalizing patients even over night, that many patients came two, three, and even four days journey on horse or on foot, over difficult trails, beaten


54


[No. 372


upon by tropical sun and often drenched by tropical rains, with the ground for a bed and the sky for shelter. Oftentimes within an hour after receiving an injection these patients started on the return journey to their distant homes again facing the hardships of the trail. The fact that no patient declined to return and receive further injections, when advised to do so, indicates as clearly as any statistics we might give either that the natives did not regard the reactions of a very serious nature or else that they considered the benefits to be derived as by far outweighing the discomforts of the reactions.

From a statistical standpoint the results of treatment in our series is of little value owing to the limited time over which the cases were observed and the fact that many patients received but a single treatment and were not seen again. The latter circumstance is easily explained. In the interior of Santo Domingo communication is largely by word of mouth and news spreads chiefly by means of the more or less chance wanderings of the natives. Wlien we went up into the interior and set up our camp it was five days before the first patient, an old woman with " gomma," presented herself for treatment. Two days later three children with a florid secondary eruption were brought to us. During the next few days patients ventured in in small numbers, but when the news of the results obtained in the early cases treated began to spread, patients came in rapidly increasing numbers. By the end of the first month we were getting an average of about 25 to 30 new cases a day, and during tlie last two weeks of our stay the daily number of new and old cases ranged between 100 to 300. In spite of the fact that we sent out notices well in advance of our departure to stop new patients from coming in, the daily number increa.sed almost up to the last day of our stay. Their appeal for help was so piteous and their condition so distressing that we could not refuse them a single injection, although we knew that we should never see them again. This accounts for the large number of cases in which we have no note as to the result of treatment.

It has been claimed that 90 per cent of yaws cases can be cured by a single injection of salvarsan. Our experience was not so favorable, though, if we had had a longer time in which to observe tlie results, we could have allowed a longer interval between injections and might have found it necessary to repeat the treatment in a smaller percentage of the cases. Moreover, the number of patients requiring more than one injection to effect a cure might have been fewer if 0.9 gr. of neo-salvarsau instead of 0.6 gm. had been adopted as the adult dose.

We have designated our results as cured, practically cured, much improved, improved, and unimproved. No patient was recorded as cured unless all the lesions (scars excepted) had entirely disappeared. If there remained at our last opportunity of observation otily so much as a few black crusts almost ready to fall, where a week or two before there had been an abundant crop of fresh granulomata, we designated such cases as " practically cured " although we were convinced that could we have seen these patients a week later, without further treatment, they would have fallen into the cured list. The remaining designations, much improved, improved, and


unimproved, are sufficiently clear without further comment, except to say that due conservatism was used in applying them and that, if error was made, it was probably on the side of underrating the actual improvement.

As to the ultimate results obtained we have no observations and even if the present condition of these patients could be ascertained, sufficient time has not elapsed to determine the permanence of the cures. We believe, however, that Ehrlich's ideal of " steriUzatio magna " is more nearly obtained with salvarsan or neo-salvarsan in yaws than in the treatment of any other disease.

There are obvious difficulties in giving a statistical statement of the results of treatment which can be correctly interpreted.


TABLE SHOWING


RESULT


OF


TREATMENT


IN


570 CASES



1 K


Results


Cured


PraotioaUy cured


Much improved


Improved


Unimproved



Number of doses


Number of doses


Number of doses


Number of doses


Number of doses


1 a


1 "^ Ma §,


1


2


3


4


1


2


31


4


1


2


3


4


1


2


3


4


1


2


3


4


M

MB' ... MB'C. MB.... MBC...

B'

B'C...

B

BC .... BCP...

C

C+....

CP

P

SL

G

G+....


15 25 13 6 5 82

..

60 106 13 327 41 60 6 37 67 12

sm


i 10

2

3

3 16

4 24 26

7 143 13 16

S 17 24

4 318


11 15 11

3

2

66 20 36 80

6 184 28 35

2 20 43

8 670


2 2

13 2 4

1

29


2 3

1 11 4 9 10 3 5 1

2

51


1

2

1

5

1 1

1 12


1


5 4 2

14 J3


2

1 3

6 5 3 6

9

1

36




6 2

1

8 3 11 36 3 27 7 5 1 3

lis


1

3

1 3 7

16 3

7

2 4 4 51


5

1 13


2 2


1 1

5

3

7

55 4

10 1 4 8

99


1

1

3

10 2 1

\

1

21


5 6



1

1

41 6 9

3 15 2

T8


••

10


1 1




93 83 179 126 89


As previously stated, many of the cases which were designated as " practically cured " might have fallen into the " cured " eolimm without further treatment, if there had been an opportunity for examing the patients after the lapse of another week. Moreover, the percentage of cures after one injection might have been materially increased, if we had allowed a longer interval of time in which to determine the result of the first injection.

The interval between injections was one week in the majority of cases; exceptionally it was as short as five days and in a moderate number of cases it was ten days or two weeks. The final result of treatment, as far as we had opportunity to observe it, was usually made one week after the last injection.

The above table gives the results of treatment in the various groups as noted at the last observation on each case and shows the number of injections each patient had received


THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1922



PLATE II


Fig. 2



ng.3


Priinaiy Stage. Madrc Buba or Mother Yaw.


THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1922


PLATE III


^







Fig. 7


ng.8


Stage. Figs. 4, 5, 6 and S, Florid Secondary Eruption. Note Swel ling of the Femoral Lyniiih-Glands in Fig. o and the Predilection for the

Muco-Cutaneous Borders and Moist Surfaces in Figs. 7 and S.


THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1922




PLATE IV


FiglO




Tig 11 Fig 12

Secondary Stage. Figs. 9 and 10 show Granulomata of Unu.sual Size. Fig. 12 shows Circinate Arrangement of Lesions on Face, Giving the Indian War Paint Appearance.


THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1922



ng 13


F1914


F13.15



Fi^ 16



Figl?


Fi^lB


Late Secondary Stage. Figs. 13, 14, 15, 17 ami IS Clavu.s. Note the Fresh Granuloiuata on the Soles ^n Fig. 13. the Unilateral Invol^ement_ in Fig. 15, ami the Marked Erosion in the Remaining Cases. Fig. 16 sliows Marked Thickening of the Skin and Siibmitaneoiis Tissues of the Feet, Probably a Rare, Late Manifestation of Yaws.


THE JOHNS HOPKINS HOSPITAL BULLETIN. FEBRUARY, 1922



ri^i9




Fig. 19.— A '


Fig.?i


rig22


Yaws " Family. Fig. 20, " Stiulded Lcsion.s." Fig. 21, Leucoderma Following " IStuddcd Lesions. Fig. 22, Arthritis, Late

Secondary Stage.


THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1922


PLATE VII



\


ri^23




i


v"


r



"^


'


s»«»




M



".

,%


>.'r'iii

.- ^


^nr


MkL


_i-il


i


hqZb




H



fig. 2 b

Tertiary Stage. " Gomma." Figs. 23 and 24. Indistinguishable Clinically from Syphilis.


THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1922



Fig 28



liH 29

Tertiary Stage. Fig. 28.— Bears Some Resemblance to Leprosy. Fig. 29.— Indistinguishable Clinically from Syphilis.


February, 1922]


55


at the time of this note. The 127 patients who gave a history of having had yaws but who had no active lesions of the disease at the ti. :e they presented themselves for treatment are not included in this table, as we had no means of judging of the results of treatment in these cases. We have also excluded from the table 31 miscellaneous cases of yaws in which tlie results of treatment were difficult to determine owing to complicating diseases or for other reasons. Exclusive of these two groups there are 888 cases and in 570 of these we have notes as to the result of treatment.

Briefly summarized, irrespective of the number of injections each patient received, this table shows the following results :

Cases Approx.

Cured 93 16.32

Practically cured 83 14.56

Much improved 179 31.41

Improved 126 22.10

Unimproved 89 15.61

Total 570 100

There were 362 cases in the above series in which the final result noted was after a single injection of neo-salvarsan. Briefly summarized they are shown in the following table :

Results After a Single Injection of Neo-Salvaesan

Cases Per cent

Cured 29 8.01

Practically cured 43 11.88

Much improved 113 3151

Improved 99 27.34

Unimproved 78 2154

Total 362 99.98

Perhaps one gets a better idea of the efficacy of treatment in yaws by considering the cases which showed no improvement following the administration of neo-salvarsan. In the above series of 570 caises only one patient (a gomma case) showed no improvement after three injections and only ten patients (3 gomma and 7 clavus cases) showed no improvement after two injections. This is certainly in marked contrast to the 113 cases which showed marked improvement after a single injection.

We have further analyzed our figures to see if they will show what stage of the disease is most readily amenable to treatment. For this purpose it seems probable that more reliable information will be obtained by combining the cured and


practically cured groups and considering only those cases in which the result noted was obtained after a single injection. They are summarized in the following table:

Cured or practicaUy cured Total No. ot .\verage No. of cases after one injection

Oiagnosis cases ageinyears Results noted Number Percent

M 15 6.6 11 7 63.63

MB' ... 25 8.5 15 6 40.00

MB'C .. 13 11.6 11 2 18.18

MB ... . 6 24.2 3

MBC .. 5 10.0 2

B' 82 S.8 66 27 40.91

B'C .... 24 12.9 20 7 35.00

B 60 9.3 36 5 13.88

BC ....106 16.5 80 7 8.75

BCP ... 13 20.5 6

C 327 21.6 184 8 4.34

C+ .... 41 29.4 28 1 3.57

CP .... 50 327 35

P 5 25.0 2

SL 37 28.8 20 2 10.00

G 67 29.3 43

G+ .... 12 252 8

The number of cases comprising some of the groups in the above table is too small to be of value for statistical purposes, but taken as a whole the figures seem to show what we would expect, i. e., the earlier the stage, the more readily does it respond to treatment.

Acknowledgments

We desire to express our appreciation of the courtesy and co-operation shown us during our stay in Santo Domingo by Eear Admiral Thomas Snowden, U. S. N., Military Governor, Commander Eeynolds Hayden, M. C, TJ. S. N., Secretary of the Department of Sanitation and Beneficence, Lieutenant Commander Ralph M. Warfield, C. E. C, IT. S. N., Secretary of the Department of Development, Public Works, etc., and to Mr. W. A. Elders, Administrator-General of the SantiagoSanchez Railway.

We are deeply indebted to Dr. Stone and Mr. Hermann who acted as interpreters for us and whose intimate knowledge of the island and its inhabitants was of the greatest service.

To Mr. H. H. Raymond, President of the Clyde Steam Ship Company, we wish to make grateful acknowledgment for extending to the members of the commission and their equipment free transportation from New York to Santo Domingo and return.


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56


[No. 378


STUDIES ON A CASE OF CHROMIC ACID NEPHRITIS


By Ralph H. Major

(Fram The Henry Ford Hospital, Detroit, Michicjan)


A great deal of light has been shed upon the obscure points of kidney patliology by the newer studies on experimental nephritis. These observations have not only clarified many of our ideas about diseased kidney function, but have also contributed much to a clearer understanding of the complex and highly specialized functions of the kidneys in health.

In the production of experimental nephritis, chemical substances have been employed almost exclusively; arsenic, cantharidin, uranium nitrate, potassium bichromate, the tartrates and mercuric chloride being most frequently used. As the result of these studies we know that in a general way arsenic and cantharidin are glomerular poisons, while uraniimi, potassium bichromate, and the tartrates and mercury seem to have an especial affinity for the tubules. The more recent work, particularly that of MacjSTider," has shown that. although a hard and fast line cannot be drawn, yet we are still justified on the basis of outspoken affinity in speaking of glomerular poisons and of tubular poisons.

The study of cases of poisoning from these chemicals that come into the hospital for treatment is important because of their relation to experimental nephritis. Corrosive sublimate has furnished the largest number of cases in this group. Lewis and Eivers ' have published extensive chemical studies on a case of bichloride poisoning and have pointed out that, while the therapeutics of this condition have merited much attention in the literature, studies on the metabolism of these cases have been very meager and superficial. The number of other ]niblished cases of chemical nephroses is extremely small.

The following studies on a case of chromic acid poisoning are presented as a contribution to the subject of kidney pathology and particularly for comparison with the numerous observations in the literature on experimental chromate nephritis. This patient, suffering from an inoperable carcinoma of the face which had been treated by the application of chromic acid crystals, lived for four weeks after the -development of the nephritis. During this period extensive studies of his blood and urine chemistry were carried out, marked variations from the normal were encountered and certain interesting changes brought about by therapeutic measures were noted. These observations have a certain interest as a study of the acidosis accompanying chromate nephritis and as a commentary on theories of renal secretion, particularly the " modern theory " of Cushny.^

Chromic acid was used as a cauterant as long ago as 184,5 when Alexander IJre " described several cases of hemorrhoids treated with this agent. Marshall" in 1857 reported a scries of cases of venereal warts in which the local application of an aqueous solution of chromic acid produced excellent results. Many similar reports appear in the literature during the succeeding years, although Gubler* in 1871 stated that "the


absorption of chromic acid is not free from danger, as patients have been poisoned by a too extensive application to the surfaces of their bodies." .J. William ^Vhite" in 1889 reported the case of a young womaji who died 27 hours after the local application of an aqueous solution of chromic acid to an extensive crop of venereal warts.

Industrial poisoning among workers in chrome plants from chromic acid has long been recognized. Pye," in 1885, reported such cases and described the perforation of the nasal septum long known among workers as " chrome holes." He stated that the possession of such " chrome holes " is an object of pride to the workers, who often carry in their pockets a bent wire which they pass through the hole for the amusement of their friends.

Gergens," in 1877, studied the toxic effect of chromic acid on rabbits and noted that it produced an acute nephritis. Kabierske,' in 1880, studied the pathological changes produced in the kidney by this chemical and Posner" continued and amplified these studies. Both Kabierske and Posner described in detail the exquisite tubular nephritis also. Kossa ' observed that potassium chromate produced a hemorrhagic nephritis, but was interested particularly in the accompanying glycosuria which he described as " chromic acid diabetes." Viron " noted the frequent occurrence of both glycosuria and albuminuria in animals poisoned with chromate, but did not carry out any extensive pathological studies. Among later investigators who used the chromates for the purpose of studying experimental nephritis are Schlayer and Hedinger,"" Heinike and Meyerstein,° Ophiils," Hellin and Spiro," Pearce Hill and Eisenbrey." Weber," Euschaupt," Austin and Eisenbrey ' and MacXider." These observers noted its particular though not exclusive affinity for the renal epithelium, and MacNider states that in the earliest stage there is a vascular injury followed rapidly by a tubular involvement which soon dominates the picture.

The patient upon whom these observations were made was a man of 59 and was suffering from a very extensive carcinoma of the left cheek which had been present for two years. This lesion, when first seen, involved almost the entire cheek, extending from the inner canthus of the left eye down upon the left half of the nose and thence down and over the cheek. The patient's mother had died of chronic nephritis, one brother had died of acute nephritis and another brother still living was suffering from chronic nephritis. The patient's urine was examined for the first time on December 8, 1920, and was normal in every respect, as was also a specimen examined on December 11, 1920. On December 11 the carcinoma was curetted and crystals of chromic acid applied until an eschar had formed. The urine, when examined on the following day, showed 4 gm. of albumin per liter. The amount of albumin


February, 1922]


57


in the urine increased and three days later there were 7.3 gm. per liter, and hyaline and granular casts, red blood cells and numerous degenerated epithelial cells made their appearance.

On December 14, a little more than 48 hours following tlie application of the chromic acid crystals, the patient had an almost total suppression of urine and the blood urea was 60 mg. per 100 c. c. From this time on he waged an unsuccessful fight which terminated with his death on Jan- , uary 9, his blood urea on the day of his death reaching 340 mg. per 100 c. c. Many marked changes in his blood chemistry and in the excretion of fluids and solids took place. An intravenous phenolsulphonephthalein test was carried out on six occasions. On December 17, December 18, December 23 and on January 8 none was excreted, on December 27 and 31 the urine showed a faint unreadable trace. One gram of potassium iodide taken by mouth on January 30 was excreted in 24 hours. The McLean index which was determined every day varied from 0.01 to 0.47, the lowest values being at the onset of the nephritis and again towards the end.

A very marked feature of this case was the comparative wellbeing of the patient for more than two weeks following the appearance of the nephritis. During this period of 18 days he felt comparatively well except for some loss of appetite and occasional headaches, in spite of the fact that his kidneys were very severely damaged, his excretion of solids markedly diminished, and his blood urea soaring up around values ten times that of the normal high average. He was very impatient of the therapeutic measures, which consisted of forced fluid by mouth, saline purges, sodium bicarbonate administered by moutli, and rectal saline irrigations.

On December 28 his pulse became somewhat irregular and on December 31, 19 days after the onset of the nephritis, vomiting appeared which became increasingly frequent and was especially severe the la.st five days. His urinary output remained at a high level but sank very low the last five days, apparently because of the markedly lowered fluid intake. The patient never showed the slightest symptoms of uremia, no visible edema developed and the blood pressure varied from 145 to 110 systolic and 90 to 75 diastolic. He was given glucose intravenously, caffeine subcutaneously but gradually became weaker and weaker, the cardiac arrhythmia became more marked and he died on January 10, 30 days after the application of the chromic acid crystals.

At autopsy only the kidneys were removed. They measured "l"3x 5 X 4.5 cm., the right kidney weighed 176 gm., the left 197 gm.; both were mottled in appearance, the cortex was swollen and the glomeruli were very indistinct. There was no free fluid in the abdominal cavity and no general anasarca.

Microscopically tlie kidneys showed extensive destruction of the tubular epithelium with debris in the lumen and marked swelling of many intact epithelial cells, the changes being especially marked in tlie convoluted tubules. There were a few mitotic figures seen in these cells, although the evidences of regeneration were not striking. Similar observations in experimental chromate nephritis were made by Kahierske (I. c.) and by many later investigators. Tlie glomeruli were


for the most part normal in appearance, although in some sections a few fibrosed glomeruli were seen. There were numerous areas of small-round-cell infiltration and much fibrosis in many places between the tubules. Because of the patient's age, it is doubtful Just how much of the glomerular and interstitial fibrosis was due to the chromate. In general, the picture was that of a pure tubular nephritis.

A great deal of care was exercised in obtaining specimens and there is every reason to believe that no gross errors occurred that would materially affect the calculations. As the chemical studies were quite extensive, it is simpler to discuss each group separately.

METHODS

The non-proteid nitrogen, creatinin, creatin, uric acid and sugar determinations in the blood were carried out by the method of Folin and Wu. The blood urea was estimated by the method of Van Slyke and Cullen, blood amino acids by the method of Van Slyke, blood chlorides by the method of McLean, Van Slyke and Donleavy, blood calcium by the method of Halverson and Bergheim, phosphates by the method of Bloor.

The urine chlorides were determined by the method of Volhard and Arnold, the total nitrogen by the method of Folin and Farmer; creatinin, creatin and uric acid by the methods of Folin, Benedict and Myers and of Folin, and the urea by the method of Van Slyke and Cullen.

1. Fluid Exchange

The observations on the fluid intake and output in this patient were quite complete and cover the entire of his stay in the hospital. The patient was urged at the onset of the nephritis to drink large amounts of water, which he did.until a few days before death. No initial polyuria was observed such as has been described in thq vascular reactions due to glomerular poisons. On the second day following the development of the nephritis, the urinary output was markedly reduced, falling to 10 c. c. Following the drinking of large amounts of water, the urinary output the following day again rose to 310 c. c, and there was a constant increase until the si.xth day after the partial suppression. The total amount of urine excreted was 1360 c. c. During the period of lowered urinary excretion, the urine contained large amounts of albumin with numerous epithelial cells and epithelial ca.sts — evidence of extensive tubular destruction. This suggests that the swelling of the tubular epithelium and choking of the tubules with debris may have caused the reduced urinary output, as observed by MacNider in experimental nephritis.

The urinary secretion remained uniformly high until four (lays before the death of the patient when it fell sharply reaching 280 c. c. the day before the patient died, this reduction corresponding in time to the period of continual vomiting with a marked dinrinution of fluid intake. The urinary record did not represent the entire fluid output, since the patient was purged constantly and considerable amounts of fluid were passed in this way. The specific gravity of the urine which


[Xo. :rrZ


was 1.025 the day the nephritis appeared, afterward varied from 1.011 to 1.019, the average specific gravity, as determined by adding all the observations together and using their number as a divisor, being 1.014. The reaction of the urine was acid before any therapy was instituted, but following the administration of sodium bicarbonate became alkaline, becoming again acid whenever this therapy was discontinued.

2. T0T.\L XlTRDGEX AXD ChLOHIDE EsCRETIOX

The total nitrogen, non-proteid nitrogen and chloride excretion fell very sharply following the onset of nephritis reaching the low level of 1.17 gm., .96 gm. and .59 gm., respectively. This marked depression persisted for four days and tlien was followed by a slow and gradual rise, until ten days after this depression the patient excreted 13.5 gm. of total nitrogen,


_"



n


V


Cl-RVE 1.

13.4 gm. of nonproteid nitrogen and 1.62 gm. of chlorides in 24 liours. Similar curves of nitrogen excretion were observed by Pearce, Hill and Eisenbrey, by Green, and by Austin and Eisenbrey in experimental chromate nephritis. If this curve of nitrogen and chloride is super-imposed on a curve of the fluid output, it will be seen that the two follow each other closely. The nitrogen output is reduced, the chloride output is markedly reduced, yet their fluctuations correspond closely to those of the urinary secretion.

3. Urea

The urea nitrogen excretion was constantly low. The first determination made after the onset of nephritis showed a total 24 output of 6.33 gm. On December 15. the daV following the marked suppression of urine, it fell to 0.81 gm. and on the following day it was only 1.2 gm. It later rose slowly, reaching the highest level on December 29 when it was 9.49 gm. During the last five days of the patient's illness it again showed a de


cided depression, falling to 1.62 gm. on the day before. the patient's death. In comparing these figures with those of t>\e total nitrogen and non-proteid nitrogen excretion, it is seen that, while the.se two are markedly diminished, yet their depression is not relatively so great as that of the urea excretion.

The blood urea, on the other hand, was high at the onset — 65.38 gm. on December 14, and afterwards showed a constant and gradual rise, reaching the high value of 340 mg. per 100 e. c. the day before death. For two weeks from December 2 to January 3, during the period when the patient, as previously mentioned, felt comparatively well, the blood urea varied from 168 to 227 mg.

These urea values are interesting in the light of Cushny's well-kno'wn, modern theory. Cushuy states that " the modern view requires that the urea, Uke the other constituents of the urine, pass out by the capsule." He cites, in proof of this view, that the excretion of urea ceases at the same time as the secretion of water by the kidney. In this patient, however, the secretion of water, after an initial drop, rose rapidly and continued at a high level while the urea output remained very low and the blood urea continued to increase markedly.

Urej, curves similar to that in this case have been frequently noted in cases of chronic dift'use nephritis showing at autopsy both glomerular and tubular lesions. Such urea values, as noted in our case of tubular nephritis, raise the question whether the older view, that urea is excreted mainly by the tubules, does not explain the picture better than the modern theory.

Further evidence in favor of this older view is found in the work of Oliver." This observer, working with xanthydrol, which produces a characteristic crystalhne product with urea, found evidence of urea excretion in both the glomeruli and tubules. The marked diminution of urea excretion in our case of chromium nephritis would indicate that a part of the urea may have escaped through the intact glomeruli, while still another fraction may have been secreted by such portions of the tubular e]iithelium as were not destroyed.

4. Ceeatixix and Ceeatik • The 24 hour excretion of creatinin fell to 0.23 gm. two days after the onset of nephritis, but following this rose gradually to normal and hovered about 1 gm. for two weeks. The la.st few days it was iigain depressed, falling to 0.3 gm. the day before death.

The blood creatinin on the other hand was +.56 gm. on December 14 and rose rapidly until the fifth day after the onset of the nephritis when it reached 14.8 mg. per 100 c. c. From this time to the end it showed a gradual rise, reaching 17 mg. the day before death. Here again the patient although comparatively free from symptoms for two weeks, showed blood creatinin values varying from 13.68 mg. to 15.68 mg. per 100 f. c, demonstrating the point emphasized particularly by Myers and Lough" that values above 5 mg. indicate an early fatal termination and also that a progressive increase in blood creatinin is a sign of unfavorable prognostic import.


February, 1922]


59


The blood creatin was increased to 12.48 mg. per 100 c. c. on the day following the partial suppression of urine and on the next day fell sharply to 5 mg. It remained about this



latter level until a few days before death when it rose abruptly, reaching 18.72 mg. per 100 c. c. on the day before death. The excretion of creatin varied from to .17 mg.

5. Uric Acid The blood uric acid values were constantly high, varying from 4 mg. per 100 c. c. on December 14, the second day of the nephritis, to 9.15 mg. on January 5. There was not the



Curve 3.


same striking increase in blood uric acid as there was in the blood urea, although the amounts were increased, the average reading being 6 mg. per 100 c. c. The uric acid excretion was consistently low varying from 6 nig. to 30 mg. in 24 hours.


This patient was on a very low purine diet and the determinations show a very definite uric acid retention, which does not seem in complete harmony with the theory of Cushny which postulates a glomerular excretion of uric acid.

6. Chlorides The plasma chlorides in this case of chromic acid nephritis show a consistently low level varying from 378 mg. to 558 mg. per 100 c. c. following the development of the kidney lesion. The total chlorides in the urine were even more markedly lowered, varying from .1 gm. to 2.76 gm. in 24 hours. No marked fluctuations were observed, although the general tendency was a gradual lowering in the amount excreted as the lirocess continued. The low values were doubtless due in part to the low chloride content of the diet, and the absence of any increase in the plasma chlorides in the presence of an extensive tubular nephritis would seem to be evidence in favor of the excretion of tliese substances by the glomeruli.

7. Sugar

The urine of this patient frequently showed traces of sugar which apparently bore no relation to amount of blood sugar present. The urine during the first 12 days showed traces of sugar on three occasions, although the blood sugar was not higher than 159 mg. per 100 c. c. The last four days of the patient's illness the blood sugar varied from 204 mg. to 229 mg. but with no glycosuria. Intravenous injections of glucose given on three occasions produced no marked change in the blood sugar curve.

Kossa {I. c.) in experimental chromate nephritis noted glycosuria in the absence of a hyperglycemia and explained this phenomenon by the assumption of an increased glomerular permeability. Cushny has attacked this theory of increased glomerular permeability used so long in phloridzin glycosuria, and has pointed out that a failure on the part of the tubular epithelium to re-absorb the excess of glucose excreted by the glomerulus explains the phenomenon equally well or better. In chromic acid nephritis with extensive tubular necrosis, such a failure of reabsorption is presumably present.

8. Carbon Dioxide, Acetone, Phosphates and Amino Acids

Evidence of acidosis in this patient was present soon after the onset of nephritis, the carbon dioxide tension in the plasma on December 15 falling to 37 per cent. Tlie patient was immediately given sodium bicarbonate by mouth with the result that there was a sharp rise to 64 per cent the following day. As the result of such alkali therapy a normal carbon dioxide teni^ion was maintained until the onset of vomiting when the tension fell to 30 per cent, and did not later rise above 37 per cent.

Acetone was present in the urine the last ten days, although it was absent in the early stages in spite of other evidence of acidosis. Determinations of inorganic phosphates in the blood were made on four occasions, sbowing 35 mg. per 100 c. c.


60


[No. 372


^ « i '5 S I



o 2 £ -J

S 6 < s


<5


THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1922


PLATE IX



Fri. 1.- .Mirnji>liL.lu';rul'h of \\\y kHlni.\- sliowing desquamation of the tubules, interstitial fibrosis and areas of small, round cell infiltration. (Hematoxylin and eosin. Bausch and Lomb obj. 4 oc. X 10.)




7 / *,r


f . ,



Fici. 2. — Micrui'liotujiraiih of tla kidney .sliowing extensive tubular desquamation with an intact glomerulus. (Hematoxylin and eosin. Bausch and Lomb obj. 4 oc. X 10.)


February, 1922]


61


on December 29 aiid 50 mg. per 100 c. e. on January 8, two days before death. The phosphate excretion in the urine was consistently low, falling to 0.1 gm. the day before death. These findings indicate an early phosDhate acidosis complicated later by an acidosis of acetone body origin. Determinations of the blood amino acids were made on four occasions and showed high values. 12.7 mg. per 100 c. c. on December 30, 1920, 33 mg. on January 7, 1921J 24 mg. on January 8 and 31.3 mg. on January 9.

CONCLUSIONS

In this case of chromic acid nephritis the kidney lesion present was that of a pure tubular nephritis. No edema was noted clinically and no anasarca or ascites was present at autopsy. No symptoms of uremia were present, and the patient, during the greater part of his illness, felt comparatively well.

The urine output following a temporary depression was high, but the urine itself was of low specific gravity and the excretion of nitrogen, chlorides, phosphate, creatinin, uric acid and urea was markedly diminished. Glycosuria appeared from time to time but it bore no apparent relationship to the amounts of blood sugar present.

A study of the blood chemistry showed very liigh values for urea, inorganic phosphates, amino acids and creatinin and values higher than normal for uric acid. Determinations of the carbon dioxide content of the blood plasma showed definite evidence of acidosis which responded promptly to alkali therapy.

In conclusion it is a very great pleasure to acknowledge the assistance of Dr. R. L. Haden, under whose direction the chemical studies were carried out.

BIBLIOGRAPHY

1. Austin, J. H., and Eisenbrej-, A. R.: E.xperimental Acute Nephritis: The Elimination of Nitrogen and Chlorides as compared with that of Phenolsulphonephthalein. J. Exper. Med., 1911, XIV, 366.

2. Cushny, A. R.: The Secretion of the Urine. London, 1917.

3. Gergens, E.: Beobachtungen ueber die toxische Wirkung der Chromsaure. Arch. f. exper. Path. u. Pharmakol, 1877, VI, 148.

4. Gubler: Quoted by White (l. c).


5. Heinike, A., and Meyerstein, W. : Experimentelle Untersuchungen ueber den Hydrops bei Nierenkrankheiten. Deutsches Arch. f. klm. Med., 1907, XC, 101.

6. Hellin, Dionys, and Spiro, Karl : Ueber Diurese. Arch, f . exper. Path. u. Pharmakol., 1897, XXXVIII, 368.

7. Kabierske. Eugen: Die Chromniere. Inaug. Dissertation, Breslau, 1880.

8. Kossa, Julius: Ueber Chromsiiure-Diabetes. .\rch. f. d. ges. Physiol., 1902, LXXXVIII, 627.

9. Lewis, D. Sclater, and Rivers, T. M.: Chemical Studies on a Case of Bichloride Poisoning. John Hopkins Hosp. Bull., 1916, XXVII, 193.

10. MacNider, William deB: A Study of the Renal Epithelium in \'arious Tj'pes of Acute Experimental Nephritis. J. Med. Research, 1912, XXVI, 79.

11. MacNider, Wra. deB.: A Study of the Renal Epithelium in Various Types of Acute Experimental Nephritis and of the Relation which exists between the Epithelial Change and the total Output of Urine. J. Med. Research, 1912, XXVI, 79.

12. Marshall: The Application of a Solution of Chromic Acid as a new Stimulant Escharotic in Warts and other Growths. Lancet, 1857, 1,88.

13. Myers, Victor C, and Lough, Walter G.; The Creatinin of the Blood in Nephritis, Its Diagnostic Value. .\rch. Int. Med., 1915, XVI, 536.

14. Oliver, Jean: Mechanism of Urea Excretion. J. Exper. Med., 1921, XXXIII, 177.

15. Ophtils, W.: Some Interesting Points in regard to Experimental Nephritis. J. Med. Research, 1908, XVIII, 497.

16. Pearce, R. M., Hill, M. C, Eisenbrey, A. R.: Experimental Acute Nephritis: The Vascular Reactions and the Ehmination of Nitrogen. J. Exper. Med,, 1910, XII, 196.

17. Posner, Carl: Studien ueber pathologische Exsudatbildungen. Virchows Arch. f. Path. Anat,, 1880, LXXIX, 311.

18. Pye, Walter: On the Local Lesions Caused by the Alkaline Salts of Chromic Acid. Ann. Sur,, 1885, I, 303.

19. Ruschaupt, W, : Beitriige zur Diurese. Arch. f. d. ges. Physiol., 1902, XCI, 595.

20. Schlayer and Hedinger : Experimentelle Studien ueber Toxische Nephritis. Deutsches .\rch. f. klin. Med., 1907, XC, I.

21. Ure, Alexander (Quoted by Ernest Hart) : Lancet, 1857, I, 543.

22. Viron, L.: Contribution a I'etude physiologique et toxicologique de quelques preparations chromees. These de Paris, 1885,

23. Weber, S.: Experimentelle Untersuchungen zur Physiologie und Pathologie der Niereniunktionen. Arch, f . exper. Path. u. Pharmakol., 1906, LIV, I.


ADAPTATION OF BACTERIA TO GROWTH ON HUMAN MUCOUS MEMBRANES WITH SPECIAL REFERENCE TO THE THROAT

FLORA OF INFANTS

By Arthur L. Bloomfield {From the Biological Division of the Medical Clinic, The Johns Hopkins University and Hospital)


In studying the problem of respiratory infection it soon became apparent that certain fundamental data in regard to growth and colonization of bacteria in the upper air passages must be assembled before real progress could be made. It has seemed advisable, therefore, to digress from the original practical problem to more purely biological questions of growth adaptation of bacteria on the respiratory mucous membranes.


The recent trend of bacteriological study clearly indicates that the conditions allowing and promoting the growth of microorganisms are vastly more complex than the early investigators in this domain were led to believe. The newer studies on the importance of hydrogen-ion concentration, and of growth accessory substances in particular, have opened roads which will undoubtedly lead into very extensive and prolific fields of


62


[No. 372


research. However, these considerations ajjply more especially to growth of bacteria on artificial nutritive media, and the facts at hand help but little in elucidating the conditions of growth of micro-organisms in the body. It seems that factors more elusive than those of acid-base equilibrium and such matters govern the actual conditions of human parasitism. To illustrate — while the pneumococcus is found in the mouths of approximately 50 per cent of normal people, we find that the pH of the mouth secretions is almost always greater than that which would allow the initiation of growtli of the pneumococcus in the test-tube.' Furthermore, certain organisms such as B. coli and Friedlander's bacilli, whose growth requirements in viiro are simple, do not colonize on the mucous membranes of the upper air passages, whereas more fastidious organisms such as streptococci are invariably present. It is apparent, tlierefore, that one cannot directly apply test-tube criteria in explaining growth on human mucous membranes.

The immediate question under consideration, then, concerns the factors which allow growth of certain organisms in the upper air passages and prevent that of others. In a previous study it was pointed out that the bacteria found in the tliroat considered from this standpoint fall into several distinct groups.' There is in the adult (with aerobic methods) a constant habitual flora consisting of non-hemolytic streptococci. Gram-negative cocci, and diphtheroids. These organisms are found widely disseminated through the mouth cavity — on tongue, tonsils, and pharynx. They occur in normal and in sick people, in those with foci of infection, and in those whose tonsils have been removed. All the evidence indicates that they grow free on the normal mucous surfaces. In distinction to this group we find another comprising for the most part potentially pathogenic organisms. These are usually localized in some definite area of infection such as the tonsil, adenoid, or a sinus, or they may occur temporarily arid sporadically on the free surfaces of the mucous membranes — evidently transients which have not actually colonized. What then are the conditions which create such a sharp and fundamental difference between these two groups of organisms? An analysis of the known facts in regard to test-tube growth requirements of the two groups does not answer this question. For example, hemolytic streptococci are no more fastidious than many of the green-producing strains, and yet the former are not members of the normal habitual flora, whereas the latter are constantly present. It seems to us necessary to fall back on a theory of adaptive parasitism, -ndthout attempting to define the exact chemical conditions involved. In other words, is it possible that the non-hemolytic streptococci gradually — perhaps during a period of thousands of years — became adapted to growth on human mucous membranes, while other bacteria show a total absence of such ada]itation or only partial and abortive degrees ?

It seemed that some information about this question might be gleaned from a study of the development of the throat flora in infants. Such individuals would furnish a most desirable experimental material for the following reasons: First, one would be dealing with a virgin soil not previously the habitat


of any bacteria. Secondly, no local foci of infection such as diseased tonsils or sinuses are present to obscure the bacteriological picture. Thirdly, the teeth with their associated collections of food particles in which organisms of various sorts may breed have not yet appeared. If it should turn out that any particular varieties of organisms appeared early, regularly, and in large nimibers, one might reasonably assume that such organisms possessed a high degree of inherent adajitation to growth in these regions. The present paper concerns itself, therefore, with a study of the throat flora of infants.

Literature

No attempt will be made to review the extensive literature on the bacteriology of the mouth. Our work concerns itself with defining the position of certain well-known organisms rather than with enumerating all bacteria which may be recovered from the upper air passages under all conditions. Brailovsky-Lounkevitch " has reviewed the literature on the bacteriology of the mouth in infants. She, as well as other observers, has found no organisms during the first few hours of life but notes their rapid appearance after the twelfth hour. Beyond this important observation, however, we find little but a general catalogue of organisms without infonnation which would indicate their significance.

Methods Tlirough the courtesy of the staff of the Obstetrical Department it was possible to examine infants shortly after birth and at more or less regular intervals thereafter. A swab wag passed over the palate and pharynx and plated on rabbit blood agar and oleate Iiemoglobin agar according to the method described elsewhere.' Care was taken to secure a good spread of colonies and careful qualitative and quantitative observations were made of the various bacteria present. A note was made of the relation of the culture to the time of nui'sing.

Results

The results are presented in Table I. The first fact of importance is that the cultures made very shortly after birth — under 12 liour^, and before the baby had nursed — were sterile. This was so in seven ca.ses (I, V, IX, XI, XII, XIV, XIX). In Case XVII a culture made three hours after birth and before nursing yielded four colonies of staphylococcus albus and two colonies of a diphtheroid. From the twelfth hour on (at which time nursing began) organisms were uniformly present in large numbers. In Case VII a culture made at 12 hours, but before nursing, showed a few white staphylococci and several hundred green streptococci. The above findings confirm those of previous observers.

A few words may now be said about each of the organisms encountered in later cultures.

1. Staphylococci (albi). — White staphylococci were present in over half of the cultures but were not a constant finding. They varied in number in various cultures from a few to innumerable colonies. 5Iany types, both hemolytic and non


February, 192-2]


G3


TABLE I Kesults of Throat Cultdres from Infants^



Aug. 6— eel. 11 hrs. (has not nursed)


.\ug. 8— at. 3 days


1 Aug. 15- irf. 10 days



Aug. n-at. 12 days


Case I— K


Xo trrowtli


Staph, albus Tetragenus Strept. (green) Strept. (grey)


20 a few


Staph, albus Tetragenus Strept. (green) Strept. (grey) Staph, aureus


a few many

50


Stajih. albus x

Strept. (green) x Strept. (grey) x



.•Vug. 8-(ct. 14 hrs. (has nursed)


Aug. 9— at. 2 days


Aug. la— at. 8 days


Aug. 17— «t. 10 days


Case II— E


Tetragenus " 1 Gram+ diphtheroid 1


Tetragenus

Gram-neg. cocti Strept. (green) Strept. (grey)


many ma ny a few


Tetragenus

Strept. (green) Strept. (grey) Staph, albus


50


Tetragenus many

Strept. (green) many Strept. (grey) x Stapli. albus few



Aug. 8— ret. 16 hrs. (has nursed)


Aug. 9— at. 2da.v8


Aug. 10-iE/. 10 days


Aug. 15— at. 8 days (culture while nursing)


Case 111— K...


Staph, albus 16


Spreaders


Tetragenus sev. Ii Strept. (green) Strept. (grey)


Lindred many


Staph, albus sev. hundred Tetragenus few Strept. (green) x Strept. (grey) x Staph, aureus 5



Aug. 9-(rt. 14 hrs. (has nursed)


Aug. 10— at. 2 days


Aug. lo- at. 7 days


Aug. 19— at. 11 days


Case IV— Fr...


Stapli. albus 200 .Strcpt. (green) a few Utrrpt. (grey) many


Staph, albus Strept. (green) Strept. (grey) Tetragenus


many

X


Strept. (green) Strept. (grey) Tetragenus.

a few


Staph, albus many Strept. (green) x Strept. (grey) many Tetragenus many Staph, aureus few



Aug. 2S-«B(. 16 hrs. (has nursed)


Aug. 24-<t(. 11 days


Aug. 26-0B(. 4 days



Case V—


Staph, albus iOO Strept. (grey) 50


Stapli. albus


120


Staph, albus Strept. (grey) Strept. (green)


few many





Gram+ coccus Tetragenus


many


Tetragenus Staph, aureus Gram+ bacillus


many

a few

6




Aug. 1— (C(. 7 hrs. (has not nursed) Aug. 2—<f.I. .'SO hours



Aug. 5-at. 3 days


Aug. 8-(E(. 6 days


Case VI— 8....


Xo growth


Staph, albus Tetragenus Strept. (green )

Gram-neg. bacillus


300 a few nmny


Staph, albus sev. hundred Tetragenus a few

Strept. (green) oo


staph, albus sev. hundred Tetragenus a few Strept. (green) sev. hundred Strept. (grey) "

Staph, aureus 12



Aug. '2— at. 13 hrs. (has not nursed)


Aug. 3 at. 31 hours


Aug. 5-(c(. 3 days


.Kug. S—at. 6 days


Case Vll— .T. . .


Staph, albus few Strept. (green) sev. hundred


Staph, albus Strept. (green) Strept. (grey) (iram-neg. cocci


few

00

few


Staph, albus Strept. (grey)


few


Staph, albus co

Strept. (grey) few



Aug. 9— at. 22 hrs. (has nursed) Aug. 5— a(. 3 days


Aug. 9— at. 7 days



Aug. li-at. 10 days


Case VIII— Sn.


Staph, albus -x: Strept. (gresn) many Strept. (grey) many


Strepl. (green)

Tetvageniis Gram+ diphtheroid


few


Strept. (green) Tetragenus Gram-neg. Ijacillus


X

numy


Staph, albus many Strept. (green) x Strept. (grey) few Tetragenus many



July 19- at. 6 hrs. (has not nursed)


July 20— at. 31 hours


July 22-15*. 3 days



July 29— «(. 10 days


Case IX— Ce...


Xo growth I Staph, albus

Strept. (green)


50


Strept. (green) Tetragenus


X

many


Staph, albus few Strept. (green) x



1 Lactis aerogcnes


4




Staph, aureus few


00 = innume

rable. ^The numbers i


ndicate number of colonics.






64


[No. 372


TABLE I— Continued



July 22-at. 20 hrs. (has just nursed)


July 23-at. 2 days

July 29— at. 8 days



Case X— H....


Strept. (green) =o Tetragenus 50 Gram-neg. cocci 50 Diphtheroid few


Strept. (green) co Tetragenus many

Staph, albus 5 Staph, aureus 1


Strept. (green) co Tetragenus few

Strept. (grey) few Staph, albus many




Jul.v 23- (cf. IJ hrs. (has not nursed)



Aug 2-ict. lO.days



Case XI— Hi...


Xo growth



Staph, albus sev. hundred Tetragenus few Strept. (grey) many Strept. (green) few




July 14-(pf. Ihr. (has not nursed)


July 15— (r«. 1 day


July 19-(rl, 5 days


July 2»-ffil. 9 days


CaseXII— Ch..


Xo growth


Staph, aureus 1 Tetragenus sev. hundred Strept. (grey) many


Staph, aureus 6 Tetragenus many Strept. (grey) many Stapli. albus co Diphtheroids few


Strept. (grey) Staph, albus Diphtheroids Strept. (green)


few many



Aug. 20-(t(. 23 hrs. (has nursed)


Aug. 2a-<e(. 3 days | Aug. 2S-(Bt. 9 days



Case XI 1 1— K..


Staph, albus 10 (iram-neg. cocci 20 Gram-neg bacillvs 50 Strept. (g recti) ra


Staph, albus 30 Gram-neg cocci oo

Strept. (green) co Diphtheroids few


Staph, albus few

Strept. (green) oo Tetragenus oo




Aug. 2S-at. 1 hr. (has not nursed)


Aug. 24-<t(. 1 day


Aug. 26— fft. 3 days


.\ug. 2S-eel. 5 days


CaseXIV— W..


Xo growtll


Staph, albus few Gram-neg. cocci many Strept. (green) many


Gram-neg. cocci many Strept. (green) co Strept. (grey) co Tetragenus x Staph, aureus 10


Staph, albus Gram-neg. cocci Strept. (green) Strept. (grey) Tetragenus


few few

few



Aug. n-<Et. 23 hrs. (culture while nursing)


Aug. 18— one. 2 days


Aug. 20-at. 4 days


Aug. 25— cf. 9 days


Case XV— N...


Strept. (grey) co Strept. (green) » Tetragenus oo B. lactis aerogenes 50


Strept. (grey) co Strept. (green) few Tetragenus co


Strept. (grey) many Strept. (green) many Tetragenus co

Staph, albus 200


Strept. (grey) Strept. (green) Tetragenus

Staph, albus


1 50



Aug. 14— <f (. 23 hrs. (has nursed)


Aug. 22-at. S days


Aug. 2i—(Et. 5 days


Aug. 29-(tl. 9 days


Case XVI— A.C.


Staph, albus 10 Gram-ueg. cocci few Tetragenus sev. hundred Strept. (grey) co Strept. (green) « 


Staph, albus . oo

Tetragenus many Strept. (green) co Strept. (grey) many Diphtheroids few


Staph, albus many

Tetragenus oo Strept. (green) oo Strejit. (grey) oo

Staph, aureus 50


Staph, albus

Tetragenus Strept. (green) Strept. (grey)

Staph, aureus


few

X

few



Aug. lo— est. 3 hrs. (has not nursed)


Aug. 16— <^^ 1 day


Aug. 18— et. 3 days


.\ug. 23— a(. 8 days


CaseXVII- Ca.


Staph, albus 4 Diphtheroid 2


Tetragenus oc Strept. (green) oo Strept. (grey) co


Tetragenus co Strept. (green) numy Strept. (grey) co Staph, aureus 6


Staph, albus

Tetragenus Strept. (green) Strept. (grey) Staph, aureus


10 many



July 19— (j(. 24 hrs. (has nursed) July 22 - ttt. 4 days


Aug. 1—at. 14 days


.Kxjg.a-at. 16 days


Aug. lO-at. 26days


Case XVIII— Fr


Tetragenus 300 Strept. (green) co

Diphtheroids oo Beta hemol. strept. 100


Strept. (green) many

Diplitheroids few Beta hemol. strept. 10 Staph, albus oo Gram-neg. coccus co


Staph, albus 300 Gram-neg. coccus oo


Tetragenus Staph, albus


many


Tetragenus sev Strept. (green) Strept. (grey)

Staph, albus


huiid. 100


February, 1922]


65


hemolytic, were encountered, the type often differing in successive cultures from the same infant. The organisms corresponded with the varieties found on the skin (see below). Their logical source is clearly the mother's skin and the milk, and this supposition is supported by the much lower incidence of white staphylococci in adults. There seemed to be no evidence of a real carrier state, but the presence of these bacteria indicates multiple transient infestations derived from nursing at four-hour intervals.

2. Staphylococci (aiirei). — These organisms were found in a few cultures — in no case as constant inhabitants. Their significance was clearly that of transients derived from the mother's skin and milk.

3. Micrococcxis Tetragenus. — Organisms of this group were found in a large percentage of the cultures but by no means constantly. Two main types were encountered (1) large uniformly Gram-positive forms in clumps and groups of four, and (2) smaller forms, many of which failed to retain the Gram stain. The colony formation also varied markedly. These organisms are common skin inhabitants, which pretty clearly explains their source.

4. Diphtheroids. — In marked contrast with what occurs in adults, diphtheroids were found only in occasional cultures and then in small numbers. Their significance was clearly that of transients, and their ubiquity on the skin surfaces and in the mouths of adults offers a ready explanation of their source. There was, however, no tendency to extensive or permanent gro\\i;h on the mucous membranes of infants.

5. Gram-negative cocci. — These organisms are found practically constantly and in large numbers in the mouths of adults. In sharp contrast to this observation was their incidence in infants. We found them in only four cases of the series (II, VII, X, XIII).

6. Streptococci. — This group was of particular interest. As is seen in the table, streptococci appeared early, usually within 24 hours, and in nearly every case were constantly present in large numbers. Two main types were encountered, first, small green-producing colonies consisting usually of elongated cocci in long chains, which exhibited many variations in form and much variability to Gram staining, and secondly, small grey colonies of intensely Gram-positive forms in short chains. No obvious source for these organisms in the infants surroundings was found save the mouths of the attendant adults.

7. Other Organisms. — A variety of other organismsm were encountered in single instances — clearly transients of no significance — a Gram-negative bacillus (Cases VI, and VIII), B. lactix aerogenes (Cases IX and XV). In Case XVIII beta hemolytic streptococci were obtained in small numbers on the first two cultures. They were clearly transients and did not colonize or produce disease, but their source was obscure. Unfortunately, no examination of the mother's milk or breasts was made.

In summary, then, the infant's mouth, sterile at birth, rapidly becomes the site of profuse bacterial growth. The flora is relatively simple compared to that of adults consisting


essentially of ( 1 ) a group of organisms constantly introduced during the process of nursing and corresponding pretty clearly with that of the skin of adults — Staphylococcus albus, M. tetragenus. Staphylococcus aureus, etc., (2) a small group of variable transients, and (3) non-hemolytic streptococci.

With a view to confirming the source of some of the above organisms a series of cultures wa.s made from the skin and from the breast nipples of a group of adults associated with the infants. A swab dipped in sterile salt solution was rubbed over an area about one inch in diameter and plated on the same kinds of media used for the throat cultures. The results summarized in Tables II and III indicate the source of certain of the orgairisms found in the infants' mouths, such as albus, aureus, tetragenus. etc.

TABLE II

Cultures from Skin op Arm of Adults M. — 50 colonies Staph, albus (non-hemolytic). 4 colonies Staph, albus (hemolytic). 6 colonies M. tetragenus.

A few colonies of a coarse rod-like Gram-neg. bacillus. E. — 50 colonies Staph, albus. 1 colony Staph, aureus.

Many colonies Gram-neg. coccus. C. — 1 colony Staph, albua (non-hemolytic).

2 colonies Staph, albus (hemolytic).

2 colonies Staph, aureus.

Many colonies spore-bearing Gram-neg. bacillus.

Many colonies M. tetragenus. G. — Many colonies M. tetragenus.

A few colonies Gram-neg. cocci.

A few colonies Staph, albus.

2 colonies Staph, aureus. S. — 00 colonies Staph, albus (hemolytic).

A few colonies Staph, albus (non-hemolytic).

Many colonies M. tetragenus.

A few Gram-pos. diphtheroids. J. — Many colonies Staph, albus.

A few M. tetragenus. D. — .K few colonies Staph, albus.

A few colonies M. tetragenus.

A few colonies Gram-pos. diphtheroids.

A few colonies Gram-neg. diphtheroids. A. — 1 colony Staph, albus. E. — 12 colonies .Staph, albus.

1 colony coarse Gram-neg. bacillus. C. — 12 colonies Staph, albus. D. — Spreaders.

TABLE III Cultures from Nipples of L.^ctating Women Case 1 — 00 colonies Staphylococci (several kinds).

Many colonies M. tetragenus.

Many colonies Diphtheroids.

A few colonies spore-bearing bacilli. Case 2 — 00 colonies Staphj-lococci (white).

Many colonies Gram-positive spore-bearer.

Many colonies M. tetragenus.

A few colonies spreaders. Case 3 — Many colonies M. tetragenus.

Many colonies Staph, albus.

Many colonies Gram-positive bacillus.


66


[No. 3:2


TABLE III— Continued

Case 4 — 00 colonies Staph, albus.

Many colonies M. tetragenus.

A few colonies Staph, aureus.

00 colonies Gram-positive diphtheroids. Case 5 — A few colonies Staph, albus.

Many colonies Gram-negative coccus.

Many colonies Yeast.

Many colonies long chain — grey streptococcus. Case 6 — 00 colonies Staph, albus.

Many colonies M. tetragenus,

A few colonies Staph, aureus.

Many colonies Diphtheroids

Spreaders.

D1SCUS.SION Above we have outlined the bacteriological facts elicited in the present study. A few words may now be devoted to the general questions raised at the beginning of the paper. It was hoped that further information might be obtained about the mucous membranes of the upper air passages as sites for bacterial growtli and the nature of their relation to the organisms found. It may be recalled that in healthy adults we deal with an apparently habitual constant and completely adapted flora, with transients, and with foreign organisms associated with acute disease or chronic foci of infection. The question of another group of partly adapted organisms has been raised in another place" and evidence of their occurrence collected. In the present work it is of interest to note the absence of such organisms as influenza bacilli, pneumococci, and hemolytic


streptococci which are relatively frequent in adults. Without direct contact observations no definite conclusions can be drawn, but the absence of these organisms rai.ses the possibility of an inherent lack of complete adaptation to free growth in the throat, and suggests that special conditions are necessary for their colonization.

Of major importance, however, from the ])rosent point of view is the practically constant finding of non-hemolytic streptococci in large numbers beginning within a few hours after birth. One seems forced to conclude that an inherent adaptation to free growth on the mucous membranes of the upper air passages exists in the case of this group of bacteria. We state the matter in this way at the present time, for as yet no exact information is available as to actual chemical or biological factors which allow the colonization of this group rather than that of hemolytic streptococci or a host of other organisms. These observations do, however, seem to give a hint that subtle biological adaptations are of importance in explaining the presence of bacteria under certain conditions, rather than the cruder and more specific chemical facts of bacterial gro^^^h demonstrable in the test-tube.

BIBLIOGRAPHY

1. Bloomfield, A. L.: Bull. Johns Hopkins Hosp., 1920, XXXI, 118.

2. Idem: Bull. Johns Hopkins Ho.sp., 1921. XXXII, 1.

3. Brailovsky-Lounkevitch : Ann. de I'lnstitut Pasteur, 1915, XXIX, 379.

4. Bloomfield, A. L.: Journal Am. Med. Assn.. 1921, LXXVII, 187.

5. Idem: Bull. Johns Hopkins Hosp., 1921, XXXII, 387.


DERMOID CYSTS OF THE OVARY

A REPORT OF FOUR CASES

By K.VRL H. Maetzloff (From the Department oj Gynecology oj The Johns Hopkins Hospital and University)


1. A small dermoid cyst accidentally discovered by needling an enlarged ovary.

2. A large dermoid of the left ovary; a small dermoid cyst of the right ovary.

3. A dermoid cy.st in the wall of a large multilocular ovarian cystadenoma.

4. A spinal-cell carcinoma developing in a dermoid cyst of the ovary.

These four cases of dermoid cyst of the ovary are presented not because such growths are rare, but because the pathological specimens came to our laboratory in rapid sequence and each case presented something of interest either clinically or pathologically. The case histories and pathological findings in brief are as follows :

Case 1. — G. G., a white female, unmarried, 24 years old, was operated on by Dr. Cullen at the Church Home and Infirmary, November 15. 1920. The patient had had several attacks of pain localized in the right iliac and the inferior portion of the right lumbar quadrants. Some of these attacks had been associated with nausea, vomiting and a chill. The historj- was otherwise irrelevant. On account of the


iliac pain the patient herself asked for a careful examination of the ovary.

The physical examination was essentially negative except for definite abdominal tenderness and muscle spasm on deep palpation o\er McBurney's point. A pelvic examination was not made.

At operation the appendix was found to be involved in a wellmarked chronic inflammatoiy process. It was removed. The right tube and ovary were next brought to view through the (gridiron) incision. The tube appeared to be normal. The ovary, however, was about half as large again as normal, and presented several large follicular cysts. Three of these were punctured with a straight intestinal needle, and all yielded a clear, colorless fluid. The ovary, however, being still somewhat too large, the needle was passed deeply into its median half where no definite cyst was apparent, and immediately there escaped a verj' small drop of an oily fluid, which against the white surface of the ovary and on account of the good illumination appeared as a small, shimmering globule. The diagnosis being evident, an elliptical incision was made over the surface of the ovary and a dermoid cyst about 3 cm. in diameter was at once encountered. This was shelled out intact, about two-thirds of the ovary being left. The left ovary was normal.

Pathological Examination (Gyn. Path. No. 26372).— The spicunen consists of a small tumor mass measuring 3.5x3x3 cm. (Fig. 1).


February, 1922]


67


About one-half of this mass (marked "dermoid cyst") has a regular, pale gray surface with a few fine shreds of pale gray tissue attached. On palpation this portion is of semi-fluid consistence and possibly is slightly fluctuant. The other part, which represents the portion of the ovarj- included in the elliptical incision, appears elevated, pale red, smooth, glistening and translucent. On section a thin-walled cyst is seen filled with a graj', granular, greasy material which is soft and contains a few strands of hair. In one portion of the wall is an elevated, thickened area from which a tuft of hair projects. The cyst wall is as thin as tissue paper except over the portion where some ovarian tissue is attached; here it is 3 mm. thick and has several smooth-walled, cystic areas in its substance.

Microscopic examination shows the picture of an ordinary simple dermoid cyst lined with stratified epithelium several layers thick. In the wall of the cyst are numerous hair follicles and sebaceous glands. In its cavity are pink-staining detritus and some strands of hair. The cystic areas to one side are thin-walled structures lined with a single layer of flat or low ciiboidal epithelium. These are enlarged Graafian follicles.

Comment. — The point of particular interest in this case is the discovery of a dermoid cyst embedded in the substance of an ovary so as to be entirely surrounded by ovarian tissue. Careful scrutiny of the fluid obtained by paracentesis led to the discovery of a dermoid cyst which would otherwise have been overlooked, and the patient wotild very probably, at some later date, have been compelled to submit to another abdominal operation. The value of paracentesis ovarii as a diagnostic procedure is well brought out in this case and can equally well be applied to other selected cases of small ovarian enlargement when it is desirable to be particularly conservative in preserving ovarian tissue and when the spilling of some of the cyst contents will not lead to peritoneal implantations as sometimes happens in ovarian papillary cystadenomata.

C.4SE 2.— M. M. (Gyn. No. 26756), a white, married woman, 2-para, 39 years old, was admitted to The Johns Hopkins Hospital April 6, 1921, complaining of pain in the lower part of the abdomen. There was nothing of importance in the family or personal history. The menstrual history was normal.

Present Illness. — For about a year the patient had complained of a dull pain in the left iliac quadrant and gradually had become conscious of a mass in this situation which seemed to be enlarging, so that finally it gave rise to a sense of fullness whene^er she sat down.

The physical examination was essentially negative except for the presence of a- Ann, rounded, smooth mass which was movable and apparently about 15 cm. in diameter. This mass was situated in the left iliac fossa and extended upward to a point mid-way between the umbilicus and the s>-mphysis pubis in a position in front of and to the side of the uterus, which appeared to be es.sentially normal. The right o\-ary was in its usual position and seemed to be about twice the normal size.

At operation. .A|iril 9. 1921, the left ovary was represented by a large tumor mass lying in the left ihac fossa and twisted on its pedicle through an arc of 90° (Fig. 2). The left tube and ovar>- were rpmoved in the usual manner. The right ovary also contained a yellowish cyst, through the wall of which some hair could be seen. This cyst was resected, leaving in .ntu about what would correspond to one-third of a normal ovary. The usual prophylactic appendectomy was performed and the uterus was left in good position by a modified Coffey suspension.

Patholoi/icnl Examination (Gyn. Path. Xo. 26756).— The resected portion of the right ovar>- measures 4.5x3 x 2 cm. It is .smooth, pale gray and glistening except for one area where the surface has some small vesicle-like areas which are yellow, glistening and translucent. The tumor is doughy in consistence. On section (Fig. 2: insert) a


cystic structure is seen filled with a sebaceous material in which there is some hair. The hair grows in a tuft from the inner aspect of the roughened yellow area noted on the external surface. The lateral portion of the mass, where it has come in contact with the normal ovarian substance, has several small, yellow, cystic areas.

The tumor mass on the left measures 12 x 10 x 9 cm. and has attached to it a normal Fallopian tube. The tumor is smooth, glistening, reddish, and a fine tracery of blood vessels is seen over its surface. It is doughy in consistence and on section presents the appearance or an ordinary dermoid c\st with \-er>' little hair.

Sections of the tumor removed from the right ovary show a thin wall, the inner aspect of which is lined with a stratified squamous epithelium, without papilla, beneath which are numerous hair follicles. The yellow cystic areas seen in the gross are small cavities lined with stratified epithelium and here one also sees numerous multinuclear giant cells scattered in the stroma forming the cyst wall.*

Sections from the large cyst on the left show a similar inner epidermal lining, without papillae but with an occasional hair follicle and sebaceous gland. Numerous epidermal inclusions are seen, some of these having the appearance of undifferentiated sweat glands. Comment. — This patient passed through an uncomplicated convalescence and when last heard of had been menstruating normally at 26-day intervals. The case affords a good illustration of the feasibility of conserving the ovarian function when some normal tissue is present, thereby avoiding the danger and inconvenience of a premature operative menopause. The dermoid cysts are interesting in that they replaced about five-sixths of what should have been normal ovarian stroma; nevertheless, the patient has had and is still having her normal catamenia.

Case 3.— L. T., a white woman, 35 years old, married, 3-para, was admitted to the Church Home and Infirmary March 27, 1921, complaining of an abdominal tumor and indigestion. The family and l)ersonal history have no bearing upon the case; the menstrual hi,story had been normal.

Present Illness. — One year before admission the patient first noticed that she had an abdominal tumor which had gradually become larger.

The physical examinUtion was essentially negative except for the abdominal findings. A large, s\-mmetrical, rounded, and freely movable tumor mass was felt in the hvpogastrium extending from the peh-is up to the umbilicus. This tumor could not be differentiated from the uterus on pelvic examination and we thought we were dealing with a freely movable myomatous uterus.

Operation. — The patient was operated on by Dr. Cullen on March 28, 1921. A small quantity of free straw-colored fluid was found in (he pelvis. The right o\-ary was represented by a large ovarian cyst, which with its Fallopian tube was removed. Convalescence was uneventful and the patient is now well and free of all s>-mptoms.

Pathological Examination (Gyn. Path. No. 26733). — The specimen consists of a large blue-domed mass to which is attached a Fallopian tube. The latter measures 10 x 1 cm. It is flattened out and stretched over the tumor mass. Its surface is covered by a smooth and glistening serosa, its lumen is patent and it.s fimbriae are delicate. A small appendix \esiculosa is present.

The tumor mass measures 20 x 17 x 10 cm. Its sm-face has a bluish sheen, is smooth, glistening, and slightly irregular in outline. Palpation elicits definite fluctuation. On section a large multilocular cystic structure (Fig. 3) is seen. It was filled with a thick, tenacious.


Dr, Cullen has frequently drawn attention to these giant cells and he feels that they are the precursors of the squamous epithelium. He goes further and states that " wherever an alveolar structure is noted in an ovaiy and where these alveolar spaces are more or less lined with giant cells, one can be ab.solutely certain that a dermoid cvst exists in that ovarj-."


[No. 372


glistening, glairy, translucent, mucinous material. One area in the cyst opposite the tube has a rather honey-combed, bubble-like appearance and here the contents are particularly viscous. On the inferior portion of the posterior wall of the cyst is seen an encapsulated mass different from the remainder of the cyst and measuring on its cut surface 1.7x1.5 cm. (Fig. 3; insert). It is easily recognized as a dermoid cyst containing some yellowish-gray, greasy material and a few strands of hair which do not appear to grow as a tuft from any one situation.

Sections from various portions of the cyst wall show a scanty stroma with numerous capillaries and occasional areas of round and polymorphonuclear cell infiltration. The inner aspect of the cyst wall is lined with a single layer of columnar epithelium which only in a few places is thrown up into a low fold. The individual cells are goblet-shaped and have a pink -staining cytoplasm with a pale central zone and a well-defined cell outhne. The nuclei are at the base of the cells, are oval or round and in some cells are crescentic in shape. The cells rest on a poorly defined membrana propria. The smaller cystic areas mentioned in the gross description contain a moderate quantity of a homogenous, pink-staining material in which are large vacuoles. In short, it is a picture of a tj-pical multilocular cystadenoma. Sections of the dermoid cyst taken through its wall where it borders the cavity of the multilocular ovarian cyst (Fig. 4) show the dermoid lined with several layers of cuboidal epithelium. In its wall are hair follicles as well as sweat and sebaceous glands. In the cavity of the dermoid is some detritus in which can be identified some strands of hair. The dermoid is separated from the cavity of the adjoining cyst by a narrow strand of pink-staining fibrous stroma which in turn is lined with a single layer of columnar epithelium similar to and continuous with the previously de.scribed epithelium lining the remainder of the multilocular cyst. No recognizable ovarian stroma is seen.

Comment. — This is the first time in the history of this hospital, as far as the records of the gynecological and patliological departments show, that a dermoid cyst has been seen in association with, and included in, the wall of a multilocular pseudomucinous cystadenoma of the ovary. Although pseudomucinous cysts of the ovary are not particularly rare and dermoid dysts of the ovary are even less uncommon, nevertheless, this particular pathological association is very unusual and the literature on it is quite meagre.

Case 4. — E. R., a white woman, married, 37 years old, 3-para, was admitted to the Church Home and Infirmary complaining of a " lump in her stomach" and was operated on by Dr. Cullen, March 1, 1921. There is nothing of importance in the family or personal history. Her menstrual history is apparently normal.

Symptoms of the present illness were first noted in December, 1920, when she began to have discomfort in the hypogastrium, and a sense of pressure, most noticeable near the rectum, which was aggravated by exercise and by the sitting posture. Lying down gave marked relief. The patient had felt a tumor mass in her abdomen about two months before entering the hospital and she was certain that the tumor had definitely, though slowly, increased in size.

The physical examination was essentially negative except for the abdominal findings. The hver edge was felt just below the costal margin, being sharp, of about normal consistence and not tender. The lower half of the abdomen was quite tender, especially in the left iliac quadrant. Here a firm, tender, mass was felt extending from the left iliac fossa upwards to within 3 cm. of the level of the umbilicus. This same mass coidd be felt behind the cervix and was only moderately movable on bi-manual manipulation.

At operation a quantity of oily fluid containing white flakes and gi-umous-like material was found free in the peritoneal cavity. The site of the left ovary was occupied by a niptured cyst which extended out into the left side of the pelvis and lay upon the rectum behind, its anterior and medial surfaces being adherent to the posterior


aspect of the uterus. This tumor mass with its attached Fallopian tube was removed as completely as possible, but a portion was left attached to the left side of the cervix. The peritoneal cavity was drained with two pelvic and two abdominal cigarette drains.

The patient had an intermittent pyrexia up to 101° F. for two days after the operation. At times she was jaundiced, bile was found in her urine, and she had constant rectal pain up to the time of her discharge from the hospital, March 27, 1921. She failed rapidly and died at her home June 21, 1921.

Pathological Examination (Gyn. Path. No. 26643). — The specimen consists of a Fallopian tube attached to a tumor mass (Fig. 5). The Fallopian tube, 7x0.5 cm., is pale gray, smooth, and ghstening; its fimbrise are delicate. The tumor mass measures 10 x 8 x 7 cm. It occupies the position of an ovary in relation to the tube to which it is attached by a meso-ovarium which has a normal appearance. Its outhne is rather iiTegular and it has several distinct nodular areas. The portion of the tumor adjoining the proximal part of the tube is pale graj-, smooth, glistening, and fluctuant, while the part inferior to the distal segment of the tube is pale gray, and finn, with opaque yellow nodular areas. The most dependent of these nodular areas,

a, has a roughened sm-face which shows some loss of substance, just at the point where the tumor had been adherent to and blended with the cervix. On section the tumor is seen to be a unilocular cyst with a dirty brown liquid conteiit in which are seen small, flattened yellow masses and large quantities of hair. Its walls measure from 1.5 mm. to 3.5 cm. in thickness; they are smooth and somewhat irregular, the irregularities corresponding to the nodular areas seen externally. At its thickest part, a, the external surface is rough and shows some loss of substance, while its internal aspect has several tufts of hair arising from it. The cut surfaces of this area are yellow, opaque, and granular, with pale gray, glistening and translucent columnar areas, which appear to be invaginations or ingrowths from the external surface. The other areas of nodular thickening show quite smooth surfaces both externally and on section.

In sectio7is taken through various portions of a the cyst is lined with a stratified epithelium, eight to ten cells thick. These cells are round and oval, their nuclei take a fairly deep blue color with the hematoxylin and eosin stain and most of them have well-defined nucleoli. Each nucleus is surrounded by a small quantity of eosinstaining cytoplasm. The cells are irregular in size, shape, and staining reaction, large mononuclear forms and mitotic figures being common. There is no papillary arrangement of the epithelium, no stratum gcrminativum as such is obseiTed, nor are any hair follicles, sebaceous or sweat glands seen. As one follows the epithelium along from the thinner portion over into the thicker part of the cyst wall, a marked metaplasia is noted and the cells invade the cyst wall in long strands and solid alveoli (Fig. 6). Much central necrosis is present in the alveoli and many bizarre degeneration forms are seen. Numerous epithelial pearls, giant cells and mitotic figures also occiir. The tumor in places occupies the entire cyst wall and penetrates it at one point over a fairly broad area. The predominant type of tumor cell is round or polyhedral, with a nucleus which has a finely granular chromatin distribution with a well-defined, dark-blue-staining nucleolus and is surrounded by a moderate quantity of cytoplasm. This cytoplasm takes a faint eosin stain or no stain at all and is surrounded by a well-defined pink cell membrane.

Sections through b (Fig. 5) show a picture similar to that seen in the sections taken from a, with the exception that no epithelial pearls are observed and the neoplastic process, while involving the entire thickness of b, does not penetrate the serosa. The epithelium lining the inner surface of the cyst about the periphery of this nodule (Fig. 7) is stratified, three to four cells thick; it shows no evidence of malignant metaplasia, being identically the same as the epithelium from other non-malignant portions of the cyst wall.

Sections through a (Fig. 5) show a picture similar to those from

b, there being no microscopic continuity between the two neoplastic processes.


THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1922


Outline of ovary ^^ Dermoid cyst



Fic. 1.— Gyn. Path. Xo. 20372.


al po..,0,, ' ';^.^ ,. Ka,,.-I,d dermoia povtio,



Resected Dei-moid



FiK. 2 (;\n I'lili \'i. 26756. Case 2, showing the dermoid with its twisted pedicle on the kit aud I he Muall quantity of normal ovarian tissue left on the right side after the resection.




Fig. 3. — G.yn. Path. No. 26733. Case 3, a multilocular pseudomucinous cystadenoma of the ovary containing a dermoid cyst.


Fig. 4,— Case 3 (Gyn. Path. No. 26733). From the dermoid cyst where it adjoins the cystadenoma. The columnar epithelium lining the cystadenoma is seen at the superior margm of the picture and the wall of the adjacent dermoid at the inferior margin.


THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1922


I





Fh;. .5. — Gyn. Path. Xo. 26643. Case 4. Spinal cell carcinoma in a dermoid cyst of the ovaiy.


Fig. 6.— Case 4 (Gyn. Path. No. 26643). Section from Fig. 5 (a) showing spinal cell carcinoma with epithelial pearl at (a).


•'JC**'




•.':'i<<r'fe'ifc'4



^.^•^^^^TLv ' ^c^^r .



Fig. 7.— Case 4 (Gyn. Path. Xo. 26643). Section from nodule (b). (Fig. 5.) At the upper margin is the epidermal lining of the cyst, being here only a few cells thick and showing no evidence of malignant change. Two low power fields to the right of this area the epithelium assumes the character of that seen in Fig. 8 and invades. At the most inferior part of the photomicrograph is seen a small clump of cancer cells. This pictm-e is taken from the periphery of (b) to show the benign appearance of the epithelium which completely surrounds these carcinomatous nodules.



Fig. 8.— Case 4 (Gyn. Path. Xo. 26643). From the cyst wal adjacent to the meso-ovarium showing the thickness of the epithelium without invasion. These cells under high power show numerous mitotic figures and marked irregularity in size, shape, and staining reaction. Mitotic figure at (a).


February, 1922]


69


The sections of the Fallopian tube and the meso-ovarium present nothing noteworthy. However, the adjacent wall of the cyst is lined with stratified epithelium, eight to twenty-five cells thick, which do not invade but are irregular in size, shape and staining reaction and show frequent mitotic figures (Fig. 8).

Comment. — It is interesting to note that while sections through a (Fig. 5) show many epithelial pearls, they are not seen in any of the others. The latter, however, show more welldefined cells and much less evidence of degeneration than at a. The carcinomatous change in various isolated portions of the cyst with intervening areas of non-malignant epidermal cells is striking and raises the question whether these small malignant nodules represent lymphatic metastases or whether they indicate separate foci of independent malignant change. The latter does not seem at all improbahle when one considers the apparent malignant metaplasia without invasion noted in the epidermal cells (Fig. 8) lining the cyst in the portion adjacent to the meso-ovarium.

A simple dermoid cyst of the ovary, without evidence of a more complex teratomatous structure, undergoing malignant change, is in our experience very rare. Out of a total of some


200 patients who have had dermoid cysts in one or both ovaries (confirmed by examination of microsections) we have had only one other authentic case of carcinoma developing in an ovarian dermoid cyst. This occurred in 1899 in a white woman, 46 years old, who was lost track of. She was operated on, her convalescence proved unsatisfactory and she was not expected to live more than a few months after she left the hospital. It is reasonable to assume that she died as the result of the carcinoma. Sections showed a well-defined spinal cell carcinoma occurring in a dermoid cyst. The incidence of carcinomatous change occurring in a dermoid cyst of the ovary in this clinic is one per cent and our mortality from this disease is, we feel safe in saying, one hundred per cent.

I wish to express my indebtedness to Mr. Max Brodel and Ills pupil, Miss A. K. Lovett, for their excellent illustrations.

ADDENDUM

The value of puncture of the ovaiy as a practical diagnostic procedure was again demonstrated by Dr. Cullen in January, 1922, in the case of a young woman, C. H. I., No. 27512, whose history, operative findings, and treatment are almost a replica of Case 1 in this article.


TITLES OF PAPERS APPEARING DURING THE YEAR 1921, ELSEWHERE THAN IN THE BULLETIN, BY THE PRESENT AND FORMER MEMBERS OF THE JOHNS HOPKINS HOSPITAL AND MEDICAL SCHOOL STAFF


PREPARED IN THE LIBRARY


Atchley, D. W., Palmer, W. W., and Loeb, R. F.

Studies on the regulation of osmotic pressure. I. The effect of increasing concentrations of gelatin on the conductivity of sodium chloride solution.— J. Gen. Physiol., Bait., 1921, iii, 801-806.

AUBR, J., Eind WiTHERBEE, W. D.

Studies on decreasing the reaction of normal skin to destructive doses of X-rays by pharmacological means and on the mechanism involved. — J. Exper. M., Bait., 1921, xxxiii, 791 813.

Baeb, W. S.

Past, present and future of orthopedic surgery. — South. M. J., Birm.. Ala., 1921, xiv, 42-48.

Baek, W. S., Brackett, E. G., and Rugh, J. T.

Report of the Commission appointed to investigate the results of ankylosing operations of the spine. — J. Orthop. Surg., Host., 1921, iii. 507-514.

Baetjer, F. H., and Waters, C. A.

Injuries and diseases of the bones and joints: their differenti.il diagnosis by means of the roentgen rays. — N. Y., 1921, P. B. Heeber. 349 p., 4°.

Baird, J. H.

The examination of the eye in neuro-surgical patients. — Viyginia M. Month., Richmond, 1920-21, xlvii, 532-536.

Bardeen, C. R.

The relation of ossification to physiological development. — ,J. Jtadiol., Omaha, Neb., 1921. il, 18.

The von Pirquet standard of normal body weight as compared with other standards (Correspondence). — .J. Am. If. Ass., Chicago. 1921, Ixxvii, 1988-1990.

Barker, L. F.

Multiglandular syndromes. Survey of literature from Sept. 1, 1920. to March 1, 1921. — In: Nelson Loose-Leaf Med., Lond. & N. i'., 1921. iii, 238-239.

The importance of psychiatry in general medical practice. — In: A Psychiatric Milestone. Bloomingdale Hospital, 1821-1921. N. Y , 1921, 55-75. [Privately printed.]

Diagnostic criteria in epidemic encephalitis and encephalomyelitis. — Arch. Neurol, d Psychiat., Chicago, 1921, vi. 173-196. The value of drugs in internal medicine. — J. Am. M. Ass., Chicago, 1921, Ixxvii, llSl-ll.'iS.

The classical endocrine syndromes. — N. York M. J., ictc.l, 1921, cxiii, 353-363.

Neutrophilic myelocytes in the cerebro spinal fluid of n patient suffering from myeloid leukemia and their significance for the diagnosis of niyeloleukemic infiltration of the leptomeninges. — ^auth M. J., Birmingham. Ala., 1921, xiv. 437-442.


On the care of patients manifesting high blood pressure. — Yirgima M. Month., Richmond, 1921. n. s., xlviii. 1-7. Also: South. M. d 8., Charlotte, N. C, Ixxxiii, 134-141.

Group diagnosis and group therapy. — Illinois M. J., 19_1, xxsix, 1-J. Also: J. Iowa State U. Soc, 1921. xi, 113-120. BATJMG.4ETEN, W., FiscHEL, W., and SOPER, H. W.

Hospital diets. — J. Missouri M. Ass., St. Louis. 1921. xvlii, 263.

B.\YNE-JoNES, S., and Wilson, D. W.

Specific immunological reactions of Bence-Jones proteins. — Proc. Soc. Exper. Biol. & Med., N. Y., 1920-1921, xviii, 220-222.

Beall, F. C.

The diagnosis of cancer of the colon. — Texas State J. M., Fort Worth, 1921-22, xvii, 343-348.

Beall, F. C, and Jagoda, S.

Injection of the bile ducts with barium. — J. Am. M. Ass., Chicago, 1921. Ixxvi. 1483-1484.

Beall, K. H.

Epidemic encephalomeningomveloneuritis ("Sleeping sickness"). — Texas State J. M., Fort Worth. 1921-22, xvii, 157-161.

Bernheim, B. M.

Whole blood transfusion and citrated blood transfusion ; possible differentiation of cases. — J. Am. M. Ass., Chicago, 1921, Ixxvii, 275279.

Berry, J. M.

I'\irther observations on the presence of roentgenological shadows associated with bursitis. — Albany M. Ann., 1921, xlii, 54-59. The differential diagnosis between tuberculosis of the hip and osteochondritis deformans juvenilis (Perthes) or osteochondral trophopathy of the hipjoint (Legg). — Albany U. Ann... 1921, xlii, 90-93. Perthes' disease. — All>any M. .Ann., 1921. xlii, 94-99. An unusual exostosis of the tibia. — Albany M. Ann., 1921, xlii, 130131. —

Reports from the Roentgen-rav Department of the Albany Hospital. — Albany M. Ann., 1921, xlii, 347-355.

BiDGOOD, C. Y.

A study of methods of procedure in resection of the oesophagus. — Ann. Surg.. Phlla., 1921, Ixxiv. 546-556.

Blackfan, K. D.

Biologic therap.\' : III. The use of antimeningococcus serum in the

treatment of epidemic meningitis. — J. Am. M. Ass., Chicago, 1921,

Ixxvl, 36-37. Blackfan, K. D., and Little, K.

A clinical and radiographic study of the thymus in infants. — .im. J.

Dis. Child.. Chicago. 1921. xxii, 459-470. Also: Tr. Am. Pcdiat. Soc,

1921, xxxiii.


[No. 37-2


Blanton, S.

The medical significance of tile disorilers of speccli. — /. Am. M. Ass.,

Chicago, 1921, Ixxvii, 373-377.

Speech defects in school children. — Moit. liny.. X. V., l'.)i;i. v, 820 827.

Block, E. B.

The etiologlc relation of wcirms to epilepsy. — /. Med .Lis. Georgia, Atlanta, 1021. x. 30U.

Bloodgood, J. C.

Cancer of the t^mgiie a preventable disease (Correspondence). —

J. Am. M. Ass., Chicago. 1SI2]. Ixxvii. 220.

Cancer of the tongue: a preventable disease. — ./. .Im. M. Ass..

Chicago, 1921, Ixxvii, 13S2-87.

Early diagnosis of cancer. — 'Wisconsin M. J., Milwaukee. 1921-22, xx.

235-236.

The patholog.v of chronic ejEtic mastitis of the female breast ; with

special consideration of the blue-domed c.vst. — Irr/i. Siirii., Chicago,

1921, iii, 445-.-i42.

Bloomfield, a. L.

The serial duantitative method of culture in the study of respiratory

disease. — J. Am. M. Ass., Chicago, 1921, Ixxvii. 187-192.

The mecbimism of the bacillus carrier state with special reference to

the Friedliin.ler b icillus.— J»i. Rei: Tiibere., Bait., 1920-21, iv, 847 85.1.

Blumee, G.

Gonococcus infection.— /«.- Oxford Med.. 1921, v, 39-70.

Report of a ease of extensive cavernous angioma of the head, face and

neck, with attacks of fever and somnolence. — Boston II. d- S. J., 1921,

Ixxxv, 58-60.

Some remarks on " cases and observations by the Medical Society

of New Haven County." — Bull. Hoc. Med. Hist.. Chicago, 1921. ii.


205


218.


(iroup practice (Correspondence). — Ixxvii. 2081.

President's address. Connecticut Connect. State Med. Soc, 1921, 69-77


'. Am.

State


M. As


Chicago, 1921. Society. — Proc.


Boggs, T. R., and Pincoffs, M. C.

Diseases of the peritoneum. — ;«; Oxford Me.l.. 1921. iii. 517-581.

Bowcock, H. M., and P.wllin. J. E.

Recent improvements in dietetic treatment of ilialieles mellit J. Med. Ass. Georgia, Atlanta. 1921, x, 076.

Boyd, M. L.

Nephritis am xiv. 36.8-:i71.

DU Bh.4Y, E. S. Svcculai- iim ruiiture into


-.Vniith. M. -J.. Bin


The


. sm of the descending tl into the' lower lobe of the left lum; ort <if a case and remarks on ruplui ni.— -l»i. ./. M. Sc, Phila., 1921, <


Ixi. 41


aorta, with direct left pleural cavity, lernoptysis in aortic 7 418.


of the thyrcuil lobes — Endocrin


Brooks, B., and Allison, N.

Bone atrophy; an experimental and clinical study of the changes in bone which result from non-use. — Surg.. Oiinec. & Oist., Chicago, 1921, xxxiii, 250-260.

Brown, N. W.

Determination of rehitive activity olofiu. Glendale. Cal.. 1021, v. 29-32

Brown, T. R.

Carcinoma and other tumors of the gastrointestinal tract. — In:

Nelson Loose- Leaf Med., Lond & N. Y.. 1921, v. 295-299.

Tuberculosis of the gastrointestinal tract. — In: Nelson Loose-Leaf

Med., Lond. & N. Y., 1921, v. 301-308.

Ulcerations of the gastro-intestinal tract (Not including peptic

ulcer).— / II.; Nelson Loose-Leaf Med.. Lond. & N. Y.. 1921, v, 309-310.

R51e of diet in etiology and treatment of migraine and other types

of headache. — J. Avi. M. As.-i., Chicago, 1921. Ixxvii, 1396-1400.

The absence of pancreatic secretions in sprue and the employment

of pancreatic extract in the treatment of this disease. — Am. J. M. So.,

Phila., 1921, clxi, 501-507,

A note on the administration of pancreatic extract in the treatment

of sprue. — J. Trap. M. [etc.]. l>ond.. 1021, xxiv, 90-92.

Bunting, C. H.

Diseases of the lymph

1920, to March 1. 1921. 1921, iii, 3G8. The leukocytic jiicture clxii, 1-9.

Bunting. C. H.. and Huston, J.

Fate of the lymphocyte. — J. Ej-per. M.. Halt.. 1921,

Burrows, M. T.

The causes of i:lisease. — J. Missou

384-392.

The reserve energy of actively growing embryonic tisi

Exper. Biol. <f Med., N. Y.. 1920-21. xviii, 133-136.

BuRWELL, C. S., and Jones, C. M.

The removal of bile and blood from the urine in iierforming the

phenolsulphouephthalein test of renal function. — .1. .tin ]/ Ass, Chicago, 1021, Ixxvii, 462-463.

Burwell, C. S., and White, P, D.

The clinical significance of changes in the form of the electrocardio gram.— J/rri. Clin. N. Am., Phila., 1921, iv, 1839-1861.

Bukwell, C. S., White, P. D., and Marvin, H. M.

The action of quiuidine sulphate in heart disease, to abolish the circus movement of auricular flutter and fibrillation. — Boston M. tC S. J., 1921, ixxxv, 647 650.


influenza. — .im. J. M. Sc.. Phila., 1921,


Ass., St. Louis. 1021, xviii, Pioc. Soc.


il I Editorial). — ./. .li,


Chicago, 1921,


from the writings of William Osier. 2. ed.. d I'ress ; Boston. Houghton, .MiSlin & Co., 356


Camac, C. N. B,

The live wire mir; Ixxvii, 129-130.

Cam.^C, C. N. B., cump. Counsels and ideals, 1021, London. Oxfo p. 8-.

Campbell, C. M.

I'ersonal factors in disease. — In: Nelson Loose-Leaf Med., Lond. &

-N. Y., 1921, vii, 145-153.

History of insanity during the past century, with special reference to

the .McLean 1 lospital — /Jostoii If. d S. J., 1921. clxxxv. 538-544.

Tile use nf tlroi.'s in ueurologj' and psychiatry. — ./. .4m. M. Ass.,

( liicaj.-". 1021. l.\xvii. 1228-1230.

Mental hygiene in industry. — Ment. Hyg., N. Y.. 1921. v, 468-478.

The education of the emotions. — Proc. Head Mistresses Assoc, Bost.,

Mass., April, 1921.

CARTER, D. W., Jr.

Irregularities of the heart beat. — Dallas M. !.. 1921. viii. 13.

The role of the pituitary body in the etiology and therapy of diabetes

insipidus. — Texas State J. M., Fort Worth, 1921, xvi, 491-495.

C.\SH, J. R.

On the develoimient of the lymphatics of the stomaih in the embryo pig. — Contrih. Embryol. No. 57, i Carnegie Inst.), Wash., 1921, xiii, 1-15.

C^SH, J. R., and Young, H. H.

A case of pseudohermaphrodismus masculinus showing hypospadias, greatly enlarged utricle, abdominal testis and absence of seminal vesicles. — ./. Vrol. Bait., 1921, v, 405-430.

C.4ULK, J. R.

Factors which influence results and mortality rate in kidney surgery. Analytic study of two hundred and sixty-three operations. — J. Am. M. Ass.." Chicago," 1021. ixxvif. 843-848.

A new m-tliod of leiuoving the median bar type of prostatic obstruction. — ./. Mi.isoiiri M. A.VS., St. Louis. 1921. xviii. 191. Renal tuberculosis. — ./. Urol.. Bait, 1921, vl. 97-113. Presentation of a cautery punch for the removal of minor obstructions at the vesical neck, with new method of anesthesia. — South. M. J., Birmingham, Ala., 1921, xiv, 816-810.

Chesney, a. M.

An immunologic study of bacillus influeuzip. — /. Inleet. Dis., Chicago, 1921. xxix, 132-140.

Churchman, J. W.

Sterilization of dosed cavities by la violet. Description of technic. — /. An 24-26.

Further studies on the behavior of bacteria toward gentian violet. — J. Exper. M.. Bait.. 1921. xxxiii. 569-581.

The cause of the parallelism between the gram reaction and the gentian violet reaction. — Pioc. Soc. Exper. Biol d- Med., N. Y., 1920-21. xviii, 17-18.

The isolation of gentian positive individuals from a suspension of a gentian negative organism (B. coli). — Proc. Soc. Exper. Biol, d Med., N. Y.. 1920-21, xviii. 19.

Relation of the gentian violet reaction to dilution of implanted suspension. — Proc. Soc. Exper. Biol, d Med., N. Y'.. 1920-21, xviii. 20. The effect of repeated re-inoculations of gentian violet agar with genti.in i".sitiv.' uruanisms. — Proc. Soc. Exper. Biol, d Med., N. T.,

The sill riive .1(1 inn of gentian violet in relation to chemotherapy. — Proc. Sue. Lxv>r. ISiol. d Med., N. Y., 1920-21. xviii, 21-22.

Chubchm.\n, J. W.. and Kahn, M. C.

Communal activity of bacteria. — ./. Exper. M.. Hall.. 1921. xxxiii, 583-591. Alio: Proc. Soc. Exper. Biol, d .Med.. N. Y., 1920-21, xviii.


Clarke, T. W.

•Colic" in the nursing infant. — : xxi, 138.

Clough, M. C. and Clough, P. W. A study of the reactions following .If. .;.. Birmingham. Ala., 1921, xiv

Cobb, S.

Some neurologii iv. 1,'!63-1S70.


VorA- State ./. .1/.. N. Y., 1921.


aspects of chorea. — Med. Clin.


an elephant. — Im. ./.


Cobb. S., and Coleman, C, C.

The course of recovery following trauma Surg., Chicago. 1921, iii, 132-139.

Cobb, S., Forbes, A,, and C.wtell, M.

An electrocardiogram and an electromyugr Physiol., Bait.. 1921, Iv, 385-389.

Cobb. S., and P.\rmenter, D. C.

Headache. — J. Indiist. ling.. N'. Y. & Bost.. 1021. iii. 173-178.

Cole, R.

Acute lobar pneumonia. (Survey of literature from Sept. 1, 1020. to March 1, 1021,) In: Nelson Loose-I>eaf Med.. Phila. & Lond.. 1921, i.


Antipneumococcus serum

112.

Prevention and specific

Lond.. 1921. xxix, 58.

Colston, J. A. C.

The value of pyelography — J. Vrol., Bait.. 1921. v


—J. Am. M. Ass., Chicago. 1921. Ixxvi. Illtreatment of pneiunonia. — ,1. State Med.,


iiplasms id" the kidne


February, 1933]


71


Cornell, W . B.

Group mental hygiene. — Am. J. Insan., Bait, 1920-21, Ixxvii. 335-342. The organization of state institutions for feeble-minded in the United States. — Cnnaa. J. Mcnt. Hyg., Montreal. 1921, iii, 65-70.

Corner, G. W.

Abnormalities of the mammalian embryo cccurring before implantation. — Contrib. Emhryol., No. 60 (Carnegie Inst. i. Wash., 1921, xiii. 61-66.

Cyclic changes in the ovaries and uterus of the sow. and their relation to the mechanism of implantation. — Contrih. Emhryol.^ No. 64

(Carnegie Inst.), Wash.. 1921, xiii, 117-146.

A review of some recent work on the mammalian reproductive cycle. —

J. Mammalogy. Bait.. 1921, ii, 227-231.

A case of true lateral hermaphroditism in a pig with functional ovary. — J. Vrol., Bait., 1921, v. 481-485.

The ovarian cycle of swine. — Science, N. Y. & Lancaster, 1921, liii. 420-421.

COWDRY, E. V.

The Office of Imperial Physicians, Peking. — J. Am. M. Ass., Chicago, 1921, Ixxvii. 307-310.

The reticular material of developing blood cells. — J. Exper. M., Bait., 1921, xxxiii. 1-12.

Crawford, A. C, and George, J. M.

The testes and certain vaso-motor reactions of the penis. — J. UroL, Bait., 1921, V, 89-ll.S.

CCLLBN, E. K.

Diverticulum of the first portion of the duodenum. — .Irch. Surg., Chicago. 1921. ii. 542-564.

Tuberculous ulcer of the anterior vaginal wall with resection of ulcer. — Surg., Gyncc, rf- Ohst., Chicago, 1921, xxxiii, 76-78.

CULLEN, T. S.

Three cases of subperitoneal, pedunculated adenomyoma. — .irch. Surg.,

Chicago. 1921. ii, 443-454.

The weak spot in American surgery. — Stirg., Gyncc. <£ Obst., Chicago,

1921. xxxiii. 67-72.

Early squamous-cell carcinoma of the cervix, accidentally discovered

when the body of the uterus was being curetted for hiemorrhage

cau.sed by hyperplasia of the endometrium and by a small submucous

myoma. — Surg., Gyncc. rf Obst., Chicago, 1921, xxxiii, 137-144.

CUSHING, H.

The personality of a hospitnl. 538.

Disorders of the pituitary gland; retrospective and prophetic M. Ass., Chicago, 1921. Ixxvi, 1721-1726.

Further concerning the acoustic neuromas. — Laryngoscope, St. Louis,

1921, xxxi, 209-228.

The special field of neurological surgery after another Interval. —

Illinois M. J., Oak Park, 1921, xxxix, 133-141 ; 185-195. Also:

Wisconsin M. ./., Milwaukee. 1920-21. xix. 501-520. Alio: Ohio .If. J.,

Columbus, 1921, xvii. 293-302; 373-380. Also: J. Jotca State If. Soc,

Clinton, 1921, xi, 337-342 ; 385-394 ; 426-430.

Dandy, W. E. ,„„,

The treatment of brain tumors. — J. Am. M. Ass., Chicago. 1921, Ixxvii. 1853-1859. , . . ^.

The diagnosis and treatment of hydrocephalus due to occlusions of the foramina of Magendie and Luschka. — Surg. Oynec. «f Ohst.. Chicago, 1921. xxxii. 112-124. „ „ , ^v ..

An operation for the removal of pineal tumors. — Surg., Grjnec. d OOst., Chicago. 1921. xxxiii. 113-119.

D.wiDsoN, E. C, and Dieuaide, F. R.

Terminal cardiac arrhythmias. Report of three cases. — Arch. Int. ilcd., Chicago. 1921. xxviii, 663-677.

Davis, D. M., and Swartz, E. O.

Action of niercurochr.ime -220 on the gonococcus. — .7. Anu M. Ass..

Chicago, 1921, Ixxvi, 844-846.

The action on the gonococcus of various drugs commonly useil in the

prophylaxis and treatment of gonorrhea. — .7. Vrol., Bait., 1921. v,

235-253.

Davis, E. G.

Urinary antisepsis ; a study of antiseptic propertie;

excretion of 204 aniline dyes. — Am. J. il. Sc, Phila..

267.

The significance of hematuria. Report of 46 cases. — J. Iowa State M.

Soc, Clinton. 1921. xi, 315.

The Young-Stone operation for urethrorectal fistula. Report of three

cases. — Surg., Oynec. i(- Ohst.. Chicago, 1921, xxxii. 225-231.

Davis, E. G., and Beck, G. H.

Urinary antisepsis. The secretion of antiseptic urine by man following the oral administration of proflavine and acriflaviue. I'reliminarv report. — J. Urol., Bait. 1921. v, 215-233.

Davison, W. C.

Biologic therapy, xiii. 1921, lxx%-i, 242-243.


-Boston il. <f S. J., 1921, clxxxv, 529Am.


Pertussis vaccine.


Davison, W. C, and Josephs, H. W.

The serotherapy of bacillary dysentery in children. — .7. Am. M. Ass., Chicago, 1921, l-xxvii, 1863-1.864.

Davison, W. C, and Rosenthal, L. V.

a bacteriological study of the fecal flora of infants and children (the lack of association of nutritional disorders with a so-called " putrefactive " intestinal flora). — Am. J. Dis. Child., Chicago, 1921. xxii. 284-298.

Denzer, B. S.

The size of the infantile palate. — Am. J. Dix. Child., Chicago, 1921. xxii. 471-47C.


Denzer, B. S., and Anderson, A. F.

Absorption of fluid injected into the peritoneal cavity. — .l»i. J. Dis. Child., Chicago, 1921, xxi, 565.

Dick, Gladys H., and Dick, G. F.

Experimental inoculations in scarlet fever. — J. Am. M. Ass., Chicago, 1921, Ixxvii, 782-785.

Dickson, E. C.

Botulismus. — In: Oxford Med., 1921. v, 231-257.

Pathology of botulism. (Correspondence.) — J. Am. M. Ass., Chicago,

1921, Ixxvii. 483-484.

Dickson, E. C, and Shbvky, R.

Botulism ; a study of the action of the toxin of B. botulinus upon the living tissues. — Proc. ,'ioc. Exper. Biol, d Med., N. Y., 1920-21, xviii, 313.

DiEU.AIDE, F. R.

The determination and significance of the electrical axis of the human heart. — .irch. Int. Med., Chicago, 1921, xxvii, 558-570.

Dunham, Ethel C.

Peritonitis as a complication of scarlet fever. — -4»i. J. Dis. Child.. Chicago, 1921, xxii, 307-309.

Dunton, W. R.

The psychosis of a famous portraitist. — Maryland Psychiat. Q., Bait., 1921, X, 50-54.

The passing of the Henry B. Faville School. — Maryland Psychiat. Q., Bait., 1921, X, 77-78.

Eb.augh, F. G., and Hoskins, R. G.

A case of dystrophia adiposogenitalis.1921, V, 21-28.


-Endocrinology. Glendale, Cal.,


Elmendorf, D. F.

Vincent's angina.


-.Mil. Surgeon. Wash.. 1921. xlix. 287-291.


Phila. & Lend.. 1921, J. B. Lippincott Co.,


Emerson, C. P. Clinical diagno 726 p. 8°.

The problem of the so-called primnrv ansemias from the internist's standpoint. — Chicago M. Recorder. 1921. xliii, 125-136. Teaching of general medicine. — J. Am. M. Ass., Chicago, 1921, Ixxvi, 869.

The acute element in the chronic nephropathies. — J. Am. M. Ass., Chicago, 1921, Ixxvii. 745-749.

Emmons, A. B., 2d.

Health in mercnntile establishments. 111. Common sanitary defects in stores. — J. Indust. Hyg.. N. Y. & Bost.. 1921. iii. 29-30.

Emmons, A. B., 2d., and Goldthwait, J. E.

A work chair. — J. Indu.it. Hyg., X. Y. & Bost. 1921, iii. 154-1.=SS.

Erlanger, J. Blood vol 207.


ind its regulatii


-Physiol, Rcc, Bait.. 1921, i, 177


duodenal ulcer. — Penii. M. J.


ERL.4NGEB, J., and White, H. L.

The effect on the composition of the blood of maintaining an increased blood volume by the intravenous injection of a hypertonic solution of gum acacia and glucose in normal asphyxiateci and shocked dogs. — Am. J. Phmiol., Bait.. 1920-21, liv, 1-29.

Estes, W. L., Jr.

Early diagnosis of perforated gastric 1920-21. xxiv, 307 309.

Eyster, J. A. E., and Meek, W. J.

Reactions to hemorrhage. — Am. J. Physiol., Bait.. 1921. Ivi. 1-15. The origin and conduction of the heart beat. — Physiol. Per., Bait., 1921, i, 1-43.

Fabyan, M., Tyzzer. E. E., and Foot, N. C.

Further observations on " blackhead " in turkeys. — J. Infect. Dis., Chicago, 1921, xxix. 26S-286.

Felton, L. D.

A colorimetric method for determining the hydrogen-ion concentration of small amounts of fluid.— 7. Biol. Chem., Bait., 1921, xlvi, 299-305.

Finney, J. M. T.

A personal appreciation of Sir William Osier. — J Chicago. 1921. Ixxvii. 2013-2019.

Acute intestinal obstruction. — Surg., Gyncc. <f Ohst. xxxii, 402-408.

Finney, J. M. T., and Friedenwald, J.

Pylorospasm in adults: its medical and surgical treatment. M. Sc, Phila., 1921, clxii, 469-481.

Finney, W. P., Jr.

Malignant timiors Surgeon, Wash., 1).


jlm. M. Ass., Chicago, 1921,


1917-1919.— Jfi(.


Fleurnoy, H.

Tin asile d'ali^n(^s an .Tnpon. Commuuic. au Congr^s des M4declns Ali^nistes de France. Strasbourg, Aoflt, 1921.

Flexner, S.

Biologic therapy. General considerations regarding serum and vaccine therapy.— 17. Am. M. Ass., Chicago, 1921. Ixxvi. 33-34. Biologic therapy. iv. Serum treatment of bacillary dysentery. — J. Am. M. Ass., Chicago. 1921. Ixxvi. 108-109.

Lethargic I encephalitis. History, pathologic and clinical features, and epidemiology in brief. — Stud. Rockefeller Inst. M. Research, N. Y., 1921, xxxvi, 119-131.


72


[No. 372


Flexner, S., and Amoss, H. L.

Experiments on the nasal route of infection in poliomyelitis. — Stud. Rockefeller Inst. U. Research, N. Y., 1921, xxxvl, 45-56.

Foley, F. E. B.

Clinical uses of salt solution in conditions of increased intracranial tension. — Surg., Oynee. d Ohst., Chicago, 1921. xxxiil, 126-136.

Fowler, H. A.

Tuberculosis of the kidney complicated bv impacted pelvic calculus. — J. Urol., Bait., 1921, v, 345-351.

Frontz, W. a.

A clinical and pathological study of contracted bladder. — J. Urol., Bait, 1921, V. 491-.^ill.

The more common causes of chronic urinary obstruction in male children. Tr. South. Med. Assoc, 1921, xv. Abstr. Jn: J. Am. M. .Iss , Chicago, 1921, Ixxvii, 1996.

Gaenslen, F. J.

The diagnosis and treatment of chronic lesions of the hip-joint. —

Minnesota Med., Saint Paul, 1921, iv, 630-635.

Sling suspension method of exercise in infantile paralysis. — Surg.,

Gynec. rf Ohst., Chicago, 1921. xxxii. 274-276.

Sacro-iliac joint arthrodesis by bone-splitting method. — Wisconsin

M. J., Milwaukee, 1921, xx, 20-22.

Gaenslen, F. J., and Schneider, C. C.

Treatment of tuberculosis of the ankle iu tlie adult. — J. -4m. M. Ass., Chicago. 1921, Ixxvii, 116.8-1171.

Gaenslen, F. J., and Thalheimer, W. M.

Congenital syphilitic epiphysitis in adolescence.Bost., 1921, ill, 8-17.

Gaither, E. H.

Interpretation of digestive symptomatology. Relative to change

in svmptoms and extrinsic factors. — J. Am. M. .-iss., Chicago, 1921,

Ixxvii, 1407-1410.

Chronic appendicitis. — South. M. J., Birmingham. .\la., 1921, xiv, 190 199.

Geraghtt, J. T.

Biologic therapy : II. Use of vaccines a

urethritis and its complications. — J. .4»i.

Ixxvi. 35.

Some general considerations regarding prostatectomy.-— .?o»(7i. M. J.,

Birmingham, Ala., 1921, xiv, 48-51.

Geraghty, J. T., Short, J. T., and Schanz, R. F.

Multiple renal calculi, unilateral and bilateral ; some observations. — T. Am. M. Ass.. Chicago, 1921. Ixxvii, 901-904.

GiFFIN, H. Z.

Present status of splenectomy as a therapeutic measure. — Minnesota Med., St. Paul. 1921. Iv, 132-13S.

GiFFiN, H. Z., and Szlapka, T. L.

The treatment of pernicious anemia by splenectomy ; second report. — J. Am. M. Ass., Chicago. 1921, Ixxvi. 290-295.

GiLMAN, P. K.

Amebic abscess of liver. — Calif. State J. M., San Fran., 1921. xix, 239. Acute suppurative thyroiditis. — Calif. State J. M., San Fran., 1921, xix. 294. Branchial cysts and fistulas. — J. Am. M. Ass., Chicago, 1921, Ixxvii,


~J. Orthop. Surg.,


20-28.

Cvsts and flstul.'e of the thyroglossal duct. Chicago, 1921, xxxii, 141-149.


-Surg., Gynec. & Ohst.,


ind treatment of cardiac disorders. — Tr. M. Ass.


VON Glahn, W. C., and Herman, N. B.

Carcinoma of the supra-ampullary portion of the duodenum.M. So., Phila., 1921. clxi, 111-119.

Goddard, C. H.

The recognition Alahatna, 1921.

Goetsch, E.

The diagnosis and treatment of hyperthyroidism. — .Y. To) 7; M. J.,

[etc.]. 1921. cxiii, 378-383.

Hyperthyroidism in pregnancy. — Ti. Y. State J. M., N. Y., 1921, xxl.

317-324.

Goodpasture, E. W.

Myocardial necrosis in hyperthyroidism. — J. Am. M. Ass , Chicago, 1921. Ixxvi. 1545-1551.

The infliience of thyroid products on the production of myocardial necrosis. — J. Eiper. M., Bait., 1921, xxxiv, 407-423.

Goodpasture, E. W., and Talbot, F. B.

Concerning the nature of "protozoan-like" cells in certain lesions of infancy. — Am: J. /)«. Child., Chicago, 1921, xxi, 415-425.

Greenhill, J. p.

.\ histological study of fetus and implantation site in a case of missed abortion. — .4«t. J. Ohst. tf Ounce, St. Louis. 1921. 11. 188-194, Tuberculous salpingitis. A clinical study of 200 cases. — Johns Hop kins Hasp. Rep., Bait, 1921, xxi, 97-156.

GUNDRUM, F. F.

Focal infection. — Calif. State J. M., San Fran., 1921. xix, 296.

"' ' exophthalmic goitre. — Calif. State J. M., San Fran.,

Guthrie, C. G.

A simple and accurate metabolism spirometer. Spirometer measurement of oxygen consumption bv the rebreathing method. — .Arch. Int. Med., Chicago, 1921, xxviii. 687-702.


GwYN, N. B.

The epidemiology and diagnosis of encephalitis lethargica. — Canad. U. Ass. J., Toronto, 1921, xi, 169-173.

H.\LSTED, W. S.

Ablation d'un an^vrysme de la premiere portion de I'art^re sousclavi^re gauche. — Lyon chirurg., 1921, xviii, 1-6.

Hanson, H.

Sanitary conditions in Peru. — Am. J. Pub. Health, N. Y.. 1921, xi, 13-10.

Harrop, G. a., Krogh, a., and von Liebermann, P.

studies on the physiology of capillaries. 11. The reactions to local stimuli of the blood-vessels In the skin and web of the frog. — J. J'hysiol, Cambridge, 1921, Iv, 412422.

Hastreiter, R. F.

Nitrous oxide oxygen, analgesia and anesthesia in obstetrics. — South. Calif. Fract., Los Angeles. 1921, xxxvl, 17-18.

Hazen, H. H.

The diagnosis of syphilis. — Am. J. Syph., St. Louis, 1921. v, 472-475. Public health activities in venereal disease control. — Am. J. Syph., St. Louis. 1921. V, 674-076.

Roentgen-ray treatment of cutaneous cancer. — J. Am. if. .4s«., Chicago, 1921, Ixxvi, 1222-1227.

Henderson, D. K.

War psychoses, the infective, exhaustive group. — Glasgow M. .J., 1921, xcvi, 321-336.

Hennington, C. W.

Abdominal incision. — X.


York State J. M., N. Y., 1921. xxi, 81 83.


Herman, N. B., and von Glahn, W. C.

Carcinoma of the supra-ampullnry portion of the duodenum. — .4m. -J. M. Sc, Phila.. 1921. clxi, 111-119.

Heuer, G. J.

Surgery of the thorax. — Jn: Surgery, its Principles & Practice. (Keen) Phila. & Loud., 1921, viii, 332-414.

Higgins, W. H.

Unusual relapse in typhoid fever. — Virginia M. Month., Richmond, 1921-22, xlviii, 347-348.

HiNMAN, F,

Multiple renal and ureteral stones in with results of ureteronephrectomy. — , Ixxvi. 237-238.

HiNMAN, F., and Gibson, T. E.

Squamous cell carcinoma of the bladder: a study of heterotopic epidermization. with a review of the literature and report of cases. — J. Urol, Bait., 1921, vi. 1-50.

HiRSCHPELDER, A. D.

Saligenin. a new non-toxic local anesthetic and its mercury derivative, a new antiseptic. — Miiincsota Med., St Paul, 1921, iv, 399-402.

Ejrschfelder, a. D., Hart, M. C, and Kucera, F. J.

Mercurv saligenin. a new antiseptic. — Proc. Soc. Eiper. Biol, rf Med., N. Y.. 1920-21, xviii. 77-79.

Hirschfelder, D., Hart, M. C., and Kucera, F. J.

Further studies on saligenin : its mercury derivative and allied compounds. ( Proceedings.) — J. Pharmacol, d Expcr. Therap., Bait., 1921. xvii. 325-326.

Hirschfelder, D., and Quigley, J. P.

The relation of substitution in the carbinol group to the pharmacological action of some phenyl carbinols (Proceedings). — ./. Pharmacol, d Eiper. Therap., Bait.. 1921, xvii, 326-327.

Hitzrot, J. M.

Fractures of the head and the neck of the radius. — .4m. J. Surg., X. Y.. 1921, XXXV. 100-109.

Hitzrot, J. M., and Murray, C. R.

The factors that influence the prognosis in fractures at the base of the radius. — .Am. J. Surg., N. Y., 1921, xxxv, 17-29.

Hitzrot, J. M., and Weeden, W. M.

The treatment of acute suppurative pleurisy. — .Ann. Surg., Phila., 1921. Ixxiii, 531-544.

Hohman, L. B.

Epidemic encephalitis (lethargic encephalitis) its, psychotic manifestations, with a report of twenty-three cases. — .Arch. Neurol, d Psjichiat., Chicago. 1921, vl. 295-333. .Also: [Abstr.] Maryland Psychiat. Q.. Bait. 1921, X, 73 77.

Holmes, J. B.

Recent progress in anatomy, physiology and pathology of childhood. — Am. J. Dis. Child., Chicago, 1921, xxil, 61 103.

Holmes, W. R.

The illness ', 1921. X, 628.


nd death of Napoleon.


Georgia, Atlanta


HosKiNS. R. G.

Some current trends in endocrinology. — .J. Am. i 1921. Ixxvii. 1459-1462.

The reaction to epinephrin administered by rectum. Ej-per. Therap., Bait.. 1921, xviii, 207-211.

HosKiNS, R. G., and Ebaugh, F. G.

A case of dystrophia adiposogenitalis.1921, V, 21-28.


.Ass., Chicago, '. Pharmacol, i


-Endocrinology, Glendnle, Cal.,


February, 1932]


73


Howard, C. P.

Obesity. — In: Oxford Med.. 1921. iv, 105-213.

Hemochromatosis. — In: Oxford Med., 1921. iv. 215-222.

Oclironosis — In: Oxford Med.. 1921, iv, 223-22S.

Riclsets. — In: Oxford Med., 1921, iv, 229-252.

Scun-y. — In: Oxford Med.. 1921, iv, 253-272.

Trentment of pneumonia with special reference to the use of serum. —

Canad. M. Ass. J., Toronto. 1921, xi, 709-713.

Howard, C. P., and Gibson, R. B.

A case of allsaptonuria with a study of its metabolism. — Arch. Int. Med., Chicago. 1921, xxviii, 632-637.

Howell, W. H.

Dr. Meltzer's influence on American physiology. — Proc. Soc. Exper.

Biol, d Med., N. Y.. 1920-21. xviii. 25-36. Memorial Number for S. J.

Meltzer.

Samuel James Meltzer. — Science, N. Y. & Lan(?aster, 1921, liii. 99-106.

Howland, J.

Prolonged intolerance to carbohydrates. (Proceedings.^ — Arch. Pediat.,

N. Y., 1921, xxxvlii, 393-396.

Measles.— y?i.- Oxford Med., 1921, v, 499-517.

Scarlet fever. — In: Oxford med., 1921. v. 519-546.

Rubella. — In: Oxford med., 1921, v, 547-551.

Howland, J., and Kramer, B.

Calcium and phosphorus in the serum in relation to riclicts. — Am. -1 . Dig. Child., Chicago, 1921, xxii, 105-119.

Howland, J., Kramer, B., and Tisdall, F. F.

Observations on infantile tetany. — Am. J. Dis. Child., Chicago, 1921, xsii, 431-437.

The clinical significance of calcium concentration in the serum of children and possible errors in its determination. — .Im. J. Dis. Child., Chic.igo. 1921. xxii, 560-564.

Howland, J., Tisd.^ll, F. F., and Kramer, B.

The concentration of sodium and potassium as compared with that of calcium and magnesium in the serum of patients with active infantile tetany. — Proc. Soc. Ed-per. Biol. & Med., N. Y.. 1921. xviii. 252-253.

HuGHSoN, W., and Weed, L. H.

The sliull as a closed box. (Proceedings.) Anat. Record, I'hila.. 1921, xxi, 8.S.

HUNNER, G. L.

Intractable blaSder symptoms due to ureteritis. — Tr. Am. Urol. Ass.,

1920. Bait., 1921, xii, 193-219.

Hunt, R.

Some factors relating to the toxic action of arsphenamin. — J. Am. U. Ass., Chicago, 1921, IxxVi. 854-S59.

HUKD, H. M.

The earlv days of the Training School for Nurses at the Johns Hopkins Hospital. — Johns Hopkins Nurses Alumnae Mag., Bait., 1921, XX. 63-71.

HURWITZ, S. H.

Some aspects of pernicious anemia and its treatment. — Calif. State J. M., Sin Fran.. 1921, six, 275.

Ingraham, C. B.

Imprcsssions gained from the use of radium during the past year. —

Colorado Med.. Denver. 1921. xviii. 72-75.

Vaginal cysts.^^/. Am. M. Ass., Chicago. 1921. Ixxvii. 14S7-14S9.

Jeidell, Helmina.

Active immunization against diphtheria. — Northwest Med., Seattle.

1921. XX. 89-92.

Josephs, H. W., and Davison, W. C.

The serotherapy of bacillary dysentery in children. — J. Am. if. Ass., Chicago, 1921. Ixxvii, 1863-1S64.

Keidel, a.

The treatment of neurosyphilis. — South. M. .7. , Birmingham, Ala., 1921. xiv, 595-601.

Keidel, A., and Moore, J. E.

Internal hydrocephalus in a syphilitic, probably due to Intraspinal treatment. — .im, J, M, Sc. Phila., 1921. elxii, 209-215. Stomatitis and aplastic anemia due to neoarsphenamin. — Arch, Dermatol, d Si/ph., Chicago. 1921. iv. 169-176.

Dermatitis and allied reactions following the arsenical treatment of syphilis. — .Arch. Int. Med., Chicago, 1921, xxvii. 716-747. Comparative results of colloidal mastic and colloidal gold tests. — Arch, Neurol, <C Psychiat,. Chicago. 1921. vi. 163-172. Studies in asymptomatic neurosyphilis. I. A tentative classification of early asymptomatic neurosyphilis. — Arch, Neurol, d Psychiat., Chicago. 1921. vi. 286-291.

Studies in familial npurnsyphilis. 1. Conjugal neurosyphilis. — J. Am, M, Ass,, Chicago. 1921. Ixxvii. 1-7.

Kelly, H. k,

Lafayette Houghton Bunnell. M. D.. discoverer of the Yosemlte. — Ann.' Med. Hist.. N, Y.. 1921. ill. 179-193.

Operation for renal calculi. — -V. Tor7.- Jlf. J,, Fete.]. 1921. cxiii. 1-3. Drainage in pelvic abdominal surger.v. — N. York M, J, [etc.], 1921, cxiv, .391-394.

The treatment with radium of cancer of the bladder. (Correspondence.) — Surg.. G:/nec. d Ohst.. Chicago. 1921. xxxii. 187. A diary of Robert Battev. M. D. — Thcrap. Gas.. Detroit. 1921, xlv, 612-62(5. .Also: J. Med. Ass. Georgia. Atlanta, 1921. x. 693-695. Uterine polyps. — Therap. Gas., Detroit, 1921, xlv, 761-767.

Kelly, H. A., and Frickb, R. E.

The use of pessaries. — Therap, Gaz,, Detroit, 1921, xlv, 5-9.


I's wealth. — ^Voman Citizen, N. Y-. A\igust,


M. Ass., Chicago, 1921.


-Arch. Int. Med,, Chicago, 1921,


Kbtron, L. W.

A note on the treatment of larva migrans. — Arch. Dermatol, d Syphil,, Chicago, 1921. iv, 368-369.

Kempp, E. J.

A minimum course in psychopathology for medical students. — Y. York M. J. [etc.], 1921, cxiii, 309-313.

Kempf, Helen C.

Child health, the natii 1921.

Kline, B. S.

Spirochetal pulmonary gangrene.Ixxvii, 1S74-1S77.

Kline, B. S., and Fishberg, M.

Spirochetal pulmonary gangrene.xxvii. 61-70.

Knox. J. H. M., Jr.

The health center, what it may mean to a community. (Proceedings.) — Arch. Pediat.. N. Y.. 1921. xxxviii. 451. The claim of the child. — Bambino. Columbus. Ohio. 1921. 10-11. Erysipelas in childhood. — South. M. /., Birmingham. Ala., 1921, xiv, 387 393.

Kramer, B., and Howland, J.

Calcium and phosphorus in the scrum in relation to ricliets. — .Im. J. Dis. Child., Chicago. 1921. xxii, 105-119.

Kramer, B., and Tisdall, F. F.

A clinical method for the quantitative determination of potassium in small amounts of serum. — J. Biol, Chem,, Bait.. 1921. xlvi, 339-349. Simple method for the direct quantitative determination of sodium in small amounts of serum. — J. Biol, Chem., Bait., 1921. xlvi, 467473.

A simple technique for the determination of calcium and magnesium in small amounts of serum. — J, Biol, Chem,, Bait, 1921. xlvii, 475481.

Methods for the direct quantitative determination of sodium, potassium, calcium, and magnesium in urine and stools. — J, Biol, Chem,, Bait, 1921, xlviii, 1-12.

The direct quantitative determination of sodium, potassium, calcium, and magnesium in small amounts of blood. — J, Biol. Chem,, Bait., 1921, xlviii, 223-232.

Kramer, B., Tisdall, F. F., and Howland, J.

Observations on infantile tetany. — Am, J, Dis, Child,, Chicago. 1921,

xxii, 431-437.

The clinical significance of calcium concentration in the serum of

children and possible errors in its determination. — Am. J, Dis. Child.,

Chicago, 1921, xxii. 560-564.

The concentration of sodium and pot.nssium as compared with that

of calcium and magnesium in the serum of patients with active

infantile tetany. — Proc, Soc, Exper. Biol, d Med,, N. Y.. 1921, xviii,

252-253.

Kratjse, a. K.

Tuberculosis : infection, patholo.gy. etiology and bacteriology. — In:

Nelson Loose-Leaf Med., Lond. & X. Y., [1921], i. 309-336.

Some problems of medical education in tuberculosis. — Am. Rev.

Tuhcrc, Bait., 1921-22. v. 755-768.

The tuberculosis problem. Some thoughts on its solution. — Am. Rei:

Tuberc, Bait.. 1921-22. v, 769-763.

Essays on tuberculosis, xx. Some phases of resistance. Part Iv.

Immunity. (Continued.) Immunization with living virulent bacilli:

Trudeau's work. — J, Outdoor Life, N. Y., 1921, xviii. 31-34; 48-49.

Essays on tuberculosis, xx. Some phases of resistance. Part It.

Immunity. (Continued.) Cattle immunization. — J, Outdoor Life,

N. Y.. 1921. xviii. 63-67. „ ^ ,

Essays on tuberculosis, xxi. Some phases of resistance. Part Iv.

(Immunity, concluded.) The nature of resistance: its determining

factors. — J. Outdoor Life, N. Y.. 1921. xviii. 247-252.

Essays on tuberculosis, xxii. Reinfection. — J, Outdoor Life, N. 1..

1921, xviii, 2~" """


The elementary pathology of tubcr1921. xviii. 305-312: 327. The pathology of tuberculosis: '. Outdoor Life, N. Y., 1921,


xvlil.


Essays on tuberculosis, xxiii.

culosis. — J, Outdoor Life, N. Y.

Essays on tuberculosis, xxiv,

spread throughout the body.—

34*^-347 35.8-359

Course of' tubercle bacillus from sputum to the child. — N, T. State J.

M.. N. Y., 1921. xxi, 83.

Enseignement de la tuberculose aux ftudiants. Mission AmSricaine

de preservation contre la Tuberculose (Fondatlon Rockefeller), Paris,

1921.

Tuberculin : its nature and its effects on tuberculous animals ; Its

.iction. Bureau of Correspondence and information. Texas State

Tuberculosis Sanatorium. 1920. Pamphlet No. 22. [1921.] 23 p. 8".

Leonard. V. JT.

A building designed to meet the requirements of group practice. — Mod. Hasp., St. Louis. 1921, xvii. 131 132.

Levy, R. L.

Advanced heart failure. General s.vmptoms. — In: Nelson Loose-Leaf Med.. 1921, iv, 285-300.

Restoration of the normal cardiac mechanism in auricular fibrillation by quinidin. Preliminary report. — -J, Am, M. Ass., Chicago, 1921, Ixxvi, 1289-1293.

Leyt, R. L., and Cohn, A. E.

Experimental studies of the pharmacology of quinidin. — Proc. Soc, Exper, Biol, d Med., N. Y.. 1920-21. xviii, 283-284.

Lewis, D. S., and Moff.att, C. F.

Standardization of certain preparations of digitalis. — Canad. M. Ass. J., Toronto. 1921, xi, 755-758.


74


[No. 372


Lewis, W. H., and Webster, L. T.

Migration of lymphocytes in plasma cultures of human lymph nodes. —

J. Exper. M., Bait. 1921. xxxiii. 261-269.

(Jiant cells in cultures from human lymph nodes. — J, Exper. M., Bait.,

1921. xxxiii. 349-360,

Wandering cells, endothelial cells, and fibroblasts in cultures from

human lymph nodes.—/. Exper. M., Bait.. 1921, xxxiv. 397-406.

LiNTHICUM, F. H.

Ozena and its relation to tuberculosis. — -4m. J. il. Sc, Phila.. 1921, clxii. 216-226.

LiSSER, H.

Does the pituitary .secretion iniiuence the development of the prostate? — -Y. York M. J., [etc.]. 1921. cxiii, 391-393.

Little, H. M.

The least common multiple in obstetrics. — .Iw, J. Obst. A Crynec, St. Louis. 1921, ii, 67-76.

LOWSLEY, 0. S.

The role of the prostate and seminal vesicles in arthritis. With a discussion of surgical and nonsurgical treatment. — N. York M. J., [etc.], 1921. cxiii, 641-646. -4(so.- Tr. Am. Urol. Ass., 1920, Halt., 1921. xii, lis.

A perineal operation for removal of stone in the lower end of the male ureter. — Surg., Oynec. d Obst., Chicago, 1921, xxxii, 300-306.

Lyman, D. R.

The limitations and possibilities in the federal care of tuberculous exservice patients. — Xat. Tuberc. Ass., Tr., N. Y., 1921, xvii.

M.icCallum. W, G.

The pathology of the pneumonia in the United States army camps durin;; the winter of 1917-18. — Johns Hopkins Hasp. Rep., Bait., 1921, XX. 1 147.

r;ithul(i;;ical anatomy of pneumonia associated with influenza, — Johns Hopkins Hasp. Rep., Bait., 1921, xx, 149-249,

MacCallum, W. G., and Moody, L. M.

Alastrim in Jamaica. — Am. J. Hyg., Bait,. 1921. i 388-409.

McCann, W. S.

Tho effect of the ingestion of foodstuffs on the respiratory exchange

in pulmonary tuberculosis. — Arch. Int. Med., Chicago, 1921, xxviii,

847-S5S.

Limitations of metabolism determinations in diagnosis. — Med. Clin. ^.

Am., Phila., 1921, iv, 1483.

McCrae, T.

Arthritis deformans. — In: Oxford Med., 1921, iv, 367-403. Pain in lower back. — Med. Clin. N. Am., Phila., 1921, iv, 973.

Macht, D. I.

On the absorption of local anesthetics through the genito-urinary organs. — J. Pharmacol. iC- Exper. Therap., Bait., 1920-21, xvi, 435-448, Pharmacological examination of cinnamein, benzvl succinate and benzyl nitrite. — Proc. Soc. Exper. Biol. & Med., N. Y., 1920-21, xviii, 177-179.

Macht, D. I., and Bloom, W.

Kxperimentnl inquiry into the cerebral and neuromuscular manifestatiiuis of digitalis. — .irch. Int. Med., Chicago. 1921, xxviii, 678-686. rhysiolugical and pharmacological studies of the prostate gland. III. ICffect of prostatectomy on the behavior of albino rats.— »/. Urol., Bait., 1921, y, 29-41,

A pharmacodynamic analysis of cocain action of the cerebrum. — Proc. Sop, Exper. Biol. <£ Med., N. Y., 1920-21, xviii, 81-82, Comparative study of ethanol. caffeine and nicotine on behavior of albino rats. — Proe. Soe. Exper. Biol. <f Med., N. Y",, 1920-21, xviii, 99-100,

The effect of prostatectomy on the behavior and learning of albino rats. — Proc. Soc. Exper. Biol. <{• Med.. N. Y.. 1920-21, xviii, 100-101. Comparative study of ethanol. caffeine and nicotine on the development of frogs' larvse, — Proc. Soc. Exper. Biol, d Med., N, Y,, 1920-21, xviii. 241-242.

Macht, D. I., and Ting, G. C.

Response to drugs of excised bronchi from nonual and diseased animals. — J. Pharmacol, d Exper. Therap., Bait., 1921, xviii, 111119.

Experimental inquiry into sedative properties of some aromatic drugs and fumes. — J. Pharmacol, d Exper. Therap., Bait,. 1921, xviii, 361. "' ' " -J. Pharmacol, d Exper.


Major, R. H.

The treatment of empyema Phila,, 1921, clxii, 397-406.


ith gentian violet,


J. M. Sc,


M.4RRI0TT, W. McK,

Ahnnrinal met.-ibolism in infancy and its relationship to symptomatology,— nnt, ./. Child. Dis., Lond,. 1921, xviii, 129-13.').

Marshall, H. W. ,

Scoliosis,— Bos/oii M. d S. J.. 1921, clxxxiv, 31-40. When to open knee-joints, — Boston M. d S. J., 1921. clxxxiv, 291-297, A case of myositis ossificans traumatica developing from torn coracoclavicular ligament without other bony fracture, — Boston M. d S. J. 1921. clxxxiv. 380-384. A questionnaire on sacro-iliac Joint lesions. — Boston M. d S. ./,, 1921.


-/. Ai.


M. Ax


Mason, C, C and Shohl, A. T.

Pood at the front lines, — Mil. Surgeon, Wash., 1921, xlviii. 386-401.

Maxwell, J. P.

Obstetrics and gynecology in South China. — China M. J.. Shanghai.


1921. XXXV. 146-1. Intestinal parasiti XXXV, 377-382.


South Fliki


-China M. J., Shanghai. 1921,


Mei-er, a.

The contributions of psychiatry to the understanding of life problems. — In: A Psychiatric Milestone. Bloomingdale Hospital Centenary 1821-1921. N. Y,, 1921, 21-54. [Privately printed.] The integrative function of a hospital laboratory. Retrospect and prospect. — State Hasp. Q.. Utica, N. Y., 1921, vi, 445-451. I'sychopathology. By E. J. Kemp. St. Louis, 1920, C. V. Mosby Co., 762 p, 8°. (Book review.) — Arch, fiearol. d Psychiat., Chicago, 1921, v. 7.'<2-790.

Medizin und Kecht. Die Beziehungen der Medizin zum Recht, die Kausalitiit in Medizin und Recht und die Aufgaben des gerichtlichmediziuischen Unterrichtes, von Prof. H. Zangger, Art. Institut Orell Fiissli. (Book review.) — ./. .4. Inst. , . . Criviinol., Chicago, 1921-22, xii, 457-458.

Miller, M. K.

Splenic anemia of infancy, with report of a case occurring in an infant at six weeks of age. — Arch. Pcdiat., N, i',, 1921. xxxviii. 11 17, Polyneuritic syndrome in young children. — J. Indiana M. Ass., Kort Wayne, 1921, xiv, 144-145.

Miller, M. K., and Lyon, M. W., Jr.

Case of meningitis in an infant due to a thread-like diphtheroid organism. — Am. J. M. Sc, Phila,, 1921, clxii, 593-598.

Mills, R. G.

Abstract of .Tapanese medical literature, — China M. ./,. Shanghai,

1921. XXXV, 67-78; 171-180.

Pathological specimens (Correspondence). — China M. J., Shanghai,

1921, XXXV, 185-186,

A preliminary study of post-operative catheterization. — CAina M. J.,

Shanghai, 1921, xxxv, 217-241.

A study of post-operative catheterization in Korea. — China M. J.,

Shanghai, 1921. xxxv, 310-331.

Ecological studies in the Tang-Mai River basin. North Korea, — Tr.

Korea Branch Royal Asiatic Soo., 1921, xii, part 1.

MiNOT, G. R.

Two curable cases of anemia. — Med. Clin. X. Am., Phila., 1921, iv. 1733-1750.

MiNOT, G. R., and Smith, L. W.

The blood in tetrachlorethane poisoning 1921, xxviii, 687-702.

MooRE, J, E.

The genesis of neurosyphilis. — Arch. Dermatol, if Ki/ph., Chicago. 1921, iv, 55-61.

The cerebrospinal fluid in treated syphilis. — ./. Am. M. Ass., Chicago, 1921, Ixxvi. 769-773.

Moore, J. E., and Keidel, A.

Internal hydrocephalus in a syphilitic, probably due to intraspinal

treatment. — Am. J. M. Sc, Phila.. 1921, clxii, 209-215.

.Stomatitis and aplastic anemia due to neo-arsphenamin. — Arch.

Dermatol, d Syph., Chicago. 1921, iv, 169-176.

Dermatitis and allied reactions following the arsenical treatment of

syphilis, — Arch. Int. Med., Chicago, 1921, xxyii, 716-747.

Comparative results of colloidal mastic and colloidal gold tests. —

Arch. Xeiirul. ,1 I'siirhint., Chicago. 1921, vi, 163-172,

Studies in ;(s,\ iiiiiIorn;itic neurosyphilis. I. A tentative classification

of early asviiiptunuitic neurosyphilis. — .\rch. Neurol, d Psychiat.,

Chicago, 1921, vi, 286-291.

Studies in familial neurosyphilis. 1. Conjugal neurosyphilis. — J. Am.

M. Ass., Chicago, 1921, Ixxvii, 1-7.

Morris, R. S.

Some difficulties in the diagnosis of empyema complicating pneumonia.—,/. Am. M. Ass.. Chicago, 1921, Ixxvi. 1336-1337. A simple and inexpensive apparatus for diagnostic or therapeutic punctures,—^. Am. M. Ass., Chicago, 1921, Ixxvii, 286.

Mosenthal, H. O.

Diabetes mellitus. A system of diets. With list of diets in pad form 150 sheets in a pad). — N. Y., 1921, P. B. Hoeher. The clinicnl value of basal metabolism determinations in diseases of the thyroid glands. — .V. York M. J., [etc.], 1921, cxiv, 41-43.

Mosenthal. H. O., and Marks, H. E.

The clinical value of basal metabolism. 1921. iv. 1403.


-.\rch. Int. Med., Chicago,


-Med. Clin. X. Am., Phila..


Nixon, P. I.

Congenital hypertrophic pyloric stenosis in infants. — Med. Rec, N. Y., 1921. xcix, 433-435,

Acute dilatation of the stomach following g.ynecological operations. — Texas State J. M., Fort Worth, 1921, xvi, 4S1-483,

Norms, C. C.

Gynecological and obstetrical tuberculosis. — X. Y'.. J921. D. Apple

ton & Co. 348 p. S'.

Ovar.v containing endometrium, — Am. J. Obst. d Gynec, St. Louis,

1920-21, i. 831-834.

The treatment of gonorrhoea in the lower genito-urinary tract in

women. — Surg., Oyncc. d Obst.. Chicago. 1921, xxxiii. 308-311,


& Lond., 1921, D. Appleton & Am. M. Ass ,


Novak, E.

Menstruation and its disorders.—

Co., 357 p, S-,

Acute postoperative dilatation of the stomach. Chicago. 1921. Ixxvii. 81-88.

[The interpretation and clinical significance of uterine haemorrhage.] — .

Med. Weikbl.. Amst., 1921, xxvii. 563-573,

Nuttall. G. H, F., and Keilin. D.

On the nephrocytes of Pedicuhis hii 1921, xiii, 184192.


-Parasitology, Cambridge.


Opie, E. L., Rivers, T. M. [et a!.]

Epidemic respiratory diseases. The pneumon of the respiratory tract acc<inin.'inying inllu Louis, 1921, C. V. Mosby Co.. 402 p. 8\


February, 1922]


75


Oliver, J. R.

The results of the application of laboratory methods to the study

of delinquency. Read at Ann. Cong. Am. Prison Assoc, Columbus,

Ohio. — Proc. Am. Prison Assoc. 1921.

Emotional states and illegal acts in connection with schizophrenia. —

Proc. Am. Psychiat. Assoc, 1921.

The causes and cures of crime. Bv Thomas S. Mosby. St. Louis.

1913, C. V. Mosby Co., 354 p. 8°. — Ment. Uyg., N. Y., 1921, v, 873 Modern criminal procedure in Switzerland. By Prof. Hafter, of Zurich. [Transl. and comments.] — J. Am. Inst. . , . Crimmol., Chicago, 1921-22, xii.

P.^LMER, W. W.

•Metabolism. (Survey of literature from Sept. 1. 1920. to March 1, 1921.) — In: Nelson Loose-Leaf Med., Lond. & N. Y., 1921, iii, 36. Diabetes insifiidus. (Survey of literature from Sept. 1, 1920, to March 1. 1921.) — In: Nelson Loose-Leaf Med., Lond. & N. Y., 1921. iii, 54-55.

Palmer, W. W., Atchley, D. W., and Loeb, R. F.

Studies on the regulation of osmotic pressure. I. The effect of increasing concentrations of gelatin on the conductivity of sodium chloride solution. — J. Gen. Physiol., Bait., 1921, iii, 801-806.

P.-iLMER, W. W., and Jackson, H., Jh.

A modification of Folin's uric acid method. — Proc. Soc. Exper. Biol, d Med., N. Y., 1920-21, xviii. 126-127.

P.\LMER, W. W., and Ladd, W. S.

The carbohydrate fat ratio in relation to the production- of ketone bodies in diabetes mellitus. — Proc. Soc. Exper. Biol. <l Med., N. Y., 1920-21. xvili, 109-110.

Parfitt, C. D.

Summary of report. Board of Tuberculosis Consultants. Dept. Soldiers' Civil Re-Establishment. — Ottawa. Canada, 1921, 21 p. 8°. Experiences in classification of sanatoria. — Nat. Tiiherc. Ass., Tr., N. Y.. 1921. xvii.

Extensive rib resection in the treatment of pulmonary tuberculosis. Report of 4 cases. — Tr. Am. Climat. & Clin. Ass., Phila., 1921, xxxvii.

Park, E. A., McCollum, E. V., Simmonds, Nina, and Shipley, P. G. studies on experimental rickets. IV. Cod-liver oil as contrasted with butter fat in the protection against the effects of insufficient calcium in the diet. — Proc Soc. Exper. Biol. <£ Med., N. Y., 192()-21, xvili, 275-277.

Park, E. A., Shipley, P. G., McCollum, E. V., and Simmonds, Nina. Studies on experimental rickets. V. The production of rickets by means of a diet faulty in only two respects. — Proc. Soc Exper. Biol, li Med., N. Y., 1920-21, xviii, 277-280.

Park, E. A., McCollum, E. V., Simmonds, Nina, and Shipley, P. G. Studies on experimental rickets. VI. The effects on growing rats of diets deficient in calcium. — Am. J. Hyg., Bait.. 1921, i, 492-511.

P.\RK, E. A., Shipley, P. G., McCollum, E. V., and Simmonds, Nina. Studies on experimental rickets. VII. The relative effectiveness of cod-liver oil as contrasted with butter fat protecting the body against insufficient calcium in the presence of a normal phosphorus supply. — Am. J. Hyg., Bait., 1921, i, 512-525.

Paton, S.

Human behavior, in relation to the study of educational, social, and ethical problems. N. Y., 1921, C. Scribner's Sons. 465 p. 8".

Peabody, F. W.

Acute poliomyelitis. — In: Oxford Med., 1921, v, 107-123.

A report of the Harvard Infantile Paralysis Commission on the

diagnosis of acute cases in 1920 ; with special reference to the

incidence of cases without paralysis. — Boston M. if- S. J., 1921, clxxxv,

174-176.

The vital capacity of the lungs in heart disease. — Med. Clin. N. Am.,

Phila., 1921, iv, 1655-1671.

Peabody, F. W., and Sturgis, C. C.

Clinical studies of the respiration, vii. The effect of general weakness and fatigue on the vital capacity of the lungs. — Arch. Int. Med., Chicago. 1921, xxviii. 501-510.

Peabody, F. W., Stukgis, C. C, Tompkins, E. M., and We.^rn, J. T. Epinephrin hypersensitiveness and its relation to hyperthyroidism. — Am.. J. M. Sc, Phila., 1921, clxi, 508-517.

Peabce, Louise.

Studies on the treatment of human trypanosomiasis with tryparsamide (the sodium salt of N-phenylglycineamide-p-arsonic acid). — V. Exper. M., Bait.. 1921. xxxiv, 1-104. (Suppl. No. 1.)

Pearce, Louise, and Brown, W. H.

Latent infections with the demonstration of Spirochete pallida in lymphoid tissues of the rabbit. — Am. J. Syph., St. Louis, 1921, v. 1-8. Experimental production of clinical types of syphilis in the rabbit — • Arch. Dermatol, d Syph., Chicago. 1921. n. s., iii. 254-262. The defensive reactions of animals infected with Spirochaeta pallida — J. Am. M. Ass., Chicago, 1921, Ixxvii, 1619-1620.

Therapeutic action of N-phenylglycineamide-p-arsonic acid (tryparsamide) upon experimental infections of Trypanosoma rhodesiense — J. Exper. M., Bait.. 1921. xxxiii. 193-200.

Superinfection in experimental syphilis following the administration of subcurative doses of arsphenamine or neoarsphenamine.^-r/. Exper M., Bait. 1921, xxxiii, 553-567.

Experimental syphilis in the rabbit. VII. Affections of the eyes — J. Exper. Med., Bait.. 1921. xxxiv, 167-183.

Note on the preservation of the stock strains of Treponema pallidum and on the demonstration of infection in rabbits.— i/. Exper. Med Bait., 1921. xxxiv, 185-188.

The penetration of normal mucous membranes of the rabbit by Treponema pallidum. — Proc. Soc. Exper. Biol, d Med., N. Y., 1920-21 XTlii, 200-201.


Neoplasia in experimental syphilis. — Proc. Soc Exper. Biol. & Med .

N. Y., 1020-21, xviii, 201-202.

Superinoculation experiments with Treponema pallidum. — Proc. Soc.

Exper. Biol, d Med.. N. Y.. 1920-21, xviii. 255-257.

Multiple infections with Treponema pallidum in the rabbit. — Proc

Soc. Exper. Biol, d Med., N. Y., 1920-21, xviii, 258-261.

Pe.«ce, Louise, Brown, W. H., and Witherbee, W. D.

Experimental syphilis in the rabbit. VI. Affections of bone, cartilage, tendons, and synovial membranes. 1. Lesions of the skeletal system 2. Clinical aspects of syphilis of the skeletal system. Affections of the facial and cranial bones and the bones of the foreaim. 3. Syphilis of the posterior extremities with other affections of a miscellaneous type.— ^. Exper. M., Bait., 1921, xxxiii, 495-514 ; 515-524 ; 525-538.

Pearl, R.

The significance of biometry and vital statistics to the science of medicine. — In: Nelson Loose-Leaf Med., Lond. & N. Y., 1921, vii, 111 The biology of death : I. The problem. II. Conditions of cellular immortality. HI. The chances of death. IV. The cause of death V. The inheritance of the duration of life in man. VI. Experimental studies on the duration of life. VII. Natural death, public health, and the population problem. — Seient. Month., N. 1'., 1921, xii, 193-214 : 321-335 ; 443-456 : 489-516. xiii, 46-66 ; 144-164 ; 193-213. Influenza studies : II. Further data on the correlation of explosiveness of outbreak of the 1918 epidemic. III. On the correlation of destructiveness of the 1918 epidemic. IV. On the correlation between explosiveness and total destructiveness of the epidemic mortality. — Pub. Health Ren., Wash., 1921. xxxvi. 273-298.

A further note on war and population. — Science, N. Y. & Lancaster, 1921. liii, 120-121.

Variation in the rate of infant mortality in the United States birth rcRistration area. — Tr. Am. Child Hug. Ass., Bait, 1921, xi, 213-229. Biometric data on infant mortality in the United States birth registration area. 1915-1918. — Am. J. Hyg., Bait, 1921. i, 419-439. A biological classification of the causes of death. — Metron, Rovigo,

Pearl, IL., and Fairchild, T. E.

Studies on the physiology of reproduction in the domestic fowl. XIX. On the infiuence of free choice of food materials on winter egg production and body weight — Am. J. Hyg., Bait., 1921, i, 253-277.

Pe.^rl, R., and Kelly, F. C.

Forecasting the growth of nations. The future population of the world and its problems. — Harper's Mag., N. Y., 1921, cxlii, 704-713.

Pearl, R., and Schoppe, W. F.

Studies on the physiology of reproduction in the domestic fowl, xviii. Further observations on the anatomical basis of fecundity. — J. Exper. Zool, Phila.. 1921, xxxiv, 101-118.

Peters, L.

Report of a case of large meningocele producing dystocia, delivery by Porro operation. — .Im. J. Obst. d Oynec, St. Louis, 1921, ii, 636-639.

PiNCOFFS, M. C, and Boggs, T. R.

Diseases of the peritoneum. — In: Oxford Med., 1921, iii, 517-581.

VON PiRQUET, C.

Children's diet. (Correspondence.) — Lancet, Lond., 1921. i. 558. Der Begriff • Aequum." — Zt.'ichr. ). Kiuderh., Berl., 1921, xxx, 14-5 Plaggemeyer, H. W.

The medical aspect of prostatic surgery. — Grace Hoxp. Bull, Detroit 1921, V, 1-7.

Post, L. T.

A study of the etiology of periodic ophthalmia in horses. — Am J. Ophth., Chicago, 1921, s. 3, iv, 330-333.

Quantitative determination of cocain and atropin absorption by aqueous humor. — J. Am. M. Ass., Chicago, 1921, Ixxvii, 1323-1324.

Post, L. T., and Shahan, W. E.

Thermophore studies in glaucoma. — Am. J. Ophth., Chicago, 1921, s. 3. iv, 109-118.

Putnam, Mary.

A survey of the rural children of western Massachusetts — Com monwealth, Bost., 1921, vii. No. 6.

Putnam, T. J., and Wislocki, G. B.

Absorption from ventricles in experimentally produced internal hydrocephalus. — Am. J. Anat., Phila., 1921, xxix, 313.

QUINBY, W. C.

The transperitoneal approach to the kidney ; its indications and limitations. — J. Vrol, Bait., 1921, vi. 135-143.

The pathology of the renal pelvis in two cases showing hematuria of the so-called essential type. — Tr. Am. Urol. Ass., 1920, Bait 1921 xii, 234-241. *

Randall, A.

Congenital yalves of the posterior urethra. — Am. Surg.. Phila 1921

Ixxiii. 477-480.

Report of a vesical calculus weighing four pounds. — Tr. Am Vrol

Ass., 1920. Bait.. 1921, xii. 53-50.

Giant vesical calculus — J. Vrol., Bait, 1921, v. 119-125.

The varying types of prostatic obstruction. — J. Vrol., Bait., 1921,

Randall, A., and Moorhead, S. W.

Sterilizer for cystoscopes. — J. Urol., Bait., 1921, v, 265-266.

Randall, A., Small, J. C, and Belk, W. P.

Tropical inguinal granuloma in the Eastern United States. — J. Vrol.. Bait., 1921, V, 539-548.


76


[No. 3:3


Reichert, F. L.

On the fate of the primary lymph-sacs in the abdominal region of th-^ pig. and the devolpment of lymph-channels in the abdominal and pelvic regions. — Contrib. EmbriioL, Xo. 08, (Carnegie Inst. I. Wash., 191>1. xiii, 17-39.

Reid, M. R.

Drainage of the choledochostomy


ommon bile duct through the cystic duct : -.ijin. ^iirg., Phila., 1921, Ixxiii, 458-409.


histamine shock. — ./. Expcr. M., Bait.,


Reynolds, L., and McClure, C. W .

Observations on the behavior of the normal pyloric sphincter in man. — Am. J. Ilocntyenol.j Detroit, 1921. viii, 158-162.

Reynolds, L., McClure, C. W., and Wetmore, A. S.

New methods for estimating enzymatic activities of duodenal contents of normal man. — Arch. Int. Med., Chicago, 1921, xxvii, 706-715.

Rich, A. R.

Condition of the cipillaries 1921. .\x.xiii, 287-298.

Richards, Esther L.

Mental nursing. — Johns Hopkins y,urses' Alumnae Mag., Bait.,

.XX, 1211-125.

The role of situation in psychopathologieal conditions. — Ment.

X. v.. 1921, V, 449-467.

The elementary school and the individual child. — Ment. Hug.,

1921, V, 707-723.

RiGGS, T. F.

The Plnney pyloroplasty.


-Journid-F.ancet, Minneapolis, 1921, xli.


Am. M. Asx., Chicago,


Exper. M., Bait.,


Rivers, T. M.

(irowth of influenza bacilli without blood. 1921, Ixxvi, 1744-1745.

Rivers, T. M., and Kohn, L. A.

The biological and the serological reactions of influenza bacilli producing meningitis. — J. Erper. M., Bait,. 1921, xxxiv, 477-494.

Rivers, T. M., Opie, E. L. [el all

Epidemic respiratory diseases. The pneumonias and other infections of the respiratory tract accompanying influenza and measles. — St. Louis, 1921, C. V. Mosby Co., 402 p. 8°.

Robinson, G. C.

Special symptoms of chronic diseases of the heart. Valvular disease. — In: Xelson Loose-Leaf Med., Lond. & N. Y., 1921, iv, 359-381.

Robinson, G. C., and Herm.^nn, G. R.

Paroxysmal tachycardia of ventricular origin, and its relation to coronary' occlusion. — Heart, Lond., 1921-22. viii. 59-81.

Rosen, R.

The phvsiopathology of the verumontanum. — I'rol. iC- Cutan. Rev., St. I>ouis, 1921, XXV, 26-30.

Rots. P.. and L.wimore, Louise D.

ICt'liitiun of the portal hltnul to liver maintenance. A demonstration of li\t'r atro|ihv louditional on compensation. — Stud. liockefeUer Inst. M. Uencarch, X". Y.. 1921. xxxvi, 157-182.

Rous, P., and McMaster, P. D.

The concentrating activity of the gall-hladder. 1921. xxxiv, 47-73.

Physiological causes for the varied character of stasis bile. — ./. Exper.

.If.," Bait., 1921, xxxiv. 75-96.

Rous, P., Wilson, G. W., and Olfver, Jean.

Experiments on the production of specific antisera for infections of unknown cause. III. The effects of a serum precipitin on animals of the species furnishing the precipitinogen. — Stud. Rockefeller Inst. M. Research, N. Y., 1921, xxxvi, 99-111.

Rqwntree, L. G.

Diabetes insipidus. — In:- Oxford Med., 1921. iv. 179-193. The differenfi.il diaenosis of polyuria, with special reference to diabetes iii-iphiiis — Uirf. r(iM. N. Am.. Phila., 1921, v. 439-453. The rAle :i[p1 .1. \ ri.,|iment of drug therapy. — J. Am. M. Ass., Chicago, 1921, Ixxvii. liiiil 1065.

The spirit of iuvisiigation in medicine. — Science. X. Y. & I^ancaster. 1921, liv, 179 1S3.

Sampson, J. A.

Perforating hemorrhagic (chocolate) cysts of the ovary. Their importance and especially their relation to pelvic adenomas of endometrial type (' adenomyoma " of the uterus, rectovaginal septum, sigmoid, etc.) — .4rc/i. Surg., Chicago. 1921, iii, 245-323.

S.^NGER, B. J.

The glucose mobilization rate in hyperthyroidism.Biol. d Med., X. Y.. 1921, xviii, 117-120.

SCHLAEPFER, K. I'eber einen w Tiibing.. 1921. T'eher tildli. "


-Proc. Soc. ETper.


'iteren Fall von Gallensteinileus. — Bcitr. ;. kiln. Chir..

oxxi. 122-135.

N'ar-hhlntuntren nach Tracheotomie bei Larvnxdiphtherie. — Hcitr. - l.-liH chir liiliiii;.'.. 11121. cxxi. 212-227. l>ie inTr.ipl' iir:it.!i i;i il. \.' inni ihre Bedeutung bei operativen Eingriffen.- i:r<i,i,„. ,1 (),,,• „, (irth;p.. Berl., 1921, xiv. 797-905. I'eber die r.( li iii^Miiii^ d.r .Vuallistcl and der Hiimorrhoiden. (Beobachtunt;en :iiii si M nkSpital in London). — Med. Klin., Berl. & Wien. 1921. xvii. i_--7 Ii's'.i Reiseeindriicki' > in*1920.) Briete aii-^ 1 11, 281-285 ; 302-306.

Seem, R. B.

Relation of the dispensarv to the Hospitjil.1921, xvi, 78-79.


-Mod. Hasp., St. Louis,


Sellards, a. W.

Bacillary dysentery. In: Oxford Med.. 1921. iv, 767-782. Amebiasis. — In: O.xford med., 1921, v, 7U9-816.

Asiatic cholera. Survey of literature from Sept. 1, 1920, to March 1. 1921. — In: Xelson Loose-Leaf Med., Lond. & X. Y., 1921, ii, 104-105.

Sellards, A. W., and Bigelow, G. H.

Investigation of the virus of measles. — J. Med. Research, Bost.. 1921, xlli. 241-259.

Sexton, L. A.

A new in and out registering device for the attending staff. — Mod. Hasp., St. Ijouis, 1921, xvi, 552-553.

Selecting the personnel for the social service department, — Mod. Hasp., St. Louis, 1921. xvii, 43-44.

Sharps, W.

The pathology and treatment of chronic brain injuries, with and

without a fracture of the skull. — Am. J. Surg-, X. Y., 1921, xxxv,

147-152.

Observations regarding the diagnosis and treatment of brain tumors. —

Internat. Clin., Phila., 1921, 31. s., 11, 227-240.

Observations regarding the surgical treatment of selected cases of

purulent meningitis. — Med. Rec, X. ?., 1921. c, 709-713.

Medical impressions of South America. — Med. Rec., X. Y., 1921, c,

1002-1065.

Shaw, H. N.

A short account of the deaths occurring in the gynecologic service of the .Tohns Hopkins Hospital during the year 1919. — Arch. Surg.. Chicago, 1921, ii, 535-541.

Shipley, A. M.

A consideration of one hundred and ninety chest injuries. — Am. J. Surg., X. Y., 1921, xxxv, 221-223.

Shipley, P. G., McCollum, E. V., Simmonds, Nina, and P.^rk, E. A. Studies on experimental rickets. IV. Cod-liver oil as contrasted with butter fat in the protection against the effects of insufficient calcium in the_diet. — Proc. Soc. Exper. Biol. <£ Med., X. Y., 1920-21, xviii,

Shipley, P. G., Park E. A., McCollum, E. V., and Simmonds, Nina. Studies on experimental rickets. V. The production of rickets by means of a diet faulty in only two respects. — Proc. Soc. Exper. Biol, d Med., N. Y., 1920-21, xviii, 277-280.

Shipley, P. G., McCollum, E. V., Simmons, Nina, and Park, E. A. studies in experimental rickets. VI. The effects on growing rats of diets deficient in calcium. — Am. J. Hyg., Bait., 1921, i. 492-511.

Shipley, P. G., Park, E. A., McCollum, E. V., and Simmonds. Nina. .studies on experimental rickets. VII- The relative effectiveness of co<l liver oil as contrasted with butter fat protecting the body against ins\itBcient calcium in the presence of a normal phosphorus supply. — Am. J. Hyg., Bait., 1921, i, 512-525.

Shohl, a. T., and Mason, C. C.

Food at the front lines. — Mil. Surgeon, Wash., 1921. xlviii, 386-401.

SlEWERS, A. B.

Eye signs in intracranial tumors of the anterior fossa. With report of two cases. — Arch, yeurol. it- Psychiat., Chicago, 1921, vl, 424-428.

Simon, C. E.

Glardia enterica : a parasitic intestinal flagellate of man. — Am. J. Hyg., Bait., 1921. i, 440-491.

SissoN, W. R., and Denis, W.

Studies on the" inorganic constituents of milk.Chicago. 1921, xxi, 389-400.

Slack, H. R.

Diseases of the tonsils, pharynx and nasopharynx. (Survey of literature from Sept. 1. 1920, to March 1. 1921.) — In: Xelson Loose-Leaf Med., 1921, ii, 18-19.

Slemons, J. M.

The prospective mother. A handbook during pregnancy. 2d. ed. NewYork, 1921. D. Appleton & Co., 343 p. 12'.

Smith, W. H.

Address to the graduating class. Training School for Nurses. Peter Bent Brigham Hospital. — Boston M. d S. J., 1921, elxxxiv, 367-371, Adequate medical service for a communitv. Some factors of importance. — J. Am. M. Ass., Chicago, 1921. Ixxvi. 1053-1062.

Steiner, W. R.

Diseases of the muscles. — In: l).xford Med.. 1921. iv. ^53-366.

Stevens, R.

A procedure for the cure of prostatic abscess. — Tr. Am. t'rol. Ass.. 1920, Bait., 1921, xii, 19-24.

Stone, H, B.

The toxic agents developeil tion, and their action. — Su, 415-419.

Strong, R. P.

Tren<* fever. — In: Oxford Med., 1921. v, 423. 437.

Remarks made at the closing session of the Inter-Allied Sanitary Commission. Paris. — Boston M. d 8. J.. 1921. elxxxiv. 27-31. International public health problems. — Xorth Am. Rev., Concord N. II., 1921, ccxiii, 319-332.

Strong, R. P., and Councilman, W. T.

Plague-like infections in rodents. — Tr. Ass. Am. Physicians, 1921,


J. Dis. Child.,


i


February, 1932]


77


Strouse, S.

Dietetic therapeutics. — Med. Clin. X. Am., Phila., 1921, v, 229-244.

SwARTZ, E. O., and Davis, D. M.

Action of mercurochrome — 220 on tlie gonococcus. — J. Am. M. Ass.,

Ciiicago, 1921, l-xxvi, S44-840.

The action on the gonococcus of variotis drugs commonly used in the

prophylaxis and treatment of gonorrhea. — J. Urol., Bait., 1921, v,

235-253.

SwARTZ, E. O., Young, H. H., and White, E. G.

Further clinical studies on the use of mercurochrome — as a general germicide.—./. Urol., Bait.. 1921. v, 353-388.

Taylor, A. S.

The use of fine silii in surgery. — China J/. J.. Shanghai, 1921. xxxv, 4C7-472.

Thomas, H. M., Jr.

Recurrent type 1 pneumonia : serum treatment of t\yo attaclis one month apart. — .im. J. M. Sc, Phila.. 1921, clxi. 103-109.

TiBBETTS, M. H.

Some essential points in the treatment of infantile paralysis. — Minnesota Med., St. Paul, 1921. iy, 484-487.

TiSDALL, F. F., and Kramer, B.

A clinical method for the quantitative determination of potassium in small amounts of senim. — ./. liiol. Chem., Bait.. 1921. xlvi, 339-349. Simple method for the direct quantitative detennination of sodium in small amounts of serum. — ,/. Biol. Chcm., Bait.. 1921. xlvi, 467-473. A simple technique for the determination of calcium and magnesium in small amounts of serum. — /. Biol. Chem., Bait., 1921, xlvii, 475481.

Methods for the direct quantitative determination of sodium, potassium, calcium, and magnesium in urine and stools. — ./. Biol. Chem.. Bait., 1921, xlviii. 1-12.

The direct quantitative determination of sodium, potassium, calcium, and magnesium in small amounts of blood. — ./. Biol. Chem., Bait., 1921. xlviii, 223-232.

Tisdall, F. F., Kramer, B., and Howland, J.

Observations on infantile tetany. — Am. J. Dis. Child., Chicago, 1921,

xxii, 431-437.

The clinical significance of calcium concentration in the serum of

children and possible lurors in its determination. — Am. J. Dis. Child.,

Chicago, 1921, xxii, 5(')0-564.

The concentration of sodium and potassium as compared with that of

calcium and magnesium in the serum of patients with active Infantile

tetany. — Proc. Soc. Exper. Biol, d Med., N. T., 1921, xyiii, 252-253.

Trueblood, D. V.

Fracture of the carpal scaphoid.279.


-Northwest Med., Seattle, xx, 27


VanderHoop, D.

The significance of vertigo. — South. M. J., Birming., Ala., 1921, xiv,

182-186.

The electrocardiograph in diagnosis. — Tirginia M. Month., Richmond,

1921, xlviii, 212-214. Also: South. If. d 8., Chattanooga, 1921,

Ixxxiii, 428-430.

VoEGTLiN, C, Hooper, C. W., and Johnson, J. M.

Trinitrotoluene poisoning, its nature, diagnosis, and prevention. — J. Indust. Hi/g., Boston. 1921-22, ill. 239-254 ; 280-292.

VoEGTLiN, C, and Smith, H. W.

Quantitative studirs in rh.'motherapy. IV. The relative therapeutic value of arsiihinaniiiir .nid ni'o.-irsphen.-imine of different manuf.acture.— ./. PhurnuunI ,i ;/;„•)•. Thrrnp.. Bait.. 1920-21. xvi. 449-461. Quantitative stiidi'-s in chemotherapy. V. Intravenous versus intramuscular administration of arsphenamin ; curative power and minimum effective dose. — J. Pharmaeol. <C E.Tper, Therap., Bait., 1921, xvii, 357.

VoEGTLiN, C, Smith, M. I., and Johnson, J. M.

Therapeutic value of chaulmoogra oil and its derivatives in experimental tuberculosis. — J. Am. M. Ass., Chicago. 1921, Ixxvii, 10171020.

Walker, G.

Symphysiotomy as an aid to the removal of cancer of the prostate. A proposed new operation. — .Ijm. Surg., Phila.. 1921, Ixxiii, 609. The secretory pressure of the kidney as an index of pathologic conditions (Preliminary report). Ann. Surg., Phila., 1921, Ixxiii, 610612.

Apparatus to aid in differentiation between an obstruction in the urinary outlet and paralysis of the bladder. — J. Am. M. Ass., Chicago. 1921, Ixxvii, 2S6-2S7.

A proposed standard treatment of early syphilis. — South. M. J., Birmingham, Ala., 1921. xiv, 683-684.

W.\RFIELD, L. M.

Clinic of Louis M. Warfleld, M. D., Milwaukee Hospital. — Wisconsin

M. ./.. Milwaukee, 1920-21, xix. .541-545.

The use of stimulants in pneumonia. — Wisconsin il/. ./., Milwaukee,

1921-22, XX, 1-4.

Clinic of Dr. L. M. Warfleld at Milwaukee County Hospital. — TFis consin M. J., Milwaukee, 1921-22, xx, 242-244.

Waters, C. A., and Baetjer, F. H.

Injuries and diseases of the bones and joints : their differential diagnosis by means of the Roentgen rays. N. Y.. 1921, P. B. Hoeber. 349 p. 4".

Waters, C. A., and Young, H. H.

Pyelography. — Soc. Internat. d'Urologie, I'aris, Juillet, 5-7, 1921.


Watkins, S. S.

Indications for removal of the laucial tonsils. — Kentucky M. J., Louisvill... 19i'l, xix, 65-67.

Fift^-^tIlt jiii-ci- in the esophagus for three months, removal through moutli.- -/nH(»r;,-i/ M. J., Louisville, 1921, xix, 523-524. .Symiitonis, diasnosis and treatment of inflammatory lesions of the nasal accessory sinuses — from the viewpoint of the general physician and surgeon. — Kentucky M. J., Louisville. 1921. xix. 682-688. Primary scleroma of the larynx in a negro born in Maryland — Surg., Uynec. if Obst., Chicago, 1921, xxxiii, 47-52.

Watts, S. H.

Traumatic chylothorax.— .4hh. Snrg., Phila., 1921, Ixxiv, 691-696.

Webster, L. T.

Lymphosarcoma. Lymphatic leukaemia. Leucosarcoma. Hodgkin's disease. — Johns Hopkins Hasp. Rep., Bait., 1921, xx, 251-314,

Webster, L. T., and Lewis, W. H.

Migration of lymphocytes in plasma cultures of human lymph nodes. —

./. Exper. M., Bait., 1921. xxxiii, 261-269.

(Mant cells in cultures from human lymph nodes. — J. Exper. M., Bait.,

1921, xxxiii, 349-360.

\Vandcring cells, endothelial cells, and fibroblasts in cultures from

human lymph nodes. — J. Exper. M., Bait., 1921, xxxiv, 397-406.

Weed, L. H., and Hughson, W.

The skull as a closed box (Proceedings). — Anrit. Record. Phila., 1921, xxi, 88,

Welch, W. H.

Introduction [to American Jour, of Hygiene], 1921, i, pp, iii-iv.

The place of Dr. Meltzer in American medicine. — Proc. Soc. Exper.

Biol. <£- Med., N. Y., 1920-21, xviii, 37-42. Memorial Number for

S. J. Meltzer.

Wesson, M. B., and Young, H. H.

The anatomy and surgery of the 1921, iii, 1-37.

Wharton, L. R.


J. Hygiene, Bait.,


trigon. — Arch. Surg., Chicago,


V based on a series of seven hundred and sixteen liicago, 1921, ii, 246-314.

icrvix of the uterus of inflammatory origin, iloma. — Surg. Oyncc. d Obst., Chicago, 1921,


lal experimentation to nuinkind. — .int. J. Pub. Health,


diagnosis of heart failure. .\ hitherto unirregularity. — J. .im. M. .iss., Chicago, 1921,


xxxiii, 145-1. >:

Whipple, G. H. Value of anil N. Y^ 1921, xi, 105-107

Whipple, G. H., and Davis, N. C.

1. Liver regeneration following chloroform injury as influenced by the feeding of c^isein or gelatin. — Arch. Int. Med., Chicago, 1921, xxvii, 679-687.

Whipple, £i. H., and Delprat, G. D.

Studies of liver function. Benzoate administration and hippuric acid synthesis.— J^. Biol. Chem., Bait.. 1921-22, xlix, 229-240.

Whipple, G. H., and Robscheit, F. S.

Iron and arsenic as influencing blood regeneration ftdlowing simple anemia. — Arch. Int. Med., Chicago. 1921, xxvii, 591-603.

White, E. C., Young, H. H., and Swartz, E. O.

Further clinical studies on the use of mercurochrome — as a general germicide.—/. Urol.^ Bait.. 1921, v. 353-388.

Wiel, H. I.

Truer standards in the emphasized form of pulsi Ixxvii, 749-753.

Wight, O. B.

Practical medical publicit.v. — Proc. Alumni .Assoc. Med. School, Univ. Oregon, 1921, 9th Ann. Meeting.

Williams, J. W.

Report on graduate instruction in obstetrics and gynecology. — Am.

Med. Ass. Bull.. Chicago, 1921. xv, 52-56.

Report on undergraduate teaching of obstetrics and gynecology. — Am

Med. Ass. Bull.. Chicago. 1921, xv, 146-152.

The problem of effecting sterilization in association with various

obstetrical procedures. — .4 m. J. Ohst. d Gynec, St. Louis, 1921, i.

783-793.

Obstetrics and the general practitioner. — Pcnn. M. J., 1920-21, xxiv,

290-296.

Twenty-one years' experience with Caesarean section. — Med. Standard,

Chicago, 1921, xliv, 14-24.

Willis, H. S.

studies on tuberculous infection. VIII. Spontaneous pneumokoniosis

in the guinea-pig. (Introduction by A. K. Krause.) — Am. Rer. Tuberc, Bait.. 1921-22. v, 189-217.

WiSLOCKi, G, B., and Putnam, T. J.

Absorption from ventricles in experimentally produced internal hydrocephalus. — Am. J. Anat., Phila., 1921, xsix. 313.

Woods, A. C.

Immune reactions following iniuries to the uveal tract. — J. Am. M. Ass., Chicago, 1921, Ixxvii, 1317-1322.

Woollet, p. G.

Blood sugar tole /. Lab. S Clin M Coinpli<-:iti..r.K .if — ./. I.aii. ,1 I'Ini Syphilid


St.


192


ince in cancer and in hypertension. (Editorial.) — . St Louis. 1920-21. yi, 227-229.

li.' arsidirnamine treatment of syphilis. (Editorial.)

1/,, SI L.oiis. 1920-21. yi, 344-347.

ithesis. (Editorial.)— J'. Lab. cC Clin. M.,


169-471.


Superinfection in syphilis in its relation to subtreatment. — /. Lab. <£ CUn. M., St. Louis, 1920-21, vl, 717-719.


(Editorial.)


[No. 372


Wright, C. B.

Duodenal ulcer : medical treatment in ambulant cases. — JournalLancet, Minneapolis, Minn., 1921, xli, 396-397.

Yates, J. L.

.\a outline of twelve Tears' study of Hodgltin's disease and allied jilTcctions. — Wisconsin M. J., Milwaukee, 1920-21, six, 447-451.

Young, C. W., and Han, C. H.

AKjrIutination titer following repeated intravenous injections of tab vaccine. — China M. J., Shanghai, 1921, xxxv, 400-404.

Young, H. H.

Surgery of the prostate. — In: Surgery. Its Principles & Practice

(Keen). Phila. & Lond.. 1921, viii, 530-607.

The value of drugs in urology. — J. Am. M. Ass., Chicago, 1921, Ixvii,

1327-1332.

Success of the campaign for combating venereal disease In the

A. E. F. — Mil. Surgeon. Wash.. 1921, xlviii, 213-222.

Demonstration of a new combined cystoscopic and X-ray table. —

Tr. Am. Urol. Ass.. 1920, Bait., 1921, xii, 344-347. Also: J. Urol,

Bait., 1921, V, 391-404.

Young, H. H., and Cash, J. R.

A case of pseudohermaphrodismus masculinus. showing hypospadias, greatly enlarged utricle, abdominal testis and absence of seminal vesicles.^. Urol., Bait, 1921, v, 405-430.

Young, H. H., and Waters, C. A.

Pvelngraphy. — Rapport de la Soc. Inteniat. d'Vrologie, Paris. Juillet 5-7. 1921.

Young, H. H., and Wesson, M. B.

The nnatomv and surgery of the trigon. — .ireh. Surg., Chicago, 1921, iii, 1-37.

Young, H. H., White, E. C, and Swartz, E. O.

Further clinical studies on the use of mercurochrome — as a general germicide.— J. Urol., Bait, 1921, v, 353-3S8.

ZiMMERMANN, E. L.

A comparative study of syphilis in whites and in negroes. — Arch. Dermatol. <f Siiph.. Chicago, 1921, iv. 7o-S8.

S.vphilitic iritis, its racial incidence and its association with secondary svphilis and with neurosyphilis. — J. Am. M. Ass., Chicago, 1921, Ixxvi. 1818-1819.

RECEIVED TOO LATE FOR INSERTION IN ALPHABETICAL ORDER

Berry, J. M.. and Howard, W. P.

Reports from the Roentgen-ray laboratory of the Albany Hospital. — Albany M. Ann., 1921, xlii, 368-376.


Burrows, M. T.

Problems in cancer research.131-138.


Cancer Research, Bait., 1921, vi.


Dickson, E. C., and Burke, Georgina S.

Botulism. A method for determining the thermal death time of the spores of Bacillus botulinus. — Proc. Soc. Exper. Biol, d Med., N. Y., 1921-22, xi.v. 99-101.

DiEU.'HDE, F. R., and D.widson, E. C.

Terminal cardiac arrhythmias. Report of three eases. — .\rch. Int. Med., Chicago, 1921, xxviii. 603-677.

Halsted, W. S.

Ligations of the left subclavian arterv in its first portion. — Johns Hopkins Hasp. Rep., Bait.. 1921, xxi. 1-96.

Higgins. W. H.

Certain types of cerebral manifestations in cardio-renal diseases. — Yirginia M. Month., Richmond, 1920-21, xlvli, 598-601.

Levy, R. L.

Alterations in the cardiac mechanism after administration of quinidine to patients with auricular fibrillation. — Proc. Soc. Exper. Biol. £ Med., N. Y.. 1921-22, xix, 88-91.

Macht, D. I.

Isopropyl alcohol, a convenient lahoratorv anesthetic for cats. — Proc. Soc. Exper. Biol, cf- Med., N. Y.. 1921-22. xix. 85.

Pe.^RL, R.

The vitality of the peoples of America. — Am. J. Byg., Bait. 1921, 1, 592-674.

Parfitt, C. D.

The care and employment of the tuberculous ex-service man after discharge from the sanatorium. — Ottawa, 1921, F. A. Acland. 77 p. 8°.

Robinson, G. C.

Oreranizntion of the medical clinic of The Johns Hopkins Hospital. — Johns Hopkins Tfurses Alumnae Mag., Bait. 1921, xx, 226-227.

Schlaepfer. K.

Die Carrel-Dakin-Behandlung infizierter Wunden. — Miinchen. med. Wchnschr., 1921, Ixviil. 1490-1492.

Tisdall, F. F.

The etiology of rickets. — Oanad. M. Ass. J., Toronto, 1921, xi, 934-943.

Webster, L. T.

Experiments with B. enteritidls (murium) on normal and Immune mice. — Proc. Soc. Exper. Biol. & Med.j N. Y., 1921-22, xix, 71-72.


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Primary Carcinoma of the Liver. By M. C. Winteknitz, j\L D. 42 pages. Price 75 cents.

The Statistical Experience Data of The Johns Hopkins Hospital, Baltimore, Md., 1892-1911. By Frederick L. Hoffman, LL.D., P.S.S. 161 pages. Price, $2.00.

Venous Thrombosis During Myocardial Insufficiency. By Frank J. Sladen, M. D., and Milton C. Winternitz, M. D. Price, 75 cents.

The Origin and Development of the Lymphatic System. By Florence E. Sabin. 94 pages. Price, $2.00.

Leukaemia of the Fowl: Spontaneous and Experimental. By Harry C. Sohmeisser, M. D. Price, $2.00.


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The Operative Story of Goitre. The Author's Operation. William S. Halsted, M. D. Price, $3.50.


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Pathological Anatomy of Pneumonia Associated with Influenza. By William G. MacCallum. Price, $1.50. (This monograph will be on sale within a short time.)


CONTENTS

  • A Study of the Relation of the Adrenal Glands to Experimentally Produced Hypotension (Shock) ; with a Note on on the Protective Effect of Preliminary Anesthesia. (Illustrated.) By Ar.xold Rice Rich .......
  • A Clinical and Anatomical Study of Fifty-One Cases of Repeated Csesarean Section with Especial Reference to the Healinw of the Cicatri.s: and to the Occurrence of Rupture Through It. (Illustrated.) By Thomas O. G.\mble ......
  • Acute Lobar Pneumonia and Haematogenous Puerperal Infection. A Case Report. By R. A. JoHNSTO.v and H. .1. ilORGAX
  • Diplitheria Bacillus Carriers. Results of Re-E.vaminatiou of Apparently Negative Cultures. By B. C. Marshall and C. G. Guthrie
  • The Ilydrogen-ion Cuneentration of Tissue Growth in Vitro. (Illustrated.) By M. R. Li:wi.s and Lloyd D. Felto.n" ....
  • The Relation of H-ion Concentration to Specific Precipitation. By V. R. Masox
  • Notes on New Books


A STUDY OF THE RELATION OF THE ADRENAL GLANDS TO EXPERIMENTALLY PRODUCED HYPOTENSION (SHOCK)

WITH A NOTE ON THE PROTECTIVE EFFECT

OF PRELIMINARY ANESTHESIA

By Arnold Rice Eich {From the Deparlmerd oj Pathology, The Johns Hopkins Medical School)


In a study of the literature dealing with either surgical shock or the adrenal glands, one meets frequently the suggestion that shock may be the result of disordered function of the adrenals. This idea has been entertained especially as a corollary of the belief that, since epinephrin injected intravenously has such a remarkable effect upon the blood pressure, and removal of the glands brings about a condition of hypotension, the adrenals are therefore probably concerned in the maintenance of the blood pressure at the normal level. Since the condition of shock is characterized most strikingly by a marked fall in blood pressure, it has been suggested repeatedly that epinephrin exhaustion or adrenal fatigue may be causative factors.

Stewart and RogofE ' and others '• ' have shown that stimulation of the splanchnic nerves brings about an increased output of epinephrin from the adrenals. Hoskins and McClure * state that a similar effect can be produced by visceral exposure and operative trauma; Cannon and Hoskins' found that


sensory stimulation increases the output of epinephrin, and Elliott " showed that the glands can in this way be quite depleted of their epinephrin content. Thus, it might be supposed that excessive intestinal or peritoneal manipulation or any severe prolonged sensory stimulation accompanying trauma may exhaust the epinephrin content of the adrenals and so bring about the condition of low blood pressure characteristic of shock. Indeed, the experiments of Corbett ° and of Cannon and Hoskins " led them to make just this suggestion, although Cannon later ° stated his belief that during shock " the adrenal glands are, if anything, over-active rather than exhausted." Quite a number of workers have reported that the epinephrin content of the adrenals is diminished by prolonged anesthesia, and it has been suggested that surgical shock may be dependent in part upon this epinephrin depletion.'"

Numerous attempts have been made to determine whether the supply of epinephrin is actually exhausted during shock, and whether abnormal variations in the epinephrin output


so


[No. 373


from the adrenals can be related to the development of shock. The results of these investigations are somewhat conflicting. Bainbridge and Parkinson ' reported that they could find no epinephrin at all in the adrenals taken from fatal cases of postoperative shock, and this was confirmed by Elliott.' Short/ however, using a very delicate test, was unable to detect any reduction in the epinephrin content of adrenals taken from shock cases. Corbett' states that "the symptoms of shock fully develop only after the supply of epinephrin is greatly depleted," but he does not describe the experiments which led him to tliis conclusion. He does, however, report that animals which were subjected to prolonged sensory stimulation (sciatic) "very rapidly went into shock after a few minutes of peritoneal traiuna" when the intestines were subsequently exposed, and he explains this by assimiing that the preliminary sensory stimulation caused a reduction of the epinephrin supply. It is noteworthy in this connection that, in spite of numerous attempts, there is not a single convincing experiment on record in which true shock has been produced by the stimulation of sensory nerves. Sydenstricker, Delatour and Whipple '° state that in animals which had been brouglit into the condition of shock by the injection of contents from a closed duodenal loop, determination of the epinephrin content of the adrenals disclosed only one-fourth of the normal amount, or even less. Bedford " reported that during shock produced by intestinal manipulation the epinephrin content of blood taken from the adrenal vein is much higher than before the onset of shock, and that the concentration increases with the prolongation of the low blood pressure. Stewart and Eogoff," however, repeated Bedford's experiments with modifications in technique which they believe insure a greater accuracy in the estimation of the amount of epinephrin present in the blood, and they conclude that the output of epinephrin from the adrenals is the same during shock as it is under normal conditions.

Experiments such as these leave the question of the relation of the adrenals to shock in an unsatisfactory condition. In the first place, an altered epinephrin content of the adrenals or an abnormal output during shock might easily be a result rather than a cause of the condition. Thus Mann,"^ stating his belief that the adrenals enter as factors in the complex of shock, wrote that "it is quite difiicult to determine to what degree they participate as primary agents in producing the state or how much they are affected by the low blood pressure and the changes incident to the condition itself." It might be thought that the removal of both adrenals would throw immediate light upon the theory of adrenal exhaustion ; and indeed Crowe and Wislocki " have reported that following complete removal of both adrenals the animal gradually develops hypotension, rapid pulse, lowered body temperature, muscular weakness, apathy and dulled sensibility — all of which are characteristic of shock. On the other hand, it is claimed that adrenal extirpation does not really reproduce the condition of shock," and Vincent " has even stated that experiments carried out in his laboratory demonstrate that a fall of blood pressure is not a characteristic effect of complete adrenalectomy. Fui-thermore,


apart from the question of the effect of the mere removal of the adrenal glands, it is well known that there is a strong tendency at the present time to believe that the adrenals normally play no direct part in regulating vascular tone,"- "• " "• " or else that their activity is of value only in emergencies when an unusual strain is thrown upon the circulation. If the latter supposition be true, it is clear that exhaustion of the adrenals during the strain of an operation or severe trauma might deprive the animal of a protection of which the adrenalectomized animal, lying quietly in its corner, would have no need. Indeed, Abelous and Langlois" pointed out long ago that muscular exertion following adrenalectomy hastens the development of the characteristic sj-mptoms of adrenal deficiency. Thus it is evident that conclusions drawn from the effects of adrenalectomy alone cannot entirely satisfy the question of the relation of the adrenal glands to shock. The present experiments were undertaken in tlie belief that if normal animals, subjected to a standardized trauma, fall into shock in a reasonably definite period of time, then worthwhile information might be obtained from a comparison of the protocols of these normal controls with the time required for the production of shock in adrenalectomized animals, subjected to the same trauma. For if shock results from epinephrin exliaustion or adrenal fatigue, the condition would presmnably develop much more rapidly in the adrenalectomized animals than in the normal controls; if abnormal stimuli going to the glands cause an excessive output of some harmful material which produces shock, removal of the glands would remove the possibility of an outpouring of any noxious secretion and the adrenalectomized animals would be very resistant to the trauma; and finally, if the development of shock is independent of the activity of the glands, the adrenalectomized animals should react as normal animals to the same trauma. The fact that bits of accessory adrenal and chromaffin tissue are present in animals has not been overlooked, but it was believed that the removal of both adrenal glands (the great bulk of such tissue) would produce a deficiency sufficient to be detected by this method of attack if adrenal function actually plays an important role in the production of shock.

EXPEEIMEN'TS

Certainly one of the most confusing things that one meets throughout the literature concerned with shock is the failure of many workers to standardize their experiments. Often, in a series of experiments where such precautions would be of value, no attempt is made to treat each animal.in as nearly the same manner as possible either as regards the degree of trauma inflicted or (what is exceedingly important) the amount of anesthetic administered during the experiments. But especially is there a lack of a criterion as to what shall be regarded as shock. Thus, while most clinical and experimental observers incorporate a marked fall of blood pressure into their definition of shock, there are some whose experiments indicate that they do not regard such a fall of blood pressure as a necessary part of tlie picture. Wiggers " considers a fall of blood pressure a characteristic of "shock" produced by intestinal exposure.


March, 1922]


81


but he does not consider it an essential part of the "central nervous system shock " which he produced by sensory stimulation." This " central nervous system shock " is merely a condition of apathy and dulled sensibility and can occur vi^ith no important blood pressure fall. Doubtless some of the confusing experiments in the literature have arisen from a failure to recognize that this condition of apathy is not true sliock. Mann " some years ago called attention to the need of a criterion for the condition of an experimental animal wliicli should be regarded as shock, and his requirements followed admirably the signs which make up the clinical condition designated as shock.

In the present experiments, an animal was considered to be in shock when the blood pressure, having fallen to 60 mm. of mercury or below, sliowed no tendency to recovery and was accompanied by a permanent dulling of the sensibility, so that the ether could be discontinued ^nthout discomfort to the animal during operative procedures performed after a lapse of time (half an hour) sufficient to allow the anesthetic effect of the ether to wear off. Strong sensory stimulation applied to such an animal might cause struggling, but the animal would at once sink back into its quiet, apathetic state as soon as the stimulation Was discontinued, although the abdominal contents were exposed and the neck opened for tracheotomy and cannulation of the carotid artery. A low blood pressure was required in these experiments because clinical shock without hypotension, although spoken of by a few writers,^ is certainly an anomalous condition except in cases following head-wounds, and it is questionable whether such conditions are fundamentally the same as ordinary shock with hypotension. The level of 60 millimeters of mercury was arbitrarily chosen as a standard after a study of the average unrecoverable fall of blood pressure usually accompanied by a permanent dulling of the sensibility. The pulse of the animal in shock was usually rapid and feeble after the condition had persisted for some time, but frequently a marked slowing of the pulse was a prominent feature of the early stages, and periods of bradycardia have been observed during deep shock. The character of the respirations was very variable in the different experiments. The superficial reflexes remained active throughout, and the body temperature always fell several degrees centigrade more than did that of normal animals merely kept under ether anesthesia for the same period of time.

In all of the experiments described below apparently healthy, full grown cats were used and a careful attempt was made to subject each animal to conditions as nearly identical as possible as regards the trauma inflicted to produce shock and the amount of anesthetic used in each experiment. It must be stated here that during the progress of this work a number of animals were encountered which exhibited a peculiar sensitiveness to ether, so that the most careful administration of the anesthetic did not prevent them from behaving in a most anomalous way. The respirations would cease, and the blood pressure would fall abruptly shortly after anesthetization, and although artificial respiration would soon restore them, such lapses would occur repeatedly, and shock would appear much


sooner than in normal animals. At autopsy no reason for tlie peculiar reaction was ever discovered. The number of such animals was relatively small, and it is felt Justifiable to exclude them entirely from consideration, since they were clearly hypersensitive to the effect of ether alone.

Reaction of Normal Animals to Intestinal Maniijulation. — The first series of experiments was carried out to determine whether normal animals would exhibit any constancy in tlie time required for the development of shock if they were subjected to a uniform trauma. Each animal was anestlietized with ether and tracheotomized. The tracheal cannula was connected through a reservoir witli a tube through wliich ether vapor could be blowai from an ether bottle by means of a foot bellows. As soon as the carotid artery could be cannulated and connected with a mercury manometer, a blood pressure tracing was made and the rectal temperature was recorded. Then the abdomen was opened at once along the midline, and the small intestines were lifted out of the abdominal cavity and spread upon gauze pads, care being taken to prevent torsion of (lie mesentery from interfering with the circulation. Every five minutes a blood pressure tracing was made, tlie temperature was recorded, the intestines were pinched firmly between the thumb and forefinger all the way from the duodenum to the caecum once, and the animal received the amount of ether vapor which was forced into the reservoir by a single pump of the bellows. In the intervals between these procedures the animal was left to lie quietly. Usually a single pump of ether vapor sufficed to keep the animals anesthetized, and a second dose between the five-minute periods was administered only when necessary. The anesthesia was never deepened enough to abolish tlie corneal reflex. A careful control of the anesthetic is of great importance in such experiments, as may be seen from a consideration of Fig. 1. In this experiment a relatively large amount of ether was administered, with the result that the blood pressure fell to the shock level within a short while, and would have remained there, simulating the condition of shock, had not the ether been discontinued. Fifteen minutes after stopping the anesthetic the blood pressure began to rise and 10 minutes later had risen 40 millimeters more and the animal liad regained full consciousness and sensibility. This effect of ether was repeated several times in the same animal, and demonstrated the necessity, in every experiment, of observing the animal for at least half an hour following the discontinuance of the anesthetic when shock is believed to have developed, in order to be certain that the low blood pressure and dulled sensibility are not ether-effects.

By following carefully the method outlined above, eacli animal received as nearly as possible the same degree of trauma and the same amount of anesthetic.

Inspection of the protocols and blood pressure tracings of this series of experiments shows that normal animals react to these conditions in a strikingly constant way. The blood pressure falls abruptly during the first five minutes after exposing the intestines and then, either continuously or after a temporary rise, it sinks gradually, with some irregularity, to the shock level, and the characteristic signs of shock make




CaT ;Z3


flHer stopped.


3^s ^'^35



Fig. 1. — Careless anesthesia resulting in condition resembling J


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I I I I I I I I I I I I I I H I I I U I I ! J-IJ-LLIU-UJXI-U-I JJ-UJ U I I I I I I I I H 111 li-U


Fig. 2.— Blood pressure tracing of normal animal durmg production of shock by mtestm^n

pressure falls, a not mlrequeff <





Ether Stopped


J-A=>»l 6-^- >37o


h recoverj' when ether is discontinued ; not true shock.



Shock present 1^ hours after exposing intestines. Note slowing of pulse as blood c 1 the early stages of shock.


84


|Xo. 37:5


their appearance. The time required for the development of complete shock in these 10 animals was remarkably constant, varying between the extremes of an hour and a half and two hours, the average time being an hour and 50 minutes. Fig. 2 represents a typical experiment from this group.

ReacHon of Animals Immediately Following Adremlectomy. — Having determined the time required to bring normal animals into shock, w-e next carried out a series of experiments to study the reaction of adrenalectomized animals subjected to the same conditions. Eacli animal was anesthetized, tracheotomized and a blood pressure tracing taken Just a.s in the first series. Then both adrenals were carefully removed extraperitoneally, and the lumbar incisions were closed with sutures. This procedure required 30 or 40 minutes and was performed with no more ha?morrhage than would stain part of a small piece of gauze. Kymographic tracings were taken every five minutes for about 20 minutes following removal of the glands in order to observe the immediate effect of the operation. During tliis time the blood pressure invariably either remained at tlie' original level or, if anything, occasionally rose a few millimeters above it. The intestines were then exposed and manipulated exactly as in the normal controls, the metliod of anesthesia being the same throughout.

The reaction of these animals was most interesting. Kymographic tracings taken every five minutes, as before, showed tliat there occurred the usual slight fall of blood pressure immediately following the opening of the abdomen. This fall was promptly recovered from in several experiments ; but in every experiment, during observations continued as long as two and a half and three hours following the exposure of the intestines, the blood pressure exhibited no further fall than the negligible depression which prolonged light anesthesia alone produces ; and cessation of the anesthetic at the end of this time was invariably followed by prompt and complete recovery, although these animals were subjected to exactly the same conditions as the normal controls which were in deep sliock, with tlie blood pressure at 60 millimeters or below, after only an hour and 50 minutes of intestinal manipulation. Fig. 3 is typical of this series. It will be seen that the blood pressure at the end of two hours and a half of intestinal manipulation stands at 110 millimeters, and has fallen from the original level no more than the blood pressure of normal animals kept quietly under ether anesthesia for the same length of time. The pulse is of splendid quality ; and when the anesthetic was discontinued the animal promptly recovered full consciousness and sensibility. Not one of these 10 animals went into shock. Autopsy showed in every case complete removal of both adrenals.

This series of experiments seemed to favor strongly the idea that shock might be the result of some abnormal secretion of tlie adrenals, since there appeared no tendency for the condition to develop in adrenalectomized animals subjected to the same conditions which regularly produced it in the normal animal. There were, however, aside from the lack of adrenals, two points in which the adrenalectomized animals differed from tlie control animals at the beginning of the intestinal ex


posure — they had undergone an operation, and they had l)e('ii kept under anesthesia for about an hour during the operation and the subsequent blood pressure observations made before the abdomen was opened. The fact that they liad been subjected to an operation before beginning the shock trauma would be expected to increase their tendency to shock, if anything, and so too would a preliminary hour's anesthesia, A third series of experiments was carried out, however, to study the reaction of animals to intestinal manipulation following a preliminary hour's anesthesia alone.

Reaction After a Preliminary Hour's Anesthesia. — After tracheotomy and measurement of the blood pressure, the animals of this series were kept quietly under light anesthesia for an hour, kymographic tracings being taken every five minutes. Then the intestines were exposed and handled just a-s before. These animals reacted precisely as those of the adrenalectomized series ; they showed no tendency to fall into shock during three hours of intestinal manipulation. Fig. 4 is a tracing from a typical experiment. The blood pressure shows no more tendency to fall after intestinal exposure than if the animal were merely kept anesthetized for tlie same length of time. Two hours and a half after the abdomen was opened the systolic pressure was 120 millimeters, the pulse was good, and when the anesthetic was discontinued, the animal regained full consciousness and sensibility and had to be killed. It will be noted that, in this particular experiment, besides the usual manipulation of the intestines every five minutes, considerable further trauma was inflicted without effect. The kidneys were roughly handled, several inches of intestine were resected at intervals, and the parietal and visceral peritoneum was stretched severely, with only a slight temporary eifect upon the blood pressure.

In order to be certain that the resistance of these animals to shock was brought about by the preliminary hour's anesthesia rather than by some unrecognized technical divergence from the method used in the normal controls, two control experiments were now repeated, the intestines being exposed and liandled immediately following the first blood pressure reading, instead of after an hour's anesthesia. These animals beliaved exactly as the original normal controls. They were in deep shock in an hour and 55 minutes and two hours, respectively.

The 12 experiments with preliminary anesthesia were clearcut, and demonstrated that an animal which has been kept anesthetized with ether for an hour immediately before opening the abdomen becomes, in some way, much, more resistant to the shock-producing effects of intestinal manipulation than are animals in which the intestines are exposed more promptly after anesthetization. No explanation of the mechanism of this protective ether-effect can be offered here other than the suggestion that during the early stages of anesthesia the circulation appears to be in a rather unstable condition, and tlie added strain of visceral trauma at tliis period can, perhaps, bring about circulatory failure more easily than in an animal which has had time for its circulation to become accommodated to the state of anesthesia, and more stabilized. It is note


Maech, 1022]


85


worthy, however, that although an hour's light anesthesia before opening the abdomen had this protective effect upon the circulation, in other experiments it was clear that, once the blood pressure had begun to fall toward the shock level after intestinal manipulation had been begun, ether exerted a marked depressant action upon the circulation and distinctly favored the development of shock.

It is evident that no conclusions regarding the relation of the adrenals to shock could be drawn from the experiments in which the glands were removed immediately before exposing the intestines. The complicating factor of the protective ether-effect precluded that. It was, therefore, decided to remove the adrenals, to allow the animal to recover completely from the anesthetic, then to reanesthetize it afresh and proceed at once with the intestinal trauma.

Reaction Seven to Seventeen Hours after Adrenalectomy. — In tliis series of experiments both adrenals were removed extraperitoneally through lumbar incisions under strict aseptic precautions. Tlie animals were then allowed to recover from the anesthetic and were left in their cages for periods ranging between 7 and 17 hours. None of the animals displayed any sign of adrenal insuiEciency on inspection. They appeared active and not asthenic. Each animal was then anesthetized, tracheotomized, a blood pressure tracing taken and the intestines at once exposed and handled as usual. It was found at the outset that these adrenalectomized animals had a very low blood pressure, the first readings averaging 82 millimeters. The pulse was more rapid than normal. All of the animals of this series fell into deep shock within 30 or 35 minutes after exposure of the intestines, the blood pressure falling rapidly to 20 millimeters in most cases. At autopsy the operative sites were found in splendid condition, and dissection of the splanchnic nerves showed injury only to the small branches which necessarily must be severed in removing the adrenals.

Fig. 5 is a tracing from a typical experiment in this series.

Although these adrenalectomized animals went into shock in one-third the time required to bring a normal animal into shock, it was evident from the low blood pressure and rapid pulse that the circulation was already affected by the removal of the adrenals before intestinal manipulation was begun. It was not possible, therefore, to draw conclusions from this series concerning tlie relation of the adrenals to shock, and it was realized that experiments would have to be carried out upon adrenalectomized animals which had been allowed to recover from the anesthetic after adrenalectomy, in order to eliminate the protective ether-effect, but which had not been left long enough for circulatory signs of adrenal deficiency to appear before the animals were exposed to the shock-trauma.

Reaction One Hour After Adrenalectomy. — Since the blood pressure does not begin to decline until several hours after adrenalectomy, a series of experiments was carried out in which, foUo^nng removal of both adrenals under aseptic precautions, each animal was allowed to recover fully from the anesthetic imtil it was able to walk about and to react nonually to stimuli. In this way the protective effect of the anesthesia administered during tlie operation was avoided, since it had been determined


in two experiments that if an animal were reanesthetized immediately after recovery from an hour's anesthesia, it retained none of the protective effect of the ether, but reacted to intestinal manipulation exactly as a normal animal. Complete recovery from the anesthetic administered during adrenalectomy required usually about 30 minutes; then the animal was reanesthetized at once, tracheotomized, and a blood pressure tracing made. The blood pressure was normal in every ease, averaging 145 millimeters. The intestines were then exposed at once and handled as usual. These adrenalectomized animals reacted exactly as normal animals, requiring an average of an hour and 45 minutes to fall into shock. Fig. 6 is a typical tracing from this group.

This series of experiments indicates clearly that shock develops in the absence of the adrenal glands precisely and characteristically as it does in normal animals. Disordered function of the adrenals cannot be invoked as the cause of shock produced by peritoneal trauma. If the adrenals were causative factors of any importance, there would have appeared some difference between the reaction of the adrenalectomized animals and that of the normal controls. It might be objected that perhaps some of the secretion of the adrenals remains active in the body for a while after the glands are removed, so that adrenalectomy does not create an immediate deficiency of the secretion. It must be clear, however, that the same objection would be more applicable to any theory postulating disordered adrenal function as a cause of shock. The importance of the accessory chromaffin tissue is recognized fully, but since the adrenalectomized animals enter the experiment with complete absence of the adrenal glands, surely if epinephrin exhaustion or adrenal fatigue were causative factors in shock, these animals should fall into shock distinctly quicker than normal animals in which a longer time would be necessaiy to exhaust the greater epineplirin supply or bring the adrenal glands as well as the accessory tissue into a condition of dysfunction.

Condition of the Heart and Medullary Centers in Shock. — During the progress of these experiments advantage was taken of the opportunities to study the condition of various body functions during shock. Most observers have found that the heart functions normally during shock. Erlanger and his coworkers ^ acquired the impression that the heart in shock has not the normal reserve power and this might be expected, since Markwald and Starling have shown that weakening of the cardiac contraction accompanies low blood pressure.^^ Boise " attributed the circulatory failure in shock to impairment of cardiac function. In the present experiments the heart during shock has invariably worked splendidly both iinder the strain of large doses of adrenalin, and when normal saline was run rapidly into the jugular vein. In every experiment in whicli an animal was allowed to die in shock, respiratory rather than cardiac failure was the immediate cause of death.

It is almost universally stated that the pulse is rapid during shock. Wiggers, however, mentions slowing of the heart during the late stages of the condition ° and Dupuytren °° wrote from clinical observations " Le pouls est d'une lenteur et d'une


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Fig. 4— Intestinal manipulation after an hour's preliminary anesthesia. Besides the usual manipulation ever}' 5 minutes, sev(

^ • Condition oi animal^"





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Condition of animal normal after 2^- hours of intestinal trauma. No shock.


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leritoneum and mesentery was made at A'; kidneys roughly handled at }'; resection of several inches of intestine at Z and Z' . l\ hours. No shock.


[Xo. 373


mollesse telles que la pliis legere pression le sufflamine," and that, if recovery takes place, " le pouls est plus fort et moins rare." In a number of the present experiments periods of pronounced slowing of the pulse were observed during deep shock. This slowing of the heart-beat is a result of the action of the cardio-inhibitory center. It has been held that inhibition or paralysis of this center is a characteristic and perhaps a cause of shock; on the other hand, the experiments of numerous workers indicate that the cardio-inhibitory center "functions normally during shock. Mann reported that stimulation of the central end of one cut vagus caused reflex cardiac inhibition " even in the most extreme degrees of shock." " Jackson and Ewing wrote that they were able to obtain the reflex only while the blood pressure remained above 60 millimeters of mercury.^ I have never failed to obtain slowing of the heart-beat during shock by this means, and the reflex has been elicited repeatedly when the blood pressure was as low as 20 millimeters (Fig. 7). In these experiments a further proof that the heart, in shock, is under control of the cardioinhibitory center was obtained by observing the efEeet of cutting the vagi. If the vagi are sectioned during one of the periods of bradycardia which occur occasionally when an animal is in deep shock, a most striking acceleration of the pulse always results immediately, as can be seen in Fig. 8, where the heart-rate increased from 80 to '200 per minute. Section of the vagi when the pulse is rapid during shock will always increase the heart-rate unless it is already too rapid to be influenced by removal of vagus inhibition; and in the cases in which Vagus section could not increase the rate, stimulation of the central end of one cut vagus has already produced slowing of the heart immediately before section of the remaining vagus, showing that the cardio-inhibitory center was capable of responding to stimuli during shock. In three experiments both vagi were sectioned before exposing the intestines; these animals went into shock no more rapidly than the normal controls, and their blood pressure curves were characteristic of the normal shock curves. It is clear that failure of the cardioinhibitory center is not a causative factor in shock.

The question of the condition of the vasomotor center has been the subject of many investigations. On the basis of their well-known experiments, Crile," Lockhart-Mummery " and others have maintained vigorously that surgical shock represents an exhaustion of the vasomotor center ; others '"• "• • '^ have produced splendid evidence that it is not exliausted. In the present experiment, a pressor response could always be elicited by stimulation of sensory nerves during shock. In most of the experiments the rise of blood pressure was less prompt and less marked than before the onset of shock, although in some cases the rise was quite as marked. Fig. 9 shows a definite pressor response obtained by sciatic stimulation during deep shock, when the blood pressure was only 22 millimeters. I can entirely agree with those who hold that exhaustion of the vasomotor center is not a primary factor in shock.

Janeway and Ewing" have stated that in shock produced by intestinal manipulation " there is absolute paralysis of every


tissue of the intestines, of the muscles, of the intestinal walls and of the arterioles," and they stress the importance of a local peripheral paralysis of the splanchnics as a factor in shock. I have never observed such a complete paralysis of the intestines during shock. Abortive peristaltic movements occur throughout the duration of shock, and not infrequently persist for a short while after death. Janeway and Ewing wrote that in some of their experiments the intestinal manipulation was quite violent, causing rhexis of the peritoneum. It is possible that excessive trauma might produce such a paralysis, but surely it cannot be regarded as a characteristic part of shock.

The Hypotension Resulting from Adrenalectomy. — It may not be entirely out of place here to describe several observations upon the group of adrenalectomized animals which may have some bearing upon the function of the adrenal glands.

In the first place, although we have the clinical evidence of Addison's disease and certain experimental evidence besides, indicating some relation of the adrenal glands to the maintenance of normal blood prressure, Vincent " reports that continous blood pressure tracings, taken up to the moment of death, after complete removal of the adrenals from the circulation, show no greater faU. in blood pressure than would have occurred in a normal animal subjected to ether anesthesia alone for the same period of time, and he concludes that " these experiments appear to show conclusively that the secretion of adrenalin into the circulation is not to be regarded as a factor in the maintenance of the normal blood pressure." The present experiments do not at all agree with such an observation. Howell " and others have pointed out that adrenalectomy has no effect upon the blood pressure for several hours, and I have observed this fact repeatedly. But the blood pressure of an adrenalectomized cat begins to fall gradually about four hours after the glands have been removed, and within the first 12 hours after adrenalectomy the blood pressure in the unanesthetized animal invariably falls to a very low level and continues to decline progressively until death. In these experiments it was demonstrated that the marked hypotension, observed in every case as early as seven hours after adrenalectomy, is a characteristic result of adrenal deficiency and not merely a condition of lowered tone in an animal several hours after an operation. For in a number of experiments both adrenals were exposed aseptically and handled even longer than woiild have been necessary to remove them. They were then left in their normal positions and the incisions closed. Seven to twelve hours later these animals were reanesthetized and the blood pressure in every case was normal and exposure of their intestines produced shock in the length of time characteristic of normal animals. In another series, under aseptic precautions, one adrenal was removed and the other exposed and handled, the operation taking as long as if both had been removed and the operative trauma being made purposely more severe. When these animals were reanesthetized after a lapse of from 7 to 15 hours, tlieir blood pressure was found to be normal and they reacted to intestinal manipulation exactly as normal controls. Autopsy showed complete removal of one


March, 1932]


89


adrenal in every case. Thus, the trauma of the operation alone is not responsible for the low blood pressure which developed in every completely adrenalectomized animal ; nor has removal of one adrenal any effect upon the blood pressure during the period of these experiments ; but when both glands are removed the blood pressure invariably falls strikingly. The splanchnic nerves were dissected at autopsy in every case in order to make certain that injury was confined only to the little branches which must be cut in order to remove the adrenals. I cannot agree with those who have claimed that the low blood pressure developing after adrenalectomy is merely tlie hypotension to be observed in any moribund animal, nor does the contention of Hoskius and McClure/' " that the hypotension is a result of asthenia, seem reasonable; for these adrenalectomized animals were by no means in a moribund condition, nor was there evident asthenia seven hours after removal of the glands. One of these adrenalectomized animals, a rather wild male, escaped from its cage just before it was anesthetized for the blood pressure reading and ran swiftly about the room, evading capture. It was caught, anesthetized, and the systolic pressure found to be 75. It seems more reasonable to believe that the hypotension leads finally to asthenia because of the impairment of the circulation.

The fact that hypotension is a characteristic effect of adrenalectomy and that it appears to be the result neither of the trauma of the operation nor of the asthenia, supports the belief that the adrenals are, after all, directly concerned in some way in the maintenance of normal blood pressure. This idea is strengthened by observations upon the powers of resistance of the circulation of adrenalectomized animals to strains (such as prolonged anesthesia and trauma) imposed upon it. These experiments are as yet incomplete, but they strongly suggest that the circulation of an adrenalectomized animal, after the development of hypotension but before the appearance of asthenia, is distinctly more unstable than tliat of a non-adrenalectomized animal with the same degree of hypotension.

Discussion

It may possibly appear inconsistent that any observations supporting the belief of the activity of the adrenals in maintaining normal blood pressure are presented here together with evidence that these glands are not concerned in the circulatory failure characteristic of shock; but certainly, even though the adrenals be concerned with blood pressure regulation, they are not by any means the only factor involved. The demonstration of the lack of any causal relation between the adrenals and the acute hypotension of shock merely points more distinctly to a disturbance of some other part of the intricate circulatory mechanism.

At the present time, the idea that the adrenals may be concerned with the maintenance of normal blood pressure is widely repudiated, and the work of Cannon, Gley, Stewart and Rogoff, Hoskins and McClure, and Vincent, in this connection is familiar enough to everyone who has given any attention to the function of these glands. The objection has been repeatedly brought forth that if adrenalin were necessary for the


maintenance of normal blood pressure, removal of the glands should result in an immediate fall of pressure; but no fall occurs during several hours after adrenalectomy."- '"• "• ^' Much has been made, also, of the fact that adrenalin can be detected in normal blood in minute amounts only; so minute, indeed, that numerous writers do not hesitate to declare that it is physiologically useless in affecting vasomotor tone, especially since the intravenous injection of small amounts of adrenalin can produce a depressor instead of a pressor effect." ^- *• ™ Perhaps these, and certain other similar obsen^ations which cannot be discussed here, deserve more critical consideration and study before they can be accepted as reasons for believing that adrenalin plays no part in the maintenance of normal arterial pressure, or that " I'adrenaline ne doit plus etre consideree comme un produit de secretion vraie." "

In regard to the objection that the blood pressure does not fall immediately after adrenalectomy (and some have actually been content with blood pressure observations continued less than two minutes after compression of the adrenal veins)" it does not seem permissible to ignore completely the fact that there is a definite supply of physiologically active epinephrin left in the accessory chromaffin tissue after removal of the adrenal glands," ^ and tliat this supply may be sufficient to sustain the blood pressure for several hours, but not indefinitely. It is true that Stewart and Rogoff have considered this point to the extent of writing : " No account is here taken of the possibility that the sporadic chromaffin tissue may discharge a certain amount of epinephrin, since, although it has been shown to contain that substance, nothing is known as to its liberation " ; ^ however, the fact of our ignorance as to the mode of liberation of epinephrin from this accessory chromaffin tissue is not a satisfactory reason for taking no account of it. The well known protective effect of minute residual fragment* of parathyroid," thyroid and adrenal " tissue left, either intentionally or by accident, in extirpation experiments demonstrates strikingly enough the role that a relatively insignificant amount of such tissue can play. It is curious, in any event, that those who feel that the adrenals have nothing directly to do with vascular tone, because hypotension does not occur the instant tlie adrenal veins are clamped, nevertheless appear to accept the belief that the glands are concerned in some way with the maintenance of muscular tone, although asthenia develops, after adrenalectomy, distinctly later than hypotension. It seems to the writer that the important fact may be, not that the blood pressure fails to fall immediately after removal of tlie glands, but rather that a primary effect of adrenalectomy is hypotension.

Concerning the minute amount of epinephrin that can be detected in the blood, it is difficult to be sure that it has no physiological significance in relation to normal blood pressure simply because the amount collected at any given moment is too small to affect the contractions of a strip of smooth muscle in vitro, or to exert a pressor effect upon the blood pressure when introduced into the circulation of an animal. Unquestionably, such procedures appear to be surprisingly delicate quantitative tests for the presence of epinephrin within wide


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Fig 5— Intestinal manipulation 11 hours after complete adrenalectomy. April 2. 11-50 p.

about, apparently normal. Intestmes exposed IO.00.


both Deep


idrenals removed; April 3, 10.40 a. ra.li! shock 30 minutes later.




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Fig. 6.-Intestinal manipulation 1 hour after adrenalectomy. June 23, 3.30 p. m„ operation for removal of both adrenals begun; o


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Fio. 7.— Slowing of the heart produced (iuring deep shock by stimulating central end of cut left vagus (B.P. 25).


Fio. S. — Shows activity of cardio-inhibitory center producing spontaneous bradycardia during deep shock. Heart rate increases from 80 to 200 per minute on section of vagi.



Fig. 9. — Pressor response elicited by stimulation of .sciatic nerve during deep shock (B.P. 22).


^*^ Sto


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Complete recovery from anesthetic at 4.40 p. m. Intestines exposed at 5.05 p. m. Shock 1 hour 35 minutes later. Compare with Fig. 2.


93


[No. 373


limits; however, they have limitations, a point which Stewart and liogoft' did not ignore when they concluded from certain experiments that the " liberation of epinephrin from the adrenals is not indispensable for life or health, nnless indeed tlie necessary quantity is, even in the adrenal vein blood, below the limits of detection by the methods used." "^ The fact that the quantity of epinephrin in the blood, at any given time, is minute or even indetectable by present methods ( Stewart and Rogoff, however, do detect it unfailingly in normal adrenal vein blood) does not entirely satisfy the question of the relation of this substance to normal blood pressure. In the first place, the methods of collecting and assaying the blood samples and the conditions under which the blood is obtained are apparently so subject to error that almost each worker has devoted some space in the literature to a more or less caustic criticism of the other's technique : and in the second place, it is highly probable that there may be a difference between the physiological potentialities of minute amounts of a substance secreted continually, and the effects which can be demonstrated when the amount that is withdrawn from the circulation at any one cross-section of time is used in an acute experiment. Otherwise, we would have to conclude from a study of small samples of normal arterial blood that the secretion of the thyroid gland has no effect upon body oxidations, and that of the para-thyroids no relation to calcium metabolism.

The most elaborate and important recent work on the adrenals *• '^^ "• "' has been concentrated upon the question of the existence of a physiological adrenalinaemia, and has been concerned not at all with the fact that the most striking primary effect of the lack of the adrenal secretion is hypotension. Unquestionably, the painstaking and ingenious experiments of these workers hold a very great interest. Because of the ease with which epinephrin can be detected, the study of the epinephrin content of the blood promised much, and it was most important that it be carried out. However, it is perhaps permissible to feel that this study, even in the hands of such able investigators, has nst led to conclusions as concordant or decisive as one might have hoped for. It must be remembered that there still exists an active controversy between these workers over the amount of epinephrin normally present in the blood, and also over the more important question of whether the epinephrin content of the blood is increased during the various reflex pressor reactions which have been assumed to be conditioned or influenced by an outpouring of this secretion. The only point of agreement, in fact, seems to be the opinion that the amouat of epinephrin circulating normally is not great enough to exert an influence upon normal blood pressure. It is quite possible that epinephrin has nothing to do with the maintenance of normal pressure, as these observers insist; it may, indeed, be that the lack of the unknown cortical secretion is responsible in some way for the hypotension that follows adrenalectomy. Nevertheless, the observations leading to a denial of any relation of epinephrin to normal arterial pressure have certainly not yet settled this important question, which must remain incompletely answered until we are aV)le to understand why the blood pressure falls


so characteristically when the adrenal glands are removed from the body.

Summary

I. Adrenalectomized animals, subjected to uniform intestinal manipulation before the blood pressure has begun to decline as a result of adrenalectomy, fall into shock exactly as do normal controls — the time required for the production of shock and the character of the blood pressure curves being the same in both series. It is therefore concluded that disordered adrenal function is not a factor in the production of shock.

II. Hypotension invariably results from removal of the adrenal glands, and with the development of hypotension the circulation of adrenalectomized animals appears to become more unstable than that of normal animals even before the appearance of asthenia. The blood pressure begins to fall several hours after adrenalectomy and becomes progressively lower until death. The fall in blood pressure is shown to be independent of the operative trauma and begins before asthenia has appeared. This is offered in support of the idea that the adrenals are concerned in the maintenance of the blood pressure at the normal level, and certain objections to this belief are briefly discussed.

III. Animals that are kept lightly anesthetized with ether, for an hour immediately before the abdomen is opened, become very resistant to the shock-producing effect of intestinal manipulation. Even when subjected to severe peritoneal trauma for a period of three hours, the blood pressure shows practically no tendency to fall and sensibility is retained. In contrast, if identical intestinal manipulation is begun more promptly after anesthetization, the blood pressure invariably begins to decline progressively within an hour, has fallen to 60 mm. o: below an hour and a half to two hours after opening the abdomen and the animal is in complete shock. An hour's ether anesthesia preliminary to opening the abdomen has proved to be a striking protective against shock, under the conditions of these experiments. If an animal is kept anesthetized for an hour, permitted to recover from the anesthetic, and at once reanesthetized and intestinal manipulation begun, the protective effect of the hour's anesthesia will have dis


IV. Ether has a distinct tendency to hasten the onset of shock once the blood pressure has begun to decline after the abdomen is opened.

V. Cardiac failure is not a factor in the production of shock.

VI. Failure of tlie vasomotor center is not a primary factor in shock.

VII. The cardio-inhibitory center is shown not only to respond to stimuli but also to function independently during deep shock. Its failure cannot be regarded as a cause of the condition.

BIBLIOGRAPHY

1. Stewart and Rogoff: Jour. Pharm. and Exp. Thera., 1916, VIII, 205.

2. Elliott: Jour. Physiol., 1912, XLIV, 374.

3. Annep: Jour. Physiol., 1912, XLV, 307.


Maech, 1922]


93:


4. Hoskins and McClure : Arch. Int. Med., 1912, X, 343.

5. Cannon and Hoskins: Am. Jour. Physiol., 1911, XXIX, 274.

6. Cannon: Natl. Health Ins., Med. Research Com., Special Rep., Series No. 25, p. 109.

7. Bainbridge and Parkinson : Lancet, 1907, 1296. S. Short: (Quoted by Cannon)."

9. Corbett: Jour. Am. Med. Assoc, 1915, 380.

10. Sydenstricker, Delatour and Whipple: Jour. Exp. Med., 1914, XIX, 536.

11. Bedford: Am. Jour. Physiol., 1917, XLIII, 235.

12. Mann: Jour. Am. Med. Assoc, 1917, 371.

13. Crowe and Wislocki: Beitr. zur klin. Chirurgic, 1914, XCV, 8.

14. Vincent: Endocrinology, 1917, I, 140.

15. Hoskins and McClure: Am. Jour. Physiol., 1912, XXXI, 59.

16. Abelous and Langlois: Arch, de Physiol, norm, et path., 1892, IV, 269.

17. Janeway and Ewing: Ann. Surg., 1914, LIX, 158. IS. Wiggers: Am. Jour. Physiol., 1918, XLVI, 314.

19. Gley : " Quatre legons sur les secretions internes," Paris, 1921, 48.

20. Wiggers: Jour. Am. Med. Assoc, Feb. 23, 1918.

21. Mann: Johns Hopkins Hospital Bulletin, July, 1914.

22. Keith: Natl. Health Ins., Med. Res. Com., Special Rep., Series No. 26, p. 36.


23. Boise: Am. Jour. Obs., 1917, LV, 1.

24. Crile: Boston Med. and Surg. Jour., 1903, CXLVIII, 247.

25. Lockhart-Mummery : Brit. Med. Jour., 1910, II, 759.

26. Seelig and Joseph : Proc Soc Exp. Biol, and Med., 1914, XII, 49.

27. Seelig and Lyon: Jour. Am. Med. Assoc, Jan. 2, 1909.

28. Porter: Am. Jour. Physiol., 1907, XX, 399.

29. Erlanger, Gesell, Ga.sser and Elliott: Jour. Am. Med. Assoc,. 1917, 2089.

30. Dupuytren: "LeQons orales de chnique chirurgicale," Paris,, 1832, Vol. II, 493.

31. Jackson and Ewing: Am. Jour. Physiol., 1914, XXXIII, 31.

32. Markwald and Starling: Jour. Physiol., 1913, XLVII, 275.

33. Hoskins and McClure: Am. Jour. Physiol., 1912, XXX, 192.

34. Hornowski: Biochem. Centralbl., 1909-10, IX, 572.

35. Cannon: Am. Jour. Physiol., 1919, 428.

36. Gley: "Quatre legons sur les secretions internes," Paris, 1921, p. 63.

37. Gley and Quinquaud: Compt. rend. Soc biol., 1919, 1175.

38. Bazzett: Jour. Physiol., 1920, LIII, 333.

39. Stewart and Rogoff : Jour. Pharm. and Exp. Ther., 1917, X, 1.

40. Fulk and McLeod: Am. Jour. Physiol., 1916, XL, 21.

41. MacCallum: Jour. Exp. Med., 1909, XI, 118.

42. Stewart and Rogoff: Am. Jour. Physiol., 1919, XLVIII, 22.


A CLINICAL AND ANATOMICAL STUDY OF FIFTY-ONE CASES OF

REPEATED CESAREAN SECTION WITH ESPECIAL REFERENCE

TO THE HEALING OF THE CICATRIX AND TO THE

OCCURRENCE OF RUPTURE THROUGH IT

By Thomas 0. Gamble (From the Obstetrical Department oj The Johns Hopkins Hospital and U nivcrsity)


In 1917 Dr. J. Wliitridge Williams published in the Bulletin OP The Johns Hopkins Hospital the results of a histological study of 50 uteri removed at Caesarean section. Included among them were 10 uteri which had been incised at a previous similar operation. They were only briefly described, as Dr. Williams stated that "the details concerning this series will be published in full later." Since that time 11 additional specimens have been added to our collection, and it is my purpose to report the results of a careful clinical and anatomical study of this material.

It is but a natural sequence that, while investigating the histories of the women from whom the uteri were removed, we should likewise consider the closely allied cases in which a conservative Ccesarean section was repeated at a subsequent pregnancy, or delivery was effected through the natural passages. It is only by a careful consideration of snch cases that we may be enabled to draw definite conclusions concerning the truth or fallacy of the oft-quoted dictum — " Once a Cesarean, always a CEesarean."

Our discussion is based tipon the study of 63 pregnancies occurring in 51 women who had previously been subjected to Cassarean section. Fifty-five of these pregnancies followed a single Caesarean section, while in eight there were two opera


tions. The manner in wliieh the pregnancies were terminated' was as follows :

A second or third Cesarean section was done in 45 cases.

Vaginal delivery occurred in 17 cases.

Rupture of the old Caesarean scar occurred in one case.

That the woman who has once been subjected to a Cssarean section, and who again becomes pregnant, presents an interesting and at the same time a somewhat puzzling problem has been generally recognized and frequently commented upon. Prior to 1876 the mortality following Cesarean section was appalling, from 50 to 60 per cent of the women dying from infection or hEemorrhage, but at the present day elective Caesarean section, performed under proper surroundings by men trained to recognize its indications, as well as its contraindications, should be attended by an immediate mortality of not more than one per cent. From an obstetrical point of view we cannot, with fairness, rest content with the immediate results, but must also consider what may happen in the subsequent pregnancies of such women. Eongy has estimated that approximately three per cent of all Caesarean section scars eventually rupture, and that at least one-half of such accidents terminate fatally. ISTotwithstanding this very definite menace, and completely ignoring the frequent warnings, which have been sounded by many vrriters in recent years, surgeons, gynecolo


94


[Xo. 373


gists, and obstetricians throughout the country are performing the operation with increasing frequency.

Proof that the uterine scar constitutes a locus minoris resistentuE in a cei-tain proportion of cases may be obtained by reviewing the hterature on rupture of the Cffisarean scar in subsequent pregnancies. Approximately 103 such cases have been reported and summarized by numerous authors. Thus, Wyss, in 1912, analyzed 4,3 cases, while four years later Bell, Schroeder, and Findley collected 79, 63, and 63 cases, respectively. To the 63 cases reported by the latter, Spalding, in 1917, added 12 others, which he had collected from the literature. Furthermore, Losee reported nine instances of partial or complete rupture in 1918, and since then Davis, DeCourcey, Howson, Freund. Novak, Baisch and Holland have reported additional cases. In addition to tlie occurrence of actual rupture, a number of cases have been reported in which the uterine scar was so attenuated that rupture would probably have occurred had the uterine distention not been relieved by operation, not to speak of those in which the rupture or extreme thinning of the scar was not recognized, or, if recognized, was not reported.

Naturally, the questions arise : Wliat is the causative factor in the production of the thin, imperfect scar, and what are the conditions predisposing to its rupture ? Numerous explanations and theories have been offered which may be roughly classified under the following headings :

1. Infection.

2. Improper suture technique.

3. Unsuitable suture material.

4. Location of the uterine incision.

5. Involvement of the placental site at operation.

6. Implantation of the placenta over the scar, with inversion of foetal elements.

7. Miscellaneous.

We shall consider each group in some detail.

1. Infection'

The important role played by infection in the production of an imperfect scar is so generally recognized that a case of rupture or extreme thinning is seldom reported without emphasis being laid upon the presence or absence of fever during tlie preceding puerperium. Losee asserts that " when infection takes place and the cut surfaces are infiltrated with leukocytes and serum, associated with more or less necrosis, then only that muscle tissue remains which has not become necrotic." The extreme necrosis which may take place in an infected wound is well illustrated by Fig. 1. Findley states that failure to secure perfect healing is partly due to septic infection of the wound, and calls attention to the possible existence of a latent gonorrhoeal infection, which " may defeat tlie most painstaking efforts to secure perfect wound healing." The character of the puerperium was noted in 66 of the 97 eases of rupture studied by Holland, who found that 51 were febrile and 13 afebrile. In commenting upon these figures, he asserts that "infection of the uterine wound may occur without rise of temperature, or with only a very slight one ; for example, few


will deny that the presence of extensive adhesions to the scar at a subsequent operation is evidence of sepsis duiing the healing process."

In our opinion the latter part of Holland's statement does not necessarily hold true, and it is permissible to suppose that adhesions may form in the absence of infection, whenever there is a rough, raw surface, such as occurs when the uterine wound has been improperly sutured. For example, in the first case reported in our series the wound had been closed with interrupted silkworm-gut sutures and the stiff knots had been left upon the surface. The puerperiimi was normal and the scar well-nigh perfect, but nevertheless was covered by dense adhesions. Consequently, if, as is likely, such adhesions resulted from irritation by the stiff knots, it behooves all operators to secure accurate coaptation between the cut edges and to do as little damage as possible to the covering serosa. It must be admitted that imperfect scars may result when the temperature has not been elevated, and in such cases some causative agent other than infection must be sought, wliile, on the other hand, a scar sufSeiently strong to withstand the strain of labor may result even thougli the record of an elevated temperature indicates that infection had occurred. Here it must be assumed that the infectious process did not involve the uterine incision, or, if it did, that no extensive necrosis resulted.

In the 183 Cesarean sections, which were done in the service up to the end of December, 1920, there was only one instance of actual rupture of the scar and in this patient the temperature had been elevated for 10 consecutive days following the primary operation. In 15 cases in which the uterus was removed later and studied, and in which we had definite information as to the character of the preceding puerperia, seven were found to be febrile and eight afebrile. In the first group, no trace of the sear could be found in six specimens, while it was only shghtly thinned in one. In the second group, the sear could not be located in three instances, while the healing was good in three, fair in one, and poor in one case. Jloreover, in three cases the uterus was removed at the third section, so that in such specimens we can only speculate as to which operation had given rise to the scar in question. Of the 13 patients in whom delivery was effected through the natural passages following Csesarean section, six presented a preceding febrile puerperium.

Such figures, while suggestive, only serve to show how difficult it is to predict the strength or weakness of the Cfesarean scar in the individual case. However, it would seem permissible to infer that the uterine scar will be weak rather than strong if frank infection has occurred in the preceding puerperium, and that such patients should not be subjected to the strain of a prolonged labor, particularly if the original section has been performed on account of pelvic dystocia. On the other hand, when it has been done for some temporary indication, or if there is only moderate pelvic contraction with a small child, even though fever has complicated the former puerperium, we believe that tlie patient may be allowed to go into subsequent labor, provided that she be kept under careful observation. This view is at variance with that recently expressed by Newell : " It [repeated Csesarean section] should, however.


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95


be considered obligatory in patients who give a history of a febrile convalescence, since this points to the probability of uterine infection, and it is in these patients that the rupture of tlie scar in subsequent pregnancies and labors is most to be feared."

3. SuTUEE Technique

HuiTied closure of the uterine incision without due care in accurately approximating the cut surfaces, the placing of the sutures too widely apart, and the inclusion of the decidua in the line of sutures may all be factors in producing an imperfect scar. In this clinic the incision is closed with two layers of catgut, the first consisting of deep buried interrupted sutures placed at intervals of about 1 cm., while a superficial running suture brings together the serosal edges. If, after the first layer of sutures has been placed, there is still considerable gaping of the niuscularis, an additional continuous buried suture is used. The decidua should be avoided, since any bits of it inverted into the wound may proliferate and develop into areas of unusual friability. Figs. 3 and 3 illustrate the technique.

Fischer, in 1912, directed attention to the danger of suturing the uterus before it has firmly contracted and retracted, and consequently Green, in 1916, advised that the operation should not be undertaken until labor had been in progress for several hours. " It stands to reason," he says, " that the scar will be thicker and stronger if the closing sutures are applied to a uterine wall thickened by several hours of contractions, than when placed in the thin, comparatively flabby wall of a uterus incised before labor has begun." Apparently the rationale of this theory rests upon a mechanical basis; for, if the sutures be laid and tightly tied while the musculature is lax, it is conceivable that when the uterine wall increases in thickness as the result of subsequent contraction, the sutures will either become untied, or else they will tear through the thickened tissue. In the latter event a gap may be left on the inner surface of the uterus, which is invaded by endometrium. Unfortunately, however, it is not always possible to wait for the occurrence of firm contraction, as brisk hsemorrhage may necessitate immediate suturing of the wound. Figs. 4 and 5 illustrate the assumed sequence of events.

Analysis of the operative notes concerning the first operation in our patients, from whom the uterus was removed at a subsequent section and its scar studied microscopically, shows that the cliaracter of the uterine contraction was recorded in 11 instances. In eight, firm contraction had occurred before the sutures were placed, and in five of these the scar was normal or could not be found, while in the three others definite thinning was evident. In one of the latter the convalescence was complicated by an outspoken infection, so that it is difficult to determine whether the infection or the slow muscular contraction had played the more important part. On the other hand, in the three instances of poor contraction, there was no trace of the scar in two, while it was very thin in the third case. Moreover, in the one instance in which the old scar ruptured in a subsequent pregnancy, it had been necessary to suture the uterus while its musculature was lax.


It must be admitted that the figures available are too few to permit final conclusions, but they clearly indicate that suture of the uterus after firm contraction has occurred does not necessarily insure an ideal scar.

3. Suture Mateeial

The fact that a wide variety of suture material has been used in closing the uterine incision is sufficient proof that none is entirely satisfactory from every point of view. Plain, formic, and chromicized catgut, silkwonn-gut, kangaroo tendon, ordinary black or white silk, metallic wire, etc., have been employed at one time or another. Plain catgut has generally been discarded on account of its rapid absorbability, although Carstens advocates it for that very reason.

In our hands chromic catgut has given relatively satisfactory results. Holland, on the contrary, believes that it is also absorbed more rapidly than is desirable, particularly in the presence of infection. Upon the analysis of a large number of cases, he found that subsequent rupture occurred two and a half times more frequently after the use of catgut than of silk. Consequently, he is of the opinion that non-absorbable sutures are preferable, and holds that silkworm-gut fulfills the requirements most satisfactorily. Plain silk is a notorious harborer of bacteria, as is admirably illustrated by Case X below. Prusmann objects to non-absorbable sutures on the ground that small channels may be formed about them, and as these may be invaded by bacteria or even by endometrium, necrosis or weakening of the scar may result. Eckstein, in 1904, indicated the advantages of metallic sutures, and suggested the use of thin flat bands of lead, wliich, in addition to being non-absorbable, would serve as supports for the scar in future pregnancies.

In our series of operations silkworm-gut was used only in a single instance, and the resulting scar was ideal. Wlien the uterus was removed a year later, the sutures were still in situ (Fig. 6), but, as has been mentioned previously, dense adhesions had developed along the entire length of the scar, probably as the result of the knots irritating the surrounding tissues. It would seem, therefore, that when this material is used the sutures should be buried, and the superficial muscle layer and peritoneum brought together with catgut over it.

Obviously, the choice of suture material is at present a matter of personal preference, and no definite statement can be made as to which possesses the greatest merit. To my mind, the technique used in laying the sutures is of greater importance than the material of which they are composed.

4. Situation" of the Incision At a Caesarean section the uterus may be incised in any one of the following four locations; (1) in the midline of the anterior wall; (3) in the posterior wall; (3) in the fundus, either transversely or longitudinally; and (4) in the lower uterine segment, likewise either longitudinally or transversely. In the last group may be included those cases of vaginal hysterotomy, in which the lower uterine segment becomes involved in the incision. "Without doubt, in the great majority


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[No. 373


of cases the median anterior wall is the site of election, although in recent years there has been a growing tendency to advocate incision of the lower segment. The uterus is opened through the posterior wall only in the rare instances in which its body has undergone extreme forward displacement.

Varying results have been obtained with the several modes of incision and a voluminous literature has accumulated upon the subject. In 1897, Fritsch described his transverse fundal incision, which has been discarded after a number of years of experimentation. Eckstein, in 1904, reported the first case •of rupture of a fundal scar in a subsequent pregnancy, and following it mmierous similar reports have appeared in the literature. SchefEzek called attention to the fact that in order to secure perfect healing of any wound, its edges should be immobilized, and admitted the impossibility of keeping the actively contracting and relaxing uterus entirely at rest. Furthermore, he pointed out that the fundal incision approached the ideal even less than one through the median wall or the lower uterine segment. In proof of this he reported the findings at autopsy upon a woman who had died from a toxEemia several days after a Caesarean section, which showed that the sutures in the fundal wound had become loosened or entirely untied, presumably as the result of active uterine contractions. By way of contrast, he also reported his observations upon 10 women who had been subjected to extraperitoneal Caesarean section. In five of them repeated section was necessary ; while of the other five, one was delivered spontaneously, and in four labor was induced in the latter part of pregnancy. In each instance the uterine scar remained intact, although in one the pains continued for 68 hours before delivery was effected. Consequently, he concluded that the scar is much more resistent after extraperitoneal section than after either the fundal or median incision. Spalding holds that " the extraperitoneal Caesarean section carries with it a better prognosis than the classical abdominal operation." Furthermore, Holland concluded that transverse fundal scars are especially liable to rupture, and Offerman, in 1916, collected 21 such accidents from the literature. In addition to this unusual liability to rupture, he feels that adhesions are especially prone to occur, and that in those cases in which infection of the uterine wound occurs, drainage will be into the abdominal cavity rather than through the abdominal wound, thereby materially decreasing the chances for recovery.

Fischer has described in detail two uteri which had been subjected to previous fundal incisions. In one a complete rupture of the scar occurred in a subsequent pregnancy, while in the other it was so thin that rupture would have undoubtedly occurred had labor not been terminated by operation. From this experience he is convinced that the fundal incision should not be used. Findley has gone even further, and says that " the transverse fundal, extraperitoneal, and cervical incisions have not lessened the liability of rupture in subsequent labors, but on the other hand have probably increased the hazard."

Since our experience with the extraperitoneal and cervical incisions has been limited to four cases, we do not feel quali


fied to make definite statements concerning their comparative merits. In none of our cases did rupture occur, although in one instance the woman subsequently went tlirough a moderately severe spontaneous labor. Moreover, in two of the uteri which were removed at a subsequent section, examination revealed no trace of the old scar. Kohrbach claims that the scar following the cervical operation practically insures against danger of rupture in future pregnancies, and it is undoubtedly true that only a few instances of this accident have been reported. It must, however, be admitted that this is too favorable a verdict, as Wolff, Franz, Freund and Labhardt have each described cases of rupture. Baisch, in 1920, reviewed the results following 170 Caesarean sections in the Stuttgart clinic, and attributed the good results to the emploj-ment ot the transperitoneal cervical operation. Twenty-four of hu patients had repeated sections, and in three rupture of the uterus occurred. In the first case it was vmquestionably through the old cervical scar; while in the other two he attempts to prove that it was not. In the second case, although the rupture involved the scar, he argues that it had originated in the body of the uterus, as at the first operation the incision had torn upward during extraction of the child so that only a part of it could be covered with the bladder. In the third case the patient had a bicomate uterus in which three pregnancies had occurred. The first was terminated by a transverse fundal incision, the second by a cervical incision, while the third terminated by rupture. On opening the abdominal cavity at that time he found that the cicatrix of the first operation had yielded, while the one in the lower segment was intact. He considers this an excellent demonstration of the superiority of the cen'ical operation. We, however, cannot agree with his contention; for, even accepting his argument concerning the second case, which appears questionable, he admits one cervical rupture in 24 repeated sections, which is somewhat higher than the 3 per cent incidence following the usual incision.

Before concluding the consideration of the location of the uterine incision, I shall refer to two cases of repeated Caesarean section wliich possess points of unusual interest, one reported by Planchu, the other by Harrar. In the former, the three linear scars were plainly visible in the anterior median line at the time the fourth consecutive section was performed. They were equidistant and approximately at the same level and were included in a broad band of thinning — 2.5 cm. wide, where the muscle had been replaced in large part by fibrous tissue. An explanation of the mode of production of such a condition is afllorded by Harrar's case. Here the uterus had ruptured after a third Caesarean section, and upon examining the specimen he found that the line of rupture did not involve an old incision but had occurred between two of them. As the distance between the scars was one centimeter, he inferred that a danger zone had been created at the previous operations by cutting the tropliic nerves and tliereby interfering with the blood supply in that neighborhood. To obviate such a danger he urges that in a repeated Cajsarean section the inci


March, 1922]


siou should be made some- distance away from the old scar, or else that the latter should be completely resected.

5. Incision into the Placental Site Writers upon the subject have advanced two reasons for assuming when the uterine incision involves the placental site that the resulting scar will, in some cases, be thinner than it would have been had the incision been elsewhere. First, as the thickness of the uterine wall at the placental site is several millimeters less than elsewhere, it is argued that the scar will be thinned in like proportion. Second, the foetal elements may interfere in the healing process. The latter view is held, in a general way, by Spalding, Fischer, and others. However, they, and practically all observers, believe that this is only an accessory factor of no great importance.

For the purpose of determining what relation, if any, incision through the placental site has upon the healing of the uterine wound, I have divided our cases into two groups. The first includes those in which the location of the placenta was noted at the first operation and in which the uterus was removed at a subsequent section and studied histologically; while the second includes patients who were delivered by the natural passages following a preceding section in our clinic. The former group includes 17 specimens, and the latter six cases. In the first group the incision involved the placental site in seven instances, and of these, two uteri showed no trace of the scar, in two there was very slight thinning, while in the remaining three the thinning was quite marked. In the 10 instances in which the placental site was not involved, no trace of the scar was visible in three, it was satisfactory in six, and was poor in one uterus. In the second group the placental site had been incised in two patients, and not in the other four. It may be added that in the single instance of rupture occurring in our series and reported below, the operative note concerning the first section failed to mention the location of the placenta.

From these figures the hasty observer might be led to the conclusion that a definite relation exists between imperfect healing of the scar and the involvement of the placental site at operation. Our observations do not prove it. and in addition it should be remembered that such few figures as are available do not justify binding conclusions. Consequently, we can only say that our findings merely point to the necessity of closer ol)servation of the influence of this factor in the future.

6. Implantation of the Placenta over the Old Scar Eckstein, in reporting his case of ruptured Cfesarean scar, laid particular emphasis upon the insertion of the placenta over the old scar as a probable cause of the rupture. He assumed that the foetal elements invaded and weakened the scar, much in the same way as occurs in tubal pregnancy. Spalding states that "while it is plausible that the placental elements might lead to poor healing of the wound in cases where the incision is into the placental site, there is hardly


sufficient evidence available to uphold the idea that the syncytium will attack sound scar tissue any more than it will attack sound uterine tissue." Consequently, he believes that the placenta, when inserted over the scar, may even act as a splint and serve to support the weakened uterine wall. At the same time he calls attention to the possibility that the formation of small retroplacental ha?matomata may eventually cause the rupture of the scar as they grow larger. In 1906, Couvelaire reported a series of nine cases of ruptured Csesarean scar and stated that in five of the six instances in which the placental attachment had been noted, implantation had occurred over the old scar. He therefore concluded that the insertion of the placenta over the scar cannot be considered the sole cause of rupture, but that when it is already thin its invasion by foetal elements must lead to further thinning and accentuation of its friability.

Our observations concerning the bearing of this factor indicate that it is not important. Strange to say, in each of the three uteri which had been removed after two previous sections the placenta at the third operation was implanted over the old scar. In the first case, both scars were seen and were quite thin; in the second, only one scar was visible and it, likewise, was considerably thinned ; while in the third, neither scar was visible. In 17 uteri which had been removed at the second operation, the placenta was implanted over the scar in three. In two of these the scar of the previous section could not be found, while it was well healed in the third uterus. Furthermore, in the one case of rupture the placenta was inserted over the old scar, but in none of these cases was there any evidence that the scar had been invaded by foetal elements.

7. Miscellaneous

(a) Excessive Distention of the Uterus. — In the cases of rupture reported by Woyer, Couvelaire, and Scheffzek, the presence of hydramnios or multiple pregnancy had subjected the uterus to abnormal distention, which was assumed by these authors to have been a predisposing factor. On the other hand, Gilles, in 1916, reported the successful termination of a twin pregnancy without rupture of the uterus, in spite of two previous Cajsarean sections. The combined weight of the two children was 4950 grams.

(b) Forcible Intrauterine Maniiiulations. — Version and extraction, the use of hydrostatic bags, uterine tampons, etc., have been mentioned as possible causes of rupture, although it is only in cases of marked thinning of the scar that such factors are of any importance.

(c) " Water-Wedge Theory." — Spalding, in attempting to explain the rupture of the scar in a certain percentage of cases, advanced the theory that a small water-wedge formed by the amniotic sac may serve to dilate the thinned-out scar in exactly the same way that the bag of waters brings about dilatation of the cervix in normal labor.

Before passing on to the consideration of the anatomy of the Caesarean scar, we shall refer to several investigations concerning its resistance, and then say a few words concerning the incidence of adhesions and their mode of production. In 1910,


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Mason and Williams studied the resistance of the Cassarean scar experimentally. They subjected a number of pregnant animals to Caesarean section and some time later removed the uterus for investigation. They attached weights to a strip of muscle containing the scar and increased them until rupture occurred, when it was found that it took place through the sound muscle and not through the scar itself. Their experiments gave such uniform results that they drew the conclusion " that a firmly united scar is even stronger than the intact uterine muscle and should easily be able to withstand any strain which the latter is capable of bearing." Moreover, the case reported by Harrar demonstrated that the normal muscle tissue may jaeld before the cicatrix, although the myometrium in that instance was regarded as having become " devitalized." As anatomical study of the well healed scar shows no reason why it should rupture before the surrounding muscle, it is probable that the statement of Mason and Williams holds true for a " firmly vmited scar." In the thin, poorly healed wound, on the other handj there can be little doubt that the rupture occurs directly through the scar and not through the adjacent tissue.

Adhesioxs

That adliesions are quite common following Caesarean section is clearly demonstrated by the following observations made in our clinic at repeated operations.



TABLE I






Atlhe


sions



Dense Filmy


Moticr- [ No ate 1 note



17 7 6 1


1 4


After two previous sections


(I



TABLE II






I'lierperium



Febrile


Afebrile


Dense adhesions


S

1







Xo note


1


Table II illustrates the fact that while adliesions are more commonly formed after a febrile puerperium, yet the absence of fever does not necessarily mean that adhesions have not formed.

It is difficult to determine just how much harm such adhesions do. Doubtless, they may give rise to considerable abdominal discomfort, which may occasionally be so great as to necessitate a second operation; and Humpstone reports an instance in which it was necessary to remove the uterus


before the symptoms disappeared. In other patients the adhesions may be so dense that the subsequent operation is performed under tremendous difficulties, and in rare instances regrettable accidents, such as injury to the gut or bladder, can be directly traced to their presence. For example, in Case XIX described below, after the adhesions had been freed, the anterior surface of the uterus presented such an extensive raw bleeding area that hysterectomy was necessary.

Can the formation of adhesions be prevented? Davis has suggested that the hability toward their development may be lessened by resorting to the high abdominal incision. This, however, is a mere supposition, and inasmuch as the advantages of the lower incision are so great, we do not feel that it should be discarded in favor of the higher one. Consequently, it seems that the only way at present by which we can lessen the incidence of adhesions in the absence of infection is by securing as perfect coaptation between the cut surfaces as possible, thereby leaving a minimal area which can excite mechanical irritation.

Anatomy of the Cesarean Section Scab For convenience in description Csesarean scars may be divided into two main groups: first, those which have ruptured or were on the point of rupturing when the abdomen was opened; second, those in wliich satisfactory union has persisted.

As Losee and also Couvelaire have pointed out, the first step in the mechanical healing of the uterine scar is the deposition of fibrin between the edges of the wound, wliich acts as a framework for the ingrowing tissue which will eventually determine the character of the cicatrix. In spite of the constant contraction and relaxation of the uterus, if infection is absent, and the sutures have been so laid that the edges of the incision remain approximated, firm union will almost invariably result. On the other hand, if there is necrosis due to infection, or if the sutures tear through, leaving a gaping wound, there is an ingrowth of endometrium, which may involve almost the entire thickness of the wound. Such a scar, when seen in a subsequent pregnancy, is made up almost entirely of decidua and peritoneum, and its gross appearance in the unopened distended iiterus is characteristic. Instead of the vertical shallow depression seen in the more perfectly healed scars, it is represented by a glistening translucent band of tissue which bulges outward beyond the general surface; while after the uterus has been emptied, hardened, and cut in ci'oss-section, the scar is marked by very deep depressions on both the outer and inner surfaces of the uterus. On microscopical examination it will be found that it is composed almost entirely of thickened and highly vascularized serosa overlying the decidua. There is an increase in the fibrous tissue and a definite decrease in the elastic fibres, while occasionally a few muscle fibres may be present.

Between a scar of this nature and one wliich has healed perfectly all gradations may be observed in so far as gross appearance and thickness are concerned. Nor is the microscopical picture markedly different in the thin scnr as con


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trasted with the well healed one, except when there has been no muscular union. Figs. 7, 8 and 10 depict the characteristic appearance of well healed scars, while Fig. 9 (A) shows a scar which is considerably thinner than the other three. In all there is a slight depression both upon the inner and outer surfaces of the uterus, while the cicatrix itself appears as a white Une joining the two depressions. Unless such scars are examined under the microscope, one is apt to infer that they are made up of fibrous tissue alone. Such, however, is not the case, and in all four specimens muscle fibres can be seen running directly across the old line of incision, with no break in their continuity and with only slight distortion of their course.

Jolly and others have reported instances of partial rupture of the old Cesarean scar. Upon studying such specimens in detail, they found that one portion of the scar was composed solely of decidua and peritoneum, while the rest was made up of normal muscle. Similar variations in thickness throughout the length of the same scar are well illustrated by Figs. 15 and 16, which are photographs from the two sides of a block one centimeter thick, and show that within so short a distance the thickness of the scar may be doubled.

Briefly then, Csesarean section scars vary considerably in thickness, depending upon the accuracy with which the margins of the wound have been brought into apposition. Under ideal conditions the muscle unites perfectly, and its fibres cross the site of the incision as if it had never been made. Wlien, however, there has been no muscle union, the scar is made up solely of decidua and peritoneum. Most scars are marked by funnel-shaped depressions on the outer and inner surfaces of tlie uterus. The muscle bundles are not much distorted, the formation of fibrous tissue is much less than would be anticipated, and when it is increased, the elastic fibres are correspondingly diminished in number. (See Fig. 7.)

Fig. 7, which represents a low power microscopic picture, gives an idea of the characteristic conditions obtaining in a wfeU healed wound, while the photographs accompanying some of the case reports clearly depict some of the gross variations which may be encountered.

In the case reports which immediately follow, we shall describe the gross appearance and microscopic structure of the Cesarean scar as it appeared in 21 uteri which were removed at a second or third section, and which will serve to amplify and reinforce what has already been said.

Case Eeports and Description of Specimens' In the following cases the uterus was either removed at operation or secured at autopsy. A brief clinical synopsis precedes the more detailed description of the specimen.

Case I.— House No. 1274, 24 years, black. Generally contracted rhachitic pelvis, D. C. 10.5 cm.

Three vaginal deliveries. Fourth labor ended by Cassarean section after a second stage of three hours. Child dead — 41S0 gm. Incision through the placental site; closure with interrupted silkworm-gut sutures. Puei-perium normal except for a rise of temperature to 100.4° on the second day. Fifth labor ended by Csesarean section followed by supravaginal amputation of the uterus. Uneventful recovery.


Omental adhesions, placenta on posterior wall. No note as to the condition of the cicatrix before the incision of the uterus.

Description of Specimen. — After hardening, the uterus measures 14x12x10 cm. On the midline of its anterior surface is a mass of adhesions, evidently over the scar of the previous operation. On removing them, a linear depression 8 cm. long becomes visible, with the silkworm-gut sutures still in place. (Fig. 6.) On cross-section through the uterus the scar is represented by depressions on its inner and outer surfaces, which are joined by an irregular whitish line (Fig. 8). The uterine wall is 11 mm. thick at the site of the scar, as compared with 17 mm. adjacent to it, a ratio of 1 to 1.54. On microscopical examination no trace of the scar is seen except for the funnel-shaped depressions and a slight irregularity in the arrangement of the muscle fibers. The external depression is filled with highly vascularized connective tissue, while the inner one is lined with decidua containing many glands. In the center of the scar is a small island of characteristic decidual tissue. The Weigert stain shows a decrease in the elastic tissue at the site of the scar.

Case II. — House No. 7145, 27 years, black. Generally contracted rhachitic pelvis, D. C. 8.75 cm.

First labor, spontaneous, premature; second, pubiotomy. The third and fourth pregnancies were ended by Csesarean section with silk sutures. Ideal recovery after both operations except for a mastitis in the fourth puerperium. The placenta was on the posterior wall in the first, and on the anterior wall in the second section. The fifth pregnancy ended in a 3 months' abortion, and the sixth was terminated by a Porro section. Puerperium normal except for a mastitis. There were dense adhesions between the uterus and anterior abdominal wall, but no traces of the cicatrices of the previous Caesarean sections were visible. The placenta lay anteriorly.

Description oj Specimen. — After hardening, the uterus measures 10 X 11 X 8 cm. Numerous dense adhesions are present over its anterior surface. On either side of the present incision is a vertical depression apparently corresponding to the scars of the previous operations. On cross-section, the scars are clearly visible and are represented by the typical funnel-shaped depressions on the outer and inner walls (Fig. 9). The scar on the left is 6 mm. thick, while the adjacent uterine wall is 23 mm., a ratio of 1 to 4. On the right side the scar is 11 mm. thick, a ratio of 1 to 2. On microscopical examination, except for the thinning of the uterine wall, there is little to indicate the location of the former incisions. There is no scar tissue and the muscle fibers run directly across from side to side. The inner depressions are lined with decidua, while the outer ones are filled with thickened scar-like peritoneum. The elastic fibers are decreased. It is impossible to say which scar belongs to the first and which to the second operation. One is almost twice as thick as the other, and the only factor noted at either operation that might have influenced the healing was the poor contraction of the uterus at the first section.

Case III. — House No. 6540, 22 years, black. Generally contracted rhachitic pelvis, D. C. 9.5 cm.

The first pregnancy ended by a conservative Caesarean section. The placenta lay posteriorly, the uterus contracted firmly, and the incision was closed with catgut. The puerperium was febrile for five days. The second labor was spontaneous premature at seven months. The third pregnancy was terminated by a Porro section, the operation being performed 19 hours after the onset of labor. There were Several dense adhesions between the uterus and the anterior abdominal wall; the placenta was inserted posteriorly; the puerperium was normal. The scar of the previous section was not noted at the time of the operation.

Description oj Specimen. — After hardening, the uterus measures 17x12x9 cm. The posterior surface is free except for a few velamentous adhesions. On its anterior surface the scar of the previous operation is indicated by a deep depression, from the lower angle of which a broad adhesion extends down to the free peritoneal margin. On cross-section (Fig. 10), the scar is represented by funnel-shaped


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depressions on both the outer and inner surfaces of the uterus. Joining them is a white puckered hne resembling scar tissue. The uterine wall measures 28 mm. in thickness, while the scar is 22 mm. thick, a ratio of 1 to 1.36. On microscopical examination the only trace of scar consists in a slight irregularity in the arrangement of the muscle fibers and some increase in the fibrous tissue. The elastic tissue is decreased.

Case IV.— House No. 6S47, 24 years, black. Generally contracted rhachitic pelvic, D. C. 9.25 cm.

First pregnancy ended by a conservative Cffisarean section. The placental site was incised, the uterus contracted firmly, and closure was with catgut. Puerperium uncomplicated.

Second pregnancy ended by a Porro section. Two broad adhesions attached the anterior surface of the uterus to the abdominal wall. The placenta lay posteriorly. No sign of the old uterine scar. Puerperium normal.

Description oj Specimen. — After hardening, the uterus measures 19 X 13 X 10 cm. Two broad bands of adhesions on the anterior surface. Careful examination, grossly and microscopically, shows no trace of the old scar. '^

Case V. — House No. 6939, 18 years, black. Generally contracted rhachitic pelvis, D. C. 1025 cm.

First pregnancy • ended by a conservative Csesarean section. Placental site not incised; closure with catgut. The character of the uterine contraction not recorded. The puerperium was complicated by wound infection, the temperature being elevated for 15 days. The second pregnane}' was terminated by a Porro Csesarean section. In attempts to extract the child through too small an incision, the uterus was torn down to the bladder and into the right broad ligament, necessitating its removal. The placenta was inserted posteriorly. The puerperium was normal except for a simple mastitis.

Description oj Specimen. — After hardening, the uterus measures 15 X 12 X 10 cm. The surfaces are free from adhesions and there is no trace of the old scar.

Case VI. — House No. 6076, 23 years, white. Generally contracted rhachitic pelvis, D. C. 10 cm.

The history of the first two labors is meagre. Both were instrumental and both children were stillborn. The third labor was terminated by a conservative Csesarean section. The placental site was not involved, the uterine contraction was poor and closure was with catgut. Puerperium febrile for six days. Fourth labor ended by a Porro section. There were a few filmy adhesions on the anterior surface of the uterus. The placenta lay posteriorly. Puerperium normal.

Description of Specimen. — After hardening, the uterus measures

14 X 14 X 8 cm. A few thin adhesions cover its anterior surface, in the midline of which is a smooth shallow depression indicating the site of the previous operation. On cross-section, except for this depression and a similar one on the inner surface, there is no trace of the scar. The uterine wall measures 26 mm. in thickness, the scar 23 mm., a ratio of 1 to 1.13. Microscopically there is no sign of scar tissue, and the muscle bundles show complete regeneration.

Case VII. — House No. 8087, 29 years, black. Generally contracted rhachitic pelvis, D. C. 8.5 cm.

The first and second labors were ended by a conservative Cesarean section and a destructive operation, respectively, both operations being performed elsewhere. The third pregnancy was terminated by a Porro section. Several loops of gut were densely adherent to the anterior abdominal wall and anterior surface of the uterus. The placenta was inserted posteriorly. Puerperium normal.

Description of Specirnen.—Aiter hardening, the uterus measures

15 X 16x7 cm. On the anterior surface is a depressed raw area, representing that portion which was covered by adhesions, the latter overlying the scar of the previous operation. On cross-section, the scar is represented by shallow depressions on the outer and inner surfaces of


the uterus. The thickness of the scar is 19 mm., that of the adjacent wall, 25 mm., a ratio of 1 to 1.3. Microscopically, the inner depression is seen to be filled with decidua, while the outer is fined with vascular serosa. The muscle fibers run directly across the line of the former incision without break in continuity. There is no increase in fibrous tissue.

Case VIII. — House No. 8137, 31 years, black. Generally contracted rhachitic pelvis, D. C. 9.5 cm.

The first pregnancy was terminated by a conservative Csesarean section. The placental site was incised, the uterus contracted firmly; closure with catgut. Puerperium normal. Second labor ended by a destructive operation elsewhere. Third labor ended by a Porro section. There were a few thin omental adhesions on the anterior surface of the uterus, but no sign of the previous scar. Placenta inserted posteriorly. Puerperium normal.

Description of Specimen. — After hardening, the uterus measures 16 x 14 X 6.5 cm. Upon the anterior wall, half a centimeter lateral from the present incision is a slight vertical depression, 2 mm. deep, and 4 cm. in length. On cross-section, the usual funnel-shaped depressions are seen on the outer and inner surfaces. The scar measures 18 mm. in thickness, the adjacent uterine wall, 22 mm., a ratio of 1 to 12. Microscopically, no trace of the scar can be found except for the depressions just mentioned. There is no increase in fibrous tissue.

Case IX. — House No. 8332, 21 years, black. Generally contracted rhachitic pelvis, D. C. 9.5 cm.

The fii-st pregnane}' was terminated by a conservative Csesarean section. The site of the placental attachment was not recorded; uterine contraction poor; closure with catgut. Puerperium normal. A conservative Csesarean section ended the second pregnancy. There were numerous filmy adhesions near the fundus, while lower down was a single broad adhesion running to the old abdominal scar. The placental site was incised, the uterus contracted firmly, and closure was with catgut. The scar of the previous operation was not visible. The puerperium was complicated by infection. The abdominal wound broke down on the sixth day, and a sinus developed which extended well down into the uterus. A pelvic abscess was opened and drained through the vagina on the seventeenth day. The third pregnancy was terminated by a Porro section. Dense adhesions covered the entire anterior siirface of the uterus. The placenta lay anteriorly. Puerperium normal.

Description of Specimen. — After hardening, the uterus measures 15 X 13 X 6 cm. The present incision lies to the left of the midline. The entire anterior surface presents a ragged appearance due to adhesions. In the midline the scar of one of the previous operations is marked by a slight depression. On cross-section there is a similar, though much deeper, depression on the inner surface, but there is no trace of a second scar. The scar is 20 mm. in thickness; of this, 4 mm. is made up of fibrous peritoneal tissue, 4 mm. of muscle, and 12 mm. of a triangular wedge of decidua. The adjacent uterine wall measures 22 mm. On microscopical examination it is seen that, although there has been some muscle reunion, the individual bundles are greatly distorted, with a marked increase in the fibrous tissue in its locality. Presumably this scar is the result of the second operation.

Case X. — House No. 8679, 24 years, black. Generally contracted rhachitic pelvis, D. C. 1025 cm.

The first pregnancy was terminated by a conservative Cssarean section elsewhere. Three years later the patient was admitted to the surgical service of this hospital with the following historv-: Fifteen months after the Csesarean section the abdominal wound began to drain, the discharge consisting mainly of blood, but occasionally containing pus. A sinus tract, which extended down into the uterine cavity, was dissected out, and a number of hea\'>- black silk sutures were removed from the uterine wall. Recovery was uneventful. Sixteen months later the second pregnancy was terminated by a Porro section. A few thin omental adhesions were attached to the anterior


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surface of the uterus. Placenta posterior. Puerperium normal except for a simple mastitis. ,

Description of Specimen. — After hardening, the uterus measures 13 X 10 X 7 em. To the left of the present incision is a slightly depressed area 2 mm. wide, and 7 cm. long, which apparently represents the old scar. On cross-section, however, there is no depression on the inner surface of the uterus, and microscopically no trace of the scar can be found.

Case XI. — House No. SS26, 24 years, black. Generally contracted rhachitic pelvis, D. C. 9.75 cm.

The first labor ended spontaneously after 30 hours, the child being stillborn. The second pregnancy was terminated by a conservative Caesarean section. The placental site was incised, the character of the uterine contraction was not recorded; closure with catgut. Temperature elevated to 101.4° on the second day. The third pregnancy was also ended by a conservative Caesarean section. Several loops of small intestine were adherent to the abdominal scar and one of them was accidentally opened. It was repaired at once with silk. The omentum was adherent to the fundus. The placental site was incised, the character of the uterine contraction was not recorded; closure with catgut. Puerperium normal. The fourth labor was terminated by a third Caesarean section and sterilization effected by resection of the tubes. Again an adherent loop of gut was opened, and was repaired with silk. A few omental adhesions covered the fundus. The placental site was incised, the uterus contracted well; closure with catgut.

On the third day of the puerperium the abdominal wound broke down, exposing the anterior surface of the uterus. This was covered with small glistening blebs filled with gas. A drain was inserted and the wound closed with silkworm-gut. Cultures of the wound showed B. aerogenes capsulatus, B. coli, Staphylococcus aureus, and streptococci. The patient died 12 hours later and autopsy showed a generalized peritonitis (gas bacillus) ; haemorrhage from the uterine incision; diphtheritic colitis; epithelial necrosis of the kidneys.

Description oj Specimen. — After hardening, the uterus measures 17x12x6 cm. On the anterior surface is a depressed area, more or less covered by fine adhesions, corresponding to the partially broken down wound of the recent operation. Several of the catgut sutures have become untied, and for a distance of 2 cm. at the upper angle of the incision there has been complete separation of its edges. On cross-section (Fig. 11), it is seen that the cut surfaces are covered by necrotic tissue and at no place is there any sign of firm union. The scars of the previous operations are not visible. Microscopical examination shows that the decidua has been replaced, in large part, by fibrin, leucocytes, and necrotic tissue. The musculature presents a pecuhar areolated appearance due to the formation of gas pockets. In many places the individual muscle cells are undergoing degeneration. There is no evidence of beginning muscular union.

Case XII. — House No. 9115, 19 years, black. Pelvis normal.

The first pregnacy was terminated elsewhere by a Cxsarean section, the indication being " convulsions." The patient was admitted to this hospital in the eighth month of her second pregnancy. Blood pressure 180; the urine contained 3 gm. of albumin per hter. Labor was induced by means of a bougie. After pains had lasted for 12 hours, the patient had her first convulsion, followed in a few minutes by a second. As the cervix was still undilated and the child dead, it was decided to remove the uterus unopened. The omentum was adherent to the anterior surface of the uterus. Puerperium febrile.

Description oj Specimen. — After hardening, the uterus measures 22x16x13 cm. On the anterior surface are a few thin adhesions. No trace of the old scar. On crosa-section the placenta is found to lie anteriorly. There is no sign of the usual depressions which so frequently represent the hne of former incision. Microscopical examination shows no increase in fibrous tissue. The Weigert stain shows the presence of large numbers of streptococci in the decidua, thus


demonstrating the wisdom of removing the uterus, rather than being content with a conservative operation.

Case XIIL— House No. 9323, 33 years, black. Generally contracted rhachitic pelvis, D. C. 9 cm.

The first pregnancy ended in a spontaneous abortion at the third month, the second in a conser\'ative Caesarean section. The placenta lay posteriorly; character of the uterine contractions not recorded; closure with catgut. The puerperium was febrile for the first three days. The third pregnancy was terminated by a Poito section, the vulva being so completely covered by a foul, sloughing mass of condylomata that a conservative operation would have almost certainl}' been attended by infection. There were no adhesions, and the placenta lay beneath the old scar. Puerperium normal.

Description oj Specimen. — After hardening, the uterus measures 15x11x6 cm. Extending from the fundus downward for a distance of 10 cm., and with its lower half slightly to the right of the present incision, is a vertical depression, representing the scar of the previous operation. It averages 1.5 cm. in width, and its deepest portion lies 0.5 cm. beneath the general surface (Fig. 11). It presents a number of transverse depressions, w-hich are apparently due to the individual sutures. On cross-section (Fig. 12) the scar is marked by typical depressions on both surfaces, whose tips are 16 mm. apart, as compared with 25 mm. in the adjacent uterine wall, a ratio of 1 to 1.59. On microscopical examination there is considerable distortion of the individual muscle bundles, although they definitely run from side to side without break. There is no increase in the fibrous tissue.

Case XIV. — House No. 9539, 24 years, black. Generally contracted rhachitic pelvic, D. C. 8 cm.

First pregnancy terminated by conservative Caesarean section elsewhere. She was admitted in her second pregnancy, after having been in labor for 30 hours with numerous vaginal examinations. A Porro section was done with difficulty on account of dense adhesions between the lower angle of the abdominal scar and the anterior surface of the uterus. The scar of the previous Caesarean was not visible before the uterus was opened. The placenta lay posteriorly. Puerperium febrile.

Description oj Specimen. — After hardening, the uterus measures 15 X 12 X 8 cm. Externally the scar is represented by a very slight depression along the upper third of the anterior wall. On cross-section (Fig. 13) the uterine cavity presents a triangular appearance, the base being formed by the posterior wall and the apex by the fimnel-shaped depression on the inner surface of the anterior wall. Upon microscopical examination no trace of scar tissue can be found and the muscle fibers at the site of the scar are only very slightly disarranged.

Case XV. — House No. 9530, 31 years, white. Simple flat pelvis, D. C. 10.75 cm.

In the first pregnancy the child was delivered by pubiotomy after a second stage of 14 hours, the D. C. at that time measuring 9.75 cm. The second pregnancy was terminated by a conservative Caesarean section with an uneventful recovery. Incision into the placental site ; character of uterine contraction not recorded; closure with catgut. The third pregnancy was ended by supravaginal amputation of the uterus. There were several large adhesions extending from the old abdominal scar to the anterior surface of the uterus. Placenta posterior; puerperium normal.

Description oj Specimen. — After hardening, the uterus measures 17 X 13 X 7 cm. There was no trace of the old Caesarean scar either on gross or on microscopical examination.

Case XVI.— House No. 10243, 21 years, black. Flat rhachitic pelvis, D. C. 10 cm.

First pregnancy terminated by a conservative Caesarean section. The placenta lay posteriorly ; character of the uterine contractions not recorded; closure with catgut. Puerperium febrile for two days. In her second pregnancy the patient was admitted to the hospital after having been in labor 15 hours with numerous vaginal examinations. Caesarean section with supravaginal amputation of the uterus, followed


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by a febrile puerperium for five days. The placenta was posterior. There was a single broad adhesion attaching the omentum to the anterior surface of the uterus.

Description oj Specimen. — After hardening, the uterus measures 14x11x7 cm. In its contracted condition a number of transverse markings are visible on the anterior surface, apparently corresponding with the sutures of the former operation. On cross-section there is no trace of the scar, except immediately adjoining the uterine cavity where there is an infolding, 7 cm. in length, perhaps indicating that union had been faulty in that location. Microscopical examination shows no trace of scar tissue.

Case XVIL— House No. 10792, 28 years, black. Generally contracted rhachitic pelvis, D. C. 9 cm.

The first two pregnancies were terminated by Cesarean sections, the first being performed elsewhere. At the second the utei-us was found loosely adherent to the anterior abdominal wall. The placenta was inserted on the anterior wall; the uterus contracted slowly, and closure was with catgut. Puerperium febrile for seven days. The third pregnancy was ended by a Porro section. Broad adhesions extended from the abdominal wall to the anterior surface of the uterus. Placenta posterior; puei-perium normal.

Description oj Specimen. — After hardening, the uterus measures 16x11x5.5 cm. The entire anterior surface presents a raw surface which was covered by adhesions at the time of operation. A single scar is visible as a shght linear depression not more than 1 mm. in depth on the external surface, while on the inner surface there is a deeper depression, 7 cm. in length (Fig. 14). Cross-sections made at various levels reveal considerable variation in the thickness of the scar (Figs. 15 and 16). On microscopical examination there is a sHght increase in the fibrous tissue, but the musculature has regenerated completely and there is no distortion of the individual fibers.

Case XVIIL— House No. lOSOS, 25 years, black. Generally contracted rhachitic pelvis, D. C. 10.5 cm.

First pregnancy ended by an extraperitoneal Csesarean section, after 24 hours of labor. Incision closed with catgut. There was a wound infection and the puerperium was febrile for six days. Second pregnancy terminated by a conservative Caesarean section. Placenta posterior; uterine contraction fair; closure with catgut. The puerperium was febrile for seven days. The third pregnancy was ended by a Porro section. There were dense adhesions between the abdominal wall and uterus and also about the site of the extraperitoneal section. The placenta lay posteriorly; puerperium normal.

Description oj Specimen. — After hardening, the uterus measures 15x12x9 cm. To the left of the present incision is the scar of the second operation. It is marked by a shallow depression on the outer surface and a much deeper one on the inner surface. The scar measures 25 mm. as compared with a thickness of 35 mm. in the adjacent uterine wall, a ratio of 1 to 1.4. On microscopical examination there is complete regeneration of the musculature at the site of the scar, but there is also a considerable increase in the fibrous tissue. There is no trace of the scar of the extraperitoneal operation.

Case XIX. — House No. 10758, 26 years, black. Generally contracted rhachitic pelvis, D. C. 10 cm.

First pregnancy terminated by a consei'V'ative Csesarean section elsewhere. The patient was in bed with a discharging wound for two months following it. At the second section done at the onset of labor. the lower two-thirds of the uterus was broadly adherent to the old abdominal scar, and after the adhesions had been released such an extensive raw bleeding area was left that it was thought best to remove the uterus. The placenta was inserted on the posterior wall; puerperium normal.

Description oj Specimen. — After hardening, the uterus measures 15 X 12 X 6 cm. On the anterior surface is the ragged area referred to above. On cross-section, the scar of the previous operation is visible as an irregular whitish line joining funnel-shaped depressions on the outer and inner surfaces (Fig. 17). On microscopical examination


there is little to mark the hne of any former incision, the muscle fibers running from side to side without break in continuity and with only very slight increase in the fibrous tissue.

Case XX. — House No. 11047, 19 years, black. Generally contracted rhachitic pelvis, D. C. 8.75 cm.

The first pregnancy was ended by a conservative Caesarean section at the onset of labor. The placental site was incised, the uterus contracted firmly, and closure was with catgut. Puerperium normal except for a rise of temperature to 101° on the second day. In second pregnancy the patient was admitted 36 hours after the onset of labor with intrapartum infection. A Porro section was performed with eventual recovery after a stormy convalescence. Dense adhesions bound the anterior surface of the uterus to the abdominal wall. Placenta posterior.

Description oj Specimen. — After hardening, the uterus measures 15x12x8.5 cm. In the midline is a slight longitudinal depression which corresponds with the scar of the previous operation. Crosssections show almost perfect healing. The thickness of the scar is 21 mm., that of the adjacent uterine wall 29 mm., a ratio of 1 to 1.4. Microscopical examination shows normal muscle nmning directly across the line of former incision, with no increase in fibrous tissue.

Ruptured Cesarean Scar

The foUovdng is tlie clinical historj' and the description of the amputated uterus from the single instance in our series in which the scar of a previous Csesarean section ruptured. Figs. 18 and 19 show the anterior surface and cross-section of the uterus.

Case XXI. — Hou.se No. 7570, 24 years, black. Generally contracted rhachitic pelvis, D. C. 9.5 cm.

The first pregnancy was terminated by a prolonged spontaneous premature labor. The second was ended by a Csesarean section, seven hours after the onset of labor. The uterus retracted poorly, and the incision was closed with two layers of chromic catgut. The puerperium was febrile for 10 days.

The third pregnancy progressed normally to the seventh month. On November 29, 1915, the patient complained of much abdommal pain, and was seen in her home by the out-patient service. As she was not in labor, and as the result of the examination was unsatisfactory, she was instructed to report to the dispensary on the following afternoon. This she did, walking a distance of six or eight blocks each way. She returned the next day with slight vaginal bleeding and was admitted to the hospital. On examination the cervix admitted one finger easily, while just above the internal os is a firm, rounded tumor apparently projected from the posterior wall of the uterus into its cavity, so that a tentative diagnosis of myoma was made. The abdomen was shghtly distended but not sensitive, and it was impossible to map out the foetus or to hear the foetal heart. Temperature normal, pulse 100.

Under the supposition that we had to deal with a myoma, which would interfere with the birth of the dead child, laparotomy was decided upon. When the abdomen was opened with a median incision, a small amount of bloody fluid escaped and the dead fcetus surrounded by the placenta and membranes lay free in the abdotninal cavity. The uterus was tightly contracted, ft'ith a large, jagged, irregular, blood-stained opening occupying its anterior wall. There was no bleeding, and what had appeared to be a myoma on vaginal examination was found to be the firmly contracted posterior wall of the utenis. The organ was then removed by supravaginal amputation, and the patient made an ideal recovery.

The interesting points in connection with the case are :

(a) the impossibility of determining when the rupture occurred ;

(b) the trifling clinical signs connected with it;

(c) the difficulty of diagnosis;

(d) the absence of serious haemorrhage, and

(e) the total absence of shock both before and after the operation.


Maecii, 192-3]


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Description of Specimen. — The uterus, after hardening, measures 10xSx6 cm. On its anterior surface, just to the left of the midhne, is a jagged, irregular blood-stained opening 6 cm. in length. There are practically no adhesions. Upon cross-section, it is seen that the muscle had failed to unite after the first section, as is shown by the fact that the edges of the opening are smooth and show no sign of recent tear. Evidently the scar had been composed only of decidua and peritoneum, which had yielded when the uterine distention had become pronounced. Microscopical examination bears out this supposition, as the decidua is found to cover the entire inner surface of the rupture, and to extend up to the peritoneum, which is quite thick and scar-like. Nowhere is there any suggestion that muscle union had occurred. The placenta had been implanted anteriorly over the scar.

Unfortunately, in a small number of our repeated Csesarean sections, which were followed by removal of the uterus, the specimen was lost or mislabeled. Likewise, in a number of instances the patient was sterilized at the subsequent section by resection of the Fallopian tubes, and consequently anatomical studies of the scar could not be made. The main


interest in such cases lies in the fact that they serve to demonstrate that the uterine scar was able to withstand the strain incident to a second or third pregnancy. Tables III and IV have been so arranged as to give the salient points in each case Avithout making a detailed report necessary.

Delivery by the Natural Passages, Following CESAREAN Section In 1904, Von Leuwen was able to find in the literature 32 instances in which a previous Caesarean section had been followed by deLivei7 through the natural passages, and since then Brodhead, J. T. WilHams, Willson, Harrar, Davis, Breitstein, Mason, Himipstone and others have reported similar cases. Study of their material shows that pelvic dystocia had only occasionally afforded the indication for the original operation, but that it had generally been undertaken for some such temporary complication as eclampsia or placenta praevia. Naturally, this is what one would expect, for had the pelvic contrac


TABLE III

Outline of the Clinical History of Patients Whose Uterus Was Lost, or of Patients Sterilized at Second

Section by Eesection of the Fallopian Tubes


Case


First operation


Second operation



number


Indication


Placental site


Closure


Uterine contraction


Puerperium


Placental site


Adhesions


Puerperium


Remarks


1530 1548


Pelvic di'stocia.


Posterior. Anterior. Posterior.


Deep silk superficial catgut.

Deep silk superficial catgut.

Catgut.

Catgut.


Not recorded. Not recorded. Firm.

Not recorded.


Febrile.


Not recorded.

Anterior.

-interior. Posterior.


Moderate. Not recorded. Dense.


Febrile.


Uterus removed but lost. No record of scar. Excessive bleeding. Patient died on table.

Death on Sth day, infection. Uterus secured

at autopsy but losi. First operation in Pittsburgh. No admissions

after 2d section. No subsequent admissions. No note of scar.


1611


Febrile. Afebrile, Febrile.


6787


Anterior.


Febrile.


8243



Not recorded.



Not recorded.


Afebrile.



Moderate.


Afebrile.


Tubal sterilization. Old scar not seen.


8303


"


Anterior.



Firm.




Dense.



Tubal sterilization. No mention of old scar.


85.37



Anterior.


1 Not recorded.



Anterior.


Not recorded.



Tubal sterilization. No mention of old scar.


8666


"


Posterior.


I Poor.



Posterior


Filmy.



Tubal sterilization. Old scar not seen.


916D



"



Febrile.



Film.v.

Not recorded.

Filmy


Febrile.


First operation extraperitoneal. No subsequent admissions.

First operation done elsewhere. Tubal sterilization. Old scar-depressed line 5 cm. long.

No subsequent admissions. Old scar not



9647


Posterior.


Catgut. Not recorded.


Afebrile.





1

Catgut. Poor.




Dense. Filmy.


Afebrile. Afebrile.


First operation in Washington, D. C. No

subsequent admissions. Old scar not seen.

No subsequent admissions. Old scar not


10212


Posterior.


Febrile.


1()?79 10631


"


Anterior. Posterior.


Good. Poor.


Febrile. Afebrile.


Anterior.


Dense. Dense.


Febrile. Afebrile.


No subsequent admissions. Old sear visible

as thin depressed line. No subsequent admissions. Old scar not


TABLE IV

Outline of Two Cases in Which Two Cesarean Sections Preceded the One in Which Tubal Sterilization

Was Effected


1


First operation


Second operation


Third operation


q O


Indication


Placental site


Closure


Uterine contraction


Puerperium


Placental site


Uterine contraction


Closure


Adhesions


Puerperium


Placental .^^hesions


[ Remarks Puerperium



Pelvic dystocia.

Pelvic dystocia.






Anterior. Posterior.


Firm.

Not recorded.


Catgut. Catgut.


Dense.

Filmy.


Afebrile. Febrile.


P t 1 ^-1


Afebrile. {First operation else where-extraperitoneal.

Tubal sterilization. Febrile. Tubal sterilization. One

of old scars visible as

depressed line.


9254


Anterior.


Catgut.


Not re- Febrile, corded.;


Anterior.


Dense.


104


[Xo. 373


tion been sufficiently pronounced to demand a CEesarean section at the first labor, those subsequent to it would not be likely to terminate spontaneously. Occasionally, however, even in such cases, the patient may not realize the gravity of her condition, and may fail to summon medical aid until labor has been in progress for a number of hours, when examination may show that the head has become sufficiently molded to permit its descent into tlie pelvis, and the labor may terminate spontaneously, or at most by a simple forceps delivery. Doubtless had most of these women been seen before the onset of labor, they would have been subjected to a repeated section, for in the presence of a definite degree of disproportion we should not allow a vigorous test of labor, although, as has already been pointed out, if the disproportion is slight, we may allow labor to progress under careful observation.

The points of interest in our 13 cases of delivery by the natural passages following a Csesarean section are outlined in Table V. It will be noted that in 11 there was a varying degree of pelvic contraction, although in three it had not been sufficiently pronounced to furnish the indication for the previous


section. Moreover, in Cases 5959, 6927, and 8572 the child was so premature that the question of pelvic dystocia did not enter into consideration at the subsequent labor. They are of interest, however, from the fact that active labor pains persisted for 18, 15, 7.75 hours, respectively, and thus adduced additional proof of the ability of the well healed scar to withstand the strain of a moderately severe labor.

As 48 of our patients were subjected to one or more repeated Csesarean sections, the 13 cases just mentioned, to which may be added four other deliveries elsewhere, indicate that 25 per cent of the women who have had a previous section possess a uterine scar sufficiently strong to withstand the strain of delivery through the natural passages. Naturally, this does not represent the entire truth, as it must be supposed that many of the uteri which were incised at the second or third section would have proven equally as strong had the disproportion not been so marked as to contraindicate any test of labor.

The gross mortality attending tlie repeated sections was 5.9 per cent. The death of one patient from haemorrhage was due to tlie inexperience of" the operator ; but the other two


TABLE V

Outline of the Clinical History of 13 Cases Delivered Through the Natural Passages Following a Previous

C.issAREAN Section


Name

Number

Color


Obstetrical history

previous

to operation


Operation


Placental Closure of


Place I«<'--»™iattachSent ^'^r."' Pu"P"ium


Labor


1899. Podalic ver- 1901.

sion. Johns

Hopkins. 1908. Abortion-4, 1909.

months. j (.'leveland.

1911.

Johns Hopkins.


1913,

Johns Hopkins.

Four labors. AUI '913. spont. at term. Chicago.

1914.

Johns Hopkins.

Two abortions. 1912. Spontaneous. One Johns tubal abortion. ; Hopkins.

1913.

, Philadel1 phia. 1909. Spont. Still- 1915.

born. Johns

'1910. Spont. Seven Hopkins.

mos. Stillborn. 1911. Spont. Term.

d. 6 weeks. 1914. Spont. Seven mos. Stillborn.

1917.

Washington.

1916.

Johns Hopkins.

1917.

Church Home, Baltimore. 1917. Spontaneous 1919. at term. Difficult .Tohns labor. Child died Hopkir from intracraniali hcemorrhage. '


Eclampsia rigid cervix.


Eclampsia rigid cervix.

Eclampsia,


2 layers.

1, Deep s

2. Chr. c


Posterior 2 lavers chr. «all. c. g.


Posterior 2 layers chr.


Febrile. Febrile.


,,G. C. funnel. 'D. C. 11 cms.

T. T. 8 cms.

Simple flat.

D. 0. 101 cms.


G. C. funnel. D. C. ll-i cms. T. I. 7} cms. G C. typical. ^. 11 cms.


7i hrs, 6Jhrs. 18 hrs.


Podalic ver- 3335 gm.

sion. 2dstage B. p. 10 cm.

2] hrs. 1

Low forceps. ;3149 gm.

2d stage 1 hr. JB. p. 9J cm.

Spontaneous. ,1400 gm. Premature. jB, p. 73 cm.


1 Manual dil. of 2080 gm. cervix from B. p. 8 cm. 5 cm. Mid j forceps. Spontaneous. 12780 gm.

B. p. 83 cm.


Spontaneous. 1980 gm.

Frank breech. B. p. — ?

Premature. Mid forceps. 2620 gm.

2d stage l-J ,B. p. Sj cm.

hrs.


Low forceps. S230 gm.

2d stage 11 |B. p. SJ cm.

hrs. Induced- 12450 gm.

Bougie. B. p. Si cm.

Convulsions.

Spontaneous. Spontaneous. 2750 gm.


In 1905 delivered in another hospital by forceps.


Uterus removed after Cesarean in 1914. Scar— Excellent. Wound healed per' primam. Fever six days.

Wound healed per


Wound prtmaii days.


Extra peritoneal Cesarean. In 1916 spont. at 7 months. Private doctor. Fever


Patient said she had

'* milk-leg." In bed

man.v weeks. Wound healed per

primam. Fever for

eight days. In 1919 spontaneous at


Wound healed per primam. Fever for nine days.


THE JOHNS HOPKINS HOSPITAL BULLETIN, MARCH, 1922



Fig. 1. — Cioss-SLctiuu of utoriis removed at autopsy from patient dying from peritonitis (gas bacillus) on third day after operation. Case XI. (A) Site of recent incision. XVi.



Fig. 6. — Scar from Case I, showing original silkworm gut sutures in situ at second section. X 1


\


Figs. 2 and 3. — Illustrating the two layers of sutures employed in closing the uterine incision. (A) Buried layer. (B) Superficial layer.



Figs. 4 and 5.— Illustrating a possible cause of imperfect scars. In 4 the sutures have been tightly tied in a relaxed musculature. In 5 contraction has taken place with resulting indentations on both uterine surfaces.


Fig. 7, — Drawing of cross-section of a comparatively well healed Csesarean scar. It demonstrates. the typical depressions on both surfaces of the uterus and the regenerated muscle fibres, with almost no fibrous tissue. X 6.


THE JOHNS HOPKINS HOSPITAL BULLETIN. MARCH. 1922


PLATE XIII


,.J^Pr^


r

K


^aJlsi^"i^


Fig. 8. — Cross-section of uterus from Case I, X yi- (A' recent incision. (B) Dense adhesions covering the old scar (C).



Fig. 9. — Croiss-section of uterus from Case II. (A) Old scar. (B) Recent incision. (C) Old scar. X Vi



Fig. 11. — Uterus from Case XIII, showing (A) old scar with transverse indentations, and (6) recent incision. X Vi


Fic. 12. — Cross-si ition of utiM\is irom Case XIII. (A) Old scar. X -A



FiG. 10. — Cross-section of uterus from C;i.s(' III. (A) Recent incision. (B) Old scar. X :'.;•


Fig. 13. — Cro.<.-i-section of uterus from Case XR (A) Old scar. X yi


THE JOHNS HOPKINS HOSPITAL BULLETIN. MARCH, 1922


PLATE XIV


A



Fig. 14.— Inner surface of uterus from Case X\I1. (A) nuJ (li) upper ;md luwer angles of old. scar. X Vs





Fig. 17. — Cross-section oi uterus nom Case XIX. (A) Recent incision. (B) Old scar. X -A


Fig. 15.


V ^~j-) i\r


Figs. 15 and 16.— Opposite sides of block 1 cm. in thickness from uterus in Case XVII. Shows variation in diameter of scar at various levels. X 1


Fig. is. — Uterus from Case XXI, showing the rupture of old Caesarean scar. X 1


Fig. 19. — Cross-section of uterus from Case XXI. Note the smooth edges of the muscle at the site' of rupture. X Vs'


March, 1923]


105


fatalities were directly attributable to the repeated abdominal operation. Our 48 •n-omen went through 63 pregnancies, 13 of which ended by vaginal delivery under our supervision, and 4 elsewhere, with only one instance of rupture of the uterine scar- — an incidence of 1 to 63 or 1.5 per cent. It might be argued that this unusually low incidence is due to the fact that We are accustomed to sterilize our patients at the third operation, instead of doing five or six repeated Caesarean sections, as is the practice of some obstetricians. Doubtless this may play some part in reducing the incidence of ruptured scars, as there can be no question that the greater the number of Caesarean sections done upon one woman, the greater will be the number of imperfect scars. Consequently, we feel that, after a patient has been subjected to the risk of three major operations, she should be relieved of the added danger of a ruptured scar, which must inevitably become increased after each subsequent operation.

COXCLUSIOXS

1. The weak Caesarean scar may be due to a single factor or to a combination of factors, the most important of which is infection.

2. An afebrile puerperium does not give an absolute assurance of perfect wound healing.

3. The perfection of technique in suturing the uterine incision will undoubtedly lessen the incidence of weak scars.

4. Chromic catgut, in our hands, has proved to be a satisfactory suture material.

5. The uterine wound should not be closed, if possible, until firm contraction of the musculature has occurred.

6. As a rule foetal elements do not invade the uterine scar.

7. Adhesions follo'wing Caesarean section are common. They are not necessarily the result of coexisting infection, and may give rise to serious complications at subsequent operations.

8. The dictmn " once a Cfesarean, always a Caesarean " cannot be accepted without considerable reservation.

9. A patient who has once been subjected to a Cffisarean section should enter the hospital several weeks prior to the expected date of confinement, so that she may have the benefit of immediate operation should rupture occur.

REFERENCES

Baisch : Die Gefahren der Kaiserschnittsnarbe und ihre Verhiitung. Monatsschnft f. Geb. u. Gyn., 1920, LIII, 57-70.

Bell, J. X.: Rupture of the Uterus in Caesareanized Women, With a Review of the Literature on This Subject to Date. Amer. Jour. Obst., 1916, LXXR', 950-954.

Breitstein, L. 1.: Rupture of the Uterus Following Caesarean Section. Jour. Amer. Med. Assn., 1914, LXIl, 6S9-691.

Brodhead, G. L.: Normal Labor Following Caesarean Section. Amer. Jour. Obst., 1917, LXXV, 702-703.

Carstens. J. H.: Abstract of Discussion — " Caesarean Section Scars " —Spalding. Jour. Amer. Med. Assn., 1917, LXIX, 1854.

Couvelaire, A.: Rupture de la cicatrice d'une ancienne operation cesarienne. Sur\'enue a la fin d'une grossesse compliquee d'hydramnios. Ann. de gynec. et d'obst., Paris, 1906, 2. s., 148-164.

Idem: Considerations sur la technique de I'operation cesarienne conser\'atrice. Ann. de gj-nec. et d'obst., Paris, 2. s., 557-586.


Davis, A. B. : A Study of Repeated Caesarean Section. Cleveland Med. Jour., 1914, XIII, 51-94.

Idem: Two Cases of Rupture of the Uterus Following Csesarean Section with Living Children. Amer. Jour. Obst., 1918, LXXVII, 136-145.

DeCourcey, J. L.: Spontaneous Rupture of the Caesarean Scar. Jour. Amer. Med. Assn., 1018, LXX, 840.

Eckstein, E.: Die erste Spontanruptur des graviden Uterus im Bereiche der alten Kaiserschnittsnarbe nach querem Fundalschnitte nach Fritsch. Zntrlbl. f. Gyniik., 1904, LXIV, 1302-1309.

Findley: Rupture of the Scar of a Previous Caesarean Section. Amer. Jour. Obst., 1916, LXXW, 411-432.

Fischer: Ueber die Ruptur des graviden Uterus in einer alten Kaiserschnittsnarbe. Ztschr. f. Geb. u. Gyn., 1912, LXX, 838-857.

Franz: Ueber Kaiserschnitt. Ztschr. f. Geb. u. Gyn., 1915, LXXVII, 215-223.

Freund, H. : Spontane Uterusruptur in einer cervicalen Kaiserschnittsnarbe. Zntrlbl. f. Gyniik., XLIII, 73-75.

Gilles, R.: Troisieme cesarienne conser\-atrice chez la meme femme. Ann. de gynec. et d'obst., Paris, 1916, 2. s., 42-43.

Green, C. M.: Caesarean Section; A Consideration of Indications, Technique, and Time of Operating. Boston Med. and Surg. Jour.,

1915, CLXXIV, 41-50.

Harrar : A Study of the Integrity of the L^terine Scar After Caesarean Section. Amer. Jour. Obst„ 1912, LXV, SOS-820.

Holland, E.: Rupture of Caesarean Section Scar in Subsequent Pregnancy or Labor. Lancet, 1920. CXCIX. 591-598.

Howson, C. R.: Report of a Case of Rupture of Caesarean Scar During Pregnancy. Jour. Amer. Med. Assn., 1918, LXXI. 728-729.

Humpstone. C. P. : The End Results of Caesarean Section. Amer. Jour. Obst., 1917, LXXV, 372-378.

J0II3', R.: Uterusruptur in der alten Kaiserschnittsnarbe. Arch. f. Gyn., 1912. XCVII. 229-236.

Labhardt, A.: Ueber Uterusruptur in Narben von friiheren Geburten. Ztschr. f. Geb. u. Gjm., 1904, LIII, 478-488.

von Leuwen: Openation cesarienne repctee. .-Vnn. de g\Tiec. et d'obst.. Paris, 1904, 2. s.. 576-580.

Losee. J. P.: The Caesarean Scar, an .Anatomical Study. Bulletin Lying-In Hosp., New York. 1918. II, 228-240.

Mason. E. R.: Vaginal Deliverv After Caes.arean Section. Boston Med. and Surg. Jour.. 1917. CLXXVI, 127-133.

Mason. E. R., and Williams. J. T.: The Strength of the Uterine Scar After Caesarean Section. \r\ Experimental and Clinical Study. Boston Med. and Surg. Jour.. 1910. CLXII. 66-72.

Newell. F. S.: Caesarean Section. G>Tiecological and Obstetrical Monographs. New York. 1921.

Novak, E.: Rupture of the Utenis Through the Caesarean Section Scar. Jour. Amer. Med. Assn., 1918, LXXI. 105-106.

Offcrmann, J. J.; Heilung und Spatfolgen der Narbe beim queren Fundalschnitt beim Kaiserschnitt nach Fritsch. Monatsschr. f. Geb. u. Gyn.. 1916. XLW, 173-186.

Planchu : Operation cesarienne pratiquee pour la quatrieme fois chez la meme femme. Ann. de gynec. et d'obst., Paris, 1916, 2. s., 45-46.

Prusmann, F.: Die Spontanruptur in der alten Kaiserschnittsnarbe. Ztschr. f. Geb. u. Gyn.. 1905, LV. 415-425.

Rohrbach, W.: Nachuntersuchungsresultate nach extra- imd transperitonealem Kaiserschnitt. Ztschr. f. Geb. u. Gyn., 1914, LXXV, 530-547.

Rongy. \. J.: Rupture of the Caesarean Scar. Amer. Jour. Obst.,

1916. LXXn^ 954-961.

Scheffzek : Die Uterusnarbe des korporealen und cervikalen Kaiserschnitts und ihre Chancen bei spiiteren Schwangei"schaften und Geburten. Ztschr. f. Geb. u. Gyn.. 1910, LXVII. 752-772.

Schroeder, E.: LTaer Rupturen der Kaiserschnittsnarbe bei nachfolgenden Schwangerschaften. Monatsschrift f. Geb. u. Gyn., 1916, XLTV. 191-231.


106


[No. 373


Spalding, A. B. : CiEsarean Section Scars. A Histological Study of Four Specimens. Jour. Amer. Med. Assn., 1917, LXIX, 1847-1853.

Williams, J. T.: Delivery by the Natural Passages Following Cesarean Section, With a Report of Two Cases. Amer. Jour. Obst., 1916, LXXIII, 425-428.

Idem.: Delivery by the Natural Passages Following Csesarean Section. Amer. Jour. Obst., 1919, LXXX, 435-441.

Wilhams, J. Whitridgc : A Histological Study of 50 uteri Removed at Cesarean Section. Bull. Johns Hopkins Hospital, 1917, XXVHI, 335-343.


Willson, P. ; Report of Four Cases Dehvered by Vagina Following a Previous Csesarean Section. Amer. Jour. Obst., 1916, LXXIV', 701703.

Wolff: Ztschr. f. Geb. u. Gyn, 1914, LXXIV, 740-746.

Woj'er, G.: Ein Fall von Spontanruptur des Schwangeren Uterus in der alten Kaiserschnittsnarbe. Monat.schrift f. Geb. u. Gyn., 1897, VI, 192-200.

Wyss, A.: Beitriige zur Uterusruptur nach Kaiserschnitt. Beitrage f. Geb. u. Gyn., 1912, 337-368.


ACUTE LOBAR PNEUMONIA AND HiEMATOGENOUS PUERPERAL INFECTION

A CASE REPORT

By R. A. Johnston and H. J. Morgan {Frovr the Department of Obstetrics and the Biological Division of the Medical Clinic of The Johns Hopkins Hospital and University)


The demonstration of a ftsed type pneumococcus as the causative agent of a puerperal infection developing during the course of acute lobar pneumonia is unusual, and makes the following case report one of considerable interest both to the obstetrician and internist.

Summary of Case.— Thirty-five year old primipara; difficult labor with prolonged second stage; chloroform anceslhesia; low forceps delivery; immediate development of signs of acute lobar pneumonia; pneumococcus (type 1) septiccemia; pneumococcus (type 1) endometritis; anti-pneumococcus (type 1) serum therapy followed by rapid disappearance of organisms from the blood stream; prolonged course suggesting "delayed resolution" ; recovery from endometritis; serum sickness; suggestive evidence of empyema; terminal hemolytic streptococcus septicoem-ia ; no autopsy.

Case Report. — A mulatto housewife, 35 years old, was admitted to the Obstetrical Service February 27, 1921. The family history was negative. The general health of the patient had always been poor. When a child she had had measles, mumps, chicken-pox and possibly pneumonia. At the age of 13 she had recovered after two months from an illness characterized by severe diarrhoea with tenesmus, blood and mucus. She denied having had diphtheria, scarlet fever, rheumatic fever, malaria or typhoid fever. She had suffered from frequent colds and occasional attacks of epistaxis. " Sore throat " had been a frequent winter complaint, and had been usually associated with enlarged tender cer\'ical glands. Six months before admission to the hospital she had suffered for a short time from pollakiuria and dysuria, which had disappeared promptly under medical treatment. Two months before admission to the hospital she had had bilateral suppurative inguinal adenitis, which had been cured by incision and drainage.

Menstruation had begun at the age of 13 ; it had been regular and of three or four days' duration. The flow had been normal in amount and accompanied by a moderate amount of pain. She had been married in April, 1920, and the last menstrual period had occurred in May, 1920.

Present Illness. — The patient was first seen by one of us in the prenatal clinic on January 11, 1921. At that time she was eight months pregnant with the child lying in the right-occipito-transverse position. The examination of the heart and lungs was negative. The sj'stolic blood pressure was 110; diastolic 70. The incisions in the inguinal regions were healing satisfactorily. The urine was normal and the blood Wassermann reaction was negative. The pelvic measurements were normal. At subsequent visits to the prenatal clinic, on January 26 and February 8, her condition was regarded as satisfactory.


She was admitted to the obstetrical ward in the first stage of labor at 9 p. m. February 27, after having walked several city blocks in a drenching rain. As the temperature was normal and examination of the heart and lungs was negative, she was regarded as being in good condition. Labor progressed satisfactorily until 3 a. m., February 28, when the second stage began. The head soon reached the outlet in the right occipito-posterior position, but as it made very little advance during the next three hours, operative delivery was decided upon. Under chloroform anaesthesia a deeply asphyxiated child was delivered at 620 a. m. after a difficult low forceps (Scanzoni) operation — the total duration of labor being 29 hours and 40 minutes. The child was revived by sensory stimulation, and weighed 3380 gm. After the repair of a vaginal laceration, the placenta was expressed from the vagina. Approximately 300 c. c. of blood were lost. The routine microscopic examination of the placenta revealed no abnormalities and a subsequent study of sections stained for bacteria was negative.

The patient left the delivery room in excellent condition. Two hours after delivery, the temperature was 99.4° F., but from then on it rose steadily until it reached 104° F. at 8 p. m. At that time the patient complained of slight pain in the right side of her chest. No chill had occurred, and there was no cough nor sputum, nor were the respirations accelerated. On examination of the lungs a soft pleural friction rub was heard over the right lower lobe, without other changes. Abdominal examination was negative. During the night the temperature fell to 102.5° F., but rose to 104.2° F. the following morning. At that time (March 1) the patient was quite toxic. The respiratory rate was 36 per minute but there was no cough. The breath sounds were slightly suppressed over the right lower lobe and an occasional fine rale could be heard. The abdomen was quite distended and sensitive, but there was no muscle spasm or evidence of fluid. A blood culture was made and 24 hours later was reported positive for the pneumococcus (type 1).

On March 2, the general condition was essentially unchanged. The temperature remained elevated and the patient was quite toxic. Frank signs of consolidation of the lower lobe of the right lung were present. Lochia for intrauterine culture were obtained (by Little's tube), and consisted of a few cubic centimeters of dark serosanguineous fluid. On microscopic examination numerous diplococci were seen, which by culture and by serological examination proved to be pneumococci (type 1). A urine culture, made on March 1, was sterile. The patient was transferred to the medical ser\'ice March 2, when examination revealed a fairly well nourished tired looking mulatto woman with high fever, tachj-cardia, moderate cyanosis, and rapid, shallow respiration. There was no cough or sputum. The pulmonary signs were those of consolidation of the right lower lobe. There was


Maech, 1922]


107


marked distention of the abdomen with considerable tenderness over its lower third, but no muscle spasm or evidence of fluid. Rectal examination revealed a large firm tender uterus. Blood pressure; systolic 125, diastoHc 65.

Blood Ex.\mi>;atiox

R. B. C. count 3,393,000

Hemoglobin (Sahh) 67%

W. B. C. count 6,250

Differential W. B. C. count (300 cells)

Pm. N 91.4%

Pm. B 00 %

Pm. E 0.77o

S. M 3.0%

L. M. and T 2.6%

Myelocytes 2.0%

Myeloblasts 0.3%

With the exception of a trace of albumin and a few white blood cells the urine examinations were negative. The Wassermann reaction (blood) was negative.

Immediately following admission to the ward, anti-pneumococcus (type 1) serum treatment was instituted, as follows: March 2, 1921, 200 c. c. antipneumococcus type 1 serum intravenously. March 3, 1921, 200 c. c. antipneumococcus type 1 serum intravenously. March 5, 1921, 100 c. c. antipneumococcus type 1 serum intravenously. March 7, 1921, 100 c. c. antipneumococcus type 1 serum intravenously. March 8, 1921, 100 c. c. antipneumococcus type 1 serum intravenously. A quantitative blood culture was made (blood-agar plate method) before the first serum treatment, and showed 173 colonies per c. c. of blood, whereas a culture made eight hours later and prior to the second treatment contained but three colonies per c. c. Specimens of blood were likewise taken before the third (March 3, 1921) and subsequent treatments, but were all sterile:

There was no systemic reaction to the intravenous administration of the serum, and the usual chill, leukopoenia and the subsequent abrupt leukocytosis did not appear. However, there was a gradual rise in the number of leukocytes and two days after the first injection they reached 18,000 per c. mm.

With the termination of the septicaemia the patient's general condition improved greatly. The toxsemia became much less evident, and the abdominal distention less distressing. However, the temperature remained elevated and the physical signs in the lungs were essentially unchanged. -There was still a moderate degree of pelvic tenderness on abdominal and rectal examination, as well as a fairly profuse, greenish, muco-purulent vaginal discharge. On March 6 (three days after the disappearance of the septicjemia) , lochia were obtained for a second intrauterine culture. Smears showed a moderate number of leukocj-tes and lancet-shaped diplococci, and pneumococci (type 1) were again demonstrated in pure culture.

For two weeks the patient's condition remained practically unchanged, with the exception of a moderate degree of serum sickness, which first manifested itself on March 11. The temperature remained elevated (102.5° F.-104° F.), and the pulse varied between 110-130. The leukocyte count was between 18,000 and 35,000 per c.mm. There was very slight cyanosis and only a moderate degree of abdominal distention. The tenderness over the lower abdomen became much less marked and the \'aginal discharge diminished in amount. On March 14 a third intrauterine culture was made and proved to be sterile. It was the opinion of those attending the patient that the prolonged course of the pneumonia was a manifestation of " delayed resolution," and that the uterine complication no longer formed a part of the picture.

On March 16, examination of the lungs showed signs suggestive of encapsulated pleural fluid high in the right axillary region; while the X-ray showed " remains of consolidation at the right base with suggestion of encapsulated fluid in the right axilla." The same


equivocal physical and radiographic findings were present the following day. On that day, the 17th, the patient complained bitterly of headache. She was very weak and slept most of the time. Ophthalmoscopic examination showed slight oedema and hyperaemia of the discs, but no other changes. Kernig's sign and neck rigidity were absent, and the reflexes were normal. Nevertheless, a lumbar puncture was performed. Clear cerebrospinal fluid under normal pressure was obtained, and contained ten cells per c.mm. The colloidal gold curve, Wassermann reaction and tests for globuhn were negative. The patient's general condition rapidly became worse. The temperature remained high, the rapid pulse became weak and thready, and drenching sweats occurred. Cyanosis became marked and delirium developed. A pelvic examination revealed no abnormalities, and exploratory thoracentesis performed at several different sites in the right axilla and back was negative. A blood culture taken on the evening of this day (March 17) revealed the presence of an overwhelming streptococcus septicaemia — approximatelj^ 7600 colonies per c. c. of blood. The patient gradually sank into coma. The pulse and respirations became irregular, and she died on the evening of March 18, the nineteenth day after delivery. Unfortunately permission for an autopsy could not be obtained.

Discussion

The case presents several interesting clinical aspects. The sequence of events seems relatively clear. A primipara, 35 years old, with a past history of numerous infections, and on the whole of rather poor health, entered the hospital for delivery. At the onset of labor she was esposed for a short time to inclement weather. Labor was completed by forceps delivery under chloroform anaesthesia. Immediately following the birth of the child an acute lobar pneumonia developed. As evidence of the lowered resistance of the patient to infection at this time, one might cite the absence of chill and letikocytosis at its onset, and particularly the existence of the septicemia with large numbers of bacteria in the blood stream (173 colonies per cubic centimeter). Intrauterine culture demonstrated the presence of the same organisms in the postpartum uterus. That this finding was not accidental, or due entirely to the normal oozing of blood infected with pneumococci, is clear; for a greenish mucopurulent uterine discharge developed, which contained numerous white blood cells and organisms. Furthermore, this condition persisted for several days after the disappearance of the bactersemia, and was accompanied by clinical evidence of uterine infection. Accordingly, it seems clear that we were dealing with a metastatic pneumococcus (type 1) puerperal endometritis, wliich developed in a woman suffering from acute lobar pneumonia.

When one considers the anatomical and physiological conditions present in the fresh post-partiun uterus, one is struck by the fact that it presents a locus minoris resistentiae, as Bondy has aptly pointed out, and offers an ideal site for the growth of bacteria seeded into it by a heavily infected blood stream. In our case the puerperal infection obviously did not spread, but remained localized to the interior of the uterus, and had entirely disappeared clinically and baeteriologically by the 14th day. The disappearance of the type 1 pneumococcus bactersemia following administration of the specific anti-pneumococcus type 1 serum in this case conforms in every respect to the observations of AveiT, Chickering, Cole and Do


108


[No. 373


chez, and others. That the serum had a beneficial effect upon the local intrauterine infection seems probable ; for the process, although caused by a virulent organism and occurring in a patient with obviously lowered resistance, was in itself of rather benign type and of short duration. We feel therefore, that the use of the serum gave the patient a much better opportunity to overcome the infection, as was evidenced by the disappearance of the baeterfemia, the markedly improved general condition, the leukocytosis, the failure of the pneumonic process to spread to other lobes of tlie lung, as well as by the disappearance of the endometritis.

In concluding the discussion of the case from a clinical point of view, we feel that we may speculate with a fair degree of certainty concerning the terminal process. Although there was suggestive evidence, both from physical findings and radiographic examinations, that an empyema was developing and the prolonged course of the disease confirmed this possibility — repeated exploratory punctures of the pleural cavity failed to substantiate such a surmise. The normal cerebrospinal fluid almost conclusively rules out meningitis as a complication, and there was no evidence of the existence of pericarditis or endocarditis. The pelvic examination made the day before death was normal and the lochia negative. In the absence of a post-mortem examination, we accordingly have to fall back upon the assumption that we were dealing with a patient whose powers of resistance were such that she could not, in the usual length of time, overcome the local puhnonary infection, and as a result of the general debilitation resulting from it became a fit subject for a terminal generalized haemolytic streptococcus infection, the respiratory tract sei-ving as the portal of entrance. Moreover, it seems likely that the streptococcus pulmonary infection engrafted itself upon the slowly resolving pneumococcus pneumonia, causing an exacerbation of the pulmonary condition and resulted in an overwhehning generalized infection. MacCallum (4) who noted the occurrence of hsemolj^tic streptococci in three cases of lobar pneumonia studied in army camps, in which pneumocoeci had been isolated from the blood during the life or from the lungs at autopsy, has suggested the possibility that the latter organisms may have acted as the predisposing agents to infection with the streptococcus.

Pneumococcus Pueepeeal Infection The infrequency with wliich the pneumococcus is encountered as the etiological factor in puerperal infection no doubt explains, to a great extent, the interest with which instances of this condition have been regarded. Bondy, in 1912, published an excellent article upon the subject, which included a report of his own eases and a review of the literature. It is necessary to recall, however, that until comparatively recently the differentiation of the pneumococcus from certain strains of non-hfemolytic streptococci was fraught with difficulty, and that even to-day occasional strains are met with in which the differentiation is not sharply defined. It is, therefore, suggested that statistics compiled before the more recent advances


in bacteriological diagnosis were made should be accepted with some reservation, particularly as concerns the reported instances of " primary infection " — or infection by pneumocoeci gaining access to the uterus by way of the vagina.

It is manifest that two routes are open for the introduction of organisms into the uterus: (1) haematogenous (metastatic or secondary), (2) vaginal (primary). We shall consider each in some detail.

Hwrnatogenous Pneumococcus Puerperal Infection. — Aufrecht, in 1SS4, was the first to produce an experimental pneumococcus endometritis by the introduction of living organisms into the blood-stream of rabbits shortly after labor. At autopsy a localized uterine pneumococcus infection was found with but insignificant changes elsewhere. Thus he proved experimentally that the puerperal uterus in that animal is a Jocus niinoris resistentite, and that the pneumococcus is capable of producing pathological lesions in it. Orthmann (referred to by Bondy) confirmed this work. Weichselbaum, in 1888, reported the first instances of hfematogenous pneumococcus infection of the puerperal uterus in women. Both occurred in patients suffering from acute pulmonary infections (exudative pleurisy and pneumonia). At autopsy the pneumococcus was found in the endometrium, as well as in the primary focus in the respiratory system. Bondy refers to the instance reported by Bumm in 1899, in which a pneumococcus peritonitis was associated with pneumonia and empyema. At autopsy pneumocoeci were demonstrated in the uterine blood vessels and secretions. Burchardt, in 1901, reported an instance of premature labor during the course of acute lobar pneumonia, in which pneumocoeci were found in the placental site and lymphatics of the litems. Furthermore, Foa and Bordoni-Uffreduzzi cite two instances of abortion in pneumonic women in which pneumocoeci were found in the uterine veins. Stanoskiadis, in 1913, reported 12 cases of lobar pneumonia in which pneumocoeci were found in the vaginal secretions : He considered that they represented instances of hsematogenous^ infection which was favored by the changes incident to abortion or delivery. Haller, Oertel and others have likewise discussed the subject.

In the light of the above reports, as well as of our own case, is seems profitable to recall that in 728 cases of acute lobar pneumonia reported by Cole, in which blood cultures were made, 27.8 per cent were positive for the pneumococcus. In other words, he demonstrated that a pneumococcus bacterEemia is probable in approximately every fourth case of pregnancy which is complicated by lobar pneumonia. Under these conditions the possibility of a pneumococcus infection of the uterus at the time of, or shortly after, its evacuation does not seem remote, and should be borne in mind by obstetrician and internist alike.

Vaginal (Primar;/) Pneumococcus Puerperal Infection. — Although our case obviously does not fall into this group, a brief survey of the subject may prove of interest. As has been intimated, our knowledge of the pneumococcus has been considerably extended during recent years, and the organism can now be more easily and accurately differentiated from other cocci. Allowances must, therefore, be made in interpret


March, 1932]


109


ing the results of investigators who worked prior to the acquisition of this knowledge.

It would seem that the pneumococcus is very rarely an inhabitant of the normal vagina. Bondy, in 1913, failed to find it in a search of the vaginal flora of 30 non-pregnant women, but found it once in the same number of normal pregnant women, as well as once in the lochia from 30 postpartum patients. Fabret and Bourret called attention to this work in 1913, and regarded it as affording conclusive evidence that the pneumococcus is not an inhabitant of the normal vagina. On the other hand, Schottmiiller in 1910 found pneumococci in the lochia of three per cent of his cases of septic abortion ; while Foulerton and Bonney in their examination of 54 puerperal women found pneumococci in four instances.

That the pneumococcus may occasionally be present in the vagina of the pregnant and puerperal women cannot be doubted, and in the light of the cases collected by Bondy and by Fabret and Bourett it seems certain that it may, under certain conditions, find its way into the postpartum uterus and there give rise to puerperal infection. The reader is referred to articles by the last named authors for an extended discussion of this question.

Treatment Beside the general supportive measures usually employed in puerperal infections, Moore has suggested that uterine irrigations with ethylhydrocuprein (optochin), 1 : 10,000, may possibly be used to advantage, on account of the powerful antipneumococcus properties of the drug. If the infection is due to a type 1 organism, intravenous serum therapy may be indicated. In our case the uterine infection was of moderate degree so that local treatment was not attempted, but all of our efforts were directed to the relief of the pulmonary condition. However, we feel that the serum treatment was perhaps incidentally responsible for the mildness of the uterine infection and its early disappearance.

Summary We have reported a case of acute lobar pneumonia (pneumococcus type 1) with septicaemia as a complication of the puerperiimi, and have shown that a hsematogenous (pneumococcus, type 1 ) endometritis developed and disappeared under, observation. Death occurred on the 19th day from generalized hsemolytic streptococcus infection.


A brief review of the literature upon pneumococcus puerperal infections is given, and instances of both secondary (hematogenous) and primary (vaginal route) types are cited. It is suggested that the possibility of a pneumococcus puerperal infection should be borne in mind when dealing with patients in whom abortion or term delivery has occurred during the course of acute lobar pneumonia.

BIBLIOGRAPHY

Aufrecht : Die crupose Pneumonia. Nothnagel, Specielle Pathologie und Therapie, Wien, 1899, XIV, Bd. I, 37.

Avery, Chickering, Cole, and Dochez: Acute Lobar Pneumonia. Prevention and serum treatment. Monogr. Rockefeller Inst. Med. Research, No. 7, 1917.

Bondy: Die Bedeutung der Pneumokokken fiir die puerperale Infektion. Ztschr. f. Geburtsh. u. Gyniik., 1912, LXXII, 631.

Burchardt: I. Die endogene Puerperal-infektion. II. PuerperalInfektion mit Pneumococcus. Frankel, Beitr. z. Geburtsh. u. Gynaek., 1901, V, 327.

Cole : Acute Lobar Pneumonia. Kelson's System of Medicine, 1920, I, 248.

Fabret and Bourret : Infection puerperale a pneumoeoque, etc. Bull. Soc. d'obst. et de gynec. de Paris, 1913, XVI, 474.

Foa und Bordoni-Uffreduzzi : Uber die Aetiologie der Meningitis cerebro-spinalis epidemica. Ztschr. f. Hyg. u. Infectionskrankh., IV, 67.

Foulerton and Bonney: An Investigation into the Causation of Puerperal Infection. J. Obst. & Gynaec. Brit. Emp., Lond., 1905, VII, 121.

Haller: Tiber Pneumonie in der Schwangerschaft. Ludwigsburg, 1911, Ungeheuer & Ulmer, 31 p., 8°.

Little: A simple method of obtaining uterine lochia for bacteriological examination. Johns Hopkins Hosp. Bulletin, 1904, XV, 250.

MacCallum : The Pathology of the pneumonia in the United States Army Camps during the winter of 1917-18. Monogr. Rockefeller Inst. Med. Research, No. 10, 1919.

Moore : The action of Ethylhydrocuprein (optochin) on type strains of pneumococci in vitro and vivo and on some other micro-organisms in vitro. J. Exper. Med., 1915, XXII, 269.

Moore: A furthei- study of the bactericidal action of ethyldydrocuprein on pneumococci. J. Exper. Med., N. Y., 1915, XXII, 551.

Oertel: Hiimatogene Puerperal-sepsis. Wiirzburg, 1913, F. Standenraua.

Schottmiiller: Zur Pathogenese des septischen Abortes. Munchen. med. Wchnschr., 1910, LVII, 1817.

Stanoskiadis : Uber die Veriinderungen des Uterus bei akutert Infektionskrankheiten. Monatschr. f. Geburtsh. u. Gynaek., 1903, XVII, 1 and 187.

Weichselbaum : Beitriige zur Aetiologie und path. Anatomie der Endocarditis. Beitr. z. path. Anat. u. allg. Path., 1899, IV, 125.


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110


rjS'o. 373


DIPHTHERIA BACILLUS CARRIERS

RESULTS OF RE-EXAMINATION OF APPARENTLY NEGATIVE CULTURES

Bj' B. C. MAESHAiL and C. G. Gi'thkie (From the Division of Clinical Pathology of the Medical Clinic, The Johns Hopkins University and Hospital)


As ordinarily practiced, the examination of throat cultures for the presence of diphtheria bacilli is made after incubation of the tubes for from 13 to 24 hours, usually over night. Not infrequently a positive result may be obtained much sooner than this and in special cases examinations are made at intervals beginning at six hours, but it is quite generally the custom to discard as negative all cultures in which diphtheria bacilli have not been found after 24 hours in the incubator. This custom has probably arisen from several causes, as for instance :

1. The desire to secure positive information as early as possible.

2. The belief that the growth of the diphtheria bacillus on a suitable medium is relatively rapid during the first 24 hours, but that after that time it is apt to be overgrown by the other organisms encountered in cultures from the throat.

3. The belief that the morphology of the diphtheria bacillus is characteristic only during the earlier period of its growth on even the best of media; that after 24 hours its staining properties are lost to a greater or less degree and involution forms may appear, thereby rendering its recognition difficult or impossible in mixed cultures from the throat.

4. The belief that if diphtheria bacilli have not been found in the examinations of a throat culture during the first 24 hours they will not appear subsequently in that culture and therefore that search made at a later time would merely entail useless routine work.

We have no criticism to offer concerning examination of throat cultures " early and often," but we believe that the practice of regarding as negative all cultures which have not shovm diphtheria bacilli up to 24 hours may yield results which are misleading, particularly in the case of bacillus carriers.

In the course of some experimental work with the so-called " elective medium " of Drigalski and Bierast.* we found that a number of the tubes, considered negative at 24 hours, were positive when re-examined a day later. It naturally occurred to us that the apparent delay in development of the diphtheria organisms might be due to the inhibitory effect of the bile in the special type of medium employed, but it soon became evident that a similar retardation might occur with other sorts of media as well. After this point was established we made it a rule to examine all cultures both at 24 and at 48 hours.


v. Drigalski and Bierast: Nachweis der Diphtheriebazillen und seine praktische Bedeutung. Deutsche med. Wchnschr., 1913, XXXIX, 1237. This medium consists essentially of LoefBer's blood serum to which a certain amount of bile has been added prior to coagulation. The object of the addition of bile is to inhibit the growth of the other organisms from the throat without interfering with the growth of the diphtheria bacillus.


At this time we had under observation a series of diphtheria bacillus carriers — some of them healthy, others convalescent carriers, some who harbored virulent and others non-virulent organisms — and from these persons throat cultures were taken daily over a period of several weeks. The cultures were made on several different kinds of blood serum media and were examined with great care. All of the cultures found negative at 34 hours and abnost one-half of the positive ones were reexamined at 48 hours. The results are presented in Tables I, II and III.

TABLE I

Results op Cultures Ex.\mined after Incubation for 24 and 48 Houns


Cultures


Examined after 1 incubation for 24 hours


Re-examination at 48

hours of cultures negative at 24 hours


Re-examination at 48

hours of cultures positive at 24 hours



Number


Per cent


Number


Per cent


Number


Per cent


Total


759



549



93



Positive . . .


. 210


27.66


52


9.47


92


93.92


Negative . .


. 549


72.33


497


90.52


1


1.07


TABLE II

Analysis of PosiTn-E Results


Total jiositives

Positive at 24 hours. . . . Positive only at 48 hour


262 210


80.15 19. S4


TABLE III

Virulence of Diphtherw Bacilli in Cultures PosiTm: Only at 48 Hou-RS


Medium


Virulent strains


Nonvirulent Total strains



24

1 3 3


20 ! 44



1



2


Drigalski and Bierast (pis serum -| bile). Drigalski and Bierast (beef serum -| bi'le).


3 3


Total


31


21





Prom Table I it is seen that of the 759 cultures from these carriers, 210, or 27.66 per cent, were positive at the first examination made after approximately 24 hours' incubation. Five


Maecii, 1922]


111


hundred and forty-nine cultures were negative at the first examination and of these 52, or 9.47 per cent, were positive when examined after an additional incubation of 24 hours. Re-examination of 93 originally positive cultures showed that 92 were still positive after 48 hours in the incubator.

An analysis of the positive results (Table II) shows that of the 262 cultures in which diphtheria bacilli were found, 210, or 80.15 per cent, were positive at the iirst examination, and that 52, or 19.84 per cent, were found positive only at the second examination which was made 24 hours later.

From Table III it is seen that among the 52 cultures found negative at the first examination but positive at the second, 31 contained virulent and 21 contained non-virulent strains of diphtheria bacilli. These 52 cultures were made on four different kinds of serum media, on all of which the diphtheria bacillus grows admirably when pure and, as a rule, also when it is present in mixed culture from the throat.

These results speak for themselves and require little comment. From them it is evident that practically one-fifth of the total number of positive cultures were regarded as negative when examined at 24 hours, but were shown to contain diphtheria bacilli when examined a day later. In all instances the original slides were saved for re-examination in case the culture should prove positive at 48 hours. Careful search showed the original report to have been justified in almost every instance, but whenever this re-examination revealed any diphtheria bacilli in the 24 hour slides, the earlier diagnosis was changed and such cases are omitted from this series. It is perhaps unnecessary to add that tubes which showed little or no growth at 24 hours are not included, even though subsequent examination may have revealed the presence of diphtheria bacilli. The practice of examining throat cultures both at 24 and at 48 hours has been continued since these figures were collected and the additional experience of several years has shown the advantage of this procedure. Since introducing it in this laboratory we have isolated typical Elebs-Loeffler organisms from 75 or more of these " delayed positives," thereby confirming the diagnosis originally based on morphology alone. The difference in morphology at 48 hours is practically negligible, being, when it occurs at all, in the nature of an increase in the number and size of the Babes-Ernst granules, thereby facilitating recognition of the organisms when the Neisser or similar contrast stains are used. In general, the development of involution forms seems to be less marked in mixed cultures from the throat than in pure cultures.

In our experience the " delayed positive " culture has been found only among carriers, healthy or convalescent, and has been quite independent of the virulence of the strain of organisms present in the throat. In cases of clinical diphtheria we have practically always found the organisms abundant and their recognition easy in throat cultures incubated for 24 hours, so that no difficulty exists from the source we have mentioned in the bacteriological diagnosis of actual cases of the disease.

The explanation of the " delayed positive " culture is far from clear. Whether the diphtheria bacilli present in cul


tures from the throat of carriers may have a more prolonged period of lag than those from patients in the acute stage of the disease we are not prepared to say. In many instances this is obviously not the case, as the cultures may show at the first examination an abundant growth consisting almost exclusively of diphtheria bacilli. The organisms present in the " delayed positive " cultures, moreover, show a normal rate of growth when isolated in a pure state. We can only suggest that this peculiar retardation may possibly be due to the inoculation of the culture with a very small number of viable diphtheria bacilU and a very large number of other organisms which temporarily overgrow or possibly inhibit the former. Almost invariably, when Klebs-Loeffler bacilli were found to be sparse at 24 hours, they were abundant at 48 hours ; if originally numerous, they were much more plentiful on the following day. In only one instance was a culture which was positive at 24 hours found negative at 48 hours. When once the diphtheria bacillus starts to grow, it apparently is able to hold its own against most of the other bacteria encountered in throat cultures with the exception of the hay bacillus and certain similar organisms. Many cultures have been examined after periods of growth longer than two days, but no evident advantage was found in this procedure.

Similar observations have been made by other workers. Knebel * collected some interesting statistics at the Hygienic Institute in Frankfurt ; the results which form the basis of his report have been condensed and are shown in Table IV.

TABLE W

Results op Examination of Throat Cultures after Incubation for One Day and Two Days

(From Knebel)


Source of cultures


Result after

incubation for

one day


Result after incubation for an additional day



Negative


Doubtful


Negative


Doubtful


Positive


Fresh diplitlieria suspects.


139 576


63 56


43

151

470


17 51


12 16


Fresh diphtheria suspects.


1 55




From Knebel's figures shown in Table IV, it is seen that of the throat cultures from 118 cases — 62 fresh suspects and 56 convalescents — all of which were recorded as doubtful at the first examination, 28 were definitely positive, 66 were definitely negative and only 24 were still considered doubtful when examined a day later.

Table IV also shows that of 159 throat cultures from diphtheria suspects regarded as negative at the first examination, only one was found positive after incubation for another day and in tliis isolated instance both the history and the physical examination of the patient suggested strongly that they were


Knebel, Max : Beitriige zur bakteriologischen Diagnose und Statistik der Diphtherie. Inaugural Dissertation, Giessen, 1912.


112


[No. 37:^


dealing with a convalescent rather than a fresh case of diphtheria. Further information is available concerning four of the seven cases -which were reported as doubtful at the second examination ; the organisms from two of these were shown not to be diphtheria bacilli ; attempts to isolate the organisms seen


A comparison of our results with those reported by Knebel is presented in Table V.

TABLE V

COMPAEISON OF OUB RESULTS WITH ThOSE REPORTED BY KnEBEL


in the culture from another were unsuccessful; the pure culture obtained from the fourth proved to be a\'irulent on animal inociilation.


1 Cultures negative at Source of cultures 24-hour


Cultures positive

when examined

at 4S hours


Conditions were quite different, however, with regard to the 576 negative cultures from convalescents; 55 or 9.54 per cent, proved to be positive when examined next day and these findings were confirmed by further study including virulence tests on the organisms obtained in pure culture. The originally



tion


Number


Per cent


Diphtheria convalescents (Knebel)...

Bacillus carriers, convalescent or healthy (Marshall and Guthrie).

Total


576 549


55 53


9.54 9.47


negative cultures from 51 cases which were moved to the


1125


107


9.51


doubtful column as the result of the second examination.




Knebel dismisses with the comment that a doubtful result is of much less importance in a convalescent than in a diphtheria suspect and that, when dealing with convalescents, one cannot go wrong provided prophylactic restrictions are not relaxed on the basis of a doubtful answer.

Neisser,* who was director of the Frankfurt Institute speaks favorably of Knebel's report and recommends that (1) all cultures showing a poor growth after incubation for one day and (2) all throat cultures from convalescents should be re-examined on the following day.

. Seidel f also lays stress on the desirability of examining all throat cultures from convalescents both at 20 and at 44 hours. He cites an instance in which failure to re-examine a culture which was negative at 20 hours resulted in the discharge of a convalescent child who promptly infected her three Uttle sisters.


From Table V it is seen that our figures agree very closely with those reported by Knebel, although his observations were made entirely upon patients convalescent from diphtheria, whereas ours were made upon bacillus carriers, some of them convalescent but others healthy carriers.

From these results it seems evident that, when dealing with throat cultures from diphtheria carriers, the customary laboratory practice of making single or repeated examinations within the first 24 hours may not yield all of the information available and may lead to erroneous conclusions. The error from this source alone, as judged from the results in 1125 cases, is about 9.5 per cent. If one is interested in determining the duration of the carrier state, in ascertaining the actual condition of affairs, rather than in merely securing some arbitrary number of successive negative cultures required by health regulations prior to discharge of a patient, further investigation is essential.

It is to be recommended, therefore, that in the study of diphtheria bacillus carriers, either healthy or convalescent, all cultures which are negative up to 24 hours be re-examined after another day in the incubator.


Neisser. M.: Bakteriologie der Diphtherie. Centralbl. f. Bakteriol., 1913. Section 1, LVII, Supplement, p. 1. Neisser. M., and Gins, H. A.: Ueber Diphtherie, in Kolle and Wassermann's Handbuch der Pathogenen Mikroorganismen, Ed. 2, Jena. Gustav Fischer. 1913. V, 931.

t Seidel, Otto: Zur Behandlung der Diphtherie, Munchen. med. Wchnschr., 1915, LXII, 1209.


THE HYDROGEN-ION CONCENTRATION OF TISSUE GROWTH

IN FITRO

By M. R. Lewis and Lloyd D. Felton (From the Carnegie Laboratory oj Embryology and the Department oj Pathology, The Johns Hopkins Medical School, Baltimore)


Introduction Before undertaking a study of the effect of bacteria upon growth of tissue culture, it seemed necessary to determine in what way media of different H-ion concentrations influence the activity of tissue cultures, and whether there is a parallelism between what we know of the determining factor of H-ion concentration on the life process of micro-organisms and on cultures of embryonic tissue. Numerous observers have shown that there is both an optimum H-ion concentration for bacterial growth and a limiting or final concentration at which


gro\\'th activity is at rest, both conditions being influenced by the constituents of the medium. It was our purpose, therefore, to determine the optimum and the limiting or final H-ion concentration for tissue cultures, and to show any possible similarity of metabolism between pure type embryonic connective-tissue cells and cellular organisms (bacteria) as gro^Ti ill vitro. At the present the comparison must of necessity be crude, both because of the different conditions under which the two types of living cells exist and because of our meager knowledge concerning the elements necessary for life and propagation of cells.


March, 1922]


113


Technique

Explants of chick embryos in Locke-Lewis solution furnished a satisfactory means of following the hydrogen-ion concentration during the growth of tissues, because of the ease with which a medium of a given H-ion concentration can be prepared and its fluidity at all ages of growth, in contradistinction to plasma. After some experimentation, a colorimetric method was devised (Felton, 1921) by which it was possible to test out the small hanging drop of the tissue culture. This method is not only very simple but also apparently quite exact. A drop of indicator of approximately the same size as the hanging drop was placed directly upon the growth on the cover-slip, shaken or stirred about and, with an abrupt blow, shaken off into a white glass plate. An exact reading of the drop wa.s then obtained by combining a drop of indicator with a drop of a known buffer solution until the same color as that of the hanging drop was obtained.

Tissue cultures were prepared in the usual manner (Lewis and Lewis, 1915). Locke-Lewis solution (85 c. c. of NaCl 0.9 per cent plus KCl 0.042 per cent plus CaCl, 0.025 per cent plus NaHCOg 0.02 per cent plus 15 c. c. chicken bouillon plus 0.25 per cent dextrose) has a H-ion concentration between 6.6 and 7, usually 6.8. When a mediimi of a given H-ion concentration was to be prepared, the sodium bicarbonate and dextrose were omitted and sodium hydroxide or hydrochloric acid was added until the solution, when tested after boiling for 15 minutes, gave the color corresponding to that of the buffer solution of tlie required H-ion concentration. To this was then added sufficient dextrose to make 0.85 per cent. Solutions of H-ion concentrations varying from 4.4 to 9.2, with an increment of 0.2, were used. Explants were made from connective tissue from chick embryos ranging from 5 to 14 days' incubation, but unless otherwise stated the results refer to tissue from embryos of 7 to 9 days' incubation.

The buffer solutions used in these experiments were furnished by Doctor W. Mansfield Clark. The indicators were thymol blue, methyl red, brom thymol blue, brom cresol purple, phenol red, cresol red, and phenolphthalein.

Vaeiabilitt of the H-ion Concentration of Locke-Lewis Solution on Different Kinds of Cover-Slips A few series of cultures sufficed to show that care must be taken in selecting the cover-slips for these experiments. With cover-slips made from certain kinds of glass the control hanging drops, after incubation, varied greatly and many of them became so alkaline that the results of any experiments with different media would have been obscured. All coverslips were placed in dilute sulphuric acid for one or more days before preparing them for use. Covers of three unknown makes, which had been in the laboratory a number of years, were the most satisfactory. When a drop of a solution of a known H-ion concentration was incubated upon these it remained almost unchanged for a number of days, so that after a period of three weeks in the incubator the H-ion concentra


tion was approximately the same as that of the original solution (6.8 to 7.0) . A number of other kinds of cover-slips were tested but proved to be unsatisfactory for our purpose, as the hanging drop sometimes changed within a few days from pH 6.8 to pH 8 or 8.6. It is clear, therefore, that the selection of cover-slips suitable for the purpose is of great importance before undertaking any experiments.

An attempt was made to render the unreliable cover-slips more satisfactory by coating them with celloidin or with paraffin. Those covered with a thin layer of celloidin were favorable for growth; the cells grew out as extensively and lived as long on such covers as on the usual ones, but the hydrogenion concentration of the control drops still varied greatly, due no doubt to the dialysis of the H-ion from the glass. It is possible that an impermeable membrane would produce almost ideal conditions. The alkalinity of these drops did not increase to such a marked extent as on the uncoated cover-slips, but the variations in the results with the individual cover-slips was so great as to render them undesirable for these experiments. On the cover-slips coated with paraffin the drops remained much more constant, but rounded up to such extent that such covers were useless for the purpose of tissue cultures. The limited number of reliable cover-slips obtainable at this time accounts for the small number of esjperiments given in the charts.

Eange of Hydrogen-ion Concentration of Media in which Chick Tissue Exhibited Growth

Pieces of chick embryos were explanted into media having a H-ion concentration varying from 4 to 9.2, with an increment of 0.2. In solutions having H-ion concentrations of 4.0, 4.4, 4.8, 5.0 and 5.2 no growth was obtained, except in one series in which a few migrating cells wandered out from explants of a 68-hour embryo in a solution of pH 5.0. Many explants, from embryos of all ages, were made in solutions of pH 5.5, but none of these grew except in the case of a chick blastoderm of 24 hours' incubation. In general, the younger the embryonic tissue the greater the percentage of growth in media of low pH value.

Approximately one hundred cultures were explanted into solution with H-ion concentrations of 6.0, 7.0, 8.0 and 9.0. The percentage of growth which occurred in these cultures was respectively 71, 93, 89 and 81. In the normal LockeLewis solution, which has a H-ion concentration usually about 6.8, over two hundred cultures were explanted. Of these, 90 per cent grew. The greatest nmnber of cultures grew in media of pH 7 and in the normal solution, and these cultures also exhibited the most extensive growth. It was frequently impossible to differentiate the series of cultures explanted into media having a H-ion concentration of 7.0, 7.2, and 7.4. What growth took place in solutions of pH 6.0 was extensive and healthy, but tissue from embryos of over 11 days' incubation seldom grew in this medium. The growth in solutions of pH 9.0 was frequently small, whereas that in solutions of pH 8.0 was more extensive and lived longer.


114


[No. 373


Htdkogen-ion Concenteation of Culttxees Geown in

Media of Vaeting Hydrogen-ion Concen TEATIONS (pH 6, 7, 8. and 9)

Table 1 shows the results obtained when cultures explanted into solutions of different hydrogen-ion concentrations (pH 6.0. 7.0, 8.0 and 9.0) were tested by means of the drop colorimetric method described above. Wliile the individual cultures varied greatly, there were no marked differences by which cultures belonging to one series could be distinguished from those of another. Cultures explanted into acid media (pH 6.0) were on the whole somewhat more acid than those in normal Locke-Lewis solution, wliile those explanted into alkaline media (pH 9.0) were a little more alkaline than those in neutral solutions.

The lack of any marked differences between the series of cultures was probably due largely to the fact that the explanted piece acted as a buffer, so that shortly after explantation the medium became changed to one more nearly neutral. This was especially so in the alkaline solutions. Cultures explanted into media, which, after explantation, had a H-ion concentration of 8.2 and 9.0, became within 3 to 4 hours pH 6.8 to 7.2 and pH 7.6 to 8.0, respectively. Not enough cultures were examined to justify any definite conclusions, but from the table it is evident that, regardless of the initial hydrogen-ion concentration of the medium, cultures. which contained healthy and extensive growth tended to be neutral, those which failed to grow had usually become slightly acid, and those which had exhibited extensive growth and then degenerated were slightly alkaline. As will be shown later, however, this last point depends upon the amount of dextrose present in the medium.

It is difficult to understand what factors caused our results to differ from those obtained by Eous (1913), who studied cultures of chick embryo tissue explanted into plasma that had been colored blue with litmus. The differences in regard to healthy cultures may be explained on the ground that diffusion takes place much less readily in plasma than in LockeLewis solution ; therefore, whatever acid was produced by the explant may have been held in the immediate vicinity of the explant and thus have become condensed to a sufficient strength to turn the blue litmus pink. This, however, does not account for the fact that in Rous's experiments cultures that failed to grow remained alkaline, while in ours such cultures were usually more acid than those exhibiting good growth. The varied results may be explained upon the basis of different media.

Htdeogex-ion Conuenteation op Cultures Geoavn in Locke-Lewis Solution The hydrogen-ion concentration of the solution used depended upon that of each preparation of bouillon. It was usually about 6.8, but in a few instances was 6.6, and in others 7.0. The amount of dextrose added to the solution varied, as it was measured, not weighed; supposedly about 0.25 per cent to 0.5 per cent dextrose was used. Two hundred and thirty-six cultures were tested in this solution (Chart 1).


Of these, 19 failed to grow, 107 exhibited extensive growth, and 110 were tested after the growth had degenerated.

The age at which the culture was tested had little bearing upon the hydrogen-ion concentration. The condition of the culture, on the other hand, appeared to have a marked influence, as it was found that cultures that had failed to grow were usually slightly acid. The greater number of those tested when the growth was extensive and healthy were neutral, with a range from pH 6.6 to 7.4 ; whereas, after degeneration had taken place, most of the cultures were slightly alkaline, ranging from pH 6.0 to 7.8.

Influence of Dexteose in the Medium upon the Htdro GEN-ION CoXCENTEATION OF THE CULTURES

Tissues grew extensively in media containing from 0.25 per cent to 2 per cent dextrose. When dextrose was omitted from the solution, the cultures often exhibited an extensive cell proliferation withia 24 to 48 hours, but soon became full of vacuoles, and degeneration took place within a few days (Lewis, 1921). When a large quantity (4 to 5 per cent) dextrose was added, the amount of growth was quite variable ; sometimes large, again small, and in some instances consisting of only a few migrating cells. The cells of this growth, however, seldom contained any vacuoles, even after many da3's. The growths in media containing a large amount of dextrose usually lived longer (1 to 2 weeks) than those in media without dextrose (3 to 5 days), but seldom as long as those in cultures containing a smaller amount of dextrose (2 to 4 weeks).

It was difficult to determine the exact amoimt of dextrose most favorable for the cultures. It varied between 0.5 per cent and 1 per cent, depending upon the series; in some experiments, culture in a medium containing 0.5 per cent dextrose exliibited larger growth and lived longer than those in a solution to which 1 per cent dextrose had been added, wliile in other series the results were reversed. From an examination of the numerous cultures (over 500) explanted into media containing different percentages of dextrose, it was found that 0.25 per cent was seldom sufficient sugar to maintain a healthy growth for many days. The cells began to develop vacuoles within 4 to 5 days and died shortly aftei-wards.

Of the cultures explanted into media without dextrose, 71 were tested at death. Of these 19 had a hydrogen-ion concentration of 7, 34 were pH 7.2, 15 were pH 7.4 and 3 were pH 7.6. The longest period of life was 9 days; the greater number of the cultures died between the third and fifth day. Most of the solutions used as media had a hydrogen-ion concentration of 6.4 and 6.6 ; a few were pH 6.8 or pH 7.0. When dextrose was not added to the medium the cultures did not become acid during growth and degeneration. Those failing to grow, however, were sUghtly acid.

As shown in Table I. Chart I, and Table II, cultures containing 0.25 per cent to 0.5 per cent dextrose behaved in somewhat the same manner. On the other hand, cultures in media containing 1 per cent or more dextrose usually had become acid at death. The range of hvdrogen-ion concentra


THE JOHNS HOPKINS HOSPITAL BULLETIN. MARCH, 1922


f(k~



Fig. 1. — A T-day culture ol cuimeetive ti.s^ue from an 8-day cliK-k tnil)r\u. 'Hit' dark area is the explanted piece and the distance from this to the cells at the top of the page may be used as an axis to indicate the extent of the outgrowth of cells wliich IS meant b.v extensive growth. X 43.


i


Maech, 1932]


115


tion varied greatly in the different cultures. Usually, cultures that contained the most dextrose ivere the most acid. Those in 5 per cent dextrose (the largest amount of sugar used in these experiments) were frequently pH 5.8 to pH 6.0. The length of life of the growth in cultures containing more than

TABLE I Hydbogen-ion Concentration of


The cultures after



pH 01 5 were pH 0.4' ?, were pH


3 "

1 was


pH


10 were pH . S


were pH 6.4 " 6.0

6.3! S " " 6.S

0.4 1 was

6.0

6.S


were pH 6.2 " 6.4


pHS


pH9


4 were pH 0. 6 '• " 7. 4 " "7.


1 was pH ' 3 were " ' 3 "


6 were pH G. 3 " "6.6 3 " " 0.8 1 was " 7.


were pH 0. 0.;


1 was 1 " 3 were


1 was pH 6.0 5 were " 6. 3 " " 7.


1 was pH 6.4


0.8


1 was pH6.6 3 were " 6.S 19 " "7.


3 were [ 3 "

8 "

6 •'


6.4 6.6 6.8


1 was pH 6.

1 " " 6.3

1 " " 6.4

7 were " 6.6

11 " " 6.8

11 " " 7.3

7 " " 7.4

3 " " 7.0

1 was " 7.8

3 were pH 0.4

6 • "6.6

7 " " 6.8


3 " " 7.0 5 " " 7.8

1 was pH 0.6

2 were " 6.8 1 was " 7.

5 were " 7.3


The hydrogen-ion concentration of cultures explanted into media having different hydrogen-ion concentrations (pH 6.0, 7.0, 8.0, and 9.0). The cultures which failed to grow were usually tested after 48 hours, but in some instances not until after three or four days. The age at which the cultures exhibiting extensive growth were tested varied from 24 hours to 14 days.

The final hydrogen-ion concentration was obtained by testing cultures just after the cells had died or while one or two still remained alive. This occun-ed between four days and four weeks, usually at the end of 15 days.

1 per cent dextrose seemed to be dependent upon the rapidity with which the formation of acid took place. When death took place, the cells appeared quite different from those in 0.25 per cent to 0.5 per cent sugar, as vacuolization did not occur nor did the cells round up ; instead they became coagulated, retaining their size and shape somewhat as skeleton forms. The cultures that died after a few days of growth had


already become acid (pH 6.0), while those that still exhibited good growth when tested, even after a much longer period of time (10-14 days), had not yet done so.

The final hydrogen-ion concentration of the tissue cultures depended more upon the amount of dextrose added to the

TABLE II


Without dextrose pH O.S.


Cultures in media without dextrose


With 1% dextrose pH 6.8


Cultures in media with 1% de.xtrose


No. of cultures


pH'


" 7.6 Average final pH^7.35


pH6.

" 6.


Average final pH=6.39


The final hydrogen-ion concentration of cultures explanted into media to which no dextrose was added and into media containing 1 per cent dextrose.



Chart I. — The hydrogen-ion concentration of 236 cultures explanted into normal Locke-Lewis solution.

(broken line) represents the hydrogen-ion concentration of the cultures which failed to grow; (smooth line)

that of cultures which were tested when the growth was ex-tensive; o — o — o — o (dotted line) that of cultures which grew well but were not tested until they had degenerated.

Locke-Lewis solution than upon the original hydrogen-ion concentration of the medium. This is shown in Table II.

Discussion From the work reported in this paper it would seem that the optimum H-ion concentration for growth in vitro of embryonic connective tissue cells of a 9-day cliick lies between 6.8


116


[No. 373


and 7.0. The question immediately arises, Why is the optimum H-ion concentration not 7.4, as it is in the blood of an adult chicken? Although not sufficient cultures were tried at a given pH to make it possible to decide this question, the wide range in which tissue cultures grew would make it appear plausible that growth can occur as well at pH 7.4 (same as blood) as at pH 6.8 to 7.0. However, it should be borne in mind tliat we are deaUng with embryonic tissue, more capable, perhaps, of adapting itself to the experimental environment than are the adult cells. This may account for the wide range of H-ion concentrations in which the cells grow. As stated above, the younger the embryonic tissue the higher the percentage of growth in more acid media. Aggazzotti (1913) has shown that there is a gradual neutralization of the yolk as the embryo develops, changing from a pH 4.6 to a pH 6.4 from the first to the twenty-third day of its development. Granting this to be true, a 9-day chick embryo is developing in a more acid medium than an older one and in a less acid medium than a yoimger one. It seems reasonable that the optimum pH for a 9-day chick might be lower than for the adult animal and that this optimum would be the same as that of the yolk-sac at each respective stage of development.

The carbohydrate (dextrose) metabolism of embryonic connective tissue is seemingly very similar to that of bacteria. In a medium without dextrose, the pH increases as it does with most bacteria grown on ordinary dextrose-free medium, while with 0.25 per cent to 0.5 per cent of dextrose the H-ion level remains the same or swings a little to the acid or basic side from the original fluid. The two factors that influence tMs difference are the size of the drop of medium (buifer) and the condition and size of the explant. However, in a medium of 1 per cent dextrose, the entire buffer effect is used up by the acid produced from the dextrose, and the H-ion concentration is always more acid than the original solution. These results


are strikingly parallel to those found in the study of bacteria under similar conditions.

SUMMABT

Tissue cultures of chick embryos explanted into LockeLewis solution of a H-ion concentration between 5.5 and 9.0 exhibited growth. The medium most favorable for growth was one having a hydrogen-ion concentration about 6.8 to 7.0. The addition of dextrose to the medium was necessary for the healthy growth of cells over a period of time longer than three days. Wliile all cultures in solutions containing up to 5 per cent dextrose exhibited growth, those in solutions containing between 0.5 per cent and 1 per cent had the greatest proliferation of cells and remained healthy for tlie longest period of time. Cultures that failed to grow were usually sUghtly acid, while cultures exliibiting extensive growth, when tested, were as a rule nearly neutral.

The final hydrogen-ion concentrations of the cultures depended upon the amount of dextrose in the medium. Those in solutions to which no dextrose had been added were pH 7.0 to 7.6, while those to which '2 to 5 per cent dextrose had been added were often pH 5.6 to 6.4.

BIBLIOGRAPHY

Aggazzotti, A.: Influenza dell' aria varefatta sail' ontogenesi. Arch, f. Entwcklngsmechn. d. Organ., 1913, XXXVII, 1-2S.

Felton, L. D.: A colorimetric method of determining the hydrogenion concentration of small amounts of fluid. Jour. Biol. Chem., 1921, XLVI, 299.

Lewis, M. R.: The formation of vacuoles in the cells of tissue cultures owing to the lack of dextrose in the media. Anat. Rec, 1921, XXI, 71.

Lewis, M. R., and W. H.: Mitochondria (and other cytoplasmic structures) in tissue cultures. Amer. Jour. Anat., 1915, XVII, 339.

Rous, P.: The growth of tissue in acid media. Jour. Exper. Med., 1913, XVIII, 183.


THE RELATION OF H-ION CONCENTRATION TO SPECIFIC PRECIPITATION

By V. E. Mason

(From the Division of Clinical Pathology oj the Medical Clinic, The Johns Hopkijis University and Hospital)


The purpose of this article is to present the results of a series of experiments designed to determine the relation of specific precipitation to the H-ion concentration of the solution in which the antigen-antibody reaction takes place.

The earlier experiments of Michaelis and Davidson ' were made with combinations of sheep serum as antigen and immune rabbit serum as antibody. The H-ion concentration of the medium in which the precipitation reaction occurred was varied by the use of solutions of sodium acetate and acetic acid. Since non-specific protein precipitation occurred, their results were subject to an error dependent on the difficulty of

^ MichaeUs and Davidsohn, Die Abhilngigkeit spezifischer Filllungsreaktionen von der Wasserstoffionenkonzentration. Biochem. Ztschr., Berlin, 1912, XLVII, 59.


determining tlie amount of such precipitation, as may be readily observed in their protocols. They found that specific precipitation occurred between [H] 3 X 10"^ and [H] 6 x 10"* when the antigen was employed in small amounts. If the dilution of antigen was less, however, precipitation occurred in the H-ion range of primary and secondary phosphate solutions, viz., from pH 5 to pH 9. They did not attempt to define the exact range of [H] in which specific precipitation occurred.

In the series of experiments recorded below crystallized egg albimien was employed as antigen. A precipitating serum was produced in rabbits by three daily intravenous injections of 0.01 gm. of antigen in physiological salt solution. At the end of about three weeks the titer of the immune sonmi


March, 1933]


iir


was usually greater than 1 : 100.000. The hydrogen-ion concentration of the mixtures of antibody and antigen was altered by the addition of various amounts of M/1 NaOH and M/1 HsPO^. Since neither of these is a protein precipitant, confusion due to non-specific precipitation was avoided. Furthermore, wide variations of the hydrogen-ion concentration were possible. The NaCl concentration was kept constant by the use of 0.85 per cent NaCl as diluent for antigen.

Procedure

Three parallel rows of 20 small test-tubes were set up and into each tube 0.1 c. c. of immune rabbit serum was introduced. The precipitin titer of the serum was greater than 1 : 100,000 in each experiment. 0.2 c. c. of a mixture of M/1 NaOH and M/1 HaPO^ was added to each tube in such a fashion that tube 1 of each series contained a solution whose pH was about 4 and tube 20 of each series contained a solution of about pH 10. The pH of the solutions in the intermediate tubes of each series ascended from 4 to 10 according to the typical curve. Antigen was next added as follows : To each tube of series 1, 0.1 c. c. of a 1 : 16..500 solution of egg albumen. To each tube of series 2, 0.1 c. c. of a 1 : 8350 solution. To each tube of series, 3, 0.1 c. c. of a 1 : 1650 solution. The tubes were shaken and placed in a water-bath at 37° for 30 minutes. Certain controls were prejjared as follows :

1. pH solutions plus solutions of egg albumen in the same amounts as used in the experiment.

3. pH solutions plus normal rabbit serum in the same amounts as used in the experiment.

3. pH solutions plus normal rabbit serum plus antigen in the same amounts as used in the experiment.

At the end of 30 minutes the results were read and the relative amount of precipitation noted. The pH of the tubes to right and left of the tube in which precipitation was just


visible was determined by colorimetric methods, the dyes recommended by Clark and Lubs being employed.

Kesults

A series of experiments similar to those outUned above were performed and the results were fairly constant. Although there was occasionally difficulty in detecting minimum amounts of precipitation, the end-point was sharp unless the pH of the solution in adjoining tubes diifered by less than 0.5. In general, precipitation was marked in the tubes which contained solutions whose pH ranged from 9.5 to 4.5 inclusive. The degree of dilution of the antigen was without appreciable effect unless this was greater than the precipitin-titer of the serum or low enough to be affected by the phenomenon of inhibition. Furthermore, although accurate methods for measuring the amounts of precipitation were not employed, there was apparently no more precipitate present in the tubes whose pH was near the isoelectric point of serum globuhn (5.4) or of crystalline egg albumen (4.8).

In a further series of experiments similar to those outlined above, antigen and antibody were allowed to come in contact, with consequent precipitation, before the introduction of acidalkali mixtures. The precipitate dissolved rapidly in the tubes which contained a mixture more alkaline than pH 9.5 or more acid than pH 4.5. In the tubes in which the H-ion concentration was between lO"-^ and 10"^-^ inclusive the precipitate persisted, apparently unaltered.

Conclusions Specific precipitation with the solutions employed above occurred between pH 4.5 and pH 9.5 inclusive. Moreover, specific precipitates permitted to fonn in a neutral medium were dissolved if the pH was reduced to less than 4.5 or increased to greater than 9.5.


NOTES ON NEW BOOKS


Ephraim McDowell (1771-1S30), "Father oj Ovariotomy" and Founder oj Abdominal Surgery, with an appendix on Jane Todd Crawford. By August Schachner, M.D., F.A. C.S., Louisville, Kentucky. (7. B. Lippincott, 1921.)

The discovery of vaccination against smallpox, the discovery of anesthesia, and the Listerian doctrine of antisepsis, were perhaps more dramatic in their presentation and reception by the world, but they were surely not more than coordinates in importance with McDowell's heroic effort in opening up the whole realm of abdominal siu'gery, which is the theme of an admirable life of Epliraim McDowell by Avigust Schachner. of Louis^•ille, Kentucky.

In this dehghtfully written work we have all the data for a complete history of one of our great medical pioneers, if not, indeed, the greatest. It has taken years of patient research to collect all the facts of the life of this great doctor frontiersman, and of his heroic patient, Jane Crawford, so that Schachner's work is conspicuous for its untiring industri', and stands out as a model for future historians.

Our author is quite clear and is fully justified in pointing out that McDowell was not merely the first ovariotomist of the world, who thus


not only maugurated a wholly new procedure, in which lor a couple of generations he easdy outstripped all competitors in his low death rate, but that he by this act of opening the peritoneum revealed the whole nascent realm of abdominal surgery.

Just one hundred and twelve years have passed since in December, 1809, Jane Crawford laid herself, a willing sacrifice, upon the table in McDowell's house, and endured the operation of cutting out a large ovarian tumor, confessedly an " experiment, repeating the Psalms as the doctor proceeded with his bold work. All precedents and the advice of all the eminent teachers of the time were against the innovation and, had it failed, what opprobrium would have fallen upon our progenitor's head; but since this rivulet started in the mountains of Kentucky, all the world has added its tributaries until it has become a mighty stream, destined still to enlarge and to flow on as long as man lives on earth and is subject to disease.

Europe at first disbelieved, then opposed, and then adopted the innovation, and last of all tried to rob the backwoodsman of his credit by faking an earlier operator. But to-day, McDowell's reputation is unassailable, and all rejoice to join with Schachner in placing laurels upon his worthy brow.


118


[No. 373


A further dramatic offset to the mis en scene is found in the objection to the operation raised by McDowell's nephew associate who lent only grudging aid in the rash procedure.

Alas, that we have so few such classics in our American medical literature as this excellent book. Mav it reach many of our doctors.

H. A. K.

The Oxford Medicine. By Various Authors. Edited by Henrt A.

Christian and Sm J.^mes Mackenzie. (Oxford University Press,

London and Neto York, 1921.) An inherently unfortunate feature of a system of medicine is this that for better or for worse it seems necessary to include all the diseases in the domain of the internist. The treatment of certain of the subjects, therefore, which are already covered by classical and altogether satisfactorj- monographs is foredoomed to inferiority. In the fourth volume of the O.xford Medicine one finds several sections which are excellent in themselves, but still suffer in comparison with previous well-known and readilj- accessible treatises. One may mention especially the chapters on the spleen, on the muscles, on the bones, and on sepsis. On the other hand, many of the articles are well worth while. Allbutt writes on gout in the older clinical style, leaving the chemical side to his associates; Longcope gives a brief but thorough summan.' of Hodgkin's Disease; Joslin on diabetes is always interesting, and Rountree summarizes the newer points of view in diabetes insipidus. The infectious diseases are well handled, but in a conventional way; the article on pneumonia by Irons is particularly valuable as a summary' of the bacteriological side of this malady. The sections on industrial medicine are of interest, especially the introductory article on the physiolog>' and pathology of work by Cecil and Katherine Drinker. On the whole the volume seems a useful one.

A. L. B.


The Hospital Bvilletin contains details of hospital and dispensarj' practice, abstracts of papers read and other proceedings of tlie Medical Society of the Hospital, reports of lectures, and other matters of general interest in connection with the work of the Hospital. It is is-siied monthly. Volume XXXIII is in progress. The subscription price is $4.00 per year.

(Foreign postage, 50 cents.) Price of cloth-bound volumes, $5.00 each.

A complete index to Vols. I-XVI of the Bulletin has been issued. Price 50 cents, bound in cloth.

NEW PTJBIICATIONS


The following monograph is for sale by The Johns Hopkins Press. Baltimore, Md.:

Relation of Tonsillar and Nasopharyngeal Infections to General and Systemic Disorders. By S. J. Crowe, S. Shelton Watkins and Alma S. Rothholtz. 63 pages. Price, S125.


PUBLICATIONS


The following twelve monographs :


Benzol as a Leucotoxin. By Laurence Selling, M. D. 60 pages. Price, $1.00.

Primary Carcinoma of the Liver. By M. C. Winternitz, M. D. 42 pages. Price 75 cents.

The Statistical Experience Data of The Johns Hopkins Hospital, Baltimore, Md., 1892-1911. By Fkederick L. Hoffman, LL.D., F.S.S. 161 pages. Price, $2.00.

Venous Thrombosis During Myocardial Insufficiency. By Frank J. Sladen, M. D., and Milton C. Winternitz, M. D. Price, 75 cents.

The Origin and Development of the Lymphatic System. By Florence E. Sabin. 94 pages. Price, $2.00.


Leukaemia of the Fowl: Spontaneous and Experimental. By Harry C. Schmeisser, M. D. Price, $2.00.

are now on sale by The John's Hopkins Press, Baltimore. Other monographs will appear from time to time.


The Structure of the Normal Fibers of Purkinje in the Adult Human Heart and Their Pathological Alteration in Syphilitic Myocarditis. By 0. Van Der Stricht and T. Wingate Todd. Price, $2.00.

The Operative Story of Goitre. The Author's Operation. By William S. Halsted, M. D. Price, $3.50.

Study of Arterio-A'enous Fistula with an Analysis of 447 Cases. By Curle L. Callander, M. D. Price, $2.50.

Ligations of the Left Subclavian Artery in its First Portion. By William S. Halsted. Price, $2.00.

The Patholo,gy of the Pneumonia in the United States Army Camps During the Winter of 1917-18. By William G. MacCallcm. Price, $1.50.

Pathological Anatomy of Pneumonia Associated with Influenza. By William G. MacCallum. Price, $1.50. (This monograph will be on sale within a short time.')


CONTENTS

  • Immunologital Reactions of Bence-Jones Proteins. II. — Differences Between Bence-Jones Proteins from Various Sources. (Illustrated.) By S. Bayne-Jones and D. Wright Wilson .
  • Study on Experimental Rickets. XIX. The Prevention of Rickets in the Rat by Means of Radiation with the Mercury Vapor Quartz Lamp. By G. F. Powers, E. A. Park, P. G. Shu'I-ey, E. V. McCoLLUM and Nina Sm.Aioxns
  • A Graphic Method for the Calculation of Diabetic Diets in the Proper Ketogenic-Antiketogenic Ratio. By R. R. Hax.xo.v, M. D., and Wii. S. McCan.n, M. D.
  • The Alveolar and Blood Gas Changes Following Pneumectomy. (Illustrated.) By George J. Hever and W. D. W. Andrus .
  • Posterior Resection of the Rectum and Rectosigmoid (Kraske or Modified) Under Regional Anesthesia. By Gaston L. Lahat, M. D., Paris
  • The Use of the Bone Graft in the Treatment of Pott's Disease. By William S. B.\er, M. D
  • A Suggested Modification of the Wright Opsonic Technique Based Upon the Differential White Blood Count. By Howard B. Cro.ss 142
  • The Dissemination of Bacteria in the Upper Air Passages. II. — The Circulation of Bacteria in the Mouth. By Arthur L. Bloohfield 14.1
  • Bacterial Nutrition Growth of a Hemophilic Bacillus on Media Containing Only an Autoclave-Stable Substance as an Accessory Factor. By T. M. Rivers, M. D 149
  • On the Presence of Nucleic Acid in Bacteria. (A Preliminary Report.) By Ale.xander J. Schaffer, Caspar Folkoff and F. Bavxe-Jones 151
  • The Role of Situation in Psychopathological Conditions. (Abstract.) By Esther Lori.xg Richariis 152
  • Notes on New Books 153

Books Received 153


IMMUNOLOGICAL REACTIONS OF BENCE-JONES PROTEINS II.-DIFFERENCES BETWEEN BENCE-JONES PROTEINS FROM VARIOUS SOURCES

Bj S. Bayne-Jones and D. Wright Wilson (From the Departments of Pathology and Bacteriology and of Physiological Chemistry, The Johns Hopkins University.)


Since 1847, when Bence-Jones^ described the peculiar substance now known as Bence-Jones protein, many preparations of it from different sources have been studied chemicallj'. It has been well established that this substance is a protein with peculiar properties which render it unique among proteins. Furthermore, as the various preparations of this protein have been found to possess in general similar properties, and as the analyses of the specimens from two cases of Bence-Jones. proteinuria made by Hoplvins and Savory ^ agreed within the limits of their experimental error, there has been a


tendency to assume that all preparations of Bence-Jones protein are identical in structure and composition.

The usual determinations of the chemical constituents of proteins, however, have not afforded sufficient data on which to base an opinion as to the identity of those substances. As is well known, immunological reactions have indicated differences between proteins which were apparently alike. In some cases, as for instance in the comparison of the proteins of the eggs of the hen and duck made by Dale and Dakin,^ there has been found some correlation between the structure of the proteins


]l.'l)


[Xo. Mi


and their s])t'cilic c-Iiaracteristics as antigens. As yet, no innniinoldgiial coniiiarisous of varions preparations of the socalled "Bence-.Iones protein" have been made.

Some aspects of Bence-.Iones proteinuria suggest that the opinion that the substance has an invariable coml)osition may not be jiistilied. Bence-Jones proteinuria has been found in association with multiple myelonut, leukemia, carcinomatosis of bone, diseases of the kidney and otiier obscure conditions. Although the origin of Bence Jones protein in the body is unknown, it is conceivable that the characteristics of the substance excreted in the urine might vary as the result of different pathological states. It is possible also that like the erythrocytes of man, and like bacterial proteins — those of the Pncmnococci for example — the specimens of Bence-Joues protein excreted by different human individuals might have specific differences. The specimens of the protein are not all alike physically. There is certainly a great difference in their tendency to crystallize, or even to precipitate spontaneously; and varying temperatures of coagulation liave been reported. Finally, the method of isolation of the protein from the urine might alter its ])Iiysical. cliemical and immunological characteristics.

The purity of the preparations has undoubtedly affected the results of immunological studies on the broad relationship of Bence-Jones protein to other proteins of iuiman origin, particularly the proteins of human serum. Until recently, it was held that an animal immunized to Bence-Jones protein formed an antibody which i)recipitated liuman serum iiroteins. Massini * and Hektoen ° liave shown that by dilution and absorption of the antibodies in sudi sera it is possible with them to show a difference between Bence-Jones protein and human serum ])roteins. In a recent paper," we have described tlie results of an immunological comparison of Bence-Jones ])i'oteins with human serum. In this, we showed tliat a crystalline Bence-Jones protein acts as a single antigen, causing the production of strictly specific antibodies wiiicli do not affect the proteins of human scrum. On the otlier hand, non-crystalline precipitated preparations of Bence-Jones protein were found to contain traces of human serum, which were responsible for the production of antibodies to human serum when these preparations were injected into animals. Aside from the effects attrii)ntable to coutamination witli traces of other proteins in the i)recipitated pre])arations, we think that the procedures, which will be described below, did not alter the fundamental antigenic (pmlities of the Bence-Jones proteins used in these experiments.

In a jtreliminary note,' we rejiorted tliat we had found immunological differences between various specimens of Bence-Jones protein. In tliis i)aper, we sliall present in detail our evidence for the opinion that Bence-Jones i>rotein is not a single substance, but that a group of similar, but not identical, proteins have been included in this designation.


List of Si-ecimexs of Benck-Joxes I'koteix The various preparations of Bence-Jones protein which ere used in this investigation were obtained as follows:


No.



Palknt


Diagnosis


Isolated by:


Method of isolation.


1.


H. M. R.


Bence-Jon es


D. W. Wilson.


Precipitated with




proteinuria


Reported by


spdium sulphate




without de

Waaters s.


and acetic acid.




monstrable



washed and dried




lesions in



with alcohol and




bones. No



ether.




evidence of






myeloma.




2.


H. M. R.


Do.


Do.


Coagulated by heating at 60° C in slightly acid solution, centrifuged and dried with alcohol and ether.


3.


H. M. R.


Do.



ITrine.


4.


H. M. R.


Do.


Do.


Crystallization.


5.


J. E. L.


Multiple m.veloma?


A. Taylor".


Precipitated like No. 1.


6.


F.


Multiple


Guthrie and


C ag u 1 ated at




myeloma.


Boggs 10.


60° C. in solution made acid with acetic acid, filtered, dried o v er H,SO..


7.


S.


Multiple


Guthrie and


Coagulated, like




myeloma.


Boggs i».


No. 6.


8.


J. E. D.


Carcin o m a


D. W. Wilson.


Precipitated like




with meta

Reported by


No-. 1.




stases to


Walters 8.





bones.




9.


J. E. D.


Do.



Urine.


10.


R. L.


Multiple myeloma.


Do.


Precipitated like No. 1.


11.


R. L. !


Do.



Urine.


12.


?


Multiple myeloma.


Rosenbloom n


Coagulated at 60° C.


The 12 preparations of Bence-Jones protein listed in Table I were derived from 5 patients affected with various diseases. Of tliese preparations, one (No. 4) crystallized spontaneously in the urine and was purified as completely as possible by recrystallization. In the comparison with human serum, which we have described, this protein acted as a single antigen. All the otlier preparations listed above contained traces of human .serum proteins.

The immunological studies of these preparations wei-e made by using precipitin, complement-tixation and anaphylactic reactions.

I'rkcu'itin Ke.vctioxs The antisera to the Bence-Jones proteins used for the precipitin and complement fixation reactions were prepared as follows :


April, 1922]


121


Rabbit No. Ill — was immunized to the crystalline Bence-Jones protein No. 1 by 6 intravenous injections of a 1% solution of No. 4 at intervals of 4 to 6 days. The first dose was 2 cc, the last, 20 cc. Ten days after the last injection, when the rabbit's serum caused a precipitate in a 1 to 1,000,000 dilution of a 1% solution of No. 4, the animal was bled.

Rabbit No. 153 — was injected intravenously at intervals of 4 to 6 days with amounts of a 0.5% solution of protein No. 12, increasing from 3 cc. to 20 cc. Six days after the fifth injection, the rabbit was bled. Precipitin titer: 1-100,000 (dilution of antigen).

Rabbit No. 189 — was immunized to Bence-Jones protein No. 7. After 8 injections of amounts of 2 to 6 cc. of a 2% solution of this protein at intervals of 3 to 5 days, the precipitin titer of the serum was 1-2000 (antigen dilution.).

Rabbit No. 195 — was immunized to Bence-Jones protein No. 6. At intervals of 6 days, 1 cc, 5 cc, and 7 cc. of a 3% solution of this protein were injected intravenously. Five days after the last injection, when the animal was bled, the precipitin titer of the serum was 1-8000 (antigen dilution).

The precii)itin tests were made in small clean sterile tubes with clear solutions of the antigens and clear sterile serum. Precautions were taken to eliminate false results due to the growth of bacteria in the mixtures. The BenceJones proteins were dissolved in salt solution with the aid of a small quantity of NaOH. The resulting solutions were neutralized with HCl until they were only very faintly alkaline to litmus. In the tests, the dilutions were made with normal saline. The pH of all dilutions above 1-100 was approximately 7. The various dilutions of the antigens were layered upon the undiluted antiserums, and the first reading made by noting the presence or absence of precipitate at the plane of junction of the two fluids after they had been in apposition at room temperature for 1 hour. The fluids were then mixed, the tubes placed in the incubator at 37° C. for 24 hours, and a second note made of the sediment in the bottom of the tubes. Controls were made by mixing equal quantities of each component, serum or antigen, with salt solution and by incubating these mixtures with the tests. When precipitation occurred in the controls, the corresponding tests were discarded or repeated. The results of the precipitin tests are summarized in the following tables (Tables II, III, IV, V), in which the amount of precipitate is indicated by plus ( + ) signs.


Precipitin reax;tions of antiserura to crystalline Bence-Jones protein vs. Bence-Jones proteins.


Serum 144 Anti— No. 4



Dilution of antigen






Precipitation






g


i






o


= s


g protein


^








""


^


^


'- 1 "


-


No. 1


+ +


+ ++ +


+ + +


+ +


+





2


+


+ +


+ + +


+ + + +


+ + +


+ +


+


3 Urine


+


+ +


+ +


±






4



+


+ + +


+ ++ +


+ + +


+ +


+


5


+ +

6


+ +


-f








7


+

8


+


+


-f


+


',




9 Urine



+


+


±





10



±








11 Urine



+








12



+ TABLE III.

Precipitin reactions of antisenim to No. 6 vs. Bence-Jones proteins.

Serum 195 Antl— No. 6


Precipitation


Dilution


of antigen





with







Bence-Jones protein


4%


1-10


1-100


1-1000


1-8000


No. 1 2 3 Urine


+








4 5


+








6


+ +


+ + + +


+ + +


+ +


+


7


+ +


+


+





S



+






10


+


±







122


[Xo. 374


Precipitia reactions of antiserum to No. 7 vs. Bence-Jon.es proteins.

Serum 189 Anti— No. 7


Precipitation


Dilution


7f antigen





with







Bence-Jones protein


4%


MO


1-100


1-1000



1-2000


No. 1



+ +


+



2


+


+






3 Urine



+ +


+





4


+








5



±


+


+ +


+


6


+ ++4


+ +


+


+



7


+ ++ +


+ + + +


+ + +


+ +


+


8



+


+ +


+ 4

+


10


+ +


+ +


+


+




Precipitin reactions of antiserum to No. 12 vs. Bence-Jones proteins.

Serum 153 Anti— No. 12



Dilution


of antigen




Precipitation

with

Bence-Jones

protein


4%


110


1-100


1-1000


1-10,000


No. 1


+








2 3 Urine


+


±






4 5


+


+


+ + +


+ + +


+


6


+ +


+ +


+ + + +


+ + +


+ +


7



+


+ +


+ + +


+


8





+


±



9 Urine


+


+ +


+ + +


+ +



10





+ +


+ + +


+


11 Urine


+


+


+ +


+ + + +


+


12



+


+ +


+ + +


+


The results of the precipitin reactions presented in Tables II, III, IV and V may be summarized as follows:

(a) The highly potent antisei'um to the crystalline Bence-Jones protein (Xo. 4), having a titer of 1-1,000,000


for its homologous antigen, precipitated all the preparations of Bence-Jones protein. All, however, were by no means afifected to the same degree. This antiserum showed a definite affinity for the preparations derived from the patient H. M. R., precipitating Nos. 2 and 4 to the endtiter, No. 1 in a dilution of 1-10,000, and a 1-1000 dilution of No. 3, which was this patient's urine. Proteins Nos. 8 and were precipitated by this antiserum in dilutions up to 1-1000, while Nos. 5, 6, 7, 10, 11 and 12 were not precipitated when diluted above 1-50. As a consequence of its high titer, this antiserum demonstrated the group or class relationship of the various preparations, and at the same time indicated the sub-grouping among them. It is to be recalled that the preparation used to immunize the rabbit which produced this serum was free from human serum proteins. This antiserum did not precipitate human serum. The precipitin reactions with it, therefore, are strictly specific for BenceJones proteins.

(ft) The antiserum to Bence-Jones protein No. C, having a titer of 1-8000, showed no affinity for the isolated protein from patient H. M. R. (Nos. 1, 2 and 4). As preparation No. G contained a trace of serum proteins, its antiserum also precipitated human serum. To this is to be attributed the precipitate produced when it was added to No. 3, the urine from H. M. R., which contained some serum proteins. While this antiserum slightly afifected the other preparations of Ifence-Jones proteins, it did not precipitate any one of these in a dilution above 1-100.

(c) The antiserum to preparation No. 7 also included a precipitin for human serum proteins, as its antigen contained traces of these proteins. It caused precipitation with all the preparations of Bence-Jones proteins. The preparations from the patient H. M. R., however, (Nos. 1, 2 and 4) were precipitated only in concentrated solutions. On the other hand, proteins Nos. 5, 6, 8 and 10 were precipitated by this serum to its end-titer.

(d) As Bence-Jones protein No. 12 contained traces of human serum proteins, its antiserum precipitated human serum. This antiserum did not precipitate preparations Nos. 2 and 4, the coagulated and crystalline protein from patient H. M. R. Preparations Nos. 1 and 3 from the same patient, containing traces of serum proteins, were precipitated in concentrated solutions by the antiserum to No. 12. The other preparations were precipitated to almost the end-titer by this serum.

While this series of comparisons is not large, it indicates that there are aniigenic differences between these


April, 1922]


123


preparations of Beuce-Jones proteins. Two distinct groups are recognizable, namely :

Groui' I. — Crystalline Bence-.Tones protein No. i, and other preparations, Nos. 1, 2 and 3 from patient H. M. K.

Group II. — Beuce-Jones proteins Xos. 5, 6, 7, S, 10 and 12.

lu addition, tliere are certain less sharply defined differences between the proteins listed in Gi-oup II. For e.xaniple, proteins Xos. 5 and 6 seem to be representatives of different groups.

An attempt was made to define these groups more sharply by applying the method of the absorption of precipitins. The conditions which at present limit the applicability of this method were discussed in our previous paper in relation to the removal of the antibody to human serum proteins from some of these antisera. The method was found to be unsatisfactoiy with the sera and solutions of proteins used in this investigation.

CoMPLEJiEXT Fixation Keactions

Tests were made to determine the ability of the antisera to the crystalline Bence-Jones protein No. 4 and to protein No. 12 to fix complement in the presence of the other Bence-Jones proteins. The sera were diluted with equal quantities of normal salt solution and heated to 56° C. for half an hour. To 0.25 cc. of each serum was added 0.25 cc. of a 1-20 dilution of a ifc solution of each Bence-Jones protein, or a 1-20 dilution of urine containing Bence-Jones protein. These dilutions were found by preliminary titrations to be beyond the limit of their anticomplementary action, except in the case of No. 2. They were, however, just within the range of the effective concentration for the occurrence of precipitation. These sterile mixtures were allowed to stand for 10 hours at 20° C. to permit precipitation to occur. At the end of that time, 0.25 cc. of a 1-10 dilution of fresh guinea-pig serum was added to each tube, and the tubes incubated in the water-bath at 37° C. for 1/2 hour. After this incubation, 0.25 cc. of antisheep red-corpuscle serum, containing 3 units of amboceptor, and 0.25 cc. of 2.5% suspension of sheep corpuscles were added, and the tubes returned to the water-bath. Readings of the presence or ab.sence of hemolysis were made at the end of 1 hour, when all the controls showed the expected results. In the following table, in which the results of these tests are collected, the degree of complement fixation is indicated by plus signs ( + ).


TABLK VI. Jomplement Fixation Reactions.



Bence-Jones


Dilution of



Serum


antigen


antigen


Results of fixation tests


Serum 144


No. 1


1-40


+ +


Anti— No. 4


2


1-20


anticomplementary


Dil. 1-2


3


1-20


+ + -f +



4


1-20


+ + + +



5


1-20


+ +



6


1-20


+



7


1-20


0?



8


1-20


+ +



9


1-20


+ +



10


1-20


-V



11


1-20


+



12


1-20


+


Serum 153


No. 1


1-20



Antl— No. 12


2


1-20


anticomplementary


Dil. 1-2.


3


1-20




4


1-20




5


1-20




6


1-20


+ +



7


1-20


+ +



8


1-20


+



9


1-20


-f



10


1-20


+



11


1-20


+



12


1-20


+ +++


The complement fixation reactions show the general group relationship between the Bence-Jones proteins, and in addition they confirm the results of the precipitin reactions in demonstrating a great antigenic difference between Bence-Jones protein No. 12 and the preparations from patient H. M. R., represented by the crystalline protein No. 4.

Anaphylactic Reactions

The anaphylactic responses of guinea-pigs and of smooth-muscle preparations from these animals were used to continue the immunological analysis of the BenceJones proteins. Young females, weighing about 150 grams, were sensitized by an intravenous injection of 1 cc. of a 1.5% solution of some of the proteins. This injection was not followed by any toxic symptoms. After an interval of 18 to 21 days the second intoxicating injection was given intravenously, or uterine horns were excised from some of the sensitized virgin guinea-pigs and used to obtain graphic records of the anaphylactic contractions according to the method of Schultz and Dale.'^ Sensitization was easily effected by a single in


124


[Xo. 374


jection of the proteins, except No. 4. For the experiments with this protein it was necessary' passively to sensitize the gninea-pigs by an intraperitoneal injection of 1 cc. of serum 144, whidi contained precipitin specific for l>rotein No. 4. Eighteen hours after this injection the animals were found to be hypersensitive to protein No. 4. The data of the experiments and the i-esults of the anaphylactic reactions are summarized in Table VII and Figures 1, 2 and 3.

In interpreting the data of these anaphylactic reactions, it is to be borne in mind that all the preparations of


The anaphylactic reactions confirm the results of the experiments with precipitins and complement fixation. They show clearly that the protein from H. M. R., represented typically by the crystalline preparation Xo. 4, is distinct from the others, and that Bence-.Iones proteins Xos. 5 and 12, while having some similarity, are probably representatives of other groups.

Summary and Comment

Twelve preparations of Bence-.Jones protein obtained by various procedures from the urines of 5 patients, who


TABLE VII. Anaphylactic Reactions.


Guinea Pig


Sensitizing dose

of

Bence-Jones protein


In


terval


Intoxicating dose

of

Bence-Jones protein


RESULT


230


No.



1 cc. 1.5% sol.


19


days


No. 1, 2 CC. 4% sol.


Typical shock, death in 1 min.


231


No.



Ice. 1.5% sol.


19


days


Xo. 4, 1.5 CC. 4% sol.


Slight reaction.


232


No.



Ice. 1.5% sol.


19


days


No. 5, 1.5 cc. 4% sol.


Shock. Death.


233


No.



1 cc. 1.5% sol.


19


days


Xo. 8, 1.5 cc. 4% sol.


-Shock. Death.


234


No.



1 cc. 1.5% sol.


19


days


Xo. 10, 1.5 cc. 4% sol.


Shock. Death.


194


No.


5,


1 cc. 1.5% sol.


19


days


Nos. 1. 4, 6, 7, 8, 10, 12,

1 cc. each. No. 5. See Figs. 1 and 2.


Excised uterus.

No contraction caused by Nos.

1, 4, 6, 7, 8, 10, 12. Strong contraction caused by

No. 5.


293


Nt7.


5.


1 cc. 1.5% sol.


19


days


Xo. 5, 0.23 cc. 4% sol.


Severe Shock.


294


No.


5,


1 cc. 1.5% sol.


19


days


Xo. 4. 1.5 cc. 4% sol.


No reaction.


296


N(7.


5,


1 cc. 1.5% sol.


19


days


Xo. 1, 1.5 cc. 4% sol.


No reaction.


270


No.


12,


1 cc. 1.5% sol.


19


days


No. 12, 0.75 cc. 4% sol.


Shock. Death.


271


No.


12,


1 cc. 1.5% sol.


19


days


No. 5, 1 cc. 4% sol.


Shock. Death.


272


No.


12


1 cc. 1.5% sol.


19


days


Xo. 4, 1 cc. 4% sol.


No reaction.


273


No.


12


1 cc. 1.5% sol.


19


days


No. 1, 1 cc. 4% sol.


No reaction.


274


No.


12


Ice. 1.5% sol.


19


days


No. 1, 1 cc. 4% sol.


No reaction.


5


Passively sensitized to


18


hours


1 cc. 4% solutions of Nos.


No contraction caused by Nos.





No. 4




5, 6, 7 and 4. See Fig. 3.


5, 6 7. Strong contraction followed by desensitization caused by No. 4.


Bence-Jones proteins, except No. 4, contained traces of human serum proteins. As we were unable to measure the amounts of serum proteins in the various preparations, we are unable to correlate the results of these reactions with that factor. The solutions of some of the preparations may have contained sufficient serum proteins to sensitize the animals to those proteins as well as to the Bence-Jones protein component of the mixture, while they may or may not have contained enough serum proteins to cause shock attributable to serum proteins in the intoxicating dose. The error due to the common effect of the presence of serum proteins would undoubtedly confuse the result, and would tend to emphasize the similarity of the preparations of Bence-Jones protein. Nevertheless, the differences exhibited by some of the proteins used in these reactions are so considerable that their significance in most instances is quite clear.


had Bence-Jones proteinuria associated with several different diseases were compared immunologically. Precipitin and complement fixation tests and anaphylactic reactions were studied with these preparations and the antisera obtained by immunizing rabbits to some of them. One of the proteins. Xo. 4, was crystalline and acted in this, as in a j)revious investigation," as a single antigen, free from serum proteins. The other preparations precipitated from urine by various means, contained traces of human serum proteins. As these preparations contained at least two antigens, one of which was not precisely measurable, some difficulties and confusion attended their use. Xevertheless, the results obtained in experiments \\ith the crystalline protein were unequivocal, and most of the reactions with some of the other preparations were sufficiently clear for the purposes of this investigation.


THE JOHNS HOPKINS HOSPITAL BULLETIN. APRIL. 1922


PLATE -XVII


'-i




Fig. 1.— Uterus of guinea pig actively sensitized to Bence-Jo-nes protein No. 5. Guinea pig 194. At A: 0.5 cc. i% Bence-Jones protein No. 4 At B: 0.5 cc. 4% Bence-Jones protein No. 1 At C: 0.5 cc. 4% Bence-Jones protein No. 12 At D: 0.5 cc. 47r Benc^Jones protein No. 5

Fig. 2. — Uterus o-f guinea pig 194 activel.v sensitized to BenceJones protein No. 5.

At A: 0.5 cc. i% Bence-Jones protein No. 10

At B: 0.5 cc. 4% Bence-Jones protein No. 8

At C: 0.5 cc. i</c Bence-Jones protein No. C

At D: 0.5 cc. 4% Bence-Jones protein No. 7 At E: 0.3 cc. human serum

At F: 2 cc. 4% Bence-Jones protein No. 5

Fig. 3. — Uterus of guinea pig No. 5.

Guinea pig passively sensitized to Bence-Jones protein No. 4 by intraperitoneal injection of 1 cc. of serum 144. Reaction tested IS hours later.

At T: 1 cc. 4% Bence-Jcnes protein 5

At R: bath changed.

At F: 1 cc. 4% .Bence-Jones protein No-. G

At S: 1 cc. 4% Bence-Jones protein No. 7

At 4: 1 cc. 4% Bence-Jones protein No. 4


April, 1922]


125


Differences and similai-ities were demonstrated among these proteins. The methods used in isolating the proteins had no appreciable effect upon their immunological relationship, nor was there any obvious correlation between the types of the proteins and the diseases affecting the patients who excreted them. Of course, more specimens of Bence-Jones protein from various different pathological, and perhaps normal sources must be examined in this manner before it can be asserted positively that neither the disease with which the proteinuria is associated nor the method of isolation of the specimen determines the basic antigenic character of the protein. It is suggested, however, that such differences as exist may be related to the fundamental impress which an organism, bacterium or animal, places upon most of the proteins which are formed in its body.

From the immunological reactions of the preparations used by us, we are able to draw the following conclusions :

Conclusions. 1. Under the term "Bence-Jones protein" have been grouped a number of proteins which are similar but not identical.


2. Certainly two, and possibly three groups of BenceJones proteins are recognizable by immunological tests.


BIBLIOGRAPHY


J. Physiol.. Cambridge, Biochem. J., Cambridge, Leipzig, 1911,


1. Bence- Jones, H.: Philosophical Transaction, Royal Scciety, London, 1848, CXXXVIII, 55.

2. Hopkins, F. G. and Savory, H.

1911, XLII, 189-250.

3. Dakin, H. D. and Dale, H. H.: 1919, XIII, 248-257.

4. Masslnl, R.: Deutsch. Archiv f. klin. Med., CIV, 29-43.

5. Hektoen, L.: J. Am. Med. Assn., Chicago, 1921. LXXVI, 929.

6. Bayne-Jones, S. and Wilson, D. W. : Johns Hopkins Hosp. Bull., 1922, XXIII, 37-43.

7. Bayne-Jones, S. antl Wilson, D. W.: Proc. Soc. Exp. Biol, and Med., 1921, XVIII, 220-222.

8. Walters, W.: J. Am. Med. Assn., Chicago, 1921, LXXVI, 641-645.

9. Taylor, A. E. and Miller, C. W.: J. Biol. Chem., Baltimore, 1916, XXV, 281-295.

10. Hoggs, T. R. and Guthrie, C. G.: Am. J. Med. Sciences, Philadelphia, 1912, CKLIV, 803-814.

11. Rosenbloo-m: J. Arch. Int. Med., Chicago, 1912, IX, 256-257.

12. Dale, H. H.: J. Pharmacol, and Bxper. Therap., Baltimore,

1912, IV, 167-223.


STUDY ON EXPERIMENTAL RICKETS. XIX.

THE PREVENTION OF RICKETS IN THE RAT BY MEANS OF RADIATION WITH THE MERCURY VAPOR QUARTZ LAMP

By G. F. Powers and E. A. Park

(Dept. of Pediatrics, Yale University, New Haven, Conn.)

P. G. Shipley (Dept. of Pediatrics, Johns Hopkins University, Baltimore, Md.)

E. V. McCOLLUM AND NiNA SiMMONDS (School of Hygiene, Johns Hopkins University, Baltimore, Md.)


In a previous article ^ we showed that when rats were placed on a rickets-producing diet (diet 3143) they did not develop rickets if they were exposed to direct sunlight.


1 The Prevention of the Development of Rickets in Rats by Sunlight. XI. P. G. Shipley, Dept. of Pediatrics, Johns Hopkins University, Baltimore, Md., E. A. Park, G. F. Powers, Dept. of Pediatrics, Yale University, New Haven, Conn., E. V. McCollum and Nina Simmonds, Schoc?l of Hygiene, Johns Hopkins University, Baltimore, Md. Proc. Soc. for Exper. Biol, and Med.. Oct. 19, 1921.

STUDIES OX EXPERIMENTAL RICKETS. XIV. The Prevention of the Development of Rickets in Rats by Sunlight. P. G. Shipley, Dept. of Pediatrics, Johns Hopkins University, Baltimore, Md., E. A. Park, G. P. Powers, Dept. of Pediatrics. Yale University, New Haven, Conn., E. V. MicCollum and Nina Simimonds, School of Hygiene, Johns Hopkins University, Baltimore, Md. Jour. Am. Med. Assn., Jan. 21, 1922, Vol. IS, pp. 159165.


In the resume of the literature on the subject of liglit in relation to rickets which is introductory to that article, attention was called to the fact that radiation other than sunlight had been used to prevent or cure rickets in human beings. Buchholz used the "Gliihlicht" which he stated was poor in chemically active rays; Huldschiiisky, Putzig, Karger, Riedel, Erlacher and Mengert reported the use of the mercury vapor quartz lamp, and Winkler the use of the X-ray.

All the evidence as to the preventive and curative effects of the radiations from the mercury vapor quartz lamp in the rickets of human beings has been furnished by the X-raj'. In order to determine the protective action of these radiations in experimental rickets in rats and also to examine the bones themselves we perfonned the following experiments :


12G


[No. 374


Nineteeu rats, mostly mixed black and white aud about seveu weeks old, were placed on diet 3143 which, as previous experieuce has shown, produces rickets comparable iu every respect to the rickets mauifestiug itself in human beings. The ratiou has the following composition:

Per cent

Wheat 33.0

Maize 33.0

Gelatin 15.0

Wlieat Gluten 15.0

NaCl 1.0

CaCOa 3.0

It contains nearly twice the optimal content of calcium aud is decidely below the optimum in its content of phosphorus and of fat-soluble A. Otherwise it is well constituted. Nine rats were kept as control animals under ordinary laboratory' conditions in a room completely screened with windows of ordiuaiy glass. Ten rats were exposed to the radiations from a Hanovia mercurj- vapor quartz lamp (Alpine type).

One of the control animals (16Y) was found paralyzed thirty-eight days after being placed on the diet (age about eighty-eight days) and was killed. We have previously pointed out that the development of paralysis of the posterior extremities not infrequently occurs in rats fed on diet 3143. Another control animal (2CY) was killed fifty-eight days after being placed on the diet (age about one hundred and eight days) ; and the other seven animals were killed sixty-four days after being placed on the diet (age about one hundred and fourteen days).

The rayed animals were exposed to the radiations from a mercury vapor quartz lamp for varying periods of time for sixty-four days aud were then killed. The animals were exposed to the radiations for two minutes ou the first day; the period was gradually increased during the succeeding seven days to one hour daily ; for the succeeding fifty-six days of the experimental period the animals wei'e rayed for two to six hours daily, the length of time being determined largely by the availability of the lamp. The cage used was constructed so that animals could not be shielded iu any way from the radiations. The floor of the cage was placed three feet from the quartz tube.*

The rayed animals never showed conjunctivitis, but

» STUDIES ON EKPERIMEINTAb RICKETS. VIII. The Production of Rickets by Diets Low in Phosphorus and PatSoluble A. McCollum, E. V., Simnionds, Nina. Shipley, P. G., Park, E. A. Jour, of Biol. Chem., Vol. XLVII. Ko. 3, August, 1021.


We have found since the conclusion of these experiments that, before our use of the Alpine Lamp was begun, it had depreciated about eighty-five per cent (estimated) in its output of ultra-vioiet rays. This estimate was purely a guess made by a representative of the Hanovia Company, but of its essential truth we have no doubt. Prolonged exposure to the radiations of the lamp has not caused pigmentation of the skin in children.


early in the experiment spots of pigmentation on the ears of some of them were observed; this was especially markcvl iu the albinos. This pigmentation was not present at the time the animals were killed. The albinos among the rayed animals showed slight yellow tinting of the hair ou their backs.

As the experiments progressed, certain differences in the behavior of the two groups of animals were ob.served. The rayed animals were extremely active, the contrast between the two groups becoming more and more marked and reaching its maximum in the second third of the experimental period. Whenever any one came near the cage in which these animals were, a constant scurrying to and fro was almost always the striking feature observed. Not only were the control animals markedly less active, but their gait was distinctly waddling in character after the third or fourth week of the experiment. The disability of the control animals was well illustrated by the fact that toward the end of the experiments seven of the animals got out of their cage and were all recovered with relatively little difficulty.

The rayed animals always seemed to be hungry and, al though the food given to each group was not measured, it was obvious that the amount consumed by the animals receiving mercury lamp radiations greatly exceeded that consumed by those in the control group. Increased appetite, then, was a striking characteristic of the rayed animals.

One of the rayed animals gave birth to six young on the thirty-seventh day of the experiments.

The autopsies revealed umny differences in the animals. As shown in the following table, the measurements corro borate the observations made as to the better physical development of the animals exposed to the radiations from the mercun' vaiior quartz lamp. P" "m

' ' '^ Increase in

Conlrol RaJialed Radiated over

Animals (8) -Animals (9) Controls

Average Weight 140 grams. 157 grams. 12

Average Nose-Tail Length 31.6 cm. 34.5 cm. 9

Average Nose-Rump Length 15 cm. 16.1 cm. 7

Average Tail Length 16.6 cm. 18.4 cm. lO

The hair of the rayed animals was noticeably thicker and coarser than that of the control animals. The hair ou the backs of the albino rats exposed to ultra-violet rays was tinted a slight lemon yellow. There \Aas no enlargement of the epiphy.seal juucfions iu the rayed aiii mals. On opening the bodies of the rayed aiiimal'< the most striking feature was the great amount of tal ileposited in the subcutaneous tissue and iu the i)eritoneal cavity. In some animals this deposition was treiuen dous. It occurred in some of the control rats but was never great. The muscular development of the rayed rats was better than that of the control animals. There were no deformities of the thorax aud no gross evidences of rickets in the long bones of the rayed auinuils.

The control rat (IGY). autopsied thirty-eight days after the beginning of the experiment, showed the tyi>ical pic


THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL. 1922








Fig. 3


Fig. 4


April, 1922]


127


ture of advanced rickets. The iucisoi- tcetli were brittle, tlie molar teeth were loosened ; there was eiilargemeut of the knees and wrists; the costo-choudral junctions were enlarged and bent inwards, and there were numerous fractures of the ribs. The tibiae and femora on section showed the typical gross picture of rickets.

The other control animals, autopsied about four weeks later, showeil less marked but equally definite signs of rickets. The teeth were only slightly more easily fractured than normal. There was moderate enlargement of the epiphyses of the long bones of the extremities. The costo-choudral junctions were enlarged but there was little deformity of the chest and no well marked fractures of the ribs. The bones of the e.xtremities cut with diminished resistance and in the femora of some there were gross evidences of rickets on section. The viscera showed no pathological chang&s. The amount of subcutaneous and peritoneal fat was much le.ss than in the rayed animals. The muscles of the control aninuils were relatively poorly developed.

Microscopic examinations of the bones were confirmatory of the gross findings. In .sections of the long bones of the rayed animals there were no evidences of rickets. The Hue of demarcation between the cartilage and shaft was sharp and clear cut. The deposition of calcium in the provisional zone of cartilage was heavy and complete. The trabeculae showed only the thin nuirgin of osteoid which is seen in healthy, growing animals and which must be regarded as physiological.

The sections of the long bones of the control animals without exception showed rickets, but in some specimens the rachitic process was moderate in severity. Tlie trabeculae in all sections wei'e surrounded by broad osteoid borders and the calcification of the provisional zone of cartilage was fragmentary and exceedingly irregular. The degree of rickets usimllj- found in rats on this diet is more severe than is shown in some of the si)ecimens from these animals. This is probably explained by the fact that the animals were fifty days old when placed on the diet and were in some instances one liundred and fourteen days old when killed. During the period covered by the experiments, therefore, activity in growth was declining and with it there was a decline in the activity of the rachitic process.

Discussions

From this experiment it is possible to say tluit rats fed on the rickets-i)roduciug diet (diet '.MA'^) are protected from timt disease by exposure to radiations from a merCU17 vapor quartz lamp. It is possible to say further that radiations from the mercury vapor quartz lamp affect not the skeleton alone but indeed the whole organism. While the development of a normal skeleton in the rayed animals is a "striking, visible and measurable" efl'ect of the radiations on a single tissue, growth, good muscular development, storage of fat, improvement in the condition of the hair, stimulation of sexual development and


reproductive power are evidences that the radiations have a favorable influence upon the animals as a whole. ISo far as we are able to discern, the action upon rats fed the rickets-producing diet (diet 3113) of the radiations of a mercury vapor quartz lamp in securing an efficient utilization of the substances which are directly or indirectly concerned with ossification and calcification and in promoting general bodily vigor is in no way ditterent in respect to these matters from the action of cod-liver oil and of sunlight.

Summary

1. The object of the experiments was to determine whether or not radiations from a mercury vapor quartz lamp prevent the development of rickets in the rat.

2. A diet was employed which at room light regularly gives rise to a disease identical in its es.sential features with rickets as seen in the human being. The diet was high in calcium, low in phosphorus and was insufficiently supplied with fat-soluble A. In other respects it w'as well constituted.

3. Nineteen rats were placed on the diet. Ten were exposed to radiations from a Hanovia "Alpine mercui-j' vapor quartz lamp for varying periods of time daily over a period of sixty-four days. Nine rats were kept under conditions of ordinary room light as control animals.

1. One of the control animals was killed after thirtyeight days; another after fifty-eight days and the remaining seven after sixty-four days. All of these animals showed gross and microscopic evidences of rickets.

5. The ten rats exposed to the radiations from the mercury vapor quartz lamp were killed after sixty-four days. These aninuils were free from rickets both grossly and histologically.

6. The beneficial effects of the radiations from the mercui-j- vapor quartz lamp were not limited to the skeleton, since the condition of the rayed aninuils underwent a general improvement.

7. The effects of the radiations of the mercury vapor quartz lamp on the growth and calcification of the skeleton of the rat and on the animal as a whole seem to be similar to, if not identical with, those brought about by direct sunlight ami by cod-liver oil.

DESCRIPTION OF PLATES Figs. 1 and 2. Mdcrophotographs of sections of femora of rats fed on diet 314 3 and exposed to radiations from a mercury vapor quartz lamp. Note sharp demarcation between shaft and cartilage at metaphysis (a), the heavy calcification of provisional zone of cartilage (b) . and the wide bony trabeculae without osteoid borders (d).

Figs. 3 and 4. Microphotographs of sections of femora of rats fed on diet 3143 and kept at room light. Note wide irregular metaphysis. Fig. 3. a — Proliferative cartilage.

a — Islands of cartilage with (bFig.3) deposition of

calcium on the diaphyseal side, c — Osteoid trabeculae. Fig. 2. b — Cartilage is irregular and uncalcified.


128


[No. 374


A GRAPHIC METHOD FOR THE CALCULATION OF DIABETIC DIETS IN THE PROPER KETOGENIC-ANTIKETOGENIC RATIO

By R. R. Hannox, M.l)., and Wm. S. McCann, M.D.

{From the Chemical Division, Medical Clinic, Johns Hopkins Hospital, Baltimore, Md.)


The study of the balance between ketogenic and antiketogenic substances in the metabolism, having been put on a quantitative basis by the admirable work of Shaffer/' -• ^- almost immediately found its application in the treatment of diabetes mellitus. Shaffer found that the ketogenic substances were the fatty acids, and certain of the amino acids of protein. The antiketogenic substances were glucose, the glucose yielding amino acids of protein and the glycerol of the fat, which is known to be capable of yielding glucose.* It was found that the complete oxidation of ketogenic substances did not take place unless there were present at least one molecule of antiketogenic substance for each molecule of the ketogenic. Shaffer arrived at these conclusions on the basis of in vitro experiments, metabolic observations on starving subjects and diabetic patients, including studies of the respiratory exchange.

Woodyatt '^ has applied Shaffer's data to the calculation of diets for diabetic individuals in whom it is desirable to preserve the proper balauce between ketogenic and antiketogenic substances. He has converted Shaffer's figures for the molecular proportions into terms of grams of the various foodstuff's. The antiketogenic substances are reduced to the term available glucose or G, which eciuals the sum of glucose available from free carbohydrate, the carbohydrate moiety of the protein molecule, and that which may arise from glycerol of the fats. Thus G=0.5S P+0.1 F+C, where r=grams of protein, F=grams of fat, and C=grams of carbohydrate.

In calculating the ketogenic substances, expressed as available fatty acids or FA, Woodyatt has not followed Shaffer's figures closely. For in.stance, 42% of the weight of protein is made up of amino acids which do not yield glucose. Of these only three, leucine, phenylalanine, and tyrosine, are known to be ketogenic, making up only 23% of the total weight of protein. Woodyatt calculates FA=0.46 P+0.9 F. In view of the unknown behavior of the remaining amino acids of protein it is believed that Woodyatt's estimate is on the safe side.

Woodyatt estimates that the equimolecular ratio of ketogenic to antiketogenic substance obtains when FA 1.5 0.46 P -f 0.9 F


G 1 0.58 P -h 0.1 F + C

This on being simplified gives the expression F=2 C+0.546C P.

In discussing the objects of dietary adjustment in diabetes, Woodyatt has called attention to a fundamental


conception which has been overlooked by practitioners who have followed the methods of treatment of diabetes largely in vogue in the past few years. This is the fact that the tolerance of the patient for glucose cannot be estimated simply from the amount of free carbohydrate in the diet, but that it must be estimated in terms of available glucose from all sources. That since the metabolism goes on uninterruptedlj- during starvation considerable amounts of glucose maj' be arising in the organism especially if the protein metabolism is high. He showed iu an illustrative case, a patient with severe diabetes in whom the protein metabolism was presumably high (urinary nitrogen figures not given), that the giving of a diet low in protein with considerable fat and free carbohydrate was well borne. This was presumably' due to a sparing of body protein by fat, in keeping with the results of Newburgh and Marsh," though unfortunately exact calculations cannot be nuide, as there were no data regarding urinary nitrogen or heat production of the patient, except a rough calculation of the requirements based on body weight.

However, the conceptions of diabetes set forth above seemed so rational that it was determined to Introduce it iu the practice of the medical clinic of the The Johns Hopkins Hospital. Since its introduction very satisfactory results have been obtained. To facilitate the work of preparing the diet prescriptions one of us (R. H.) has prepared the graphic chart. Fig. 1, which has been so useful that we have been led to make it available for general use. All points on the graph bear the relationship between protein, fat and carbohydrate expressed in Woodyatt's equations previously given. The chart is given much additional value by reason of the fact that it provides for the calculation of this relation.ship over a wide range of levels of protein metabolism. In the plan outlined by Woodyatt " the total caloric I'equirement of the patient was estimated on the basis of body weight, and an arbitrary figure for protein was used, 1 gram protein per kilogram of body weight. It seemed more rational to estimate the measure of total metabolism iu terms of calories per square meter of body surface area, and to consider the protein metabolism in terms of percentage of the total. Thus, on the graph, diagonal lines represent the total calories. Radiating lines from the intersection of the axes represent the percentage of total calories in the form of protein. The ordinates represent grams of protein, the abscissae the grams of carbohydrate which are required to maintain ketogeuic-antiketogenic balance for any given level of protein metabolism. Thus


THE JOHNS HOPKINS HOSPITAL BULLETIN. APRIL. 1922


PLATE XVIII


/v?


/0%



10 20


B


X 40 50 60 70 ao 90 100 HO 120 130 140 150 160 170 160 190 CARBOHYDR/iTE IN GRAMS.


April, 1922]


129


if the patient requires 2000 calories per dieru, and if it is desired to give lO^o of the calories in the form of protein, the point of intersection of the 2000 caloric line and the 10% line locates on tJie ordinate 49 gms. of protein, and on the abscissa 68 gms. carbohydrate.


Total calories — (calories fro m protein-fcaibohydrate) _ 9.3


gi-ams fat.


To avoid this latter calculation a second graph has been superimposed upon the fli-st. A vertical line AB, parallel to the ordinate axis, is intersected at various points by the radiating percentage lines. For each intersecting point a second ordinate scale gives the ratio of fat to carbohydrate ¥/C This is the factor by which the weight of carbohydrate must be multiplied to give the requisite number of grams of fat.

Thus the 10% line intersects the line AB at a point which indicates that F/C is 2.39. Then the number of grams of fat required =2.39X68=162.5. The prescribed diet would then be protein 49 gm., carbohydrate 68 gm., fat 162.5 gm. This diet would furnish 1920 calories, and would yield a maximum of 113 grams of glucose in the metabolism.

If the minimal protein metabolism for a particular diabetic jiatient were known (urine N. figures), and if his caloric requirement were properly estimated or measured, it would then be possible to find the minimum carbohydrate and the maximum fat allowable if the patient is to be maintained at the minimal level of nitrogen balance. For instance, a man 30 years old, 170 cm. in height, weighing 60 kg., requires at least 1612 calories per diem. After a period of observation on a diet furnishing 5% of the calories from protein, it is found that his protein metabolism, as shown by the urinary nitrogen excretion, has reached a minimum of 50 grams per diem. Reference to the chart shows that this constitutes 12.6% of his total metabolism. If a diet is to be given which will just cover this minimal protein requirement (50 gm. protein), the quantity of carbohydrate which is prescribed will be 51 gms., and of fat 2.53X51 gins.=129 gms.

It will be found interesting to make the following calculation of two diets each furnishing 2000 calories from the graph. In one case the protein forms 40% of the total energy value. In the other case protein furnishes only 10% of the total energj\


40% Trotein Cals. 10% Protein Cals.


2000 calorie diets. Available

P F C Glucose

195 125 9 134.6

49 165 68 112.9


It will be seen that a patient, whose tolerance might be just sufficient to permit the taking of 2000 calories with the smaller amount of protein, would probably


develop hyperglycemia or glycosuria if the same number of calories were given with the higher percentage of protein. The diet containing less protein permits the use of much greater amounts of free carbohydrate.

It is of interest also in this connection to consider the diet of the Eskimo, which has been studied by Krogh and Krogh,' who found that about 447© of the total energy was derived from protein. The graphic chart shows at a glance that in such a dietary very small amounts of free carbohydrate serve to prevent ketogenesis.

It is a matter of common observation, to which attention has been called by Allen and DuBois,* that the level of protein metabolism is almost invariably high in patients with severe diabetes and acidosis. One might well ask, therefore, whether an increase in amount of pi'otein metabolized may not be one of the mechanisms by which the diabetic organism protects itself against undue ketogenesis.

At a recent meeting of the American Society of Biological Chemists, Shaffer made a further report of his studies on antiketogenesis which indicated that at times as much as two molecules of fatty acid can be metabolized completely in the presence of one molecule of antiketogenic substance. Since the 2: 1 ratio does not hold in all cases, it has seemed much better to adhere to the formulae constructed on the basis of the 1 : 1 ratio, as this gives a small margin of safety. Tlie data regarding the molecular proportions of ketogenic and antiketogenic substances in the metabolism of our patients will be given in a subsequent communication.

REFERENCES

1 Shaffer. P. A.: Antiketo'genesis I. An in vitro analogy. Journ. Biol. Chem., 1921, XLVIl, 433.

"Idem: Antiketogenesis II. The ketogenic-antiketogenic balance in man. .Journ. Biol. Chem., 1921, XL.VII, 449.

'Idem: Antiketogenesis III. Calculation of the Ketogenic Balance from the Respiratory Quotients. .Journ. Biol. Chem., 1921. XLIX, 143.

Cramer: Miinchener Med. Wochenschr., 1902. XLIX, 944. ' Woodyatt, R. T.: Object and Method of Diet Adjustment in Diabetes. Arch. Int. Med., 1921, XXVIII, 125.

6 Newburg, L. H. and Marsh, P. L.: The Use of a High Fat Diet in the Treatment of Diabetes Mellitus. Arch. Int. Med., 1921, XXVII, 699. Reference No. 6.

'Krogh, A., and Krogh, M.; Diet and Metabolism of Eskimos. Medelelser oni Gronland Kommissionen for Ledelsen af de Geologiske og Gecgrafiske Undersogelser I Gronland, Copenhagen, 1914.

8 Alleni, F. M. and DuBois, E. F.: Clinical Calorimetry. 17th Paper. Metabolism and Treatment in Diabetes. Arch. Int. Med., 1916, XVII, 1010.


130


[No. 374


THE ALVEOLAR AND BLOOD GAS CHANGES FOLLOWING PNEUMECTOMY

By (lEoRGE J. Heier and W. 1). W. Aniirus. (From the Himterian Laboratory of Experimental Surgery.)


In some pieviotis experiments ' it was found that very shortly after the removal of one Inng the remaining lung would begin to enlarge, and by this enlargement eventually would fill the entire thoracic cavity. As the lung enlarged, it displaced the heart so that this organ later came into contact with the lateral thoracic wall, and by necropsy examinations it was repeatedly demonstrated that when the heart was in contact with the thoracic wall the enlarged lung completely filled the thorax. A method was, therefore, at hand of following the enlargement of the lung by observing the displacement of the heart with the fluoroscope, and as a result of many examinations it was found that the lung which remained after a total pneumectomy completely filled the thorax in from four to six weeks. The capacity of the lung to undergo this compensatory enlargement seemed very great. Even when not only the entire lung upon one side but the largest of the three lobes upon the other side were removed, the two remaining lobes of one lung, with the exception of the space obliterated by the retraction of the thoracic wall and the elevation of the diaphragm, would enlarge to fill the entire thorax. As to the exact nature of this enlargement w-e have no knowledge at present, but some work to determine this point is being carried on in the Hunterian Laboratory.

This anatomical change in the remaining lung we have naturally considered a compensatory enlai'genient — an attempt on the part of the organism to replace the loss of lung tissue. As has been stated, the enlargement begins early, but it requires from four to six weeks to reach its maximum. Yet during this period of four to six weeks the animals apparently do not suffer from the lack of lung substance. They are lively and active; they are not dyspueic. AVe have thought, therefore, that there must be some immediate functional compensatory mechanism whereby the respiratory needs of the animal are probably assured, until the comparatively late anatomical changes in the remaining lung shall have taken place. Tlie purpose of the present work was to discover whether or not there was such an immediate compensatory mechanism.

In such a mechanism probably the circulation and


respiration both jilay a jiart, the circulation by an increase in the rapidity of blood flow through the remaining lung, the respiration by changes in the alveolar air and blood gases. It is only with the latter — the changes in the alveolar air and blood gases — that this report concerns itself.

Methods. — In animals, the subjects of these experiments, determinations of (1) the alveolar carbon dioxide content, (2) the alveolar oxygen content, (:>) the carbon dioxide content and capacity of the blood plasma, (4( the oxygen content and capacity of the whole blood, (5) the hemoglobin content and red cell count, were made before operation to serve as controls for subsequent similar determinations. The alveolar air was collected by the Plesh - method, the animals rebreathing a certain amount of air from a hag until equilibrium was established between it and the air in the lungs. Samples from the bag were then analyzed in a Hablane apparatus for carbon dioxide and oxygen. The collection and analysis of the blood were made by the method of Van Slyke,^' * all necessary precautions being taken to eliminate contact of the blood with the air or loss of blood gases by diffusion. All samples both of air and blood were obtained after the dogs had been absolutely at rest for at least ten minutes. The observations on the alveolar air and blood gases were made immediately after operation, 24 hours after operation, three and five days after operation, and thereafter at intervals of several days to a week. Controls were made upon animals subjected to operations other than pneumectomy, in order to eliminate the possible effects of operations themselves upon our findings.

Summary of Results. — [a] Effect an Alveolar Carbon Dioaide. The increased ventilation of the lungs due to anesthesia causes a fall in the alveolar carbon dioxide tension. After operation, however, the alveolar carbon dioxide tension rises, and within 24 hours is about equal to or above the normal value as determined before operation. It continues to rise until about the eleventh day, then gradually falls, reaching normal by about the twenty-fifth day (Curve 1).


April, 1922]


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(6) The Effect on Alveolar O.ryyen. Anesthesia causes a rise of the alveolar oxygen of approximately 2 per cent above the normal value as determined before operation. Following operation the alveolar oxygen shows a marked fall, averaging Si^ per cent, until about the eleventh day, after which it again tends to rise to its normal level. In two animals it reached the preoperative value in twentyeight days ; in another it had not reached its former level in sixty-six days. The second rise in the alveolar oxygen value occurs coiucideutly with the fall in alveolar carbon dioxide tension (Curve 2i.


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(c) The Effect on Blood Carbon Dioxide Content and Capacity. The anesthesia causes an average fall in the carbon dioxide content of the blood of from 8 to 10 volumes per cent. For a period of ten days after operation there occurs a rise of from 41/2 to 13 volumes per cent (average, 91/2) above the normal value as determined before operation : then a gradual fall to about normal by the twenty-fifth day (Curve 3).



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(d) The Effect on the Blood Oxygen Content. Ane.sthesia causes a slight rise of about 2 volumes per cent. This is followed within 24 hours after operation by a marked fall of approximately 4i^ volumes per cent, in oue case by a fall of 11 volumes per cent, or nearly half the total oxygen capacity of the blood. This fall in the blood oxygen content continues approximately up to the eleventh day after operation. In two cases it again rose to normal by the twenty-fifth and the thirtieth days; in one animal it remained at a low level until the twentythird day (Curve 4).

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CHART 4 — VENOUS BLOOD « 0, CONTENT O O'. CAPACITY

(e) Effect on Blood Oxygen Capacity. The effect of anesthesia is in our experience variable, there being either a rise or fall in the blood oxygen capacity. Following operation there is an average rise in the oxygen capacity of the blood of 3i/4 volumes per cent, this increased value being niaintaine<] during the period of our observations


132


[Xo. 374


(sixty-six days.) In one animal dying from distemper twenty-eight days after operation, there was a progressive fall in the oxygen capacity (Curve 4|.

(/) The Effect on Oxygen Unsaturutioii, Percentage. Anesthesia causes a rise in the oxygen unsaturatiou I)ercentage in two cases, a fall in tiiree cases. Within 24 hours of operation there is a very marked rise of from 9 to 30 per cent, with an average rise of 19.6 per cent. This rise in the oxygen unsaturatiou percentage continues up to the eighth day, at which time the average rise is 23.4 per cent. Subsequently, there is a fall but not quite to the previous normal value as determined before operation (Curve 5).



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(//) Ohseri-atiom on the Blood Count. The day following operation there is an average rise in the red cell count of 666,000. On the third day after operation this rise averages 800,000 above normal, one aninml showing an increase of 1,200,000 red cells. This rise in the red cell count corresponds to an increase in hemoglobin of from 15 to 20 per cent. So far as our ob.servations go (extending to the sixty-sixth day in one case) this increase in the red cell count is maintained, two dogs observed on the fifth-third and sixty-sixth days having blood counts of 7,000,000 or more (Curves 6 and 7i.

Briefly, then, the effects of pneumectomy are a rise in alveolar carbon dioxide and a fall in alveolar oxygen, these alveolar air changes being associated with a tempoary rise in the carbon dioxide content and capacity of the blood, a marked fall in the oxygen content, and a marked rise in the percentage of oxygen unsaturatiou. Concomitantly, there is a marked rise in the hemoglobin content of the blood and therefore in its oxygen-carninf



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.„.



^^








t;:

.




.


.


....



...^.

.


7 ') 11 13 15 17 19 21 23 25 27 29 31 Days alter operation

CHART 7 — HEMOGLOBIN (Calculated)


capacity, which may be interpreted as a compensatoiT mechanism. As has been noted, the changes in the alveolar carbon dioxide, alveolar oxygen, carbon dioxide content and capacity of the blood, and percentage of oxygen unsaturatiou, are only temporary; and approximately within thirty days normal relations are again established. The increased hemoglobin and oxygen-carrj-ing capacity of the blood, however, persisted during our period of observations (sixty-six days). They serve at least in part to supply the respiratory needs of the animal perhaps until complete anatomical changes in the remaining lung have taken place.


April, 1922]


133


PROTOCOL. OF EXPERIMENTS



Date


Day


Alveolae Air


Venous Blood


Dog


c

<D


a o

i B


a


a o


1

s s


o

o" u


a <v

a

8 o"



a o

5 g 1 "

Bf

d"


.2 ^

XJ 0)

o -JJ

11


a

o O

U

m


T,


11/ 1/21


—1


5.34


40.6


15.72


119.5


39.8


46.4


14.64


19.03


23.1


103.4




11/11/21


+9


5.04


38.3


11.23


85.3


41.4


48.1


16.47


20.95


21.4


112.8




11/18/21


16


5.10


38.7


10.43


79.2


52.3


58.6


15.13


20.95


23.0


112.8




11/25/21


23


5.39


40.9


11.22


85.2


57.8


62.5


14.82


24.41


39.3


131.9




12/ 2/21


31


5.48


41.6


10.23


77.7


51.9


55.7


17.18


24.12


28.7


130.4




12/15/21


44


5.38


40.8


11.71


89.0


49.4


53.2


14.50


23.70


38.8


127.5


7,192,000



1/ 6/22


66


5.21


39.6


13.26


100.8


42.4


48.1


14.87


23.54


36.8


127.2


7,360,000







T/


11/12/21


—2


4.76


36.1


12.08


91.8


41.6


62.5


13.66


19.00


28.6


102.7




11/14/21



3.45


26.1


15.60


118.5


35.0


38.7


15.36


19.08


19.5


103.1




11/15/21


+1


3.51


26.6


13.50


102.6


35.0


42.4


9.70


15.95


39.2


86.2




11/17/21


3


4.74


36.0


12.95


98.3


44.5


48.4


10.25


21.14


51.5


114.3




11/19/21


5


5.08


38.6


12.39


94.16


46.4


52.0


7.90


16.40


57.9


88.7




11/22/21


8






50.2


57.6


5.46


17.29


56.8


93.5




11/25/21


11


5.61


42.5


10.00


76.0


43.6


48.5


9.75


16.72


41.7


90.4




11/30/21


16


5.07


38.5


11.83


89.9


43.3


50.5


7.80


16.38


52.5


88.5




12/ 5/21


23


4.80


36.4


11.99


91.1


42.3


47.5


6.44


14.53


55.7


78.5



T,


11/14/21


—1


5.07


38.5


12.80


97.3


47.3


55.9


15.81


23.12


31.7


125.0




11/15/21



3.60


27.4


16.01


121.7


38.8


49.2


17.74


22.42


20.7


121.2




11/16/21


1


4.80


36.5


12.20


92.7


57.7


72.0


9.26


23.24


60.15


125.6




11/18/21


3


5.39


40.9


11.00


83.6


52.0


61.6


12.95


21.95


41.0


118.6




11/21/21


6


5.29


40.2


11.10


84.3


59.6


67.2


11.91


24.45


51.3


132.1




11/22/21


7


6.24


47.4


11.08


84.1


59.2


79.0


14.23


25.59


44.4


138.2




11/26/21


11


6.12


46.5


8.38


63.7


60.1


67.5


18.34


24.89


26.3


134.8




12/ 1/21


18


5.80


44.1


12.00


91.2


52.5


58.5


14.29


22.86


37.2


123.9




12/ 8/21


25


4.97


37.7


12.28


93.3


50.0


59.5


15.02


22.97


34.6


124.2




12/15/21


32


5.62


43.3


11.32


87.16


51.6


56.5


16.42


23.69


31.9


128.0




1/ 3/22


53


5.12


38.9


12.37


94.0


47.1


53.8


14.21


24.26


40.6


131.1


7,000,000








Died of distemper on the 28th day after operation


134


[No. 374


PROTOCOL OP EXPERIMENTS — Continued.



Date


Day


A-LVEOLAR Air


Venous Blood


Dog




o


a

S3


d _o

a

o'


a

a o U

o" o


oi

O

d" o


1 o o O


1

6


a d"


.s s

II

ii 1^


a o

oi


T.


11/26/21


—1


5.25


39.9


14.05


106.8


52.0 56.5


16.91


23.72


28.8


128.2


5,296,000



11/27/21



4.20


31.9


16.08


112.9


49.5


55.2


19.02


22.44


15.2


121.3




11/28/21


1


5.23


39.6


11.31


86.0


52.4 59.0


15.86


25.52


37.9


137.9


5,872,000



11/30/21


3


5.42


41.2


12.22


92.9


61.3 65.3


14.29


25.21


43.4


136.3


6,480,000



12/ 5/21


8






51.0


61.0


16.22


27.61


41.3


149.2


6.096,000


Ts


12/ 3/21


—1


5.02


38.2


11.14


84.7


48.1


59.5


19.16


24.27


21.1


131.1


5,392,000



12/ 4/21



4.94


37.5


12.94


98.3


33.8 40.0


20.11


25.51


26.7


137.4


5.700,000



12/ 5/21


1


5.23


39.7


9.60


73.0


44.3 52.3


13.10


26.25


50.1


141.9


5,970,000



12/ 7/21


3


5.35


40.7


9.29


70.6


52.4


60.0


8.42


25.69


67.2


138.8


5,816,000



12/10/21 12/13/21


6


4.89


37.1


13.36


101.5


49.5 1 59.5


12.87


23.61


45 5


127.4


4,888,000



9


5.26


39.5


10.89


52.8


46.2 1 53.8


10.26


22.06


50.3


119.6


5,328,000



12/16/21


12


5.37


41.0


10.95


83.2


51.9 55.7


10.12


25.21


59.8


136.2


5,912.000



1/ 3/22


28


4.96


38.1


12.00


93.2


47.1 52.8


12.38


25.35


46.1


137.0


5,872,000






-^",0


12/11/21


—1


4.87


37.0


12.42


94.4


45.8 55.3


18.00


25.39


29.1


137.2


4,816,000



12/12/21



5.22


39.7


13.36


101.5


51.5


55.7


18.39


28.95


36.1


156.4


4,896,000



12/12/21


6 hi-s.P.O.


5.52


41.9


10.95


83.2


51.9


59.5


15.53


24.99


37.9


135.1


4,944,000



12/13/21


1


5.30


40.3


11.44


86.9


46.5


55.7


13.99


25.76


45.7


142.7


5,560,000


BIBLIOGRAPHY

1. Heuer, G. J., and Dunn, G. R.: Experimental pneumectomy. Bull. Johns Hopkins Hosp., 1920, XXXI, 31-42.

2. Plesh, J.: Hamodynamische Studien. Ztsclir. f. exper. Path, u. Therap., Berl., 1909, VI, 380-618.


3. Van Slyke, D. D.: Studies of acidosis. II. A method for the determination of carbon dioxide and carbonates in solution. J. Biol. Chem., Bait., 1917, XXX, 347-368.

4. Van Slyke, D. D.: Gasometric determination of the oxygen and hemoglobin of blood. J. Biol. Chem., N. Y., 1918, XXXIII. 127-132.


POSTERIOR RESECTION OF THE RECTUM AND RECTOSIGMOID (KRASKE OR MODIFIED) UNDER REGIONAL ANESTHESIA*

Bj- Gaston L. Labat, M.D., l'ari.s {Special Lecturer on Anesthesia, The Mayo Foundation, Rochester Minnesota.)


Apart from early diagiicsis and the choice of methods iu dealing with cancer of the rectum and rectosigmoid, one of the most interesting problems connected with the surgery of that portion of the large intestine is the choice


Presented before The Johns Hopkins Hospital Medical Society, Baltimore, October, 1921.


of the method of anesthesia, especially if tlie operability is raised, as has been the teutlency for the past few years. Among tlie patients suffering from the disease are those with chronic conditions of the urinary, respiratory, or circulatory systems, which make them poor operative risks under ordinary circumstances. Obesity is apt to


April, 1922]


13a


increase the mortality, or at least to cast a heavy shadow ou the operative jjrognosis. The colostomy itself, in the case of very obese persons, is attended by considerable risk.

Nephritis is one of the important causes of operative mortality. It is usually of an acute type, superimposed on a chronic process. Many patients die some weeks after the operation from nephritis, cardiovascular disease, and so forth, which they had at the time of the operation. Infection (general peritonitis, pelvic cellulitis), obstruction and exhaustion are, according to the present study, the most frequent causes of death.

Although the anesthetic agent used for long and traumatizing operations such as the Kraske or any other type of posterior resection of the rectum is seldom mentioned in the literature, the presumption is that it has almost always been general anesthesia by ether inhalation. The morbid influence of ether on lungs, kidneys, and arteries with pathologic lesions is too well known to be deserving of more than mere simple mention in this paper. The fatal blow given by the lipoid solvent to the progressively exhausted heart laboring under fatty degeneration needs no discussion. In apparently normal ])ersons, the unfavorable influence of ether on the kidneys, lungs, and gastrointestinal tract is most apparent in the early days following operation; and the patient recovers generally without any complication attributed to the auesthetie. Albuminuria, glycosuria, lipemia, glycemia and acidosis, all clear up within a relatively short time. But occasioiuilly a condition of exhaustion exists at the time of the operation, a condition chiefly due to anesthesia or the inability of the patient to adapt himself to ether inhalation. Some patients recover from this condition ; but others And their power of resistance gradually decreasing. The natural reaction to infection is thus greatly diminished. Cellular life is weakened in the central nervous system which loses control over the vital functions of the economy. The kidneys at times find themselves helpless to deal with the abundant waste material coming directly from the operative wound, and the material which overflows or leaks from the defective liver.

Siich disturbances may be avoided or considerably lessened by the use of regional anesthesia, which does not, as a rule, aft'ect the general condition of the patient. But it must be clearly understood that the block method is not meant to improve chronic conditions which are present at the time of the operation, nor to prevent the development of acute disease started just before the operation. Regional anesthesia does not increase the resistance of the jiatient, but it reduces to a minimum an unfavorable oi)ei'ative prognosis by not atfecting the vital functions of the main organs of the body. Regional anesthesia does not prevent pulmonary embolism, but it takes away the danger of pulmonaiy complications, since it does not interfere with the respiratory organs. Edema


of the lungs, pulmonary congestion, or pneumonia will not set in as a postoperative complication if the usual elementary precautious are taken. Since regional anesthesia does not affect the gastrointestinal tract, there is no postoperative nausea and vomiting, no acute distension of the bowels with consequent paresis, and no strain on the abdominal cavity and its contents immediately after the operation. Postoperative paralytic ileus is prevented more effectually by the normal i)eiistaltic movements of undisturbed bowels. Tendency to bleed is also greatly reduced and convalescence rendered shorter. In considering the advantages and the bright postoperative clinical picture shown by the majority of patients who were considered very poor surgical risks before the operation, regional anesthesia has unquestionably strong claims against ether anesthesia or any other form of iidialation narcosis, which occasionally results in serious complications. Regional anesthesia is the method preferred for posterior resection of the carcinomatous rectum and rectosigmoid, whatever be the condition of the patient. In this type of case, it can be said without error that all patients are amenable to the method; but it may be well to emphasize a few points which are occasionally, if not always, overlooked, especially if regional anesthesia is only applied to i)articularly poor surgical risks.

In trying to increa.se the percentage of operability, the question of local conditions of the disease and of metastasis is generally solved by exploration at the time colostomy is performed. How far the radical cure is indicated, and the type of operation best suited to the particular case, are matters I shall not discuss, although the choice of operation is a significant factor in the final settlement of the prognosis quoud vitam in cases of carcinomatous rectum and rectosigmoid. After the operation has been decided on, two questions remain to be answered: Will the patient stand the operation? Will he stand the anesthesia needed for the operation added to the operation itself? The answei-s depend on the condition of the main organs and their surgical resistance, measured in terms of their progressive alteration from the time of the colostomy, the coefficient risk being added to the operative prognosis by the personal equation of the surgeon. The risk due to the type of anesthesia has too long been overlooked ; and it is now time to consider the opportunity of using regional anesthesia exclusively for the Kraske or any other types of posterior resection of the rectum and rectosigmoid.

The preconceived idea of the absolute safety of regional anesthesia is apt to influence the operability favorably, although it cannot be expected to alter the pathologic conditions existing at the time of exploration. All patients who seem to be good operative risks quoad the lesion may otherwise be veiy poor surgical risks ; and, in raising the operability, one should be cautioned against those cases that are on the borderline. In considering


13C


[Xo. 374


the advisability of a radical cure, the actual resistance of the patieut after the colostomy should be the chief guide. Some patients continue to decline after the colostomy, and can scarcely pull through that first-stage operation, especially when it has been performed under ether anesthesia. I'rogressive dehydration cannot be avoided, and from fifteen to twenty days after, which is the usual time for the second stage oi)eration, these patients are weaker than ever. Whatever anesthesia is then used, they will seldom come out of that condition of pogressive exhaustion which silently cai'ries them across the borderline into a state of coma which starts during the operation and ends with life on the second or third day. In those desperate cases regional anesthesia only permits the surgeon to risk the colostomy, and the prognosis of the second-stage posterior resection is greatly improved.

A study of thirty-three cases in which operation was performed in the Mayo Clinic from October, 1920 to June, 1921, inclusively, brings out jjoints which tend to prove the innocuousness of the method of regional anesthesia:

1. Previous diseases do not seem to influence the operative risk, provided no acute process prevails at the time of the operation. Patients having a previous history of diphtheria, pneumonia, grippe, pleurisy, scarlatina, measles, chicken pox, acute Bright's disease, and so forth, whether contracted recently or several years before, have made uneventful recoveries from operations performed by means of regional anesthesia.

2. Chronic lesions of the heart, with or without compensation, are not conditions which contra-indicate the use of the regional method, provided the resistance of the patient seems fair. Patients with enlarged hearts (1.5 to 2 cm. to the left) with extrasystoles, associated with a systolic blood pressure of 1G5 mm., diastolic 96 mm. and deficient kidneys; patients presenting mitral incompetence and aortic stenosis, with a systolic blood pressure of HO mm., diastolic 90 mm., and pulse 116, have left the hospital in from ten to twenty-two days following the posterior resection of the anus, anal canal, rectum, and lower sigmoid.

3. Pulmonary tuberculosis does not seem to influence the operative prognosis. An operation was performed under paravertebral and sacral block on a woman, aged thirty-six years, who gave a history as follows: She had had four pregnancies, two of which were extra-uterine, one rupturing. One pregnancy ended in a miscarriage at three months. She had had "anemia" twelve years before; pneumonia, in childhood, and eight and two years before; typhoid fever with peritonitis twenty two years before; and active tuberculosis ten years before. Her sputum was positive May 4, 1921, when a left inguinal colostomy was performed under regional anesthesia. One month later the anal canal, entire rectum, and 25 cm. of the sigmoid were excised. The growth was in the rectosigmoid, extending down into the rectum. A loop of the


sigmoid and one of the small intestine had dropped down and become adherent to the growth. The small intestine was separated, but the peritoneal coat, where it was adherent, was removed. A loop of the sigmoid about 10 cm. above the, growth, which had become adherent to the growth, was removed with it. The gland.s ami fat which were involved and adherent to the promontory and sacrum were removed. The upper end of the sigmoid was turned in twice and fastened to the peritoneal wound. The posterior wall of the uterus was drawn into the cavity to help fill the large peritoneal defect.

The extent and type of the operation performed in this case is a real test of the method of regional anesthesia. No particular care was taken to avoid or lessen the usual manipulations generally adopted under ether anesthesia. The patient made an uneventful recovery and left the hospital on the twentieth day after the operation.

5. Diabetes, at least mild and chronic, easily controlled by dietary measures, has to all ai)pearances no influence on the operative prognosis if regional anesthesia is used. A woman, aged seventy-two years, was operated on for carcinoma of the rectum April 1, 1921, while sufl:ering from mild chronic diabetes. Her urine output was 800 c.c. in twenty-four houi-s. The urinalysis showed specific gravity 1.016 ; reaction, acid ; sugar, a trace; and pus cells, 1 to 6. The patient left the hospital twenty days after the operation with a clean postoperative record.

6. Operation may also be safely performed in renal conditions of a chronic type. A woman, aged forty-seven years, had an average urine output of 500 c.c. in twentyfour hours, the urinalysis showing specific gravity 1.029; reaction, acid; albumin 1; pus cells 3; and a combined phenolsulphouephthalein return of 35 per cent. She gave a previous histoi-y of having had diphtheria, scarlatina, pneumonia, grippe, and pleurisy, and at the time of the operation was surtering from mitral incompetence and aortic stenosis. A posterior excision was made of the anus, anal canal, rectum, and lower sigmoid. She passed an average of 650 c.c. of urine every day following the operation. She recovered uneventfully, and left the hospital ten days after the operation.

Preparation of Patients for Regional Anesthesia

For the one-stage Kraske operation, the patieut receives a preliminary hypodermic injection of morphin 1/6 gr. and scopolamin 1/300 gr., one hour before anesthesia is begun, and a second dose of the same strength immediately after the completion of the anesthesia.

For the colostomy in the two-stage operation, one hypodermic injection of the narcotics is, as a rule, sufficient to dull the mentality of the patieut and dismiss any apprehension due to consciousness at the time of the operation, provided it is given one hour before the anesthesia, and the colostomy is performed ten minutes after the completion of the anesthesia. In very nervous


April, 1922]


137


patients, if the first dose does not seem to liave produced the desired effect, a second dose is given at the time of the anesthesia.

The patient is prepared for the second stage Kraske in the same manner as for the one stage. Individual cases sliould be considered in administering two doses of the combined narcotics. If during thp manipulations for inducing anesthesia, the attitude of the patient reveals suflicient psychic control there is no reason for giving the second dose; it should be reserved for alleviating postoperative pain.

The use of morphin and scopolamin in such weak doses is not meant to produce, and in fact does not produce, a twilight sleep nor a semiwaking condition during which the surgeon loses control of his patient, but simplj- to enable the patient to feel more comfortable in that rather awkward position he must assume during the operation.

Anesthesia for the Colostomy

For the left rectus colostomy, two procedures are available, the abdominal field block, and the paravertebral block.

The abdominal field block is the procedure iisually employed because it is easily and quickly accomplished, and requires no special long and delicate training. It affords almost complete relaxation of the abdominal muscles and perfect anesthesia of the parietal peritoneum within the blocked area. If gentleness is used, the pelvic organs, as well as the liver, may be explored, provided the incision is long enough to allow the hand to steal into the abdominal cavity without force. This is most easily done after the lips of the wound have been clamped and raised. In the majority of cases, there is no sharp pain during gentle exploration, but only an abdominal sensation referred to the epigastrium, such as that due to intestinal colic. The sensation ceases with the exploration, which ordinarily is of very short duration. Some patients require just enough ether or gas to make them lose consciousness during this stage of the operation. If the excitation period is reached, exploration becomes impossible, owing to lack of relaxation which can only be obtained by bringing the patient to the surgical stage of general anesthesia; and in such case he loses the benefit of the regional anesthesia. It is, therefoi-e, wise to insist on the necessity of a judicious use of ether or gas during exploration.

The average patient, well prepared by the preliminary narcotics, and familiar with the requirements of regional anesthesia, cooperates willingly and, if gentleness is used, the colostomy is painlessly performed. If the patient is obese, or if the mesocolon is short, a few^ whiffs of a general anesthetic contributes greatly to establish favorable conditions. This combined method is safer than any general anesthetic alone.

The patient lies in the recumbent dorsal position, and the operative field is prepared as for any surgical opera


tion ; one coat of tincture of iodin is sufficient for the [)urposes of regional anesthesia. Intradermal wheals are raised with a fine needle along the left costal margin, from the xiphisternum to the tip of the eleventh rib, and from that point to the iliac crest, (Fig. 1). A fine needle of convenient length (8 to 10 cm.) is then passed through each of these wheals in succession and deep injections made within the muscle laj'ers of the abdominal wall, followed by subcutaneous injections which join all the wheals, except the first to the last. All the injections along the costal margin are made in a plane perpendicular to the surface of the skin and passing through the wheals; those from the costal margin to the iliac crest are made in a similar manner. Two walls of anesthesia, meeting at about the level of the tip of the eleventh rib, are thus created, cutting off the nerve supply of half the abdominal wall. The anesthetic is a 0.5 per cent solution of neocain * or procain, containing 15 minims of adrenalin solution 1:1000 per 100 c.c. The quantity injected varies from 100 to 200 c.c, according to the weight of the patient.

The paravertebral block is more difficult and, in order to give it successfully, fairly good training is required; but it affords a wider field of anesthesia and greater facility in handling the bowel, in case the mesocolon is short. It is customary to inject from the eighth dorsal to the third lumbar nerve on the left side with from 5 to G c.c. of a 1 per cent, neocain or procain solution at each nerve. Paravertebral block thus performed does not abolish the abdominal sensation present during exploration, but it lessens it to a certain extent. In the majority of cases, the colostomy is performed painlessly without the aid of ether or gas. If regional anesthesia is to be induced by the average surgeon, the abdominal field block, according to my experience, should be given preference.

Anesthesia for the Kraske or Any Modified Posterior Kesection

One hour after the preliminary hypodermic injection of morphin and scopolamin has been given, and twenty to thirty minutes before the hour fixed for the operation, the patient is gently wheeled into the operating room or into the special room which, in a few institutions, is specially equipped for inducing regional anesthesia. He is placed flat on his stomach and a cushion slipped under his hips to raise the sacral region and render the landmarks more accessible. The operative field is prepared in the usual manner, exposing the whole lumbosacral region, from the first lumbar vertebra to the tip of the coccyx. One hundred and fifty cubic centimeters of a 1 per cent, procain solution containing 15 minims of adrenalin solution 1 :1000 is placed in a cup at hand, and the special regional anesthesia syringe with one set

Neocain' is a French product made by Corbiere and Lionnet, Paris. France, put up in sterile capsules of 0.5 gm. each. It is readily soluble in saline solution and of very low toxicity.


138


[No. 374


of needles of different dimensions tested as to efficiency before starting tlie manipulations.

The best results are obtained by combining the caudal, transsacral, and paravertebral block of the last three lumbar nerves (Fig. 2), starting with the caudal block, then injecting the sacral nerves, and finishing with the paravertebral block. Whatever be the level of the grow-th, one and the same procedure should be applied, although anorectal and rectal lesions require a smaller anesthetic field. It is always preferable to prepare the patient in such a way that no sub.sequent injections will be necessai7, if the surgical manipulations are cari-ied beyond the contemplated area. For instance, an error of diagnosis may be followed by the excision of many centimeters of bowel through the posterior route, in order to reach the growth situated high in tlie sigmoid colon. When the lesion lies in the rectosigmoid juncture, the procedure described here gives absolute anesthesia throughout the operation. It is, therefore, advisable, I insist, not to modify the procedure according to the height of the lesion, but to use it integrally in all cases. 1. Caudal or epidural bZocA-.— The sacral hiatus is defined by a depression which is felt in the middle line, at about the juncture of the coccyx with the sacrum, and bounded by the sacral cornua on each side and the fourth sacral spinous process on the middle line a little higher up. These three prominences, palpable in the majority of cases, form the angles of a triangular surface at the middle point of which the needle is introduced with ease and success. The spinal puncture needle, with its stylet in and its bevel turned upward, is introduced at this point, in a direction making an angle of about 45 degrees with the surface of the skin. After piercing the sacrococcygeal membrane which, like a screen stretched across the sacral hiatus, closes the lower extremity of the sacral canal, the point of the needle strikes the anterior wall of the canal. It is then withdra^^^l 1 or 2 mm. and the hub of the needle swung downward toward the gluteal cleft, reducing the angle of 45 degrees to about 20 degrees. The needle is advanced gently and gradually into the sacral canal, always keeping along the middle line, until about 6 cm. of its length have disappeared. If the point of the needle impinges on the posterior wall of the canal and is stopped a short distance from its point of entrance, it is ordinarily released by the application of pressure on the sacrococcygeal membrane with the left forefinger placed on the needle at the site of puncture. If this device is not successful the needle has to be withdrawn and reintroduced a little higher. When the needle has been correctly introduced, its stylet is withdrawn and time is allowed to make sure that no blood or cerebrospinal fluid comes out. In such case the needle is drawn back a few millimeters until the flow ceases and the syringe, filled with a 1 per cent, solution, is connected with the needle. It is a verj' good practice to aspirate before injecting fluid, so as to feel quite certain that


no intraspinal nor intravenous injection is actually made. Abnormal extension of the dural sac below the second sacral vertebra is exceptional, but its existence cannot be denied. Injection should be very slow, owing to possible after-efl'ects due to rapid absorption by the structures contained in the sacral canal. A total amount of 30 c.c. of the anesthetic solution thus injected into the sacral canal establishes favorable conditions for the transsacral block.

2. Transsacral ilock. — This procedure consists in injecting the sacral nerves individuallj* hj introducing the needle through the posterior sacral foramina, which can be reached with some precision only by taking accurate superficial landmarks. These ai-e the posterior superior spine of the ilium and the sacral cornua. A wheal is raised about 1 cm. medial to and below the said iliac spine and another wheal is placed just above the sacral cornu on the same side. The distance between them is divided into three parts by two other intermediate wheals. The second, third, fourth, and fifth sacral foramina are thus easily and accuratelj' defined. The first sacral foramen is found by raising a wheal about 2.5 cm. above that which nuirks the second sacral foramen, following the same general direction. The thickness of the soft tissues overlying the sacrum being much greater in the upper portion of the bone, needles of different lengths are used according to the height of the puncture. It is most convenient to use a needle 5 cm. long for the last three foramina, one 8 cm. long for injecting into the second sacral foramen, and one 10 cm. long for the first foramen which is vei-y deeply situated (Figs. 3 and 4). It is customary to begin with the second foramen, which seems to be easier to locate than the first and which helps considerably in locating the others. The needle is introduced perpendicularly to the surface of the skin and gently advanced toward the posterior aspect of the sacrum until its point touches the bone. A little practice ordinarily gives an almost accurate tactile sense of the rich fibrous structures overlying the foi-amen and spreading out, so to speak, in its immediate neighborhood. The direction of the needle is slightly changed if the foramen is not reached by a first puncture; but gentleness should be used in approaching the bone so as not to hurt the patient, traumatize the region by repeated punctures, and damage the point of the needle, which bends to a hook and tears through the tissues while it is withdrawn. This faulty techuic of most beginners can be improved rapidly by a short training on the cadaver, especially if every effort is made to visualize the framework through the soft overlying structures. After losing contact of the posterior aspect of the sacrum, the needle passes through the posterior sacral foramen and, according to the foramen, is introduced more or less deeply, because of the uneven thickness of the bone. For the same reason the quantity of solution injected varies with the foramen. It is customary to inject 6 c.c. of the solution in the first


THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL. 1922


PLATE XIX fl.

4



April, 1922]


139


foramen and to reduce by 1 c.c. each time the quantity injected into each subsequent foramen. Starting from the second foramen injection is therefore made of 5, 4, 3, and 2 c.c. respectively, in descending order of foramen, thus injecting 40 c.c. of the solution, which, added to the 30 c.c. used for the caudal block, makes a total of 70 c.c. for the sacral block.

3. Paravertehral block.- — After inducing the sacral block, as described, bilateral injections of the last three lumbar nerves are made as follows: Wheals are raised 3.5 to 4 cm. from the middle line of the spine, according to the weight of the patient, opposite the upper edge of the spinous process of the third, fourth, and fifth lumbar vertebne (Fig. 2). A needle 12 cm. long is introduced through each of these wheals in succession and advanced in a direction perpendicular to the skin surface until contact is taken with the transverse process of the vertebra. The needle is then withdrawn a little, for the purpose of changing its direction, and reintroduced toward the spine, making an angle of about 20 degrees with the middle plane on the body. The needle passes above the transverse process and is stopped at 2.5 to 3 cm. after it has passed the bone, and 8 to 10 c.c. of the solution is injected while the needle is slightly moved to and fro. Efforts should be made not to hit the nerves, but to deposit the solution in their immediate vicinity. The same rule applies to the sacral block. In order to reach the fifth lumbar nerve the needle is passed below the transverse process of the fifth lumbar vertebra. The aspiration test for blood should be renewed several times during each injection, thus making sure that the point of the needle does not lie within the lumen of a blood vessel. Not more than the exact quantity of the solution should be taken in the syringe each time, so as not to exceed the total amount of 150 c.c. of the 1 per cent, solution prepared beforehand. The injection of greater quantities is likely to produce toxic symptoms. Procain is ten times less toxic than cocain, but still its toxicity must be remembered, and likewise the possible presence of impurities in the commercial drug. Toxic symptoms are exceptional ; but if they should appear, a subcutaneous injection of spartein sulphate 0.05 gm., caffeiu 0.25 gm., and strychnin sulphate 0.001 gm. improves the condition. No such mishap is expected from the method itself which is the safest now known; but attention should be called to the fact that it may occur through faulty technic, and the anesthetist should know what to do in such cases.

After making the last injection, the .sensibility of the anus and perineum is tested by clamping the region. Complete relaxation of the anal sphincter is a proof that the entire rectum, bladder, and prostate have been anesthetized, although there is no way of testing beforehand the sensibility of the parietal peritoneum in connection with the mesosigmoid, and the pelvic organs in women.


Conclusions

1. The choice of the method of anethesia is one of the most interesting problems connected with the surgery of the rectum and rectosigmoid.

2. Most of the postoperative complications may be attributed to inhalation narcosis, especially ether, and can be avoided or considerably lessened by the use of regional anesthesia.

3. Regional anesthesia does not increase the resistance of the patient, but leaves the vital functions of the body in the same condition.

4. The anesthesia does not prevent pulmonary embolism, but excludes the danger of pulmonary postoperative complications, provided no acute condition exists at the time of the operation.

5. The anesthesia has no ill-effects on the gastrointestinal tract; thus the possibility of paralytic ileus and the tendency toward hemorrhage are reduced.

C. All patients are amenable to the method, but one should be cautioned against borderline cases.

7. Previous conditions, such as chronic lesions of the heart, with or without compensation, high blood pressure, pulmonary tuberculosis, diabetes, at least mild and chronic, easily controlled by dietary measures, and chronic renal conditions do not seem to interfere with the operative prognosis.

8. The use of morphin and scopolamin controls the psychic state of the patient and greatly contributes in establishing favorable conditions during the operation; but the stage of twilight sleep must not be reached.

9. With the abdominal field block procedure, colostomy is performed painlessly, provided the patient is not too obese and the mesocolon is not too short. Exploration is possible in the majority of cases, if gentleness is used.

10. The sacral block, consisting of the caudal or epidural and trans-sacral block, added to the paravertebral block of the last three lumbar nerves on both sides, constitutes the method of choice for the posterior resection of the carcinomatous rectum and rectosigmoid.

11. The administration of the anesthesia is not diflBcult, but it requires practice and patience, irrespective of the gentleness which must always be used in handling conscious patients.

12. If the anesthetic does not give complete anesthesia throughout the operation, the administration of a first stage ether anesthesia during the deep manipulations constitutes a combined method much safer than general narcosis alone.


140


[No. 374


liEGENDS

Fig. 1. — Abdominal fieJd block for Colostomy, resulting in anesthesia of left half of abdominal wall.

Fig. 2. — Regional anesthesia for posterior resection of rectum and rectosigmoid.

-)- Site of puncture for caudal or epidural block.

1, 4, 3, 2, 5. Sites of puncture for transsacral block.

6, 7, 8. Sites of puncture for paravertebral lumbar block.


Fig. 3. — Oblique lcm;gitudinal section of the pelvis showing the right sacral foramina, the entire sacrum being preserved. This is intended to show the variable thickness of the soft tissues overlying the sacrum and the different directions of the needle.

Fig. 4.— Oblique longitudinal section of the pelvis passing through the right sacral foramina, showing the progressively decreasing thickness of the sax;rum from top to bottom, a condition which commands the use of variable quantities of anesthetic solution according to the site of injection.


THE USE OF THE BONE GRAFT IN THE TREATMENT OF POTT'S DISEASE.

By William S. Baer, M.D. (Associate Professor of Clinical Orthopedic Surgery, The Johns Hopkins University.)


The ten years which have now elapsed since Albee first called attention to the use of the bone graft as an aid in the cure of tuberculosis of the spine, furnish a period of time sufficient to allow us to draw some conclusions as to the value of the procedure. With this aim in view I have collected the cases of tubei-culosis of the spine treated by this method by myself or my associate, Dr. Bennett, and our assistants.* The cases to be reported are fifty in number and in each one the bone graft operation was done pi'ior to December 31, 1919. Thus two years at least, and in many cases more, have elapsed since the operation, so that a careful analytical study of the series will throw some light upon the efficacy of the operation and the indications for its employment.

We have arbitrarily^ divided our cases into three groups, according to the results obtained.

First: Good results. In this class there are

a. Ko symptoms or signs of active tuberculosis in the

vertebral column. I). No support is necessai-y.

c. There is no kyphosis present or no increase in the preoperative kyphosis.

Second : Fair results. In this class there are a. No symptoms or signs of active tuberculosis. 6. No brace or support has to be used at the pre.sent

time. c. A post-operative increase of the kyphos has

occurred.

Third: Poor results. Patients in whom the process is still active ; those in whom support is still necessary, or those who have died. Again, the cases have naturally divided themselves into three groups, according to age at the time of operation. a. Up to the age of six years, the period of infancy. h. From six to sixteen years of age, the period of greatest growth.


I am greatly indebted to Dr. Wlnthrop Phelps for his work In correlating these cases.


c. From sixteen years upwards, — the period when growth for the most part has ceased.

This means that in Class a — up to six years of age — our results have been as follows: Good — 7. % Fair — 21.5% Poor — 71.5%

In Class 6 — six years to sixteen years : Good — 33-1/3% Poor — 66-2/3%

In Class c — sixteen years and upward : Good — 90% Poor — 10%

These figures go to show that if the operative procedure is instituted before the age of six years the ultimate result is apt to be poor, while between the age of six to sixteen years it is somewhat better. If, however, we include in class a under good results tlie cases in which all symptoms have ceased, but where the kyphos has inci'eased, the relative comparison is a good result in class a of 28.5% against a good result in class 6 of 33-1/3%, or, almost the same. According to these figures, then, operative procedures in the ages of infancy and of growth, have been successful in less than one-third of the cases, even if we are so lenient as to include those cases in which the kyphosis has been increased.

On the other hand, in class c, of the patients operated upon after the age of sixteen, ninety jjer cent have given a good result. This would tend to show that in adult cases in which growth of the body has ceased, and in which the human body has concentrated its efl'orts on repair, the addition of a bone graft has given excellent results. The rationale of this improvement may be that the bone graft acts as an intra-corporeal support so that traumatism is better resisted ; or that the blood supply between the various vertebral bodies is increased and changed by the new medium placed along the spinous processes.


April, 1922]


141


Localization' of the diseaJic:

For the cervical region tlie poor results were 100%.

For the iniddorsal and lower dorsal region there

were good results in 39% and poor results in 61%.

For the dorso-lumbar and lumbar region there were

good results in 73% and poor results in 23%.

Those regions of the spine in which the vertebral body is the largest and hence relatively more resistant to necrosis have given better results. Contrary to what would naturally be supposed, the amount of lessened mobility of the spine, owing to anatomical conditions, as in the mid-dorsal and dorsal region, does not seem to have had any favorable influence on the progress of the case toward recovery.

The effect of the presence of a kyphosis on the ultinwte result of the operation: In the cases in which there was no kyphosis at the time of operation the result of the operation was 100% recovery. In those in which there was a slight kyphosis at the time of the operation, the result was a cure in 50% of the cases. In the cases in which there was a moderate kyphosis there was a cure in 50% of the cases. In those in which there was a marked kyphosis there was a cure in only 25% and a failure in 75%. In other words, the greater the kyphosis at the time of operation the less the chances of a cure. There are several factors which probably afl'ord an explanation of these results.

Tuberculosis starting after the age of growth is far less likely to produce a kyphosis than when the human body is in the growing stage. Most of the patients who have little or no kyphosis are adults. As we have already mentioned, in adult ca.ses a cure is effected in 90%.

When a kyphosis is large, the bone graft is iisually weakened in making it conform to the curve of the kyphosis ; indeed, under these circumstances it has often been broken. The graft may break at the time of the operative procedure, or it has been known to hold for as long as two years after it has been embedded and then break. It has further been noted that when a graft has broken, the acute symptoms, which had been overcome by the operation, have reappeared almost immediately. It behooves us, then, in operating, to employ as large and stable a graft as can be obtained.

The numher of spines fixed at the time of operation: This has varied from four to eight spinous processes. It has always been our aim to take in the spinous processes of the affected vertebrae and, when possible, at least the spinous processes of two normal vertebrae above and below the affected ones. In marked kyphoses, composed as they are of many diseased vertebrae, this is not always possible, and when accomplished, it is often done at the expense of breaking the graft. Kit when it is broken, mobility occurs. The fixation is tested in various ways : ( 1 ) by a lateral picture of the spinal column sometime after the graft has been embedded; (2) by a leadline tracing of the patient in an upright position and in a


forward bending posture. The results of our cases have shown that the fixation has been complete in 75% of our cases.

Duration of the disca.se before operation: This plays a very definite role as regards the successful outcome of the case. In general, the longer the duration of the disease before the operation, the more likelihood of recovery. In the ca.ses in which the disea-'se had existed less than six months previous to the operation good results were obtained in 37.5% and poor results in 62.5%.

When the disease had existed one year: Good results — 55% Poor results — 45%

When the disease had existed two years: Good results — 60% PcTOr results — 40%

AVhen the disease had existed over two years: Good results — 78% Poor results — 22%

The real cure of any case of tuberculosis of the spine depends on the amalgamation or fusion of the aft'ected vertebrae and of the aft'ected vertebrae to the normal vertebrae above and below. This takes time. There is no known method which will afford a short cut by which this may be accomplished. Calv6 states that in tuberculosis actual ossification that assures repair does not begin until about three years after the onset of the disease. Hence, the cases which have been in existence two years are farther on the road to repair than those of more recent date. The bone graft does not bring about directly consolidation of the vertebral bodies, but only of the spinous processes. But, I believe that it helps indirectly by the formation of a new blood supply and that by its stabilizing effect it alleviates the acute process of the disease.

Duration, of post-operative fixation: The after-treatment of Pott's cases recommended by Albee was as follows : The patient is kept in the recumbent position without any plaster jacket or other support for six, eight or ten weeks; he is then allowed to move around without any support, on the assumption that the graft becomes stronger and that too more quickly if the normal physiological activity of the body be permitted. Our experience does not support this view; on the contrary, we believe that proper support must be given in all cases after the operation. In adult cases the period of fixation after operation is much less than in those of infancy and during the years of growth. In the adult case our average was six months, whereas, in infancy and during the period of growth, it was from two and one-half to thi-ee years. If this support were not applied, acute exacerbations of the disease soon appeared. It was also found in this growing period that, if a proper support were not w^orn after the operation, the kyphosis invariably increased, the graft itself was not capable of preventing further deformity; being viable, it was subject to the same


142


[No. 374


influences and the same laws of strain that had brought about the original kyphos, and instead of preventing a further deformity as growth went on, it bent, becoming more rounded and indeed even acute in outline. In oi'der to prevent the occurrence of a deformity a proper brace or support had to be worn over a long period of time, at least through most of the period of growth.

Influences o-n abscesses: In general the implantation of a graft has had a beneficial action on the active symptoms of the disease and on the abscess formation. In several cases in which an abscess was present before operation, the rapidity of its disappearance was hastened by the implantation and consequent fixation. On the other hand, absces.ses often reappeared when the graft became broken or fixation was not good.

Mortality: Although we have been fortunate enough to encounter no immediate fatality following the operation, the ultimate mortality, properly attributable to it, was eight per cent. The gravity of the operation should make one vei-y careful in the selection of his cases. Children, in infancy and in the growing period, afl'ected with tuberculosis of the spine, and in many cases having other foci of tuberculosis, are not good risks. An extensive procedure of this nature is such a severe drain on their vitality that they are made more liable to a spread of the tuberculosis and to secondary infections, such as influenza, which ultimately prove fatal. The adult, however, is a far better risk and far better able to undergo it.

Conclusions In drawing conclusions, therefore, from this series of cases, one can hardly agree with the statement of Dr.


Albee that "Pott's disease must now be regarded as a distinctly surgical affection, the operative treatment a sine qua non, to be given precedence over all other therapeutic measures. Mechanical treatment must now occupy a minor position, to be employed only as a post-operative adjunct, or with patients who refuse surgical intervention or are not good surgical risks." My own feeling is tliat in Pott's disease operative procedures should be used only in selected cases, and simply as one of the aids in making a cure, but not as the chief means. Pott's disease is a pathological condition which must necessarily run a very chronic course and its cure is accomplished only when amalgamation of the vertebral bodies is assured. This necessarily takes time. Mechanical means, therefore, particularly in infancy and in the growing child, must be the main method for stabilization of the vertebri¥, and when the graft is used it is to be regarded only as an aid and must not be relied upon alone. In infancy the operation is questionable owing to its magnitude and to the tendency which it has to weaken the system and thus favor the incidence of general tuberculosis and other infectious diseases. In this class of cases the ultimate, if not the immediate, mortality is high. In the growing period, from six to sixteen years of age, in carefully selected cases the bone graft may be used, but must be considered only as an aid, and proper mechanical treatment must be kept up until the period of growth is over or amalgamation of the vertebrse has taken place. In adults the bone graft is indicated in the majority of cases, but even here mechanical support should be used for at least six months.



BOOKS RECEIVED


Greek Medicine in Rome. The Fitzpatrick Lectures on the History of Medicine Delivered at the Royal College of Physicians of London in 1909-1910. With ether historical essays. The Right Hon. Sir T. Clifford Allbutt, K. C. B., M. A., M. D., F. R. C. P., F. R. S., Hon. F. R. C. P. I., Hon. M D., Hon.LL.D., Hon. D. C. U. Hon. D. Sc, etc. 1921. 8°. 633 pages. Macmlllan & Co., London.

Life and Times of Amhroise Parr. l.'iVi-l.'i'id. With a New Translation of his Apolog>' and an Account of his Journeys in Divers Places. By Francis R. Packard, M.D. With twentytwo text illustrations, twenty-seven full page plates and two maps of Paris of the 16th and 17th centuries. 1921, 8°. 297 pages. Paul B. Hoeber, New YoTk.

The Oxford Medicine. By Various Authors. Edited by Henry A. Christians, A. M., M. D. & Sir James Mackenzie, M. D.. F. R. C. P., LL. D.. F. R. S. In six volumes. Illustrated. Volume IV. Diseases of Lymphatic Ti,isue. Metabolism, Locomotory Apparatus. Industrial Disease and Difectious Di.'ieases. 1921, 8°. 938 pages. Oxford University Press. American Branch, New York.

History of the Pennsylvania Hospital Unit. (Base Hospital No. 10, U.S.A.) In the Great War. 1921. 8°. 253 pages. Paul B. Hoeber, New York.


Laboratory Handbook for Dietetics. Ph. D. Revised edition. 1921. 8': Company. New York.


By Mary Swartz Rose, 1.56 pages. Macmillan


Woman's Hospital in the ^tate of Netv York. Report of the Scientific Work of the Surgical Staff. Edited by George Gray


Ward, Jr., M. D., F. A. C. S. Volume III, 1920. 8°. 195 pages. C. V. Mosby Company, St. Louis, Mo.

Morris's Human Anatomy. A Complete Systematic Treatise by English and American Authors. Edited by C. M. Jackson, M. S., M. D. Sixth edition, revised and largely rewritten. Eleven hundred and sixty-four illustrations, five hundred and fifteen printed in colors. 1921. 4". 1.507 pages. P. Blakiston's Son & Co., Philadelphia.

American Child Hygiene Association. Transactions of the Eleventh Annual Meeting. 1921. 8°. 440 pages. Press of Franklin Printing Company, Baltimore, Md.

Columbia University in the City of New York. Studies from the Laboratories of the Department of Surgery. Volume III, 1918-1920. 8°.

Connecticut fitate Medical Society. Proceedings of the 129th Annual Convention. Editor Charles Williams Comfort, Jr. 1921. 8 = . 265 pages. Published by the Society.

Ergebnisse der Chirurgie und Orthopiidie. Herausgegeben von Erwin Payr und Hermann Kiittner. Vierzehnter Band. Redigiert von H. Kiittner. Mit 137 Textabbildungen. 1921. 8°. 956 S. Julius Springer, Berlin.

The Rockefeller Institute for Medical Research. Studies. Volume

XXXVIII. 1921. 8°. 580 pages. The Rockefeller Institute for

Medical Research, New York. The Heart. Old and Keiv Views. By H. L. Flint, M. D. With

Illustrationis. 1921. 8°. 177 pages. Paul B. Hoeber, New

York.


Syphilis and Its Treatment. With Especial Reference ta Sypliilis of the Sliin. By Wilfred S Fox, M. A., M. D.. B. C. (Cantab.), M. R. C. P. (London). With fifty-three illustrations, twentytwo in colour on fourteen plates and thirty-one in blacli and white on twen'ty-eight plates. 1921. 8°. 195 pages. Paul B. Hoeber, New York.

Text-Book of Materia Medica for Nurses. Compiled by Lavinia L. Dock. Seventh edition. Revised in accordance with the ninth decennial revision of the U. S. pharmacopseia. 1921. 12°. 315 pages. G. P. Putnam's Sons, New York and London.

Modern Italian Surgery and Old Universities of Italy. By Paolo De Vecchi, M. D. Fareword by George D. Stewart, M. D. With fifteen full page illustrations. 1921. 8°. 249 pages. Paul B. Hoeber, New York.

The Microtomisfs Vade-Mecum. A Handbook of the Methods of Microscopic Anatomy. By Arthur Bolles Lee, Hon. F. R. M. S. Eighth edition. Edited by J. Bronte Gatenby, B. A., B. Sc., D.Phil. (Oxon.), D. Sc. (Lond.), F. R. M. S. With the collaboration of W. M. Payliss, M. A., D. Sc. (Oxon.), F. R. S., F. R. M. S. [and others]. 1921. 8°. 594 pages. P. Blakiston's Son & Co., Philadelphia.

The Diseases of Children. By the Late Sir James Frederic Goodhart, Bart., M. D., LL. D. Aberd., F. R. C. P. Eleventh edition. Edited by George Frederic Still, M. A., M. D., F. R. C. P. With 60 illustrations. 1921. 8°. 942 pages. Paul B. Hoeber, New York.

The Principles and Practice of Medicine. By the Late Sir William Osier, Bart., M. D., F. R. S. and Thomas McCrae, M. D. Ninth thoroughly revised edition. 1921. 8°. 1168 pages. D. Appleton and Company, New York and London.

Diseases of the Skin. By Richard L. Sutton, M. D. With nine hundred and sixty-nine illustrations, and eleven colored plates. Fourth edition, revised and enlarged. 1921. 8°. 1132 pages. C. V. Mosby Company, St. Louis.

Studies in the Palaeopathology of Egypt. By Sir Marc Armand Ruffer, Kt., C. M. G., M. D. Edited by Roy L. Moodie, Ph. D. 1921. 4°. 372 pages The University of Chicago Press, Chicago, Illinois

The Lister Institute of Preventive Medicine. Collected Papers. No. 15, 1918-19: No. 16, 1919-20. Part 1. Bacteriological, Epidemiological, Pathological and Statistical Papers. Part II. Physiological, Zoological and Biochemical Papers. London.

A Guide to Urinary Diseases. By Adolphe Abrahams, O. B. E., M. D. (Cantab.) M. R. C. P., (1-ond.) and A. Clifford Morson, O. B.E., F. R. C. S. (Eng.). 1921. S = . 120 pages, Longmans, Green & Co., New York. Edward Arnold & Co., London.

Atlas for Electro-Diagnosis and Therapeutics. By F. Miramond de Laroquette, M. D. Authorized Translation by Mary Gregson Cheethan. With Foreword by Robert Knox, M. D. 1921. 8°. 180 pages. Paul B. Hoeber, New York.

The Blood Supply to the Heart in its Anatomical and Clinical Aspects. By Louis Gross, M. D., C. M. With an Introduction by Horst Oertel. With twenty-nine full page plates and six


text illustrations. New York.


1921. 4°. 171 pages. Paul B. Hoeber,


A Manual of Selectei Biochemical Methods as Applied to Urine, Blood and Gastric Analysis. By Prank P. Underbill, Ph. D. 1921. 8°. 232 pages. John Wiley & Sons, Inc., New York.

Surgical Diseases of Children. A Modern Treatise on Pediatric Surgery. By Samuel W. Kelley, M. D., LL. D. Second edition, revised and enlarged; illustrated. 1914. 8 = . 789 E. B. Treat & Co., New York.


A Pocket Surgery. By Duncan C. L. Fitzwllliams, C. M. G., M. D., Oh. M., F. R. C. S. (Edin. and Eng.). 1921. 12". 348 pages, Longmans, Green and Co., New York; Edward Arnold, London.

Human Embryology and Morphology. By Arthur Keith, M. D.. P. R.S., LLlD. (Aberdeen), F. R. C. S. (Eag.) Fourth edition, revised and enlarged with nearly 500 illustrations. 1921. 8°. 491 pages. Longmans, Green and Co., New York: Edward Arnold, London.

A Manual of Diseases of the Stomach. By William MacLennan, M. B. With the Assistance of J. SalisbuiT Craig, M. B., Ch. B. 1921. 8°. 392 pages. Longmans, Green and Co., New Y'ork and London.

The Life of Jacob Henle. By Victor Robinson. M. D. 1921. 8°. 117 pages. Medical Life Company, New York.

Clinical Surgical Diagnosis. By P. de Quervain. [Third English edition.] Translated from the seventh edition by J. Snowman, M. D. With 731 illustrations and 7 plates. 1921. 8°. 914 pages. William Wood & Co., New York.

The Oxford Medicine. By various Authors. Edited by Henry A. Christian, A. M., M. D., and Sir James Mackenzie, M. D., F. R. C. P., LL. D., F. R. S. Volume V. Infectious Diseases (Cont'd) and Diseases Due to Animal Parasites. Volume VI. Diseases of the Cmitral Nervous System. Under the Editorial Supervision of Sir James Purves Stewart, K. C. M. G.. C. B., M. D., P. R. C. P., 1921, 4°. Oxford University Press, American Bi-anch, New York.

Oxford Medical Publications. Publishers: Henry Prowde, London; Hodder & Stoughton, London. The following 5 volumes:

The Early Diagnosis of the Acute Abdomen. By Zachary Cope, B. A., M. D., M.S., Lond., F. R. C. S. Bag. 1921. 8°. 223 pages.

The Care of Eye Cases. A Manual for the Nui-se, Practitioner and Student. By Robert Henry Elliott, M. D., B. S. (Ijond.). Sc. D. (Edin.), F. R. C. S. (Eng.). With 135 illustrations. 1921. 8°. 172 pages.

^Heart Disease and Pregnancy. By Sir James Mackenzie. M. D.. P. R. C. P., LL. D., Edinburgh antl Aberdeen. P. R. S.. P. R. C.P.I. 1921. 8°. 138 pages.

Obstetrics and Gynaecology. Edited by John S. Pairbairn, M. A., B. M., B. Ch. (Oxon), P. R. C. P. (Lond.), P. R. C. S. (Eng.) 1921. 4°. 950 pages.

The Anatomy of the Human Orbit and Accessory Organs of Vision. By S. Ernest Whitnall, M. A., M. D., B. CH. (Oxon.), M. R. C. S.. L. R. C. P. (Lond.) Illustrated largely by photographs of actual dissections. 1921. 8°. 428 pages.


CONTENTS

  • The Evolution of Human Races in the Light of the Hormone Theory. By Prof. Sir Arthur Keith 155
  • The Pharmacological Action of Adrenalin on the Sphincter Pylori of the Foetus. By P. G. Shipley, M. D., and K. D. Blackean, M. D. 159
  • Occurrence of Ansemia in Rats on Deficient Diets. (Illustrated.) By William M. Happ 163
  • The Significance of the Influenza Bacilli. By Arthur L. Bloomfield
  • The Intercolumnar Tubercle, an Undescribed Area in the Anterior Wall of the Third Ventricle. (lUustratei.) By Thacy Jackson Putnam ISl
  • Pseudomyxoma Peritonei. By Edward Novak, A. B., M. D.
  • Histamine as an Inflammatory Agent. By William Bloom
  • Treatment of Non-Encapsulated Brain Tumors by Extensive Resection of Contiguous Brain Tissue. By Walter E. Dandy 188
  • Spontaneous Labor Occurring Through an Obliquely Contracted, Kyphotic, Funnel Pelvis. (Illustrated.) By J. Whitridge Williams 190


THE EVOLUTION OF HUMAN RACES IN THE LIGHT OF THE HORMONE THEORY

By Prof. Sir Arthur Keith (Conservator of the Museum and Hunterian Professor, Royal College of Surgeons, London. Eng.)


There is no need for a Herter Lecturer to apologise to Alumni and students of Johns Hopkins LTniversity for choosing a subject which has apparently no direct bearing on medical practice. No LTniversity has perceived more clearly than Johns Hopkins that rational medical practice must be based on a complete knowledge of the normal machinery of the animal and human body and has, therefore, in the past welcomed every enquiry which was likely to broaden the basis of this knowledge. When we set out to discover how the races of mankind have arisen, we have to make a full demand on all we know concerning the factors which regulate the growth of the


Abstract of Lecture I under the Herter Foundation delivered before the Johns Hopkins University on October 5, 1921.


human body — particularly on the action of the glands of internal secretion. Much of what the world knows concerning these glands it has learned from Johns Hopkins University — from Howell, Gushing, Goetsch, Abel, Barker, MacCallum and many others. In these lectures I hope to return, with some degree of interest, the preliminary outfit which the anthropologist borrowed from the clinician and pathologist.

Darwin, Hunter and the Hormone Theory I can best introduce the problems to be discussed in these lectures by carrying my audience to Darwin's home, near the village of Down, situated in the chalk uplands to the south of London, where, in the year 1870, the great observer was applying his machinery of evolution to the


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"Descent of Man." After he had made use of all the natural agencies at his command, the action of selection, the supposed effects of use and disuse, the manner in which one part of the body is correlated with that of another part, he had to declare that none of these could explain how the Negro had come by one set of characteristic features, the Mongol by another set and the European or Caucasian by a third. The missing agency which Darwin was in search of has been discovered accidentally by medical men working on disorders of nutrition and growth in the out-patient departments and wards of public hospitals. It was working under such circumstances that clinicians came to realize that there is placed in the human, as in the animal body, a group of glands, which, through the formation of chemical substances — or Hormones as Starling named them in 1904: — determine the individual and racial characters of every man, woman and child. It is a matter worthy of remark that not only Darwin but also his great predecessor, John Hunter, stood on the verge of this discovery — and yet both were sidetracked. John Hunter successfully transplanted the testes from one fowl to another; he grafted the cock's spur on the hen's leg, and the hen's spur on the cock's leg; his earliest investigation was to show that the human testis which failed to descend was arrested because of imperfect development; no one ever realized more clearly than Hunter did that the growth of all these features of the body, which he named secondary sexual," depends on the presence of healthy sexual glaads. Darwin also realized this to the full, but he concentrated his attention, not on how sexual characters are produced but on how they may be selected and perpetuated once they have come into existence. In the history of discovery we learn as much from the failures of brooding geniuses as from their successes. Both Hunter and Darwin had the misfortune to work ahead of the physiological knowledge of their time.

The Features of Neanderthal Man and of the Acromegalic Contrasted

Soon after 1908, when the Council of the Royal College of Surgeons of England placed me in charge of the Museum which a long line of Conservators had built up round Hunter's glorious nucleus, I had to rearrange the skulls of ancient and modern human races. In one section w^ere two specimens of historical interest ; one was a cast of the Neanderthal calvarium which Shaatfhausen had sent to Huxley in 1860 and on which the latter had based his statement that Neanderthal man was the most primitive, most ape-like and most ancient type of humanity known to him. The other specimen was a remarkable modern skull which led Dr. Barnard Davis, the BTitish craniologist, flatly to contradict Huxley by asserting that Neanderthal characteristics could still be found in the population of Europe. I noted with interest that the pituitary fossa in the Barnard Davis skull was double


the ordinary size, that all the characteristics of a regulated acromegaly were present and that it was these acromegalic traits which gave the apparent resemblance to the Neanderthal type. At the date of wiiich I write there was ample evidence to prove that a disordere<l enlargement of the pituitary was directly related to the appearance of acromegalic traits and that the effects could be best accounted for by regarding the pituitary as a centre in which growth-hormones were elaborated. The query naturally arose in my mind, as it did in that of others : Can the pituitary be concerned in the evolution of human races?

At the time I commenced this investigation an important truth was dawning on the minds of European anthropologists. The late Professor Gustav Schwalbe of Strassburg, strongly backed by Dr. Adloflf of Berlin, led a movement which completely altered the then prevailing conception of Neanderthal man ; Schwalbe held that he must be regarded, not as the Pleistocene ancestor of modern Europeans, but as a separate and extinct species of humanity. With the establishment of Schwalbe's position, we had to alter our mental vista of man's past. All the existing races of mankind are members of a single species but as we go into the far past we find not only separate species of humanity, but separate genera. We have to base our conception of the conditions under which mankind was evolved not on what wc .see in the modern world of man, but on what we can see now' among man's nearest allies — the anthropoid apes. These we find broken up into diverse genera and .species, confined to definite localities. All discoveries of recent years justify the belief that in the remote past mankind was represented by numerous local genera and species and that the machinery of evolution must have been both active and effective. The nature of this machinery is not beyond recall ; we may safely presume that it may be studied now in living groups of anthropoid apes — amongst gorillas, chimpanzees and orangs. We shall find among anthropoid apes the same hormonic mechanism which shaped the ancient and motlern racial types of mankind.

Here, too, before following the straight thread of my lecture, I may mention another line of evidence which has influenced the direction of my investigations. We are apt to think of evolution as a process of the past and that mankind has now come to an evolutionary standstill — so far as racial difi'erentiation is concerned. When we look at the distribution of the chief types of humanity as seen in the modern world it is no longer possible to share in this belief. We cannot explain why the Mongolian type was formerly confined to one region of the earth, the negro to another and the European to a third, or why intermediate types link them together, unless we proceed on the hypothesis that evolution has been and is now at work. In every continent we find human races at all stages of differentiation — from an


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incipient state such as is exemplified by the British Anglo-Saxon and Celt, where the degree of physical differentiation is slight, up to a complete stage, such as represented by Negro and white man where the degree of physical differentiation is unmistakable. The quest we set out on is the discovery of the physiological machinery concerned in the differentiation of mankind into its various physical types.

Acromegaly is a True Disorder of Growth

For the purpose of our search uo condition is so instructive as that known to clinicians as Acromegaly. In a short period of years after the onset of this disorder, a new and distinctive type of being is produced which the clinician recognizes at a glance as acromegalic. All the bodily structures and characters involved in the change are just those which tlie anthropologist knows to be concerned in the differentiation of human races. The texture and frequently the tint of the skin is changed; the growth and distribution of hair alters, the nose, lips, jaws, cranium and thorax undergo characteristic transformations; stature and the proportions of the body and limbs become modified. To study and estimate the degree and nature of these acromegalic changes we must apply the same exact methods as anthropologists employ in the study of human races.

Ten years ago I published the results of a craniological examination of acromegalic skulls ^ and showed the general nature of the changes which had occurred in them. At that time I had not sufficiently appreciated the complexity of the processes involved iu the growth of the normal cranium, for, to provide room for the growing brain, new bone has to be laid down at varying rates along certain sutural lines, while along other lines it is being absorbed. No less elaborate is the growth mechanism of the face, for, as the teeth erupt, additional bone is interpolated along certain sutural lines and deposited on certain areas while a process of absorption is taking place along other lines and areas. Each bone of the cranium and face represents a separate growth element and it is only by studying the changes which occur in each element that we come by a precise knowledge of how the face of a boy of five years of age is transformed into the face of an adult man. The result of study along these lines on additional acromegalic material has been to show that the differences between a uornuil and an acromegalic skull are exactly of the same nature as those seen when we compare the skull of a boy in his thirteenth year with one of an adult num. Beyond any doubt, with the onset of acromegaly a ti'ue growth process is reawakened and that reawakening is a continuation of the normal process which should cease when the adult stage is reached. The disorderly enlargemeut of the pituitary is directly related to the resurrection of the process of growth.


1 An Inquiry into the Nature of the Skeletal changes in Acromegaly. Lancet, April 15, 1911.


Acromegalic Changes Have a Functional Significance

It is only when we realize that the size and shape of the skull are determined by the functional purposes which it has to serve and by the manner in which it serves them, that we really profit by craniological enquiry. In the fii'st place the skull has to serve as a brain carrier, providing a cavity with walls so fashioned that additional accommodation can be easily and economically provided for the growing brain. In the second place, the skull has to serve as a carrier of sense organs — the eye, nose and ear. In the third place, it has to provide the whole of the bony scaffolding concerned in mastication, and which also answers, in a secondary degree, to the needs of speech and respiration and deglutition. In the fourth place it has to serve as a complex mobile lever on which the muscles of the neck act.

Let us look for a moment at the alterations undergone by acromegalic skulls in respect to these four functions. Apparently the brain increases in bulk and the cranial cavity in size; at least the mean cranial capacity of the acromegalic skulls at my disposal is distinctly above the average for normal skulls. As a sense carrier there is no change, save as regards the nose. But as regards its third or masticatory function, very remarkable and instructive changes occur. The area on the side of the skull from which the temporal muscle arises, becomes greatly extended, particularly in a forward direction. In the forward extension the frontal bone undergoes a transformation involving changes along the coronal suture, the throwing out of great supra-orbital bulwarks which serve as fulcra of origin for the temporal muscle. The transformation is usually facilitated by an enormous extension of the frontal air sinuses. The origin for the masseter muscle — the zygomatic arch — is strengthened, elongated and lowered in position. The areas and processes from whicli the pterygoid muscles arise, are also strengthened and extended. The ascending ramus of the mandible, which has to provide an area of in.sertion for those muscles, elongates greatly and sometimes increases iu width as well. All parts of the body of the mandible become the sites of true growth; the alveolar margin, carrying the tooth-sockets, is remodelled and extended. The chin and the lower mandibular border are greatly augmented — strengthening and extending the bony scaffolding on which the floor of the mouth is set. All parts of the upper jaw — with one exception — share in the general enlargement of the masticatory system. The exception is the area cari-ying the alveolar margin and liard palate; these parts, we shall see anon — may not suffer a perceptible degree of change.

Now the parts just named — the chin, the size and form of the mandible, the prominence of the cheek-bones, the size and projection of the ascending nasal process of the


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upper jaw, the degree of developiueut of the supra-orbital ridges — are all of them immediately concerned in giving the face its individual, as well as its racial, characteristics. All of them are linked together to serve in one function — mastication. The pituitary acts not in an anatomical but in a physiological manner; it can somehow stimulate and correlate the growth of all the anatomical elements concerned in a single function. We shall see presently that other hormones, besides those arising in the pituitary, can and do influence the growth of the face. It is sufficient for the meantime to be certain that the characterization of the face — the chief signboard of race — is under the control of a hormone system.

Further evidence in favour of the view that the growth functions of the pituitary are grouped on a physiological — not an anatomical — basis is seen when we study the adaptations undergone by the skull to serve as a lever. To that area of the skull to which the muscles of the neck are attached we nmy give the name of "nuchal platform"; it is fashioned out of cartilage bone, comprising the whole of the cartilaginous part of the occipital bone and the mastoid part of the temporal bone. In acromegaly the nuchal platform has its area greatly enlarged ; all its bounding and intercrossing muscular ridges — comprising the mastoid processes and occipital ridges — are enormously strengthened. The need for some mechanism to correlate the growth of the masticatory bony scaffolding and nuchal platform is made very evident in the skulls of anthropoid apes. The gorilla exerts the strength of its massive body through its huge jaws ; hence in this animal a supreme development of the masticatorj' scaffolding is correlated with an enormous expansion of the nuchal platform. In the chimpanzee, a near relative of the gorilla, the jaws are reduced and so is the nuchal platform. The difference between Neanderthal man and modern man — in respect of jaw and neck — corresponds in degree to that seen between gorilla and chimpanzee. As a boy's jaws gi"ow, his neck enlarges; he continues to take a bigger size in collars as each new tooth erupts. In women the head is poised on a slender neck ; their maxillary and nuchal development represent an adolescent stage of the male. In these instances, we see the pituitary acting on a series of anatomical elements moulding and adapting them to a single physiological end. Nuchal characters also serve to differentiate races. It is a remarkable fact that the most extensive facial and nuchal development is found amongst Europeans.

All Systems of the Body Are Affected

IN Acromegaly

Too much stress cannot be laid on the fact that in acromegaly all the tissue systems of the body are involved. In every case of acromegaly which has received a complete examination, it has been found that not only are


the skeletal and cutaneous tissues affected but so too are the circulatory, the pulmonary, the alimentary-, renal and connective tissue systems. All of them are involved in overgrowth with the exceptions of the sexual system, which undergoes atrophy, and the nervous system, regarding which our evidence is incomplete. Nor can too much emphasis be laid on another fact that in the later stages of the disease — all of these systems suffer degeneration and atrophy. Some years ago the Museum of the Royal College of Surgeons obtained a subject of this disease — a man who had begun to show symptoms of acromegaly at the age of twenty-four and had died twenty-five years after the onset, the disease having been steadily progressive. Preparations, naked-eye and microscopic, were made from all the sj'stems and organs of this individual and are now preserved in the Museum of the College. Evei-y cell of the body of this subject was found to have suffered in the general disorder of growth. For example, the muscles of mastication had not merely undergone a normal degree of hypertrophy; they had undergone a real process of growth — the individual fibres having increased in length, diameter and number. This was also true of all the muscles of the tongue and mouth. The temporal and facial arteries were abnormally large and their muscular coats greatly increased, but, as was the case throughout the whole arterial system, the inner coat was thickened, it encroached on the arterial lumen. From these facts one infers that the pituitary acts upon all the structural elements which are comprised within a functional unit and somehow keeps their growth in unison The Nature of the Disorder Known as Acromegaly So far I have merely put forward the evidence in support of the view that in Acromegaly we have exposed for us part of the growth-machinery concerned in the differentiation of racial characteristics. The pituitary and substances formed within it are essential parts of the machinery. Before we proceed further it is necessary to ask the question: Is Acromegaly the result of a breakdown of one of the growth mechanisms of the normal body? I think this question must be answered in the affirmative. It is a breakdown of the body's chief adaptational mechanism — the mechanism which "makes the back equal to the burden it has to bear." That a mechanism of this nature must be present in the body, becomes apparent, I think, if one will but mark what happens in the various systems of the body when a man or animal is placed under training. The muscles are the structures chiefly concerned but it would be useless for them to undergo a hypertrophy unless they had some means of calling forth a corresponding growth reaction from heart and vessels so as to be supplied with an increased amount of blood, from the lungs, to meet their increased need of oxygen ; from the alimentary system, so as to be supplied with increased energy-material ; from the kidneys, so as to rid them of their increased refuse


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products, from the skeletal ami articular and ligaineutous systems, so that they become fit to withstand the increased stresses produced In* hypertrophied muscles. These effects cannot be produced in a merely mechanical way; we must postulate an organized system of some kind and the one which answers all the circumstances of the case is that of hormones. In Acromegaly we find a disorderly manifestation of all the results which follow increased use of muscles — bones strengthen, particularly their muscular ridges and impressions; the joint-surfaces enlarge, the ligaments are thickened, the heart, arteries and veins hypertrophy, the lungs and chest undergo a true growth; the apparatus of mastication and the alinientar\- canal become hypertrophied, renal substance is increased. If we suppose that this adaptational mechan


ism, which makes hypertrophy answer to increased action, were to be set in motion, not through the normal stimulus of muscular activity but through some condition arising in the pituitary itself, then we can understand why it is that the human body should be subject to such a disorder as Acromegaly.

One other fact supports the theory here put forward regarding the nature of Acromegaly. AVhy should the hands and feet be the parts of the body which suffer first and most in Acromegaly? If my explanation is the true one, then the feet and hands should be the most susceptible, for nothing is more certain than that hard manual labour will produce marked growth responses in the hands and feet.


THE PHARMACOLOGICAL ACTION OF ADRENALIN ON THE SPHINCTER PYLORI OF THE FOETUS

V. G. Shipley, M.D.

AND

K. D. Blackfan, M.D.

(From the Department of Pediatrics, Johns Hopkins University. Baltimore, Md.)


Pirie's f recent suggestion that hypertrophic stenosis of the pylorus in newly born infants may be due to fcetal hyperadrenia makes it necessai-j' to view that condition from an entirely new angle.

The development of hypertrophic stenosis according to I'irie comes about as follows: — (1) Reflex stimulation of the adrenal medulla from some internal or external receptor, e. g., the preputial nerve endings, is followed by (2) the discharge of an increased amount of adrenalin into the blood stream.} (3) This increased adrenal discharge stimulates the splanchnic and causes, according to whether it is constant or intermittent, either increased tone or spasmodic Contraction of the alimentary sphincters (ileocolic and jtyloric I because of the socalled reverse innervation of these muscle groups. Hypertrophy of the sphincter pylori follows because of this spasm or increased tone, and persists into post-f(etal life. The cause of stimulation disappears or is persistent only as some minor defect (phimosis) which is not usually recognized as causally associated with the graver pathological result. It mav, however, be sufficient to maintain


t Pirie. G. R.. Lancet, September 2fl, 1919.

Jin the British Medical Journal of Xovember 26. 1921, (p. 891) Gray and Reynolds have suggested that the hypersecretion of adrenalin may be maternal as well as foetal.


the severity of the morbid condition for which the infant comes under treatment.

Pirie cited cases of babies suffering from hypertrophic stenosis who recovered after circumcision and mentioned the autopsy of a child dead from hypertrophic stenosis at which gross adrenal lesions were found to support this attractive hypothesis. It is obvious that this hypothesis is dependent on the so-called "reversed innervation" of the gastrointestinal sphincters. In other words, the statement must be accepted that while the augmentor fibres supplying the gastrointestinal musculature in general reach the digestive tract from the vagus nerve and the inhibitors from the splanchnic, the muscles of the pyloric and ileocolic sphincters are augmented through the splanchnic and depressed by way of the vagus. Stimulation of the splanchnic nerves (peripheral), according to this theory, results in relaxation of the entire gastrointestinal musculature except the ileocolic and pyloric sphincters which are said to be thrown into a state of increased tonus by the impulse following splanchnic excitation.

Almost nothing is known about the behavior of the intestine during intrauterine life.

It has been generally accepted that peristalsis occurs before birth because lanugo hairs are found in the first meconium. These hairs could only have reached the large intestine by passing through the whole gastrointestinal tract after having been swallowed with amniotic fluid into which the_y had been cast off. The general opinion regarding ante-natal intestinal movement has been that peristalsis is feeble and infrequent until just before the birth of the foetus. Yanese,* indeed, found that in human foetuses he was able to produce peristalsis and local contractions as early as the ninth week of intrauterine life. Before this date, when the myenteric plexuses and the longitudinal muscle coat begin to develop, this author claimed to have been able to produce neither peristaltic movements nor local contractions by direct stimulation. He concluded, therefore, that peristaltic movements are of neurogenic rather than myogenic origin.

In the course of a study of the physiology of the gastro-intestinal tract in the foetus we have observed the action of adrenalin solutions on the musculature of the stomach and intestine, and since the appearance of the hyperadrenia theory of pyloric stenosis, it has seemed worth while to record the reaction of the foetal sphincter pylori to solutions of adrenalin. Solutions of adrenalin were tested on ring and strip preparations of isolated sphincter pylori and on preparations of the pylorus in situ.

Isolated preparations of embi-yonic pyloric muscle show very characteristic regular spontaneous contractions when kept in oxygenated warm Kinger solution. The graph made by such an isolated ring is shown below (Fig. No. 1). Contractions usually start two or three minutes after the preparation is set up and increase steadily and rapidly in strength until a maximum contraction is reached, which may be maintained for two or three hours. WhUe the contractions are usually singularly rhythmic, the rhythm maintained may be multiple (in groups of two or three beats, Fig. No. 2) and occasionally, in chilled or shocked preparations, the contractions are irregular in rate and force. The character of the curve made by these muscular contractions is strikingly uniform — a rapid contraction indicated by a steep, almost vertical ascending limb, and a rapid initial relaxation slowing to its completion, so that the descending limb of the curve blends gently with the horizontal. Ascent or relaxation may be interrupted by secondary' contractions which produce ana- or cata-crotic notches preceding the relaxation of the muscle, or the curve may be topped by a smooth or serrated plateau; double contractions may occur which are followed by a contraction wave of extra height, or by a compensatory pause, a phenomenon which we shall discuss in more detail later.

Now if a solution of adrenalin be instilled into the Ringer bath in which the strip of muscle is working, a pronounced change in the rhythm and force of the contraction takes place which is characteristic and constant for a given dose of the drug. If a small dose of the salt is given (0.0005 mgm. in 50 c.c. of the bath solution), the interval between the contractions is lengthened immediately so that three or four times the usual period may intervene between contractions without any departure of the lever from the base line (Fig. 3b). When the muscle does contract, however, it may do so with somewhat greater force, so that the resulting curve of the contraction wave is very slightly higher than the curve of the contractions immediately preceding the instillation of the adrenalin solution. On the other hand, after a slightly larger dose, the amplitude of the contraction may be diminished, the interval remaining the same, or both amplitude and frequency of contraction may diminish. When the amplitude of the contraction is very much diminished, the return to normal contraction force may be gradual (Fig. 3a). This is maintained until the preparation is washed out or the drug is destroyed by oxidation. This decreased frequency of contraction is more pronounced as larger doses of the drug are given until, following the exhibition of massive amounts (0.3 mgm. in 50 c.c), the muscle may remain completely paralyzed for half an hour or more, even though the specimen has been twice or three times washed. Return of contractility to such a paralyzed muscle is like the onset of contractions in a fresh, shocked, preparation. The muscle contracts at first to a hardly recordable extent and gradually progressively, minute by minute, the contraction attains its full strength (Fig. 4). The action of adrenalin on pyloric strips is quite the same.

The description of the increase in the size of the contraction following the administration of small doses of adrenalin might make one feel that, besides the depressor action of the drug, some pressor action was present also which increased the contraction of the muscle, but a study of the graphs made from untreated preparations shows that an increase in the strength of contraction is seen following any pause in the course of the spontaneous rhythmic muscular movements or lengthened inten^al between contractions. It will be seen, therefore, that this apparent increa.se in contraction is analogous to the heightened response of the cardiac muscle after the removal of the inhibition caused by vagus stimulation.

The above account of the results of splanchnic stimulation holds good not only in the pig foetus, on which most of our studies have been made, but also in all other mammals which we have studied, including man. Since pyloric stenosis occurs only in man, as far as we at present know, an examination of human foetal material is necessary in order to exclude the possibility of special peculiarities. This is especially so since human tissue, at least in one instance, is said to vary from that of other mammals in its response to chemical stimulation (see Barbour's description of the response of the human coronary arterj- to adrenalin). It may be well, therefore, in this connection to give a protocol of one of the experiments on the pylorus of a human foetus.

The child R. M., female, prematurely born in the sixth month, weight 907 gms., admitted in the eleventh hour of extra-uterine life. The child was said to have grown progressively weaker since birth.

Death at 8.30 A. M., the day following admission.

At 10 P. M. the stomach was opened and found filled with a slightly alkaline fluid consisting of the milk feeding given two hours before death. The milk showed no evidence of coagulation.

The pylorus was normal to inspection. It was cut into strips one of which was immediately suspended in 50 c.c. of oxygenated Tyrode's solution at 39° C. and attached to a light lever.

Strip No. 1. Spontaneous contraction of the muscular strip started immediately and continued with experimentally induced variation until 11.20 P. M., when the preparation was discarded. The instillation into the bath of 0.1 c.c. of a 1 : 100,000 solution of adrenalin chloride (P.D.) (a concentration of 1: 50,000,000) was followed by no other change in the contraction than a slight slowing of the contraction rate. The instillation of double the amount of the drug was equally unproductive of appreciable effect. Following the instillation of 1 c.c. of 1 : 100,000 solution of the drug, however, (1 : 5,000,000) the amplitude of the contraction curve was considerably diminished and the exhibition of 1 c.c. of a 1 : 10,000 solution (1 : 500,000 concentration) caused a relaxation of muscular tone and diminution of contraction amplitude to approximately one-fifth of the normal value, a condition of affairs which persisted until, just before removal of the strip from the bath, stimulation with 0.1 mgm. of histamine restored approximately the pre-experimental muscular vigor (Fig. 5).

Strip No. 2. four hours and 20 minutes after death, 2 hours and 50 minutes after removal from the cadaver, gave an equivalent reaction to that given by preparation I.

Strip No. 2, studied at 3.30 P. M. on the day following death under the same conditions described above, gave only feeble contractions which were marked by inhibited adrenaline chloride 1 : 50,000,000 and which entirely ceased under the influence of the same drug 1 : 5,000,000. This strip was kept at refrigerator temperature in Ringer's solution for 31 hours after death.

It will be seen from the above experiment that the re action of the human foetal pylorus differs in no respect from the response to adrenalin given by the pyloric musculature of foetuses of other mammalian species. This response is in the nature of relaxation and inhibition rather than of stimulation and augmentation.

We have been able to confirm the results given by ring


and strip preparations, isolated from the foetal body and maintained in vitro, by experiments in which the pylorus was left in situ and the adrenalin was exhibited to the pylorus with the blood and nerve supply uninterrupted.

Increased secretion of adrenalin il would seem, could hardly result in anything else than a decrease in the tone of the pyloric muscle, and intermittent discharges of adrenalin, instead of inducing periodic pyloric spasm, would rather result in periods of relaxation of the gastrointestinal motor mechanism.

Furthermore, since the action of adrenalin on the muscle of the gastro intestinal tract depends on stimulation of the endings of the splanchnic, reversal of valvular innervation, if it exists in the adult intestine, must be a phenomenon confined to post-foetal life.

It is interesting to note that in the pig foetus, even in those with a C. R. length of only 6 cm., it is possible to see definite peristalsis when the gut is exposed after delivery from the uterus. Foetal peristaltic movements follow the "law of intestine" as laid down for the adult animal, bear the same relation to the Tonus rings and are affected in the same way by stimulation. Contractions of segmentation occur and are more readily seen than in the adult gastrointestinal tract and, in brief, intestinal motor mechanism has the potentiality to carry out the movements described as characteristic for the gastrointestinal tube in post-embryonic life.

Fig. 1. — Spontaneous contractions of an isolated ring of embryonic pyloric muscle (pig).

Fig. 2. — Spontaneous contractions of a ring of pyloric muscle from a pig embryo, to show compound contractions and multiple rhythm in a cooled preparation. Temperature of the bath 36° C.

Fig. 3. — a and 6 show the effects of small doses of adrenalin chloride on the contractions of rings of embryonic pyloric muscle (pig) suspended in 50 c.c. of Ringer-Locke solution. While the contraction rate is much slower after very many doses of adrenalin, the tone of the muscle remains unchanged. Recovery may be sudden or gradual. During the period of recovery the amplitude of the contractions may return to normal or slightly above, while the frequency is still diminished. The immediate effect of the drug is the diminution of both amplitude and frequency of contraction.

Fig. 4. — ^Shows complete cessation of contractions of a ring of pyloric muscle of a pig embryo after 0.3 mgm. of adrenalin chloride was added to a bath of 5 c.c. Ringer-Locke solution.

Fig. 5. — Curve showing the effect of adrenalin chloride on a preparation of the pyloric muscle of a human foetus which contracted spontaneously in 50 c.c. of Ringer-Locke solution. This curve shows that the tone of the muscle was impaired by the drug as well as the frequency and amplitude of the contractions.


1


162 JOHNS HOPKINS HOSPITAL BULLETIN [No. 375

Fig. 1. Spontaneous pontraction of a ring of pyloric muscle. Pig foetus C. R. 115 mm. Ringer-Locke solution.

39° C. 39° C.

Beginning fatigue.

4.05 P.M. 4.10 P.M. 4.15 P.M. 4.25 P.M. 4.30 P.M.


Fig. 2. Compound contractions and multiple rychm of a ring of pyloric muscle induced by cooling. Pig fcEtus C. R. 14 6.1 mm.

k a ill .Liii k kii- L k k k 'hijj.


Fig. 3a. Pylorus of a pig foetus. C. R. 157 mm. in 2 c.cm. of Ringer-Locke solution.


fi 1


Adrenalin chloride— .01 mgra. Rate slowed —Amplitude slightly increased.


Fig. 3b. Effect of Adrenaline Cliloride on pylorus of a pig embryo. C. R. 171 mm. Ringer-Locke. 38° C.

Adrenalin! Chloridi 0.005 mgm. A. C. 0.01 nigm. A. C. 0.0005 nigm.


Effect of adrenaline chloride on the spontaneous contractions of the pylorus. Pig embryo C. R. 155 mm. Ringer-Locke

solution. 20 c.cm.


».Jo^AjvAAJt-^AJJ-U^^AAMAAA/jJiAj'XUiA/L_


A. C. 0.3 mgm. Washed out.


R. M. Pyloric muscle (strip). Human premature — lived 32 hrs. Weight 4410 gms.

A. C. 1.0 c.c— 1100,000.


May, 1922]


163


OCCURRENCE OF ANAEMIA IN RATS ON DEFICIENT DIETS

By William M. Happ

(From the Department of Peiliatrics. The Johns Hopkins University.)


Introduction. Numerous attempts Lave been made to produce aiia?mia in animals by means of diets poor in iron. In these experiments attempts Lave often been made to ascertain wLetLer inorganic iron given by luoutL causes the regeneration of the blood in anaemia. Meyer ' summarized the literature on this subject in I'JOG.

Hall - fed white mice on the following diets :

1. Casein 37. S

Starch 28.3

Fat 30.1

Salts* 3.7

2. Casein 20.0

Butter 3.34

Fat 11.66

Cellulose 0.7

Starch 60.5

Salts 3.7

He found that the total iron content of the ash of the mice kept for three weeks on these diets decreased 40 per cent. The feeding of iron by mouth increased the number of red blood cells and hsemoglobin. The ingredients of these diets were purified foodstuffs and relatively free from iron. The nature of the fat used was not stated. The animals lost rapidly in weight and lived only four weeks on diet No. 1 and six weeks on diet No. 2. No water soluble B was supplied in these diets.

Schmidt ^ was not able to produce ana?mia in tLe first generation of wLite mice fed on a diet poor in iron. The blood of their young, however, showed a reduction of haemoglobin and red blood cells, with poikilocytosis, anisocytosis and polychromasia. When iron was added to the diet, the blood became normal. Enlargement of the spleen was noted in these anaemic mice.

Other autliors, Kunkel,* Cloetta, Abderhalden," MulIcr," Tartakowsky,* and others, fed animals on diets of milk, milk and bread, and milk and rice, to study the regeneration of tLe blood following bleeding and tLe effects of the administration of inorganic iron. These experiments sLowed that a reduction in the amount of iron bound in the tissues (reserve iron) and in the circulating blood (circulating iron) resulted in animals fed on such diets. The depletion could be made up by feeding iron by mouth either in inorganic or organic combination. They showed further that the reserve iron was depleted before the amount of iron circulating in the blood as haemoglobin was diminished. There have

Composition of salt mixture.

K,CO,, 0.97

NaCl 0.7

CaHPOi 1.8

MgCl, 0.18


been few studies other than those regarding the hiemoglobin content of the blood of animals on deficient diets.

It is a fact that the prolonged feeding of milk alone to an infant may be followed by the appearance of a secondary anannia. Because of the work of Bunge and Abderhalden " this ana'inia has been attributed to a depletion of the reserve store of iron with which these infants are born, and a consequent reduction in the circulating iron (ha-moglobin). Again, there are anaemias associated with rickets in infancy in which a peculiar symptom complex is present, associated with various qualitative and ([uantitative cLanges in tlie blood picture. Children with these anaemias usually have an enlargement of the spleen, which is occasionally extreme, and a slight enlargement of tLe liver and lymph nodes, and a secondary an.emia with or without leucocytosis. There is often a lymphocytosis, and immature cells of both red and white blood cell series are found in the circulating blood (normoblasts, megaloblasts, myelocytes, pathological lymphocytes, etc. ) . This clinical picture has received various titles, such as "von Jaksch's anaemia," "anaemia pseudoleuka'mica infantum" and "splenic anaemia of infants." It is in all essential respects a secondary anannia. The frequency of its association with rickets has been emphasized by practically every author on the subject (.see review bj' Evans and Happ).^" The cause of this aniemia has not been established. Anaemia of this type appears to depend upon more factors than does the simple secondary anaemia which results from a diet low in iron, such as a prolonged milk diet.

On account of the frequency of anannia in infants with rickets the question arose as to the existence of anaemia in rats made rachitic by faulty diets. Through the kindness and co-operation of Dr. McCollum, Miss Simmonds and Doctors Shipley and Park, I was able to study the blood of rats on various faulty diets. These authors have found that if growing rats are placed on diets in which certain fats, butter fat, cod-liver oil, etc., are absent, or pi-esent only in small quantity, and in which there is a certain disproportion between the amounts of calcium and phosphorus, lesions of the bones result which are analogous to the lesions of the bones of young children with rickets."

The result of the examination of the blood of rats on various faulty diets is given, togetLer with the diet employed in each instance.

Technic. Klineberger and Carl,'- and later Powdermaker," found that the number of cells in blood obtained from the tails of rats was subject to great variation. For this reason the following procedure was employed in obtaining blood for


164


[Xo. 375


counting. The rat was lightly anesthetized and laid on a board, ventral side up. The hair over the thigh was cut close. The femoral (superficial) vein, which lies just beneath the skin, was exposed. This vein is quite prominent, especially in albino rats. It was cut with sharp scissors. In this way sufficient blood could be obtained with insignificant trauma for a red and white blood cell count, hcemoglobin determination, a cresyl blue preparation for reticulated red blood cell count, and smears for a differential blood count. As a rule, the flow of blood stopped promptly, and if the animal was to be kept, a drop of collodion was placed on the wound. The counts given in this paper, however, are the results of the first examination, unless otherwise stated. No animal was bled previous to the making of the blood count, the results of which are given. The red and white blood cell counts were done in the ordinary manner, Tiirck's and Hayem's solutions being used for diluent, and the blood was counted in a Karl Zeiss hasmocytometer with Neubauer ruling. The haemoglobin determinations were made with the Sahli apparatus. The hsemoglobinometer standard was so prepared that it gave a reading of 95 per cent for blood from the normal human adult. A reading of 95 per cent indicated approximately 14.25 grams of haemoglobin per 100 c.c. of blood. The blood films for differential counts and for the counting of the reticulated red blood cells were made by the following technique: A clean glass pipette of small bore or a white blood cell pipette was rinsed with a saturated solution of sodium oxalate, the fluid withdrawn and the inside of the pipette thoroughly dried. Several drops of blood from the incised thigh vein were drawn up into the pipette and blown in and out several times on a watch-glass. In this manner the blood was kept from clotting. A film was made from this oxalated blood in the usual manner. These films were stained, when dry, with Wilson's modification of Romanowsky's stain, mounted on a slide, a differential count of the white blood cells was made and the nature of the red blood cells noted. Then a drop of the oxalated blood was drawn into the pipette together with a drop of 1 per cent cresyl blue in normal salt solution. The blood and the stain were well mixed by blowing the contents on a watch-glass. A drop of this mixture was then blown on a cover-slip, films were made and stained with Wilson's modification of Romanowsky's stain, dried and mounted. By this method a preparation was obtained which showed beautifully the reticulum in the red blood cells. These preparations were permanent. Films kept for one year in this laboratory still show the reticular stain of the red blood cells. The percentage of reticulated cells was determined by counting a certain number of red blood cells, 500 or 1000, and recording the number of cells showing reticulum.

Cages. In these experiments three kinds of cages were employed. They are designated as

1. Galvanized iron cages. The iron wire was well insulated by galvanized metal.

2. Wood and iron cages. These are standard cages used in Dr. McCollum's laboratory. They consist of a wooden frame with galvanized iron-wire sides.

3. Wooden cages, made entirely of wood and glass. Food Cups. Zinc cups were employed in the first two types

of cages and glass cups in the third.

Drinking Water. The stock rats were given tap-water, the remaining rats were given doubly distilled water. This was first distilled through a copper still and then redistilled through glass. Animals receiving such water were given one drop per week per animal of the following solution:


Iodine 2 grams

KI 5 grams

H^O 500 c.c.

The norvuil blood of the rat. Klineberger and CarP= give the following average counts for the blood of the rat (blood from thigh vein) :

R. B. C. ...9,300,000 P. M. N 16.

Hb 105% (Sahli) P. M. E 3.5

W. B. C 15,200 L. lymph 24.5

S. lymph 53.5

L. M 0.5

T 2.

100.0 These authors found no difference in the blood of the

two sexes. The red blood cells of normal animals showed

some auisocytosis and polychromasia. The leucocytes

were predominantly small lymphocytes. The platelets

tended to group themselves in masses.

Donaldson " gives the following average counts for

albino rats on a "scrap" diet.

R. B. C 7,600,000 — 9,200,000

Hb 85% to 100%

W. B. C 7,200 to 16,000


P. M. N, P. M. E., P. M. B, Lymph.

the


nor


. .44 to 71% . . to 3% . . . .30 to 55

type of the


Neither the source of the blood ha?moglobinometer used is stated.

Gelling and Green/° in a preliminary report of some studies on blood regeneration in the rat on various diets, give the normal red blood count as between 7.5 and 10.5 millions and the haemoglobin percentage as 110 to 140 (Smith-Cohen). They state that the number of blood cells per c.mm. in rats of different ages and sexes falls within these limits.

In discussing the blood of normal rats several factors should be taken into consideration : first, the species of rat used ; second, the diet given as the stock diet ; third, the presence of respiratory infections which are common in laboratory rats and which may modify the total leucocyte count and differential formula; and fourth, the source of the blood. White blood cell counts made on blood from the end of the tail are higher than counts made from venous blood and show a higher polymorphonuclear percentage. I also found that blood from the heart contained a uniformly lower white blood cell count than blood from the veins. The number of red blood cells and the percentage of haemoglobin, however, were the same in blood from both these sources. It was necessary in some of the small rats to draw the blood from the heart, as a free flow could not be obtained from the cut vein. It should be remembered that the white blood cell counts are lower in these cases than if they had been made on blood from the thigh vein.

In our series of experiments the rats used were hybrids of the albino and the black Norway rat.

The diet employed as a stock diet for our animals was as follows:


May, 1922]


165


Whole ground wheat Cracked corn Ground rolled oats Flaxseed meal


3 parts 1 part


This was given ad Ubitiim and in addition the rats received a small quantity of pasteurized milk and tapwater daily.


CHART I. BLOOD COUNTS OF NORMAL RATS AT DIFFERENT AGES.



Blood from


Hb. %


R. B. C.


W. B. c.


Reticulated R. B. C. %


DIFFERENTIAL |


REMARKS



P. M. N.


p. M. E.


Lymph.


LM. T.


u.


Newlyborn* Newlyborn


Heart


75


3,200,000


4,000 4,000


93


24 43


2


30 17


8 5


8 32


Myelocytes 4. Nucl. . Anisocytosis.

R.B.C. 250 in count. 1 Polychromasia cor.

ing 100 W.B.C. f responding to per. Myelocytes 2. Nucl. / centage of Retic.

R.B.C. 280 in count- \ R.B.C. See photo ing 100 W.B.C. j graph.


15 Days


Heart




1,800


19


5



95





No Nucl. R. B. C. Marked leucopenia.


20 Days


Heart Thigh vein


80


4,800,000

'5;i2o;ooo


3,600 4,800 3,600 4,200 9,000


20


2 22




90 76


8 2




No Nucl. R. B. C. Rarity of P. M. N. forms.


26 Days


Thigh vein


85


18


12



76


4


8



1 Mo.


Thigh vein Thigh vein


80 85


7,000,000 6,592,000


6


16 24




76 74


8 2




2 Mos.


Thigh vein


90


7,680,000


8,000


9


16



84






4 Mos.


Thigh vein Thigh vein


110


11,200,000


9,600 8,000


3


24


6


68


2




9 Mos.


115


10,800,000


1


26


4


68


2




10 Mos.


Thigh vein


110


9,856,000


12,000


—1


14



85


1





Under newly born are included rats under 24 hours old. Chart I shows the results obtained in rats of different ages. The blood of a young rat differs from that of the adult, in that in the former the haemoglobin content and the red blood cell counts are relatively lower, the white blood cell count is lower (a relative leucopenia) and the percentage of lymphocytes is relatively higher. Therefore, it is important in studying the blood of a rat of known age to compare it with a normal for its age. The normal count for a young rat would indicate a slight anaemia for an adult rat. We may, therefore, speak of a physiological anaemia in the nursing rat.


The diets which were used in these experiments may be roughly divided into two groups. The first of these included simple diets which had milk in one form or another as a basis. The second group includes the more complex mixtures of various purified foodstuffs. Rats were fed on

1. Pasteurized milk.

2. Pasteurized milk and bread.

3. Evaporated milk (Pet Brand).

4. Condensed milk (Eagle Brand).

5. Dried skimmed milk (Krystallak).

6. Dried skimmed milk with various additions.

A diet of pasteurized milk alone will not cause pathological changes in the blood of rats, and rats may be reared to the third generation on diets of milk and bread without developing antemia.

Neither evaporated milk (Pet Brand) nor condensed milk (Eagle Brand) induced ansemia in rats even when the intake was limited to 8 c.c. and 4 gm., respectively, per diem in order to restrict the growth of the animals.

The attempt to cause anajinia by diets of dried skimmed milk (Krystallak) was a failure. Nor was anaemia produced by diets which contained Krystallak with yeast, butter fat or bread, or any combination of these additions to the skimmed milk diet. When, however, casein was added to a ration of Krystallak and butter fat, an anaemia was produced in two animals.


A. A female rat was started on a diet of

Krystallak 95

Butter fat 5

100 at the age of 25 days, when she weighed 30 grams. She was on the diet five months, during which time she gained in weight to 130 grams. At this time casein was substituted for 15 per cent of Krystallak:

Krystallak 80

Casein 15

Butter fat 5

100 The animal was kept in a galvanized iron cage on this diet for four weeks and lost 30 grams in weight. The rat appeared pale. Blood was taken from a thigh vein:

R. B. C 1,920,000

Hb 20% Leucopenia too marked

W. B. C 1,600 for accurate differential.

Red cells showed slight anisocytosis and poikilocytosis and there were many nucleated red cells. Polychromasia was fairly well marked. Approximately 70 per cent of the white cells were lymphocytes.

Autopsy. The tissues were very pale. The spleen was normal in size. The bones appeared normal and cut with resistance. Lungs normal.

. B. A male rat, which was in cage with the above rat, was put on the same diet at the age of 25 days, when weighing 30 grams. He was on the diet five months, during which time he gained in weight to 1^0 grams. Fifteen per cent of casein was added, and the rat was kept on this diet for 6


166


[No. 37.'.


weeks, on which he lost 20 grams in weight and developed pallor. Blood from thigh vein:

R . B. C. . . .1,472,000 P. M. N 51

Hb 15 — 20% Metamyelocytes 5

W. B. C 5.600 P. M. E 5

Eosinophilemyeloeytes. 1

Lymph 27

T 1

Unclassified 10

100* 67 nucleated red cells were seen in counting 100 W. B. C. There was slight anisocytosis and poikilocytosis. Polychromasia was well marked.

Autopsy. As for above rat.

Microscopic sections: Bone. The cartilage was not calcified. There was a narrow subchondral zone of irregular trabeculae with a great deal of osteoid tissue. The cortex of the shaft was thickened and spongy. The marrow was congested.

The following types of complex diets were also studied to determiue if possible the relations of certain deficiencies and excesses to the production of anaemia.

7. Purified diets (a) without iron, (6) with iron.

8. Diets low in fat-soluble A.

9. Diets low in calcium.

10. Diets low in calcium but with au excessive amount of fat-soluble A.

11. Diets low in water-soluble B.

12. Diets low in phosphorus and fat-soluble A.

13. Diets low in calcium and in fat-soluble A.

li. Other diets which produced changes in the bones. 7. No anwmia resulted in the first generation and only slight anwrnia in the second generation from a [jurified complete ration without added iron.

For this series of animals a purified diet was used (indicated below as purified diet without iron).

Salt mixture.

Washed casein . . 25** NaCl 0.173

Butter fat 10 MgSO, 0.266

Agar 2 K,HPO, 0.954

Wheat germ 10 CaH,(POJ2.. 0.540

Salt mixture 3.5S Ca Lactate. . . 1.300

Washed dextrin, .qs. ad 100 NaH.PO^ .... 0.347


3.580


In the formulas of the differential counts. P. M. N. = polymorphonuclear neutrophile leucocytes.

P. M. E. = Eosinophile.

Lymph. ^Lymphocytes (large and small).

T. = Transitional monocytes.

•* I take pleasure here in thanking Dr. McCollum for outlining and analyzing for me this and the other complex diets which were used.

t The diets of the mother rats were never changed during lactation, that is. if the mother of a litter was on a deficient diet, she continued to receive it while the young were being nursed. The second generation animals received the same food as their parents, unless otherwise stated. Animals of the second generation on a faulty diet may be said, therefore, to have received the deficient food since birth, although it has been shown that the breast milk of a mother on a deficient diet is a better food for her young than the diet she receives is for her.


For the control .series the identical diet (indicated below as purified diet with iron) was used except that ferrous lactate 0.118 grams was added to the salt mixture, bringing the salt mixture to 3.7 in.stead of 3.5S7c.

Both of these groups of rats were kept in wooden cages with paper for bedding and with glass doors and glass food and drinking cups. They did not come in contact with iron.

7a. Purified diet without iron.

A. A mother rat was put on the purified diet without iron at the birth of her young and remained on it while she nursed them.f Blood was examined from thigh vein of a male rat of this litter which had been on the same diet for 2% months. His weight at this time was 250 grams.

R. B. C 12,240,000 P. M. N 18

Hb 1157c Lymph 70

W. B. C 12.000 T 2

Reticulated R. B. C. .1% Unclass 10 (smudge cells)

100 At the age of 2 Vi months a splenectomy was performed under ether anesthesia. The spleen was larger than normal and weighed 0.91 grams. The animal recovered promptly and was kept 2 1/^ months longer on this diet; weight 320 grams (total of 5 months on a diet); blood from thigh vein:

R. B. C 9,920,000 P. M. N 7

Hb 110% P. M. E 6

W. B. C 40,000 Lymph 84

Reticulated R. B. C. . . 3% To 3

100 This animal had a severe respiratory infection.

Microscopic examination of the spleen showed a simple hypertrophy.

Autopsy. Subcutaneous fat abundant. The tissues were of good color. There was no infection about the wound and no hypertrophy of the lymphatic tissue. The bones were hard and normal in appearance.

B. A male rat of the same litter as the preceding rat on the same diet five months, but no splenectomy performed; weight 2 80 grams, blood from thigh vein:

R. B. C 12,300,000 P. M. N 11

Hb 1.15% P. M. E 6

W. B. C 12,800 Lymph 78

Reticulated R. B. C. 3% T 3

LTnclassified 2

100 Autopsy. The spleen was larger than normal, weighing 0.85 grams. Autopsy findings as in preceding rat. 7b. Purified diet with iron.

A. Control rat for the above. The mother of this rat was put on a purified diet with iron at birth of the young. A male rat of her litter was on this diet for 2% mohths. Weight 250 grams. Blood counts at this time from thigh vein gave the following result:

R. B. C 11.872.000 P. M. N 14

Hb 115% P. M. E 2

\V. B. C 15.000 Lymph 76

Reticulated R. B. C. 1-2% T 4

Unclassified 4


100


I


I


May, 1922]


167


A splenectomy was performed under anesthesia; the weight

of the spleen was 0.52 grams. The animal made a good

recovery and was kept on this diet for 2 % months longer,

making a total of 5 months on "a diet. Weight 310 grams. Blood from thigh vein:

R. B. C 9,920,000 P. M. N 29

Hb 115% P. M. E 9

W. B. C 12,400 Lymph 60

rr 2

100 Microscopic examination of the spleen showed it to be normal.

Autopsy. Entirely negative, wound perfectly healed. B. A male rat of the same litter as A. on the same diet for five months. No splenectomy performed; weight 290 grams; blood from thigh vein was counted as follows:

R. B. C 12,640,00 P. M. N 10

Hb 115% P. M. E 1

W. B. C 14,400 Lymph 84

T 5

100

Autopsy. The spleen weighed 0.62 grams. Examination entirely negative.

The blood of two other i-ats of this series was examiued with i)ractically the same results. The blood of rats of the first generation on a purified diet without iron was found to be practically identical with that of rats on the same diet with iron added. The spleen of rats on the former diet, however, was uniformly larger than the spleen of those on the latter diet. Splenectomy had no effect on the blood picture.

^J'Kjht aiKTiiiia resulted in some of the animals in the second generation receiving the purified diet tvithout iron.

A. A female rat, whose mother had been on the purified diet without iron since her birth, at the age of 19 days weighed 21 grams. The blood of the mother was normal after the weaning of the litter. She had been on the deficient diet during lactation. Blood from thigh vein:


P. M. N 32

Lymph 64

T 4


R. B. C 4,112,000

Hb 45%

W. B. C 3,400

Reticulated R. B. C. 15-20%

100 No nucleated red cells were seen. There was slight anisocytosis. no poikilocytosis. but fairly marked polychromasia.

Autopsy. Spleen normal in size, weight 0.77 grams, tissues somewhat pale, bones cut with resistance.

B. A young rat, whose mother had been on a purified diet without iron since her birth, at the age of 4 2 days weighed 29 grams. Blood from thigh vein:


R. B. Hb. . W. B. Retic.


C.


. .6,400,000

60%

4,600

C. . . .15%


P. M. N 40

Lymph 60

T

100


The red cells showed moderate polychromasia, otherwise they were normal.

Autopsy. The spleen was small, weighing 0.1 gram. Liver and tissues fairly good color. Lungs normal. The bones cut with resistance.


C. One of the young of a mother rat which had been on a purified diet without iron since birth, at the age of 24 days, weighed 2 5 grams. Blood from thigh vein:

R. B. C 7,360,000 P. M. N 28

Hb 67% Lymph 72

W. B. C 7,600 T

Retic. R. B. C. ...10%

100 Slight aniso- and poikilocytosis and polychromasia. No nucleated R. B. C. seen. No autopsy.

D. A young rat of the same litter as the preceding but aged 2 months. Weight 110 grams. Blood from thigh vein:

R. B. C not done P. M. N 14

Hb 100% Lymph 86

W. B. C 5,600 T

Retic. R. B. C 8%

100 Slight polychromasia, red cells otherwise normal in appearance.

Autopsy. Tissues and viscera of good color. The spleen was slightly enlarged, the thymus persistent and bones cut with resistance.

E. Mother rat was put on purified diet with iron at birth. Blood of mother normal after weaning litter. One female of this litter at the age of 19 days weighed 32 grams. Blood from thigh vein:

R. B. C 6,144,000 P. M. N 10

Hb 80% Lymph 88

W. B. C 3,400 T 2

Retic. R. B. C 10%

100

There was a slight anisocytosis and polychromasia. No

nucleated red cells were seen.

Autopsy. The spleen was normal in size, weighing 0.1

gram; the thymus somewhat enlarged. The bones were hard

and cut with resistance.

F. Rat, aged 1 month, weight 40 grams. Third generation on purified diet with iron. Blood from thigh vein:

R. B. C 10,240,000

Hb 110%

W. B. C 2,600

The red cells appeared normal and the differential blood picture was essentially normal.

No autopsy.

7a. Diet 2.

Casein 12.5

Butterfat 10.0

Wheat germ 5.0

Agar 2.0

Salt mixture without iron. . 3.7 Dextrin 67.0

100.0 The diet was made of purified food stuffs. It was iron free and had about half the protein content of the last mentioned diet. Two generations of rats were reared on this diet. Four rats of the second generation, weighing 33 to 40 grams, were kept on this diet from the age of 3 days for three months. At the end of this period they weighed 130 to 150 grams, on purified diet with iron. Blood from thigh vein:

R. B. C 10,880,000

Hb 90%

W. B. C 7,000

The smears showed red blood cells which were apparently normal. The differential count was normal.


168


[No. 375


\j. Tissues and viscera of good color. The spleen was enlarged; the bones appeared to be normal.

Microscopic sections of the bones of rats raised on the above purified diets showed practically normal bones. The cartilage was well calcified but the trabeculte were somewhat fewer in number than normal, i. r., the bones were slightly osteoporotic.

8. Tlic hlood of rats on a diet so deficient in fat soluble A as to produce xerophthalmia showed no anwmia.

The diet which was used had the following composition.

Rolled oats 40.0

Flaxseed oil meal 8.3

NaCl 1.0

CaCOa 1.5

Dextrin 4 9.2


100.0 9. The following diets were adequate in all respects except for a deficiency in calcium.

Wheat 20.0

Maize 15.0

Rice 9.5

Rolled oats 9.5

Peas 10.0

Navy beans 10.0

Casein 10.0

While milk powder 5.0

NaCl 1.0

Butter fat 10.0

100.0

Wheat 20.0

Maize 19.5

Rice 9.5

Rolled oats 9.5

Peas 9.5

Navy beans 9.5

Casein 10.0

NaCl 1.0

NaHCOj 1.5

Butter fat 10.0


100.0


The blood of rats fed on these diets was quite normal. 10. This was also true of the hlood of rats which were

kept on the following diet which contained an excessive

amount of calcium and fat.

Wheat 20

Maize 10

Rice 9

Rolled oats 9

Peas 9

Navy beans 9

Casein 10

NaCl 1

CaCOs 3

Butter fat 20


100


11. Rats on a diet so deficient in tcater soluble B as to produce polyneuritis iccrc not anemic but showed a Icucopcnia with evidences of diminished leucopoietic activity.

The diet had the following composition:

Casein 18

Salt mixture No. 185 3.7 Agar 2.0

Butter fat 5.0

Dextrin 71.3


100.0

A. A male rat was put on this diet, at the age of 55 days, when weighing 70 grams. At the end of 137 days he weighed 6 5 grams. In a state of polyneuritis. Blood from thigh vein:

R. B. C. ... 10,320,000 P. M. N 19

Hb 100% Lymph 35

W. B. C 2,600 T 1

55 The red cells appeared normal, the polymorphonuclear cells were chiefly cells with 5 or 6 lobed nuclei. The nuclei often filled the entire cells.

B. A male rat, weighing 56 grams, was put on diet at the age of 50 days. At end of 114 days weighed 50 grams. Animal in a state of polyneuritis. Blood from thigh vein:

R. B. C 10,000,000

Hb 110%

W. B. C 1,800

The smears showed very marked leucopenia; the red cells appeared normal. The white cells were about equally divided between polymorphonuclears and lymphocytes. The polymorphonuclear cells had multilobulated nuclei.

Autoi)si€s. These rats with polyneuritis were poorly nourished rats. The spleens were of normal size. Thymus glands atrophic. Tissues of good color and the bones hard on section. Microscopic section of the bones of these animals showed that the cartilage was thin and well calcified. Few trabeculs were visible. The marrow was hfemorrhagic.**

Findlay'" described the same changes in the blood in beriberi in man as we have found in rats, namely, leucopenia and a shift to the right in the Arneth formula without important changes in the red cells and h;ruioglobin.

12. Diets which are relatively high in calcium but which are low in phosphorus and in an uncharactcrized substance tchich is present in certain fats do not produce anwmia in rats.

McCollum, Simmonds, Shipley and Park have described a very severe form of rickets which is produced by diets which have the above described characteristics. The animals whose blood was studied were fed on their diet No. 3113 which was made up as follows : f

Wheat 33.0

Maize 33.0


Salt mixture No. 185 is the same as the salt mixture above in the purified diet without iron.

The pathological condition of the bone and bone marrow of these rats with polyneuritis is described by Shipley, McCollum and Simmonds, Jour. Biol. Chem., Dec, 1921.

t The blood counts on these animals were made by Dr. A. A. Weech.


May, 19221


169


Gelatin 15.0

Wheat gluten 15.0

NaCl 1.0

CaCOa 3.0

The blood of four animals on this diet was studied. The diet did not produce anaemia iu any case and the leucocytes were quite normal.

13. Diets lore in calcium, normal or relatively high in phosphorus and low in a substance contained in certain fats caused bone changes in rats tohich were closely related to rickets. These diets also produced anwmia in both first and second generations.

A brief review of the work of Shipley, Park, McCollum and Simmonds may serve to make the following discussion clearer. These authors have found that on diets in which an organic substance, present in codliver oil and to a less extent in butter fat, which may or may not be identical with fat soluble A, is small in amount and in which there is a disproportion between the calcium and phosphorus, a condition of the bones results which is practically identical with liuman rickets. Park and Shipley have frequently noted in these animals varying degrees of enlargement of the spleen and marked pallor of the viscera particularly of the liver. The rats whose blood counts are recorded below were from their series and had been in cages made of wood and galvanized iron. The blood of rats on six diets differing in composition but with the same faults were examined.

Six rats, aged 4 5 days, whose average weight was 4 5 grams, were put on the following diet which contains a poor fat and an insufficient quantity of calcium but an abundance of phosphorus:

Wheat 30.0

Maize 19.5

Peas 8.5

Rolled oats 8.5

Rice 9.5

Navy beans 8.5

Casein 10.0

NaCl 1.0

NaHCOa 1.5

Cottonseed oil 3.0


100.0

A. One female was examined at the beginning of the experiment. Blood from her thigh vein was examined with the following result:

R. B. C 7,928,000 P. M. N 9

Hb 92% Lymph 82

W. B. C 4,700 T 9

100 Slight polychromasia, no anisocytosis or poikilocytosis.

B. A male was examined after receiving the diet for 3 months. Blood from his thigh vein showed:

R. B. C. ... 10,208,000 P. M. N 22

Hb 100% P. M. E 2

W. B. C 14,400 Lymph 74

Retic. R. B. C 8% T 2


Slight polychromasia and anisocytosis were present.


Autopsy. The spleen was of normal size. The tissues were of good color. The thorax was much deformed.

Microscopic sections. There was a great overproduction of osteoid tissue in the epiphysis and the shaft was irregularly calcified and was invaded by blood vessels. There were large numbers of trabeculiB in the shaft each surrounded by a broad zone of osteoid. The cortex of the shaft was thickened. The spaces between the trabeculfe near the marrow cavity contained large numbers of basophilic cells. The spleen showed marked congestion. The Malpighian bodies were larger than normal.

C. A female was examined after being on the diet for 4% months. She weighed 84 grams. Blood from thigh vein showed

R. B. C 9,600,000 P. M. N 10

Hb 110% Lymph 88

W. B. C 9,000 T 2

Reticulated R. B. C.

less than 10%. The red cells showed slight polychromasia, were normal.

Autopsy. The spleen was slightly enlarged. The thorax was deformed and the costo-chondral junctions were enlarged. The bones cut easily and showed broad metaphyses.

Microscopic section. The changes in the bones were similar to those just described. The Malpighian bodies of the spleen were enlarged and contained nests of erythropoietic cells.

D. A female was examined after being on the diet for 6 months. The animal was pale and weighed 80 grams. Blood from thigh vein:




Eighteen nucleated red cells were seen in counting 100 white cells. There was a marked polychromasia. The polychromatic red cells corresponded with the number of reticulated red cells {see Figs. II, III, IV). Anisocytosis and poikilocytosis were fairly well marked.

Autopsy. The spleen was large, weighing 0.8 grams. The liver and other tissues were very pale. There was marked rickets. The bones cut easily and showed broad metaphyses.

Microscopic section. The bone showed more extensive rickets than in the preceding animal. There was no calcification of cartilage, which was very irregular (see Figs. V and VI).

The Malpighian bodies of the spleen were fewer in number than in the spleen of the preceding rat. There was infiltration with round cells and large mononuclear cells. There was myeloid metaplasia of the spleen with evidences of the assumption of hematopoietic function.

Summary. A rat fed upon a defective diet for 6 months had severe rickets, splenomegaly, and actively regenerating secondary anemia.

E. A rat of another litter fed upon the above defective diet from birth at age of 2 months weighed 30 grams. Blood from the thigh vein:

R. B. C 7,360,000

Hb 110%

W. B. C 2,200

Reticulated R. B. C 10%

The red cells showed slight polychromasia. There was leucopenia with a normal differential formula.

Autopsy. The spleen was normal. There were signs of early rickets.


170


[Xo. .*}75


F. A female rat, at the age of 40 days, when weighing 55 grams, was put on the following diet which is deficient in calcium and fat:

Wheat 25.0

Maize 19-5

Rice 9-5

Rolled oats 9.5

Peas 9.5

Navy beans 9.5

Casein 10.0

NaCl 1.0

Dextrin 1.5

Whole milk powder 5.0

100.0 At the end of 7% months her weight was S3 grams. Blood from the thigh vein contained:

R. B. C 5,232,000

Hb 60%

W. B. C 10.000

Reticulated R. B. C 2 4%

The red cells showed moderate polychromasia, marked anisocytosis and some poikilocytosis. A few nucleated red cells were seen. About 7 5 per cent of the white cells were lymphocytes. There were no myelocytes in the blood film.

Autopsy. The thorax was much deformed. The spleen was slightly enlarged, weighing 0.55 gram.

Microscopic, section. The bones showed rickets in process of healing. The spleen showed evidences of hematopoiesis.

Summari/. A moderate anemia for a rat of this age with active regeneration of the red cells. Slight enlargement of the spleen. Rickets.

A. A female rat, aged 4 5 days and weighing 65 grams, was fed upon the following diet, which is also deficient in calcium and fat:

Soy bean 30

Wheat gluten 5

Casein 10

Wheat germ 5

NaCl 1

Maize 20

Dextrin 29

100 Her weight was 7 5 grams at the end of 7 8 days. Blood from thigh vein:

R. B. C 3,120,000 P. M. N.. . 22 (incl. 2 meta Hb 35% myelocytes)

W. B. C 13,000 P. M. E.. .

Retic. R. B. C. .75-80% Lymph. . . 78

100 Seventy-five nucleated red cells were seen in counting 100 W. B. C. The red cells showed anisocytosis and poikilocytosis and marked polychromasia (see Pigs. VII and VIII).

Autopsy. The spleen was very much enlarged. There were marked changes in the skeleton. The cartilage was redundant. Calcification was very defective and irregular. The metaphysis consisted of osteoid tissue in the form of trabeculae, somewhat irregularly arranged. At the periphery of the bone, processes of unchanged cartilage ran down from the cartilage into the metaphysis. There were small islets of cartilage cells in the metaphysis. The cortex of the shaft was spongy. There was a great deal of osteoid tissue around all of the trabeculce in the spongiosa. There were no signs of abnormal resorption in the metaphysis but resorption was going on actively in


the cortex and in the spongiosa near the marrow cavity (see Pigs. IX and X).

Summary. Rachitic rat; enlarged spleen; severe secondary anjemia; evidences of active regeneration of red cells.

13. Ancrmia teas caused in the necond generation of rats fed upon the followinfj dict.s that produced changes in the bonrs.

A. A male rat. aged 4 1 days, weighed 22 grams. The mother was on the following diet for 217 days before birth of her litter:

Wheat 19.3

Maize 20.0

Rice 10.0 This diet is deficient in

Rolled oats 10.0 calcium, while contain Peas 10.0 ing a fat which is not

Navy beans 10.0 strongly protective

Casein 10.0 against rickets. There

NaCl 1.0 is a relatively large

NaHCOj 1.5 amount of phosphorus.

CaCO, 0.2

Butter fat 8.0

100.0

Blood from heart:

R. B. C 448,000

Hb less than 10%

W. B. C 1,000

Reticulated R. B. C 70%

The red cells showed marked anisocytosis and polychromasia

and some poikilocytosis. A few nucleated red cells were seen.

There was leucopenia with many early forms of the bone

marrow series.

Autopsy. The tissues were pale. The liver was nearly white.

The spleen was pale, but not enlarged. There were no gross

signs of rickets.

B. A female rat, aged 24 days, weighed 18 grams. The mother had been on the following diet 60 days before the birth of her litter:

Rice 10.0

Wheat 32.5

Maize 15.0

Peas 10.0 This diet is deficient

Navy beans 10.0 in calcium and fat.

Rolled oats 10.0

Casein 10.0

NaCl 1.0

NaHCOj 1.5

100.0 Blood was taken from the heart. The blood was thin and watery, and enough to count could not be obtained. Smears were made which showed fairly well marked anisocytosis and poikilocytosis and polychromasia. Many nucleated red cells were seen. There was a leucopenia.

Autopsy. The tissues and viscera were very pale. The spleen was not enlarged.

C. A female rat. aged 16 days, weighed 10 grams. The mother had been on the above diet for 84 days before the birth of her litter. Blood from heart:

R. B. C 5,044.000

Hb 75%

W. B. C 1,200

Reticulated R. B. C 10%

The red cells showed slight polychromasia. There was a marked leucopenia, but the white cells seen appeared to be normal. No nucleated red cells were seen.


THE JOHNS HOPKiNS HOSPITAL BULLETIN. MAY, 1922


PLATE XX,


%^


"^^v


t>.


Fig. I.


Fig. IL


Fig. III.



Fig. V.



PLATE XXI



Autopsy. The spleen was small. There was no thoracic deformity. The costo-chondral junctions were slightly enlarged. The long hones were thin and cut easily.

Microscopic sections showed well calcified osteoporotic bones. D. A female rat, aged 19 days, weighed 14 grams. The mother of this animal had been on the following diet 70 days. She continued on the diet while she nursed her litter:

Wheat 30

Maize 30

Rice 10 This diet is deficient

Rolled oats 10 in calcium and fat.

Peas 10

Navy beans 10

100 Blood from thigh vein:

R. B. C 6.20S.00O P M. N 15

Hb 10% Lymph 80

\V. B. C. . . . not counted T 5

100 There was anisocytosis, poikilocytosis and a moderate degree of polychromasia. An occasional nucleated red cell was seen. The animal had a marked leucopenia.

The bones of the mother showed typical rickets. The bones of the second generation rat showed no osteoporosis and no rickets.

In five other rats of the second generation a practically normal blood picture was observed. Discussion

A diet deficient in iron alone does not produce ana>mia in the rat in the first generation. It would appear eitlier that the rat is born with a store of iron sufficient to carry him through life, or that only a very small quantity of iron is necessary to meet his requirements. On the other hand, diets deficient in an organic substance contained in cod-liver oil and to a less extent in butter fat and which also have certain improper calcium-phosphorus ratios (diets which produce rickets in the rat) produce ana-mia in some animals. Tlie ana?mia in these animals is not due simply to a deficiency of iron in tlie diet. While these diets contained only a small amount of iron, they contained as much of this element as the stock diet or the other diets used upon which no anaemia developed. It would seem that tlie disturbance in the inorganic metabolism resulting from certain diets with Avhich there is a lack of calcification of the bones also resulted in, or was accompanied by, a disturbance of the iron metabolism. It will be noted that the phosphorus content was relatively normal or increased and calcium relatively low in all the diets upon which anannia developed.

When, however, the diet contained relatively excessive amounts of calcium but was low in phosphorus, no ana'inia was produced in the rats Avhich I examined. Diets of this type cause an exaggerated form of rickets to develop in rats and the calcium and phosphate content of their blood is identical with Hint seen in many severely rachitic children.

Milk diets except those in which ca.sein was present in high percentage did not produce anitmia. Two rats which received the latter diet were the onlv animals in


the series on diets of milk or modified milk which showed prof(mnd disturbance of calcification of the bones. I have no explanation to offer for this at present.

Enlargement of the spleen appeared to be as variable a feature in rats with rickets as it is in children with rickets. Enlargement of the spleen was frequently obsei'ved in rats in association with an ansemia of the actively regenerating type just as splenomegaly is commonly observed in infants with rickets and ana'iuia. However, although rickets makes its appearance relatively early in the rat, especially when the animal is put on the faulty diet at an early age, anaemia does not make its appearance until the rat has been on the diet for a long period. For this reason it is difficult to study ana'inia produced by faulty food in rats, since they usually die from malnutrition or embarrassed pulmonary or cardiac function resulting from the marked thoracic deformity, or from pulmonary infection, before there is time for the an:pinia to become manifest. The rats in which anaemia occurred had been on the faulty diet for a long period, or the aua>mia was observed only in the second generation. Rachitic rats are usually sterile, so that second generations are not often raised.

The examination of films of the blood of the same rat, made simultaneously, the one stained with cresyl blue and Wilson's stain following the technique outlined above, the other with Wilson's stain alone, showed that if the polychromatophilic ( diffusely basophilic) red blood cells and the reticulated erythrocytes were counted, the counts were practically the same. This would seem to indicate, at least as far as the rat is concerned, that polychromasia of the red blood cells is an indication of a young cell. Because of the stimulation of the bone marrow which occurs in the course of anaemia of the type described in these rats, these immature cells are poured into the circulation in large numbers. They compose a large percentage of the red blood cells present. In the blood of the normal adult rat they are seldom encountered.

Although the au;rmic animals were not treated, it would seem logical to assume that the.se anaemias require antirachitic therapy primarily. Iron would not seem to he primarily indicated because the amount of iron in any well balanced diet is sufficient to meet an animal's needs.

Conclusions

1. The normal blood picture of the rat varies with age. Young rats have a relatively lower red blood cell count, white blood cell count, and luemoglobin percentage, and a higher lymphocytic percentage, than the adult rat. Diet and the presence of respiratory infections are factors which may influence the blood picture,

2, Well balanced diets, deficient in iron, do not produce aiKcmia in the rat in the first generation, nor do diets consisting solely of cow's milk or milk and bread. Slight ampmia may occur in rats of the .second generation on these diets.


172


[Xo. 375


3. Diets deficient in fat soluble A or water soluble B, although they cause severe nutritional disturbauces, do not produce ana'iuia in the rat. Diets so deficient in water soluble B as to produce polyneuritis diminish leucopoietic activity and cause a severe leucopenia with a shift to the right in the Arneth formula.

4. Diets low in an organic substance contained especially in cod-liver oil with a low calcium but high phosphorus content, which produce rickets-like changes in the rat, may also produce aui^mia, provided the animal is kept for a long period on the diet. Animals of the second generation on this diet may also become anaemic. This aniemia is associated with evidences of increased htematopoietic activity. There is often an enlargement of the spleen. This condition resembles the amemias seen in association with rickets in human beings.

5. A diet low in the organic substance contained in cod-liver oil and low in phosphorus with a normal calcium content, a diet that produces severe rickets with great uniformity, does not produce antemia.

LEGENDS FOR FIGURES.

Fig. I. — Blood of normal newly born rat, stained with cresyl blue and Wilson's modification of Romanowsky's stain, showing the high percentage of reticulated red blood cells present.

Pigs. II and III. — Blood of rat D, (p. 171), stained with Wilson's modification of Romanowsky's stain, showing one nucleated red cell and polychromasia of many red cells.

Fig. IV. — Blood of same rat stained with cresyl blue and Wilson's modification of Romanowsky's stain, showing reticulation of the red cells.

Figs. V and VI. — Sections of femur of same rat at different magnifications, showing rickets.

Fig. VII. — Blood of rat A (p. 170), stained with Wilson's modification of Romanowsky's stain, showing polychromasia.

Fig. VIII. — Blood of same rat stained with cresyl blue and Wilson's modification of Romanowsky's stain, showing reticulation of the red cells.

Figs. IX and X. — Sections of femur of same rat at different magnifications, showing rickets.


REFERENCES.

1. Meyer, E.: Ergebn. d. Physiol., Wiesb., 1906, V, 698.

2. Hall, W. S.: Arch, f, Anat. u. Physiol., Physiol. Abteil.. Leipz., 1896, 49.

3. Schmidt. M. B.: Verhandl. d. deutsch. path. Gesellsch. Berl., Jena, 1912, XV, 91.

4. Kunkel: Arch. f. d. ges. Physiol., Bonn, 1895, LXI, 595.

5. Cloetta, M. : Arch. f. exper. Path. u. Pharmakol., I^eipz., 1897, XXXVIII, 161; 1900, XLIV, 363.

6. Abderhalden, E.: Ztschr. f. Biol., Miinchen u. Leipz., 1900, XXXIX, 113, 195 and 487. Ztschr. f. Physiol. Chem., Strassb. u. Berl., 1901, XXXIV, 500. Lehrbuch der physiol. Chem., Berl. u. Wien, Urban u. Schwarzenberg, 1914, II Teil, 756, //.

7. Muller, F.: Arch. f. path. Anat. (etc.), Berl., 1901, CLXIV, 436.

8. Tartakowsky, S.: Arch. f. d. ges. Physiol., Bonn, 1904, C, 586; CI, 423.

9. Bunge, G.: Ztschr. f. physiol. Chem., Strassb. u. Berl., 1884, IX, 49. Ibid., 1889, XIII. 399. Ibid., 1892, XVI, 173. Ibid., 1893, XVII, 63.

10. Evans, P. A. and Happ, W. M.: Johns Hopkins Hosp. Bull., Bait., 1922 (to be published).

11. Shipley, P. G., Park, E. A., McCoUum, E. V., Simmonds, N. and Parsons, H. T. : Jour. Biol. Chem., 1921, XLV, 333. Ibid., 1921, XLV, 343.

Shipley, P. G., Park. E. A., McCollum, E. V. and Simmonds, N.: Johns Hopkins Hosp. Bull., 1921, XXXII, 160. Proc. Soc. for Exper. Biol, and Med., 1921, XVIII, 275. Ibid., 1921, XVIII, 277. Am. Jour. Hyg.. 1921, I, 492. Ibid., 1921, I, 512. Jour. Biol. Chem., 1921, XLVII, 507. Dental Cosmos (in press).

12. Klineberger, C. and Carl, W.: Die Blut-Morphologie der Laboriums-Tiere. Leipz., Johann A. Barth, 1912.

13. Powdermaker, F. : Personal communication.

14. Donaldson, H. H.: The Rat, Memoir No. 6. The Wistar Instit. of Anat. and Biol., Phila., 1915.

15. Gelling, E. M. K. and Green, H. H.: Proc. Soc. Exper. Biol, and Med., N. Y., 1921, March 16, 191.

16. Findlay. G. M.: J. Path, and Bacteriol., Edinburgh., 1920, XXIII. 490.

17. Shipley, P. G., Park. E. A.. McCollum. E. V. and Simmonds, N.: Lesions in the Bones of Rats Suffering from Uncomplicated Beriberi, Jour. Biol. Chem. (in press).



V. AN OPERATIVE PROCEDURE FOR HYDROCEPHALUS

By Walter E. Dandy


Strictures of the aqueduct of Sylvius recur after any attempt to restore the lumen. For this reason, if treat


Read by title before the Johns Hopkins Hospital Medical Society on April 3, 1922.

♦* These patients are nearly always blind in one or both eyes at the time of operation.


ment is to be successful, the fluid must be sidetracked into its normal channels. With this in mind, a procedure which apparently is anatomically correct has been devised, to supersede any direct attack on the aqueduct. This consists in removing the floor of the third ventricle. A small opening is made in the skull and dura in the frontal region, the frontal lobe is elevated until the


190


[Xo. r.T.j


bulging; third ventricle is well exposed. Usually, it is necessary to divide one of the optic nerves, for in hydrocephalus these nerves are very short; usually the chiasm lies directly on the anterior border of the sella turcica. This opening in the floor of the third ventricle affords an exit from the dilated ventricles, so that the fluid can now pass directly into the cisterna chiasmatis and interpeduncularis — the normal distributing centers for cerebrospinal fluid. AVe now have proof that an opening made in the fourth ventricle will remain permanently patent, and this encourages the hope and belief that this opening in the floor of the third ventricle will also be permanent. The ventricular wall is a very thin membrane and oft'ers a minimum of glia tissue to repair the defect.


This procedure is by no means analogous to making an opening in the roof of the third ventricle. The latter can have no beneficial result because the fluid escapes into the subdural space where the absorption is slightly, if at all, greater than in the ventricles. Moreover, the opening is through cerebral tissue which proliferates and closes it, unless a good deal of the brain has been destroyed.

AVe have employed this method 6 times. No claim is made for its success. Time alone will decide. If successful, it should also be applicable to occlusions of the foramina of Luschka and Magendie and to those cases of communicating hydrocephalus in which the cisterna chiasmatis and interpeduncularis are patent.


VL DIAGNOSIS AND LOCALIZATION OF SPINAL CORD TUMORS*


Bv W.\LTER E. Dandy


In 1"J1!), a report of intraspiiious injections of air was presented. In several cases, the air was found in skiagrams of the head and proved to be useful in defining blocks in the subarachnoid space, resulting from tumors or inflammations. The air was shown in the upper part of the spinal canal and it was suggested that blocks of the spinal canal should lie similarly demonstrable or could be excluded when not present. In five cases of possible spinal cord tumors we have made intraspinous injections of air. In four, it passed through into the cranial chamber and was demonstrable in the subarachnoid space and the ventricles, so that tumors could be excluded, and other diagnoses could be considered.

In the ca.se of one of Dr. H. Thomas's patients the upper margin of the air was shown at the fifth cervical vertebra; sharp pains were at once carried down the sixth cervical nerves on each side (the site of the tumor). Xo headache


Read by title before the Johns Hopkins Hospital Medical Society on April 3, 1922.


occurred in this case, because the air did not reach the cranial chamber. The skiagram of the head also failed to demonstrate air either in the cerebral sulci or in the ventricles. As the AVassermann for the blood and spinal fluid was positive, anti.syphilitic treatment was instituted with the result that the patient recovered completely from the paralysis. Before his discharge from the hospital, the intraspinous air injection was repeated ; headache at once appeared ; and air was shown in the skiagram of the cerebral ventricles. No pains developed along the cranial nerves at this time. It was evident that the tumor had been absorbed, and that air could pass freely through the region which previously had been blocked. This method should give the same results as the combined spinal and cisternal punctures of Ayer. It is hoped that the air shadow will be sufficiently clear not only to permit the diagnosis of a subarachnoid block but also to establish its localization. How sharply shadows in the thorax and abdomen will be defined, I do not know.


SPONTANEOUS LABOR OCCURRING THROUGH AN OBLIQUELY CONTRACTED, KYPHOTIC, FUNNEL PELVIS^


By -I. AA'iiiTRiDGE Williams.


This case seems worthy of being recorded for two reasons — first, because it aft'ords a striking illustration of the mechanism by which certain skeletal changes may aft'ect the shape of the pelvis, and secondly, because the conservatism with which the labor was conducted aft'orded conclusive evidence of the ability of the uterine cicatrix following Caesai'ean section to withstand the strain


Case report made before the Johns Hopkins Medical Society, Dec. 5, 1921.


of labor, as well as to demonstrate the fallacy of the dictum "once a Caesarean, always a Caesarean."

The patient was a twenty-one year old colored girl, who was markedly deformed by kyphotic changes in the vertebral column and by ankylosis of the left hip and knee originating from tuberculosis developing during the second year of life. The two previous pregnancies had been ended by Caesarean section in another city in liU!) and 1!)20 respectively, and she was admitted to the ward on September I'C, W21. under the belief that she was in labor at term — the last menstrual period having begun on December 20, 1920.

In view of the previous histoi-y, the woman entered the service for a third Caesarean section and, as she was anxious to avoid the possibility of its repetition, it was tentatively proposed to remove the uterus by supra-vaginal amputation after evacuating its contents. On examination, there were occasional uterine contractions, and a small child presented in R. O. P. with its head deeply engaged in the pelvic cavity. In the absence of disproportion, I declined to do a radical operation and predicted a spontaneous outcome, but advised that forceps be applied early in the second stage in order to prevent unnecessary strain upon the scars of the previous sections.

As it proved that the patient was not in labor, I examined her thoroughly the next day with the following results: a frail young woman weighing S3i^ pounds and measuring 130 cm. was lying on her back in bed. The heart and lungs were nonnal. The thorax was unusually arched and, with the large sagging breasts and pendulous abdomen, presented a peculiar picture. The fundus of the uterus reached to within three fingers of the xiphoid, and the abdominal enlargement projected in such a way that its lower part extended vertically downward. A jagged Caesarean section scar extended one-third above and two-thirds below the umbilicus. A small child lay in R. O. 1'. with the hetul deeply engaged. In the left groin just below Poupart's ligament was an old scar indicating the point of discharge of a psoas abscess. The left leg was atrophic as compared with the right, and was fixed at the hip-joint in slight flexion. The knee was flexed and comijletely ankylosed, while a long indrawn scar upon its posterior surface indicated the site of an operation which had been performed when the patient was five years of age.

Upon inspecting the standing patient from the front, (Fig.l) one was impressed by the extreme shortness of the torso, the pendulous condition of the abdomen, and the fact that the body weight was supported entirely by the right leg, while the toes of the left foot scarcely touched the floor. The abdomen was so pendulous that no trace of the abdominal cicatrix was visible, and the umbilicus lay T cm. below a line joining the iliac crests. When viewed from the rear, four striking features were noted. First, the presence of a double kyphosis, with one gibbus in the upper dorsal and the other in the lower lumbar region; second, tilting of the entire vertebral column so that the right shoulder was higher than the left ; third, collapse of the torso to such an extent that the lower-most ribs were in contact with the iliac crests, which was indicated externally by a deep transverse furrow of the skin on either side; and fourth, oblique tilting of the pelvis so that the right iliac crest was 2 cm. higher than the left.


As is shown by Figure 2, there is nothing I'emarkable about the upper gibbus, but the lower one, which is separated from the former by a moderate lordosis, is of interest, partly on account of its location, but particularly because its lower limb passes directly into the sacrum. The existence since childhood of such a lumbar kyphosis led us to suppose that the pelvis would be funnel-shaped, while the unilateral lameness would give rise to an oblique contraction. Careful examination confirmed both suppositions.

External pelvimetry gave the following nijeasurements: 21, 23, 27 and 17.5 cm., and showed that the pubic arch was asymmetrical and somewhat narrowed, with the transverse and anteroposterior diameters of the outlet measuring 7.25 and 10.75 cm., respectively. On internal pelvimetry, the diagonal conjugate was found to measure 12 cm. and the entire right side of the pelvis was flattened and pushed upward, inward and backward, while the left side presented normal curvatures. At first glance it appeared that we had to deal with a typical generally contracted funnel pelvis, associated with oblique contraction resulting from the unilateral lameness. Closer consideration showed that this was not the case, as the diagonal conjugate of 12 cm., although slightly shorter than normal, was disproportionately large for such a pelvis. On the contraiy, we were forced to conclude that it was really relatively lengthened, while both the transverse and anteroposterior diameters of the inferior strait were absolutely shortened. In other words, all of the criteria for a kyphotic funnel pelvis were fulfilled.

Figure 3, which represents an X-ray of the superior strait, clearly shows the existence of the oblique contraction and demonstrates that it had resulted from the unilateral lameness. In this instance, the patient since early childhood had supported her body weight almost exclusively upon her right leg, with the result that with each step a greater upward and inward force had been exerted through the right than through the left acetabulum, and consequently the right side of the pelvis had become flattened and slowly forced upward, inw-ard and backward, while the left side had developed normally, thus giving rise to an oblique contraction involving the entire pelvis, but more particularly the superior strait, which has assumed an obliquely ovate form. That the contraction was not more pronounced is probably attributable to the fact that the patient has always walked with a crutch, and thereby diminished to some extent the extreme mechanical possibilities of her lameness.

Reverting to the kyphosis. The presence of a "hump back," no matter what the situation of the gibbus, is always a source of anxiety to a pregnant woman and causes her to anticipate serious difficulty at the time of labor. Experience, however, shows that such fears are generally exaggerated, as the great majority of kyphotic deformities do not lead to serious dystocia. This is due


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to the fact that wheu the gibbus is .situated iu the cervical or dor.sal region, or even wheu it is dorso-lumbal iu character, the development of a marked lordosis below it results in such compensation, that the body weight is transmitted to the ba.se of the sacrum iu such a manner that the pelvis is not affected. On the other hand, as has been shown by the researches of Breisky, Chantreuil, Tarnier and others, wheu the kyphosis involves the lumbar region, there is no longer any possibility for compensation, as the lower limb of the gibbus articulates directly with the base of the sacrum, with the result that the body weight is transmitted to the upper end of the lower limb of the gibbus iu such a way that a parallelogram of forces is developed whicli resolves itself into two factors — one directed downward and the other downward and backward. The latter tends to displace the lower limb downward, and at the same time to draw it backward. As its lowermost extremity is firmly united to the base of the sacrum, this results in a rotation of the sacrum about its transverse axis so that its base becomes retropulsed, wliile its tip is displaced forwards, thereby increasing the length of the conjugata vera and diminishing that of the anteroposterior diameter of the inferior strait. At the same time the sacro-iliac joints are spread apart, with the result that the innominate bones rotate about their transverse axes, so that the ischial spines and the tubera ischii approach one another and thus diminish the transverse diameters of the plane of least pelvic dimensions and of the inferior strait with the production of a funnel pelvis, as is demonstrated by the example before us.

In most kyphotic funnel pelves which have been studied in the dry state a further change has been noted — namely, a lengthening of the sacrum from tip to base, as well as a slight diminution in its concavity arising from the fact that the traction exerted upon its base tends to draw the bodies of the sacral vertebrae out beyond the level of the alae. Whether this was present in the pelvis under discussion I am unable to state, but no evidence of it was apparent upon palpating the sacrum or in the X-ray plate.

The patient fell into labor early iu the morning of October 13, 1921, and three hours and twenty minutes later vaginal examination showed that the cervix was fully dilated and the head on the pelvic floor in R. O. A. The membranes ruptured spontaneously at this time, and low forceps were applied in order to spare the uterine cicatrix the strain incident to expulsion, and a male child weighing 2120 grams and measuring 46 cm. in length, with a biparietal diameter of 9 cm., was easily delivered without injury to the perineum.

The convalescence was uneventful except for a mild colon bacillus pyelitis, which developed three days before the onset of labor and caused a febrile reaction, which continued until the fifth day of the puerperium. The


patient was discharged in excellent condition on the 15th day and suckled her child, which on discharge exceeded its birth weight bj' 80 grams.

The labor was of interest from two points of view. First, that the small child passed through the abnormal pelvis without difficulty, and secondly, that neither the distention of the uterus incident to pregnancy nor the strain of the second stage of labor had any untoward effect upon the scars of the previous sections.

Through the courtesy of the hospital at which the previous Caesareau sections had been done, we learned that the children weighed 2880 and 2190 grams, respectively, as compared with 2120 grams in the present instance. This at once raises the question as to whether radical operative interference was necessary. While criticism is not permissible unle.s.s one is in possession of all the facts, it appears probable that the second labor, at lea.st, would in all probabilitj' have ended spontaneously had it been given a chance, and that the actual indication for the second Caesareau section was fear of the behavior of the uterine scar following the first operation. The result in our hands shows that such fears were groundless, and brings us tlo the discussion of the behavior of the Caesareau scar in general.

A pj-iori, one would be inclined to believe that the scar tissue in the cicatrix would represent a locus minoris rcsi^tentiae, which might predispose to rupture in subsequent pregnancies, and the actual occuri-ence of such accidents indicates that the danger is a real one. I shall not, however, discuss the question at any length, as an extensive article bj- Dr. Thomas O. Gamble ba.sed upon the experience of our service has just been published.

In Gamble's paper, evidence was adduced to prove that, while rupture sometimes occurs, its frequency is much less than is currently taught. This is due to the fact, which we first demonstrated, that when the uterine wound has been properly sutured, and infection has not occurred, microscopic examination shows a surprising lack of scar tissue, and demonstrates that muscular fibres cross the site of the old incision in all directions just as if it had never been made. Indeed, in a number of iiteri which W'Cre removed at a second or third section, no trace of the previous incision could be discovered, except perhaps a slight furrow upon the external and internal surfaces of the anterior uterine wall, and in certain specimens even this was lacking.

On the other hand, if the incision has not been properly sutured, and more particularly if infection has occurred, good union may not obtain, with the result that the uterine wall is thinner at the site of the old incision than elsewhere. In such circumstances, it is conceivable that, as the distension of the uterus increases, the thinning may become so accentuated as to lead to rupture with its serious consequences.


THE JOHNS HOPKINS HOSPITAL BULLETIN. MAY. 1922


lie


PLATE XXII



Fig. 1. — Showing shortened tnrsd. pendulous abdomen and body weight borne upon right leg.


Fig. 2. — Showing double gibbus and collapse of torso.



Fin. ?j. — Showing obliquel.v ovate superior strait.


May, 1922]


193


The case before us offers additional proof that the uterine scar can withstand the strain of subsequent pregnancy and labor, and again demonstrates that the dictum "once a Caesarean always a Caesarean" does not always hold good. Indeed, my experience leads me to believe that its importance has been greatly exaggerated. At the same time, it should always be remembered that,


as the Caesarean scar may represent a locus tninoris resisfentuie, this fact affords the best possible argument for restricting the employment of the operation within the narrowest limits, instead of employing it more indiscriminately as is advocated by so many obstetricians and surgeons.


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Study of Arterio Venous Fistula with an Analysis of 447 Cases. By Curle L. Callander, M. D. Price, $2.50.

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THE JOHNS HOPKINS HOSPITAL BULLETIN


The Hospital Bulletin contains details of hospital and dispensary practice, abstracts of papers read and other proceedings of the Medical Society of the Hospital, reports of lectures, and other matters of general interest in connection with the work of the Hospital. It is issued monthly. Volume XXXIII is in progress. The subscription price is $4.00 per year.

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194


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Pedicated bv his Pupils to William Henky Welch, on the twenty-Httli anniversary ot his Doctorate. This volume contains 38 separate papers.

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Twelve papers on pneumonia. By Drs. Chatard, Fabyan, Emerson, Marshall, McCrae, Steiner, Howard and Haxes.

A Study of Diarrhoea in Children. J. H. ^UsoN Knox, Jr., M. D., and Edwin H. Schorer, M. D.

.Skin Transplantation. By John Staige Davis, M. D.

Epidemic Cerebrospinal Meningitis and Serum Therapy at The Johns Hopkins Hospital. By Frank J. Sladen, M. D.

VOLUME XVI. 070 pages with 151 figures.

Studies in the Experimental Production of Tuberculosis In the Genitourinary Organs. By George Walker, M. D.

The Effect on Breeding of the Removal of the Prostate Gland or of the Vesiculffi Seralnales, or of Both ; together with Observations on the Condition of the Testes after such Operations on White Rats. By George Walker, M. D.

Scalping Accidents. By John Staige Davis, M. D.

Obstruction of the Inferior Vena Cava with a Report of Eighteen Cases. By J. Hall Pleasants, M. D.

Physiological and Pharmacological Studies on Cardiac Tonicity in Mammals. By PEIiClVAL DOITGLAS CAMERON. M. D.

VOLUME XVII. 586 pages with 21 plates and 136 figures.

Free Thrombi and Ball Thrombi in the Heart. By Joseph H. Hewitt,

M. D. Benzol as a Leucotoxin. By Lawrence Selling, M. D. Primary Carcinoma of the Liver. By Milton C. Winternitz, M. D. The Statistical Experience Data of The Johns Hopkins Hospital, Baltimore,

Md.. 1892-1911. Bv Frederick L. Huffman, LL. D., F. S. S. The Origin and Development of the Lymphatic System. By Florence K.

Sarin, M. D. The Nuclei Tuberis Laterales and the So-called Ganglion Opticum Basale.

By Edward F. Malone, M. D. Venous Thrombosis During Myocardial Insufficiency. By Frank J. Sladen,

M D., and Milton C. Winternitz, M. D. Leukaemia of the Fowl : Spontaneous and Experimental. By Harry C.

SCHMEISSER, M. D.

VOLUME XVIII. 445 pages with 124 figures. Fasciculus I.

A Study of a Toxic Substance of the Pancreas. By E. W. Goodfasture,

M."D., and George Clark, M. D. (lid Age in Relation to Cell-ovcrgrowth and Cancer. By E. W. Goodpasture, M. D., and G. B Wislocki, M. D. The Effect of Removal of the Spleen Upon Metabolism in Dogs ; Preliminary Report. By J. H. King, M. D. The Effect of Removal of the Spleen Upon Blood Transfusion. By J. H.

King, M. D. B. M. Bernheim, M. D., and A. T. Jones, M. D. Studies on Parathyroid Tetany. By D. \\"^ight Wilson, M. D., Thornton

Stearns, M D., J. H. Jannev, Jr., M. D., and JIadge DeCJ. Thurlow,

M. D. Some Observations on the Effect of Feeding Glands of Internal Secretion

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Sch.meisser. M. D. Studies on the Relation of Fowl Typhoid to Leukaemia of the Fowl. By

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Knox, M. D., H. R. Wahl, M. D., and II. C. Schmeisser. M. D. A Fatal Case of Multiple Primarv Carcinomata Bv E. D. Plass, M. D. Congenital Obliteration of the Bile-ducts. By James B. Holmes, M. D. Multiple Abscesses of the Brain in Infancy. By Ja.mes B. Hol.mes, M. D. Gastric Carcinoma in a Woman of Twenty-six Years. By R. G. Hussey,

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HlssEY, M. D. Heart Block Caused by Gumma of the Septum. By E. W. Bridgeman,

M. D., and H. C. Sch.meisser, M. D. Analysis of Autopsy Records.

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Clinical Representatives on the Staff of the Department of Pathology. Donation.

Fasciculus II. The Role of the Autopsy in the Medicine of To-day. By M. C. Winternitz, M. D. Experimental Nephropathy in the Dog. Lesions Produced by Injection

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M. D., and William C. Quinby, M. D. Mesarteritls of the Pulmonary Artery. By M. C. Winternitz, M. D., and

H. C. Sch.meisser, M. D. A Clinical and Pathological Study of Two Cases of Miiary Tuberculosis of

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M. D. The Blood-vessels of the Heart Valves. By Stanhope Batne-Jones, M. U. Equilibria in Precipitin Reactions. By Stanhope Bayne-Jones, M. V. Carcinoma of the Pleura with Hypertrophic Osteoarthropathy. Report of

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Stanhope Bavne-Jones, M. D. The Interrelation of the Surviving Heart and Pancreas of the Dog in

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Burrows, M. D. The Functional Relation of Intercellular Substances in the Body to Certain Structures in the Egg Cell and Unicellular Organisms. By

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T. Burrows, M. D., and Edw-ards A. Park, M. D. Papilloma of the Larynx Report of a Case Treated with Radium with

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VOLIIME XIX. 358 pages with 29 plates.

The Structure of the Normal Fibers of Purkin.ie in the Adult Human Heart and Their Pathological Alteration in Syphilitic Myocarditis. Bv O. Van Der Stricht and T. Wingate Todd. M. D.

The Operative Story of Goitre. The Author's Operation. By William S. Halsted, M. D.

Study of Arterio- Venous Fistula with an Anal.vsis of 447 Cases. By Curle L. Callander, M. D.

VOLUME XX. 314 pages with 82 plates.

The I'athologv of the Pneumonia in the United States Army Camps During the Winter of 1917-18. Bv Willia.m G. MacCallu.m, M. D.

Pathological .Anatomy of Pneumonia -Associated with Influenza. By William G. MacCallum, M. D.

Lymphosarcoma. Lymphatic Leukaemia. Leucosarcoma. Hodgkln's Disease. Leslie T. Webster, M, D.


CONTENTS

  • The Evolution of Human Races in the Light of the Hormone Theory. Racial Status and Form of Body. By Prof. Sir Arthvr Keith ..... 195
  • The Relation of Nutrition to Tooth Development and Tooth Preservation. I. A Preliminary Study of Gross Maxillary and Dental Defects in Two Hundred and Twenty Rats on Defective and Deficient Diets. (Illustrated.) By E. V. McCoixuM, NixA Simmonds, Ethel M. KiNNEV and Clarence J. Grieves . . . 202
  • Studies on Experimental Rickets. XX. The Effects of Strontium Administration on the Histological Structure of the Growing Bones. (Illustrated.) By P. G. Shipley, E. A. Park, E. V. McCollum, Nina Simmonds and Ethel May Kinney . . 216
  • Carcinoma of the Cervix Uteri. A Very Early Case. (Illustrated.) By Karl H. Martzloff . >< .221
  • The Capillaries of the Bone Marrow of the Adult Pigeon. (Illustrated.) By Charles A. Doan 222
  • The Effect of Slight Increase of Temperature on the Bacteriostatic Power of Gentian Violet. (Illustrated.) By John W. Churchman 227
  • Studies on Experimental Rickets. XXI. An Experimental Demonstration of the Existence of a Vitamin Which Promotes Calcium Deposition. By E. V. McCoLLUM, Nina Simmonds, J. Ernestine Becker and P. G. Shipley ..... 229


THE EVOLUTION OF HUMAN RACES IN THE LIGHT OF THE HORMONE THEORY - RACIAL STATUS AND FORM OF BODY

By I'rof. Sir Arthur Keith {Conservator of the Museum and Hnnterian Professor, Royal College of Surgeons, London, Eng.)

Herter Lecture No. 2.


Giantism, and Acromegaly. — Giants are us^ually the subjects of acromegaly as well as of overgrowth of trunk and limbs. There have been authentic cases of giantism which were free from the usual manifestations of acromegaly. There are also cases, certainly few in number, of adolescents who were the subjects of acromegaly and yet showed no increase in stature. From such instances one infers that, although giantism and acromegaly may be present in the .same subjects, they represent disturbances of two correlated yet distinct growth mechanisms. During the years of growth there must be some ever pre

Abstract of Lectures Nos. 2 and 3 of the thirteenth course of lectures under the Herter Foundation, delivered before the Johns Hopkins University, October 6, 1921.


sent process at work controlling the growth of the correlated functional systems of the body. Since the pituitaiy is enlarged in giants, who are free from acromegalic traits, we may infer that this mechanism is also represented in the pituitary — in part at least — for other centres of growth also influence stature. Giantism represents a disorder of the hormone mechanism presiding over, not the reactional, but the normal growth of parts. Localised Acromegalies. — In seeking to unravel the nature of acromegaly one is at first tempted to suppose that the condition is merely the result of the pituitary throwing increased doses of a growth-elixir or hormone, into the circulatory blood. A study of cases of localized overgrowth or partial acromegaly shows that the expla


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[No. 376


nation cannot be so simple. The most instructive cases of this kind are these seen in children in whom there is a marked unilateral hypertrophy of the apparatus of mastication. One side of the face is acromegalic, the other is normal. A minute examination of such cases shows that the overgrowth is shaqaly limited to the parts concerned in mastication — to one half of the mandible, to the corresponding maxilla and palate, and to the bones which give attachment to the cori-esponding muscles of mastication. The tympanic plate is involved in the overgrowth, showing that it is part of the apparatus of mastication. The disorder must commence in foetal life, for the teeth of the affected side are much larger than on the normal side. There is no evidence as yet that there is an anatomical change in the pituitary glands in such cases, but as we have here an undoubted manifestation of localized acromegaly, it is legitimate to infer that we must be dealing with a disturbance of the same hormone-machinery that lies behind generalized acromegaly. In such cases we see the anatomical elements of a single functional unit picked out. In generalized acromegaly all functional units are affected.

The mechanism of Growth Hormones. — These localized cases of acromegaly show that growth is not merely the result of the presence of an activating substance thrown into the general circulation by one or by a number of glands of internal secretion. A local as well as a general mechanism must be concerned. In the case of functional hormones, such as secretin and adrenalin, and also in the case of growth hormones formed within the testicle, we see that such substances, although offered to all the tissues of the body are selected and accepted only at certain definite points or regions. It is not difficult to conceive that one of these local receptive mechanisms might be heightened in avidity or susceptibility and thus give rise to a local hypertrophy. Whatever the nature of the central and peripheral growth mechanisms may prove to be, there can be no doubt that they are arranged on a physiological basis — one which bends a collection of anatomical elements to serve definite functional ends. It is this complex dual mechanism which is inherited from generation to generation and which fashions mankind into different functional types and races.

Examples of the Pitwitary Mechanism at Work in the Evolution of Types.— lip to this point I have endeavoured through a study of acromegaly to unravel the complex mechanism which regulates the growth of the human bodj', concentrating attention more especially upon the apparatus of mastication. To exemplify the manner in which the pituitary growth mechanism produces its effectSj no finer example can be chosen than man's nearest relative — the gorilla. He is the greatest and strongest meniber of the zoological group to which man also belongs— the Higher Primates. The skull of the baby gorilla is smooth and rounded like that of a child ; after


infancy there sets in a series of growth changes which transform the whole appearance of the individual; the masticatory apparatus reaches a supreme degree of development; the temporal lines rise up to form the great sagittal and lambdoidal crests of bone, the lower part of the frontal bone is extended forwards until it forms a great ledge-like bar of bone above the orbits ; the jaws and face become massive. Behind this transformation must lie the same pituitary groA\'th mechanism which is revealed in the acromegalic. In the chimpanzee the growth machinery comes to a standstill at a stage reached in the juvenile gorilla ; in man it is arrested at a stage represented in the childhood of the gorilla. In Neanderthal man we also see the pituitary mechanism vigorously at work. The ape-like supraorbital ridge, the massive jaws, and the wide expanse of the nuchal platform are evidences of this influence. But it is among peoples of the Caucasian or European type that we may best mark the peculiar effects of this mechanism among modern races of mankind. The homeland of this type extends from the western confines of India to the Atlantic shores of Europe. So far as the facial features are concerned, a long narrow prominent nose, a prominent chin with a tendency to elongation and narrowing of the face are the chief racial marks of this type. These are features which almost invariably become greatly exaggerated in the acromegalic. In the shaping of the European type, the pituitary mechanism has had much to do. In shaping the racial charactei-s of the European type the pituitary influence seems to have dominated the other centres of hormone-production ; in the Mongolian and Negro types other centres, such as the thyroid and adrenals seem to have gained in potency.

The Origin of neto racial ch<iraeters and types. — Although I have by no means exhausted the anthropological lessons to be derived from the study of pituitary disorder.s — such as are seen in giantism, Frohlich's disease (dystrophia adiposo-genitalis ) , dwarfism, infantilism, progeria — it is impoi-tant, before we proceed further, to study the manner in which new racial characters come into existence — particularly those relating to the colour of skin and hair and to the nakedness of the human body. In the Museum of the Royal College of Surgeons there has been exhibited since the conservatorship of Sir Richard Owen, the pregnant uterus of a chimpanzee, dissected so as to expose a foetus iu the seventh month of development. Prof. Louis Bolk of Amsterdam has a similar specimen. Independently he and I have realized the important bearing which such specimens have ou the theory of hormone evolution.* So human are the uterus and foetus in appearance that a superficial observer might well believe he had before him the womb and fruit of a woman. The skin of the body is nude, except for the


"The Part Played by the Endocrine Glands in the Evolution of Man." Lancet, 1921, XI, 588.


June, 1922]


197


presence of a flue lanugo; on the other hand, the scalp is covered with hair of a brown colour. The distribution of hair is human — not anthropoid. The skin is scarcely pigmented; it is ashen grey in colour; at a corresponding stage the negro foetus is not dark skinned. Prof. Bolk draws the conclusion, and I agree with him, that man has come by his naked skin and the European by his white colour by inheriting a foetal condition from his anthropoid ancestry. A transient foetal condition of the anthropoid has become fixed permanently in the human adult. We have seen that in his masticatoi-y apparatus and in his nuchal fixation, man retains stages seen in the childhood of anthropoid apes. Man's new characters have first been elaborated within the uterus of the ape; later these foetal characters have been incorporated in the make-up of the human adult.

Up to this point Prof. Bolk and I proceed together. But we must go further and ask ourselves the question. How do these foetal characters arise in the anthropoid womb? I have laid stress u]ion the fact that the pituitary mechanism — the whole mechanism of growth hormones — has been elaborated and organized on a functional or physiological basis. This was made apparent when dealing with the effects of the pituitary mechanism, in fashioning the apparatus of mastication. Nor do we make any extravagant demands on our imagination when we proceed to ^ippose that such hormone mechanisms are constituted and elaborated during the foetal life, in the same way as the mechanisms of instinct and of reflex action are given a concrete representation in the nervous s.A'stem. The nerve-machinery of an automatic action is inherited. One may hazard the presumption that this aLso may be true of the hormone machinery, which presides over the functional fashioning of the body. The long developmental intra-uterine period of higher vertebrates, particularly of the higher primates, gives the hormone system the shelter necessai'y for working out its effects in the f(i4al body and the opportunity of attempting fresh experiments. It is under the infiiience of this automatic hormone mechanism that new characters are elaborated and fresh experiments launched during the developmental stages of life. Darwin's Law of Natural Selection tests these experiments, accepting the successes, and rejecting the failures.

Hair and Skin Clutracters. — Colour is one of the principal marks of race, but in explaining why we should find all shades from the deep black of the negro to the fair skin of the Norseman, we are handicapped by our ignorance of the part played by i)ignient in the economy of the body. The facts at our disposal are these: When the medullary parts of the adrenal bodies are injured or destro.yed by disease, the skin becomes pigmented — as Thomas Addison noted in 1855. John Hunter inferred that the original colour of man's skin was black and all the facts we have gathered since his time favour this


view. The gorilla is the negro amongst anthropoids, he is deeply pigmented at birth. The chimpanzee darkens after birth, some races early, others later. In the orang the hair is red but the skin has a slaty hue. We have already seen that the foetus of man, as of anthropoid, is free from pigment.

There is thus a relationship between pigmentation and these important centres of hormone production — the adrenal glands. AVe obtain some light on our problem when we remember that the adrenals are closely connected with the important function of maintaining the body at a temperature — under all extremes of heat or cold — of approximately 98.4° Fahr. The regulation of the blood supply to the skin, the secretion of sweat, and the development of subcutaneous fat, are the important means by which this end is secured. The development of hair on the body, the amount and distribution of pigment and fat must also be accessory .circumstances in the regulation of temperature. We have seen how anatomical elements are combined into functional units by means of a hormone mechanism and I infer that future research will reveal a growth mechanism which presides over the parts concerned in the regulation of temperature and that skin-pigment will be found to be included in this system. The mechanism must be a complex one in which pituitary and thyroid are also involved, for there is no doubt that disorders of the pituitary ai'e followed by definite changes in hair and skin ; thyroid disorders also give rise to changes, but they are of another kind. From these facts we see that the skin is dominated by a hormone mechanism in which adrenal, thyroid and pituitary are combined — a mechanism of a complex nature.

Thyroid Effects. — On entering into a discussion on the effects produced by thyroid substances in shaping the racial characteristics of mankind, it is necessary to recall some of the statements made regarding the nature of the machinery lying behind the growth changes produced by hormones. I am regarding the glands of internal secretion as centres for the elaboration and distribution of hormones and believe that the organs and tissues of the body are endowed with special affinities for the hormones in circulation and that very probably these local centres have also a means of making their needs known at the centres of hormone production. In dealing with pituitai-y effects I have proceeded on the belief that we are witnessing positive results — an increased action of the pituitary producing increased activity in definite peripheral sites of growth. Thyroid substances can produce acceleration of growth ; this is strikingly shown by the manner in which extracts of the gland can increase the growth of cretinoid diildren and hasten the metamorphosis of tadpoles. 1 presume that thyroid and pituitary growth hormones utilize the same local or peripheral mechanism in producing their effects.


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Cretinism. — It is, however, not the positive or exaggerated action of the thyroid, but its minus or defective one which brings out the part played by this gland in the differentiation of races. In cretins, growth of all the tissues of the body is not only retarded but positively distorted. The effects are best seen in the cartilaginous growth discs of long bones. The cartilage cells multiply slowly and irregularly; osteoblasts cease to have the power to invade and overcome them. The cartilaginous ba.se of the skull suffers in this way ; the root of the nose becomes drawn in and widened ; the nose itself, which is built over a foundation of cartilage, is wide, short and not prominent. The face, which in acromegaly is long and narrow and wedge-shaped, is short, wide and flat in the cretin. The skin is dry, the hair scanty, and the subcutaneous tissue thickened. These are the results of a gross deficiency of thyroid substances. When thyroid extracts are administered, the characteristics previously produced disappear and are replaced by the normal. We have in cretinism positive evidence that the thyroid has to do with regulation of stature and the determination of characters of face, hair and skin — all being marks employed by anthropologists in the classification of races.

Mongolism and Achondroplasia. — Cretinism is a result of a gross deficiency of thyroid substances. There are at least two disorders of growth — mongolism and achondroplasia — which one has reason to attribute to a defective or altered action of thyroid substances. It is true that the exhibition of ordinary thyroid extracts has no effect upon such cases, nor has any one succeeded in producing these conditions experimentally in animals, yet there are clinical manifestations and structural alterations in both of these disorders, which are also seen in cretinism, and for this reason I feel justified in attributing both mongolism and achondroplasia to disturbances in the complex effect exerted by thyroid substance on the growth and differentiation of the body. Dr. Langdon Down, in 1866, recognized that a certain class of imbecile was characterized by traits which recalled those seen in the faces of Mongolian peoples. My friend, Dr. Francis Crookshank has explained the appearance of such traits as a harkback to a Mongolian ancestry. Not only is there a lack of evidence that a Mongolian people has at any time populated Europe, but there is circumstantial evidence that the Mongolian type of humanity is one of the most recently evolved of racial forms. The theory which best explains all the facts is to suppose that Mongolian features arise under a peculiar or altered action of the growth mechanisms centered in the thyroid gland.

It is not necessary to recall the bodily characteristics of achondroplasia or "bulldogism" — for the disturbance of growth is that seen in all varieties of the bulldog breed. The trunk is normal in size but all segments of the limbs, including shoulder and pelvic girdles, are retarded and distorted in growth. In particular, the base


of the skull suffers ;* the cerebellar fossa and the area of nuchal fixation are reduced in size and greatly altered in shape ; the root of the nose becomes drawn in between the ej^es, and broadened just as in cretins. The facial bones laid down over the nasal capsule are retarded in growth, so that the anterior part of the maxilla is drawn up, producing a pug-face. As in dachshunds, the limbs may be affected while the base of the skull and nose develop normally. The disorder occurs in all races of mankind and in varying degrees of severity. Darwin described a bulldog breed of cattle from the Argentine. Dr. Seligman found that the cretinoid or bulldog calves of Kerry cows had disordered thyroids. Dr. Douglas Symmers observed that in a proportion of stillborn achondroi)lastic children there was a structural disorder of the thyroid gland. In achondroplasia we are clearly dealing with a disorder of a growth mechanism which is widely distributed in the animal kingdom and the evidence points to this mechanism having its centre in the thyroid gland.

Now Mongolian peoples are characterized by limbs which are short in comparison with their trunk length. The nasal region between the eyes is wide, flat and frequently sunken in typical Mongols. The flattening of the root of the nose is even better seen in the true Negro type. In the Mongol, as in the cretin, eyebrow ridges are poorly developed or absent. It is not only amongst human races that these supposed thyroid effects can be traced. The orang is the bulldog or Mongol amongst anthropoid apes; he is pug-faced, the nasal region of his face being greatly reduced and drawn in, the supraorbital ridges are developed to only a minor extent — especially when contrasted with their development in the gorilla. With this conformation goes a silent and rather morose temperament. The orang differs in colour from other anthropoid apes just as the Mongolian colouring contrasts with that .seen in the negro or Eviropean. The late I'rof. H. Klaatsch was struck by the points of resemblance which linked the Mongolian and orang types and sought to explain the similarity by supposing that the Mongol and orang had a common ancestiy. The explanation I offer is that both have inherited a common mechanism of growth hormones and they are superficially alike because, in both, the thyroid effects of this mechanism have become dominant.

Dirarf -Races and Stature. — No anthropological problem has been more discussed than the position to be assigned to pygmy or dwarf varieties in the scale of human evolution. In finding the proper solution to this problem, it has to be remembered that all living dwarf breeds are members of the negro race and that each dwarf variety has many resemblances to the breed of negro existing in the same region. The central African pygmies are dwarf


Quart. Journ. Med., 1912, Vol. 5, p.l57.


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forms of the true negro ; the Bushman is a dwarf form of the Hottentot breed and the pygmies of the Far East are varieties of the Eastern Negroids. From their characters and distribution one infers that pygmy peoples have been produced locally from normal members of the negro race, just as dwarf races of horses, dogs and cattle have arisen locally from breeds of normal size. It is also worthy of note that the Dinkas and Shilluks of the White Nile are amongst the slenderest and tallest examples of mankind. Stature is a highly variable factor in the negro race. When we attempt to distentangle the e.xact nature of the growth mechanism which leads to the production of dwarf races, we become keenly alive to the complexity of the problem and to a need for further knowledge. All tissues of the dwarf body are fashioned on a miniature scale, but we can best realize what happens by concentrating our attention on the epiphyseal lines or growth discs of long bones which are so directly related to stature. Epiphyseal lines represent local growth mechanisms, activated and controlled by substances thrown into the circulation at centres of hormone production. Pituitary substances play on these sites of growth ; we explain giantism by an oversupply, and infantilism, such as is seen when the pituitary is compressed by a cyst, by an un(ler-suj)ply. The sexual glands can also influence the rate of growth at epiphyseal lines, but they exert their influence not directly on the cells of the epiphyseal lines but indirectly through the cortical part of the adrenals. A fuller knowledge of the part played by the growth hormones of the thyroid is likely to give us an explanation of the origin of dwarf breeds.

The Hottentot Type— The wide, flat interocuiar field of the typical Mongol is to be regarded, so I think, as an efl'ect of thyroid action ; the same inference must also hold good in the case of the Negro. Now, in the most peculiar breed of existing Negroes — the Hottentots of South Africa — the interocuiar field is particularly wide and flat; the bony skeleton of the nose is reduced ; the supra-orbital ridges are poorly developed. Many anthropologists have noted Mongolian traits in the Hottentot face, as well as the yellowish tint of their skin. These traits are also to be noted in the face and skin of the Bushman. If we admit that there is a tendency for the thyroid mechanism to become dominant in the Negro type, then we can explain the appearance of Mongolian traits in the Hottentot — undoubtedly a member of the Negi'o race. No other theory can give a satisfactory explanation of the racial features and of the distribution of the varieties of the Negro-type.

Dystrophia adiposogevltalis. — Having touched on the Mongolian traits of the Hottentot, it is convenient at this point to discuss another anthropological character by which the females of this racial type are marked — a tendency to the accumulation of fat on the buttocks and outer aspect of the thighs. This peculiar character occurred in certain peoples who lived in Europe towards the close of


the ice age, as we know from discoveries of statuettes and drawings of that distant period. These fat-buttocked women were of the European type, although their skulls do show some negroid traits. The changes which occur in modern women at the menopause help to throw some light on the physiological machinery underlying the appearance of such a feature as a race mark, for, as is well known, atrophy of the ovaries is frequently followed by the deposition of fat, particularly in the region below the waist. The same result frequently follows removal of the ovaries or testes. In the growth disorder first described by Frohlich — dystrophia adiposo-genitalis — there is a like tendency to the subcutaneous accumulation of fat, but in such instances deposition follows enlargement of the pituitarj' gland and an atrophy of the sexual system. On our present evidence, we cannot say whether the change in the pituitary or in the sex glands is the primary one — very probably it will prove to be the latter — but we may safely attribute the deposition of fat and the assumption of a female configuration of body as a direct result of the sexual atrophy. In Hottentot women the physiological process underlying the localized deposition of fat comes into play independently of any loss of sexual function and yet upon the evidence of pathology we must suppose that this process is controlled through a hormone mechanism centred in the sex glands. There is ample evidence to show that a close functional relationship exists between the centres of hormone production — the adrenals, pituitary, pineal and thyroid glands. The sex glands have apparently the power, by means of ovarian or testicular hormones, to influence and set into operation the growthcontrolling machinery situated in the glands of internal secretion. All other evidence points to the influence of the sex glands as being one which is exerted, not directly on the tissues of the body, but through the intermediation of other centres of hormone production. The deposition and absorption of fat we nuist regard as controlled by an interaction between adrenals and thyroid — the glands concerned in regulating the metabolic rate and temperature of the body. The regional deposition of fat recalls, as do localized acromegalics or overgrowths, the need for postulating a local as well as a central machinery in our explanation of the efl'orts of growth-hormones. It is worthy of remark that the profuse wrinkling of the face, so commonly seen in adult Bushmen and Hottentots, is also present in eunuchs and eunuchoid beings. In these conditions the texture and elasticity of the skin are also affected.

The Nilotic Type of Negro. — Before leaving the Negro type, from which I have selected the foregoing instances to illustrate the application of the hormone theory- to the explanation of racial features, there is a further example I may be allowed to cite. The Negro tribes along the White Nile are slender and tall, their height being largely due to length of limb. Their extremities, in opposition to


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those of the Mongolian type, are long in comparison to length of trunk. Now castration, as is well known, results in a delayed clo.sure of the epiphyseal lines. Eunuchs are taller and longer limbed than are normal men belonging to the same place and race. At puberty, when the influence of the sex glands begins to play on the other hormone centres, the body loses the slenderness of boyhood and girlhood ; in the Nilotic negro type the slenderness of youth is retained in adults — a further example of the evolution of a new racial type by the fixation of parts at an immature phase. The sex glands in this type appear to reach maturity without setting in motion the machinery which expands the framework of the body and thus undoes the slenderness of youth. It is an example similar to that cited in the Hottentot women — where menopause characters appeared without impairment of the sexual function of the ovaries.


Herter Lecture No. 3.


Sex-Glands and Adrenals. — From remote times mankind has known that removal of the sex glands completely alters the characters of body and mind of the human as well as of the animal body. What is new in this department of knowledge is the hormone theory — an explanation of how the effects of castration are brought about. Until the postulation of the theory of hormones by Starling in lOOJr, medical men had supposed that the parts and systems of the body were provided with only one means of intercommunication — a nervous or telegraphic system. By 1904 knowledge had reached a point where it could be seen that there was an infinitely older system of intercommunication — a postal or hormonic system — which as regards the growth of the body is very much more important than the nervous system.

Tumours of the Adrenal Cortex. — The important role of the pituitary gland as a regulator of growth was an accidental discovery. Clinicians and pathologists discovered that disorderly overgrowth of the body was accompanied by an enlarged and adenomatous condition of this gland. Medical science benefitted by Nature's pathological experiment. In exactly the same way we have learned that the cortex of the adrenals is an important centre of


See Keith. Journ. of Anatomy and Physiologj'. 1910, Vol. 44, p. 251; ibid. 1913, Vol. 47.

t Prof. T. R. Elliott (personal communication).

On my arrival in New York I visited Prof. Stockard's Laboratory, Cornell University, and found that he had also arrived at many of the conclusions which are given expression to in these lectures. Prof. Stockard has applied the theory of hormones to explain the various breeds of dogs as well as of human beings.

t (1) For recent literature on the pineal gland, see Krabbe: Meddel. fra Rigshosp. Borneafdeling. 1917. No. 48.


growth-control. This glandular tissue is also liable to become the site of a localized overgrowth or an adenoma in the young and is accompanied by a very definite series of growth changes in the body. Recently my friend Prof. E. E. (Jlyn * of Liverpool has rendered an important service by tabulating the data relating to cases of tumour of the adrenal cortex, adding several instances which have come under his own observation. I had an opportunity of seeing the classical case described by Bulloch and Sequeira in 1903. The occurrence of such tumours in young boys is accompanied by a premature development of all the bodily changes which should not take place until the age of puberty. A boy of five years of age will become sturdy and thick-set — an infant Hercules; his voice will break ; hair will grow on the face and pubes ; his penis becomes developed ; the testes become active. The adrenal cortex presides over the development of all of the structural parts which are fashioned into "secondary sexual characters" — the name given to them by John Hunter. Cases are recorded in which these changes have set in soon after birth — pubertal changes masking the features of babyhood. In female children or in young women, cortical tumours of the adrenal produce a different effect; they tend to bring out the sexual character of the male. With the surgical removal of such a tumour, the normal female configuration of body, voice and of mind becomes restored, the adventitious male characters disappearing.!

On the evidence of embryologj' alone one would suspect that there must be a close functional relationship between the sexual glands and the adrenal cortex ; both are differentiated at the same site and appareutly from a common embryological basis. One infers that it is through the adrenal cortex that the sex glands bring about the complex series of growth changes which transform the human body at puberty. Through the pituitaiy mechanism these same glands can play upon the general growth of the body systems.

Tumours of the pineal gland nmy be accompanied by a series of growth changes almost identical in nature and scope to those following tumours of the adrenal cortex. How such a function has come to be resident in tho pineal is an enigma at present — one which futiire research will probably clear up. J

TJie Role of the Adrenals in Raee Differentiation. — It is scarcely necessary to recall the fact that secondaiy sexual characters, which are apparently controlled by hormones elaborated in the adrenal cortex, are employed by anthropologists as marks for differentiating one race of mankind from another. The beard and hairiness of body which characterize the European or Caucasian type of man, and also, to a lesser extent, the Australoid type —


June, 1922]


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the most primitive of existing races — I look upon as an ancient and characteristic of humanity. In Mongolian and in Negro types the tendency is to a hairless face and body. In this respect these types are more highly evolved than the European. The immature stage, seen in the European youth, is tending to become fixed as the adult stage in the Mongol and Negro. The growth mechanism which determines the woolly hair and thick everted lips of the negro we do not know, but are justified in regarding both of these features as non-anthropoid and of recent origin. Large labia majora, on the other hand, are characteristic of the European type. I'rof. Bolk has pointed out that these structure;" are relatively large in foetal stages of ape and man and that the European has acquired this feature by a foetal becoming an adult char acter.

The Periods of The Life-Span. — All the evidence at our disposal points to the evolution of higher human races as having been accompanied by a lengthening of the various growth periods which make up man's normal span of life. The more civilized races of man have longer lives than the primitive races and the primitive races than the great anthropoid apes. It is quite apparent, from what occurs in children suffering from tumours of the adrenal cortex, that Nature has a hormone mechanism at her disposal for accelerating or retarding the nuituring of the body. The action of the adrenal cortex must be connected with the regulation of the periods of growth and with the span of life. We have further examples of an interference with the normal maturation of the body in the group of cases ai present described under the generic term — infantilism. There are forms such as that illustrated by a specimen in the Museum of the Royal College of Surgeons — the skeleton of Crachami — a girl, 8I/2 years of age, but in size and in many other features similar to a baby only a few months old. Dr. Hastings Gilford has distinguished this form as a fa'tal type of "infantilism." Then there is a type illustrated by such cases as that of Jeffrey Hudson who died at G3, and Bornolaski who died at the age of 98. In such cases the span of childhood covers the whole period of life. They may become sexually potent and yet retain a childish size and appearance, their epiphyseal lines remaining open late in life. Again there are those remarkable cases of infantilism to which Hastings Gilford has given the name of Progeria. Such individuals assume an aged appearance while still in their girlhood or boyhood. The exact nature of the growth disorder in these cases is not known, but it is probable that both pituitary and adrenal mechanisms are involved. Compression or atrophy of the pituitary does arrest the growth of the body — produces a condition of infantilism. In the case of progeria that I have examined, the pituitary fossa is relatively small and the neck of the gland is surrounded by a bony ring formed out of the clinoid processes. The atheromatous condition of the arteries, and


the prenmture appearance of senility suggest that the adrenals may also be involved. The evidence is sufficient to awaken an interest in the role played by hormones in regulating the length of life's span.

Conclusion

I am well aware of the imperfect nature of the evidence on which I have based a plea for regarding hormones as the agencies which control growth and evolution. Before coming to a conclusion as to whether a prima facie case has been made out, I would beg the reader to look narrowly at the position in which all who believe in the evolution of living things are now placed. Darwin gave the law of Evolution an abiding place in Biologj' ; his great difficulty was to explain how a multitude of anatomical elements became simultaneously modified to serve a single definite fuuctional purpose. A study of the growth disorders reveals the fact that the hormone .systems, centered in the pituitary and adrenal glands are organized on a functional basis. Hormone systems repre.sent automatic growth mechanism which, like all living qualities, are hereditary and variable. Hormones repi-esent the elements of an automatic .system for the control of growth. For this reason new characters do not appear at the end of a developmental stage but early in the growth of the foetus. New characters appear first in utero; later they become fixed as a new character in the adult stage. The hormone growth machineiy is just such a one as Darwin was in search of. He propounded the elaborate theory of Pangenesis as a substitute.

In these lectures 1 have been applying the theory to problems relating to the origin and evolution of human races. But the day is certainly coming when it will be made applicable to the realms of Zoology and Botany and provide a real scientific basis for these branches of knowledge.

From the experiments carried out in India by Lt. Col. Robert McCarrison it now seems possible that the substances named vitamines may influence and alter the growth mechanisms of the animal body.

Lastly, from the study of English human remains, representing samples of the inhabitants who have lived in that land at successive periods during the last 4000 years, there is a convincing body of evidence that structural changes are taking place in the jaws, palates and faces of a large proportion of the present population of England. A full knowledge of the hormone system of the human body is likely to reveal not only the cause of these structural changes but also the steps which may have to be taken to combat them.


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THE RELATION OF NUTRITION TO TOOTH DEVELOPMENT AND TOOTH PRESERVATION. I.

A PRELIMINARY STUDY OF GROSS MAXILLARY AND DENTAL DEFECTS IN TWO HUNDRED AND TWENTY RATS ON DEFECTIVE AND DEFICIENT DIETS

By E. V. McCoLLUM, Nina Simmonds,

and Ethel M. Kinney

(From the Department of Chemical Hygiene, School of Hygiene and Public Health, Johns Hopkins University, Baltimore)

and

Clarence J. Grieves

(From the Department of Pediatrics, Johns Hopkins University )



STUDIES ON EXPERIMENTAL RICKETS. XX. THE EFFECTS OF

STRONTIUM ADMINISTRATION ON THE HISTOLOGICAL

STRUCTURE OF THE GROWING BONES

By r. <i. Shh'ley and E. A. 1'akk

{From the Department of Pediatrics, The Johns Hopkins University) and E. V. McCollum, Nina Simmonds and Ethel May Kinney {From the Department of Chemical Hygiene, School of Hygiene and Public Health, The Johns Hopkins University)


CARCINOMA OF THE CERVIX UTERI

A VERY EARLY CASE

By Karl H. Martzloff

(From the Department of Gynecology of The Johns Hopkins Hospital and University)


The case reported is one of very early eartiuoma of the cervix. A panhysterectomy was performed and today the patieut feels perfectly well. Of the ultimate result, however, nothiug can as yet be said with certainty.

The patient, Mrs. M. M. (Gyn. No. 27080-271()5) is a white woman, widowed, 55 years of age, who has had two normal pregnancies and two miscarriages. Her menopause occurred five years ago.

Three months before coming to The .Johns Hopkins Hospital the patient began to have a profuse, watery, vaginal discharge which soon became blood-tinged and malodorous. On admission to the hospital, August 13, 1921, examination revealed nothing grossly abnoiiual. Nevertheless, the history of a foul-smelling, blood tinged, watery, vaginal discharge commencing five years after the menopause was so suggestive of malignancy that it was decided to perform a diagnostic dilatation and curettage.

When the cervix was dilated, a small quantity of purulent material escaped, evidently from the uterine cavity. Curettement brought away a very small quantity of tissue, and not the large amount usually obtained in definite cervical cancer. Frozen sections made at the time of this operation showed nothing that could positively be identifled as cancer, so the patient was returned to the ward. Celloidin sections made on the following day, however, showed tissue which we considered undoubtedly malignant, though by no means giving the picture of a fullblown cancer (Figs. 1 and 2).

The patient at that time refused a radical operation, and left the hospital, only to return in two weeks, when a moditied Wertheim operation was done. Her convalescence was uneventful and she is now apparently well.

On macroscopic examination, the pathological specimen with its apparently normal cervix was, to say th<j least, depr essing, for we felt that through a grave error

Read before the Medical Society of Tlie Johns Hopkins Hospital, November 7, 1921.

t This photograph was retouched in order to bring out more distinctly the smooth surface of the mucosa lining the vaginal cuff and cervix.

t In this connection it is only fair to state that when the sections represented in Figs. 1 and 6 were submitted to four well known pathologists, three considered the tissue to be cancerous and one did not consider the evidence sufficient to warrant such a diagnosis. However, after seeing the serial sections represented in Fig. 9, the opinion in favor of cancer was unanimous.


in diagnosis on our part the patient had been subjected to a serious and unnecessary operation. Figure B.f is a photograph of the specimen in longitudinal section and tells graphically why, so far as could be seen, we were in the face of a surgical success but a diagnostic failure.

Pathological Examinntioii: (Gyn. Path. No. 27099). — The specimen consists of the entire uterus with its adnexa and a liberal margin of vaginal mucosa. The uterus measures 7 x 4 x 3.5 cm. The vaginal cuff measures from 1 to 1.5 cm. in length and is normal in appearance. The lips of the cervix and the cervical canal are pale grey, smooth and glistening, and present nothing noteworthy. The uterine cavity is dilated, its walls are somewhat irregular, of a dull, dirty, grey color, and scraj)ing brings away nothing in the nature of an exudate or a necrotic mambrane. Blocks are taken from all portions of the cervix, uterus, parametrium, and adnexa.

Sections of the uterus show the myometrium infiltrated with numerous round and occasional polymorphonuclear leucocytes. No endometrium is present. The only other sections of interest are those taken from the area indicated at "A" (Fig. 3) on the anterior cervical wall. Here the cervical epithelium proximal to "A" has for the most part its usual appearance, but in certain areas it shows a definite departure from the normal. In Figure 1 both the normal and abnormal stratified cervical epithelium is seen. At x the epithelium is hyperplastic and shows a well defined metaplasia in which the epidermal cells have lost the normal gradation from stratum mucosum to stratum germinativum. Instead, one sees large oval and broad spindle-shaped cells' rather unifonn in size, with hyperchromatic nuclei which show some irregularity in staining reaction. There are some nucleoli, and mitotic figures (Fig. 5, a) are not uncommon. These cells have practically no eosinstaining cj'toplasm.

Just distal to "A" (Fig. 3.) sections .show cell-nests (Fig. 6.) in which the cells resemble those just described, although here the irregularity in size, shape, and staining reaction is more marked and the mitotic figures are more numerous (Figs. 7 and 8.).

We believe that this is an early carcinoma of the cervix uteri of a type which we have been seeing rather frequently of late and concerning the nature of which competent pathologists are not in accord. $

Because of the difference of opinion which occurred after the reading of this paper, we were glad to follow


[No. 370


Dr.MacCallum's suggestion and make serial sections of the entire cervix, in order to find, if possible, some areas of more advanced carcinomatous invasion. Serial sections made from the right half of the cervix, from which the original blocks were taken, show a condition quite similar to that which has just been described. Serial sections from the left half of the cervix show cell-nests (Figs. 9,b and 10) similar to those represented in Figure 6, but in addition there are areas of actual lymphatic invasion (Figs. 9,c and 11), small clumps of cancer cells lying free in what appear to be endothelialliiied spaces. The microscopic invasion in none of these sections goes beyond a depth of 2 mm. below the surface of the cervical canal and the entire neoplastic process is limited to the anterior portion of the cervix. This, we feel, proves conclusively that our case is one of a true malignant neoplastic process and also demonstrates the value of making serial sections, in disputable cases, when numerous routine sections do not furnish the information desired.


Discussion

Dr. Thomas S. Cullen : "Dr. Martzloff's squaiuouscell carcinoma is evidently a very early one. We have never found nuclear figures in the squamous epithelium of the cenix except in ca.ses of carcinoma of the cervix."'

After discussing briefly an early squamouscell carcinoma of the cervix, which he had reported in Surgery, Gynecology and Obstetrics, in August, 1921, Dr. Culleu added : "We fully realize that nuclear figures do occur in the squamous epithelium, otherwise there could be no reparation when defects occur. But they are so uncommon that we have not encountered them in our routine work except where malignancy exists. We have also failed to note them in the cylindrical epithelium of the cervix.

"On the other hand, nuclear figures are regularly met with in the epithelium of the body of the uterus, and in cases of hyperplasia of the endometrium nuclear figures are frequently found in the stroma cells of the mucosa."


THE CAPILLARIES OF THE BONE MARROW OF THE ADULT PIGEON


By Charles A. Doan (f?-o»i the A7iatomieal Laboratory, Johns Hopkins University)


THE EFFECT OF SLIGHT INCREASE OF TEMPERATURE ON THE BACTERIOSTATIC POWER OF GENTIAN VIOLET

By John W. Churchman

(yew York)



STUDIES ON EXPERIMENTAL RICKETS. XXL

AN EXPERIMENTAL DEMONSTRATION OF THE EXISTENCE OF A VITAMIN WHICH

PROMOTES CALCIUM DEPOSITION

By E. V. McCoLLUM, Nina Simmonds,

J. Ernestine Becker

(From, the Department of Chemical Hygiene, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore)

and

P. G. Shipley

(From the Department of Pediatrics, The Johns Hopkins University, Baltimore)


Although there is no longer any room to doubt the efficacy of cod-liver oil in curing rickets, the nature of the active principle in the oil is still unknown. It has been stated that the fat-soluble A is responsible for the beneficial effect from its administration in this disease. We have, however, published certain evidence which led us to believe that the protection against rickets which codliver oil affords is not due to fat-soluble A.

Hopkins has shown that this vitamin is readily destroyed by oxidation. Following his lead we oxidized cod-liver oil for from 12 to 20 hours at 100° C by blowing air through it. Oil which was treated in this way did not cure xerophthalmia, even though its administration was begun at the onset of the disease, when edema of the eyelids was first noticeable. On the other hand, it was just as effective in curing rickets in rats as the untreated oil. The bones of rachitic animals which were given daily a


curative dose of the oxidized oil to the amount of 2 per cent of the weight of the ration (average daily consumption of cod-liver oil about 70 mgs.) for 11 days showed quite as advanced evidences of healing as those shown by animals which had received the same amount of unoxidized oil for the same length of time.

The antirachitic effect of cod-liver oil is not due, therefore, to its content of fat-soluble A, but to some other factor which the oil contains.

The existence of this substance, which exerts its effects in so remarkable a manner on the growing bones, is now as firmly established as is the existence of any of the three hitherto recognized vitamins. From its mode of action, and the very small amounts of it which are required to exert its directive infiuence on metabolism, it must, we believe, be classed with this group of essential nutritive principles.



VOLUME I. 423 pases, 09 plates.

VOLUME II. 570 pages, nith 2S plates and fieures.

VOLUME III. 766 pages, «itli 69 plates and figures.

VOLUME IV. 504 pages, 33 charts and illustrations.

VOLUJIE V. 480 pages, «ith 3S charts and illustrations.

VOLUME VI. 414 pages, vilth 79 plntes and figures.

VOLUME VII. 537 pages with illustrations.

VOLUME VIII. 532 pages «lth illustrations.

VOLUSIE IX. 1060 pages, 66 plates and 210 other illustrations.

Contributions to tlie Science of Medicine. Dedicated Ijv his I'upils to William IIexky Welch, on the twentytifth

annivei-sar.v of his Doctorate. This volume contains 38 separate

papere. VOLUME X. 516 pages, 12 plates and 25 charts. VOLUME XI. 555 pages, with 3S charts and Illustrations. VOLUME XII. 54S pages, 12 plates and other illustrations. VOLUME XIII. 605 pages, with 6 plntes, 201 figures, and 1 colored

chart. VOLUME XIV. 632 pages, Trith 97 figures. VOLUME XV. 542 pages, nith 87 Illustrations. Twelve papers on pneumonia. By Drs. Chatard, Fabyan, Emeksox,

Marshall. McCrae, Steixer, Howard and IIaxes. A Study of Diarrhoea in Children. J. H. Mason Knox, Jr., M. D., and

EDWIX H. SCHORER, M. D.

Skin Transplantation. By John Staige Davis, M. D.

Epidemic Cerebrospinal Meningitis and Serum Therapy at The Johns Hopkins Hospital. By Frank J. Sladex, M. D.

VOLUME XVI. 070 pages with 151 figures.

Studies in the Experimental Production of Tuberculosis in the Genitourinary Organs. By George Walker, M. D.

The Effect on Breeding of the Removal of the Prostate Gland or of the Vesicula; Seminales, or of Both ; together with Observations on the Condition of the Testes after such Operations on White Eats. By George Walker, M. D.

Scalping Accidents. By John Staige Davis, M. D.

Obstruction of the Inferior Vena Cava with a Report of Eighteen Cases. By J. Hall Pleasants, M. D.

Physiological and Pharmacological Studies on Cardiac Tonicity in Mammals. By Percival Douglas Cameron, M. D.

VOLUME XVII. 586 pages with 21 plates and 136 flgures.

Free Thrombi and Ball Thrombi in the Heart. By Joseph H. Hewitt, M. D.

Benzol as a Leucotoxin. Bv I..awrence Selling, M. D.

Primary Carcinoma of the Liver. Bv Milton C, Wixterxitz. M. D.

The Statistical Experience Data of The Johns Hopkins Hospital, Baltimore, Md., 1892-1911. By Frederick L. Hoffman. LL. D., F. S. S

The Origin and Development of the Lymphatic System. By Florence K. Sarin, M. D.

The Nuclei Tuberis Laterales and the So-called Ganglion Opticum Basale. By Edward F. Malone, M. D.

Venous Thrombosis During M.vocardial InsufiBciency. By Frank J. Sladen, M. D., and Milton C. Winternitz, M. 1).

Leukspmta of the Fowl : Spontaneous and Experimental. By Harry C. Schmeisser, M. II.

VOLUME XVIII. 445 pages nith 124 figures. Fasciculus I.

A Study of a Toxic Substance of the Pancreas. By E. W. Goodpasture, M.D., and George Clark, M. D.

Old Age in Relation to Cell-overgrowth and Cancer. By E. W. Goodpasture, M. D., and G. B Wislocki, M. D.

The Effect of Removal of the Spleen Upon Metabolism in Dogs ; Preliminary Report. By J. H. King, .M. D.

The Effect of Removal of the Spleen Upon Blood Transfusion. By J. II. King, M. D.. B. M. Bernheim, M. D., and A. T. Jones. M. D

Studies on Parathyroid Tetany. By D. WItiGHT Wilson, M. D., Thornton Stearns, M. D., J. H. Jannev, Jr., M. D., and Madge DeG. Thcrlow, M. D.

Some Observations on the Effect of Feeding Glands of Internal Secretion to Chicks. By M. C. Winternitz, M. D.

Spontaneous and Experimental Leukaemia in the Fowl. By H. C. Schmeisser, M. I).

Studies on the Relation of Fowl Typhoid to Leuksemia of the Fowl. By M, C. Winternitz, M. D., and H. C. Schmeisser, M. D.

Hyaline Degeneration of the Islands of Langerhans in Pancreatic Diabetes. By M. C. Winternitz. M. D,

Generalized Miliary Tuberculosis Resulting from Extension of a Tubercular Pericarditis Into the Right Auricle. By M. C. Winternitz, M. D.

Acute Suppurative Hypophysitis as a Complication of Purulent Sphenoidal Sinusitis. By T. R. BoGGS, M. D.. and M. C. Winternitz, M. D.

A Case of Pulmonary Moniliasis in the United States. By T. R. BoGGS. M. D., and M. C. Pincoffs, M. D.

Gaucher's Disease (A Report of Two Cases in Infancy 1. By J. H. M. Knox, M. D,. H. R. Wahl, M. D., and H. C. Schmeisser; M. D.

A Fatal Case of Multiple Primary Carcinomata By E. D. Plass, M. D.

Congenital Obliteration of the Bile-ducts. By James B. Holmes,' M. D.

Multiple Abscesses of the Brain in Infancy. By James B. Holmes, M. D.

Gastric Carcinoma in a Woman of Twenty-six" Years. By R. G. HnssEY,

Subdiaphragmatic Abscess with Rupture Into the Peritoneal Cavity Fol


lowing Induced Pneumothorax for Pulmonary Haemorrhage. By R. G.

HussEY, M. D. Heart Block Caused bv Gumma of the Septum. Bv E. W. Bridgemax,

M. D., and H. C. Schmeisser, M. D. Analysis of Autopsy Records.

A. The Johns Hopkins Hospital. (Table Showing Percentage ot

Autopsies.)

B. The City Hospitals, Bay View. (Table Showing Percentage of

Autopsies.)

"The Jlonday Conferences."

Clinical Representatives on the Staff of the Department of Pathology.

Donation.

Fasciculus II.

The Role of the Autopsy in the Medicine of To-day. By M. C. Winternitz, M. D.

Experimental Nephropathy in the Dog. Lesions Produced by Injection of B. bro)wlusepticus into the Renal Artery. By M. C. Winternitz, M. D.. and William C. Quixby, M. D.


A Clinical and Pathological Study of Two Cases of Milary Tuberculosis of

the Choroid. By Robert L. Raxdolph, M. D., and H. C. Schmeisser,

M. D. The Blood-vessels of the Heart Valves. By Stanhope Bayne-Jones, M. U. Equilibria in Precipitin Reactions. By Stanhope Bavne-Jones, M. D. Carcinoma of the Pleura with Hypertrophic Osteoarthropathy. Report ot

a Case with a Description of the Histology ot the Bone Lesion. By

Stanhope Bayne-Jones, M. D. The Interrelation of the Surviving Heart and Pancreas of the Dog in

Sugar Metabolism. By Ad.mont II. Clark, M. I). Congenital Atresia of the Esophagus with Tracheo-Esophageal Fistula

Associated with Fused Kidney. A Case Report and A Summary of the

Literature on Congenital Anomalies of the Esophagus. By E. D.

Plass, M. D, Ectopia Cordis, with a Report of a Case in a Fifteen-Month-Old Infant.

By James B. Holmes. M. D. Studies in the Mechanism of Absorption from the Colon. By Samuel

G0LDSCH.MIDT, M. D., and A. B. Dayton, M. D. Report of T\^•o Fatal Cases Following Percy's Low Heat Treatment of

Carcinoma of the Uterus. By V. N. Leonard, M. D. and A. B. Dayton,

M. D. The Relationship in Typhoid Between Splenic Infarcts and Peritonitis

Unassociated with Intestinal Perforation. By A. B. Dayton, M. U. Left Duodenal Hernia. By A. B. Dayton, M. D.

Histological as Related to Physiological and Chemical Differences in Certain Muscles of the Cat. By H. Hays Bullard, M. D. A Method of Clearing Frozen Sections. By H. Hays Bullard, M. D. On the Occurrence and Significance of Fat in the Muscle Fibers of the

Atrioventricular System. By H. Hays Bullard, M. D. Studies on the Metabolism of Cells in vitro. 1. The Toxicity of a-Amino Aeids for Embyonic Chicken Cells. By Montrose T. Borrows, M. D.,

and Clarence A. Ney.mann, M. D. The Significance of the Lunula of the Nail. By Montrose T. Burrows,

M. D. The Oxygen Pressure Necessary for Tissue Activity. By Montrose T.

Burrows, M. D. The Functional Relation of Intercellular Substances in the Body to Certain Structures in the Egg Cell and Unicellular Organisms. By

Montrose T. Burrows, M. D. Studies on the Growth of Cells in vitro. The Cultivation of Bladder and

Prostrate Tumors Outside the Body. By Montrose T. Burrows,

M. D., J. Edward Burns, M. D , and" Yoshio Suzukl. M. D. The Study of a Small Outbreak of Poliomyelitis in an Apartment House,

Occurring in the Course of an Epidemic in a I^arge City. By Montrose

T. Burrows, M. D., and Edwards A. Park. M. D. Papilloma of the Larynx. Report of a Case Treated with Radium with

Resultant Chronic Diffuse Thyroiditis. By William C. Duffy, M. D. Analysis of Autopsy Records. .\utopsy Statistics.

(a) Bay View.

(b) Johns Hopkins Hospital. Report of the Photographic Department. General Improvements.

Donations.

VOLUME XIX. 358 pages -nith 29 plates.

The Structure of the Normal Fibers ot I'urkinje in the Adult Human Heart and Their Pathological Alteration in Syphilitic Myocarditis. By O. Van Der Stricht and T. Wing.kte Todd. M. D.

The Operative Story of Goitre. iTie Author's Operation. By William S. Halsted, M. D.

Study of .Arteriovenous Fistula with an Analysis of 447 Cases. By CcBLE L. Callander, M. D.

VOLUME XX. 314 pages nith 82 plates.

The Pathologv of the Pneumonia in the United States Army Camps During the Winter of 1917-18. By William G. MacCallum, M. D.

Pathological .\natomy of Pfieuiionia Associated with Intluenza. By WiLLiA.M G. MacCallum, M. D.

Lymphosarcoma. Lymphatic Leukaemia. Leucosarcoma. Hodgkln's Disease. Leslie T. Webster, M. D.


CONTENTS

  • Studies in Asymptomatic Neurosyphilis. II. The Classification, Treatment and Prognosis of Early Asymptomatic Neurosyphilis. By Joseph Earle Moore, M.D
  • The Biochemistry of Tuberculosis. By Esmond R. Long, Ph.D.
  • The Dissemination of Bacteria in the Upper Air Passages. III. The Relation of Bacteria to the Mucous Membranes. By Arthur L. Bloomfield.
  • The Changes in the Omentum of the Rabbit During Mild Irritations; with Especial Reference to the Specificity of the Mesothelium. (Illustrated.) By R. S. ClNNINGHAM
  • The Elementary School and the Individual Child. (Abstract.) By Esther Loring Richards 265
  • Notes on New Books 267


STUDIES IN ASYMPTOMATIC NEUROSYPHILIS II. THE CLASSIFICATION, TREATMENT, AND PROGNOSIS OF EARLY ASYMPTOMATIC NEUROSYPHILIS

By Joseph P^arle Moore, M.I).

Baltimore

(From the Syphilis Department of the Medical Clinic,

The Johns Hopkins Hospital)


The work of many observers during recent years has demonstrated that in a large jn-oportion of all patients who have contracted syphilis the central nervous system is invaded bj' the Treponema pallidum at the time of its general dissemination in the firet months following infection. This invasion is easily detected, in most instances, by ewly examination of the cerebrosjjinal fluid. The perqpitage of patients thus found to have

This clinical research has been aided by grants from the United States Interdepartmental Social Hygiene Board and from the American Social Hygiene Association.


early fluid abnormalities approximates the incidence of late clinical neurosyphilis — one fact which makes it probable that when central nervous system invasion does take place, it practically always occurs during the first months of the infection rather than at some later period. If this view])oint be accepted, it is essential to examine the conditions under which neurologic invasion may occur. In addition, this pai)er will discuss the clinical and laboratory methods necessary for its detection, and the response to treatment of these early forms of neurosyphilis.


[No. 377


Leaving out of consideration the occasional precocious appearance of the characteristic late forms of clinical neurosvpliilis such as paresis, tabes, etc., we have classifieil early iieurosy])Iiilis ai)pearing within a year or less from the date of infection under five clinical groups: —

1. Acute si/philitic iiirnviif/itifi, occurring in ])revi()usly untreated patients. It may be recognized as syphilitic by the accompanying signs of a recent early syphilis and by the characteristic cyto-biologA- of the cerebrospinal fluid.

2. Pncorious rdxciiltir iii'innxi/jihili.s, indicated by transitory aphasia, niono])legia, hemiplegia, etc.

o. ycurorcciirrciicr. This type occurs only under definite conditions, i.e.. in a ])atient with early syphilis who has received an amount of treatment insulticient to eradicate the disease, which is then followed by a complete lapse of treatment. The clinical manifestations are varied, but usually consist of a subacute meningitis, commonly with, but sometimes without, focal cranial nerve lesions (most off en paralyses of flie seventJi or eighth cranial nerves i. Occasionally e]>ilei)fiforni seizures occur.

4. Xriirosyi)hHif< iiKiiiiicxtfd hi/ iiiild syiiiptoiiis nr sH(jht iJn/xicdl signs, not of themselves diiif/nostir of central iicnyiiia si/stcm damage. I'atients iu this group may coini)lain of headache, neuralgic pains, insomnia, vertigo, or "nervousness," or may have no symptoms. Those with symptoms may or may not present the minor physical abnormalities which characterize the symjjfom free group, such as slight i)upillarv abnormalities (myosis. mydriasis, anisocoria, irregularity, or sluggish light reaction), and exaggeration, sluggishness, or inequalities of the reflexes. These symptoms and signs are not pathognomonic and may occur in nou syphilitic patients.

5. Asymptomatic neurosyphilis. The patienfs in this


' Zimmerniann, E. L. : Xeurorecurrences, following treatment with Arsphenamin. Arch. Derm, and Syph., V, 723, (June) 1922. This paper deals with the neurorecurrences observed in this clinic, and contains a thorough review of the literature.

Mt is recognized that nothing in this paper can he applied to the early detection of purely vascular neurosyphilis. The lesion in this type of case may be a small perivascular infiltration deeply buried in nervous tissue, and inaccessible to early clinical or laboratory methods of detection.

' Keidel, A., and Moore, J. E.: Comparative Results of Colloidal Mastic and Colloidal Gold Tests. Arch. Neur. and Psych., VI, 163, (Aug.) 1921.

' For five years, spinal puncture has been performed in the outpatient clinic, the patients being instructed to go home to bed for 48 hours. In that period, more than 3000 spinal punctures have been done, with no serious after-results. About half the patients suffer with puncture headache, but this unpleasant reaction is more than counter-balanced by the value of the information gained. Of course, this procedure is not advised it hospital beds are available.

"Weed, L. H., Wegeforth, P., Ayer, J. B., and Felton, L. D.: -A Study of Experimental Meningitis. Monographs Rockefeller Inst, for Med. Research, Xo. 12, March 25, 1920.


group have no complaint, and show uo physical abnormalities. The neurologic invasion is detected only by examination of tiie cerebrospinal fluid.

The first two of these five groups, precocious meningeal and vascular neurosyphilis, are rare, and for the purposes of this paper may be disregarded. The grotip of neurorecurrences has been comprehensively .studied by others.'

Groups -1 and 5 constitute the largest and most important class of patients. Owing to their minor character, the symptoius and signs detailed under the fourth group may be disregarded for the i)urpose of discussion, and these two groups considered together under the common name of early asymptomatic neurosyphilis. It will be shown that the recognition of the.se cases is easily accoml)lished ; that from the ranks of these patients may arise certain of the future outs])oken neurosyphilitics;- that a study of the spinal fluid abnormalities observed permits a division into three sub-groups; and tliat the adjustment of treatment to the type of case will usually bring about a clinical and serologic "cure."

This j)ai)er is based on the study of :!.")l.' i>atienfs witii l)rimary or secondary syphilis from the Syphilis Department of the Johns Hopkins Hospital. In this series are arbitrarily included those jititients whose disea.se on admission was of less than one year's duration. The available data in all cases consist of anamnesis, careful physical and neurologic examinations, accurate details of treatment, and blood and spinal fluid examinations. The last usually includes cell count, globulin test ( Tanily I , AVassermann test with 0.2, 0.4, and 1.0 cc. of fluid, with botli plain alcoholic and cholesterinized antigens, and colloidal gold and mastic curves. In a few cases cell counts or colloidal tests are lacking. Spinal puncture was performed as a routine after one or two courses of arsphenamin (from two to six months after admission),^ though in a few cases it was done much earlier or much later in the cour.se of treatiuent. I'nncture before treatment has been considered unjustifiable, ])artly because of the delay necessary in starting treatment, and partly becau.se of the theoretical danger of transferring organisms from an infected blood stream to a non-infected cerebrospinal axis, either directly through the puncture wound with hemorrhage into the subarachnoid space, or by an alteration of the meningeal periueability.'

TABLE I.

The incidence of early neurosyphilis in primary and secondary

syphilis.


I


Total cases

Acute syphilitic meningitis

Precocious vascular neurosyphilis

Neurorecurrences

Early asymptomatic neurosyphilis

Total early neurosyphilis


Number


Per cent.


352


100


2


0.56


1


0.28


19


5.3


72


20.4


94


26.4


July, 1922]


23a


Niuety-four of the 352 patients developed early iienrosyphilis, and are subdivided as shown in Table I. Of these early neurosyphilitics, 76.6 per cent were asymptomatic. The importance of this sub-group is at once apparent.

In a preliminary communication " a tentative division of early asynii)tomatic neurosyphilis into three groups was outlined, the grouping being based in part on the type of spinal Unid abnormalities (in Kid cases i, and in part on the response of the various types to treatment. Further observation of this much larger series lends support to this tentative classification, and indicates that an ai)preciation of the grouping has a real prognostic value.

The first group of this classification includes those cases in which the spinal fluid abnormalities consist of

TABLE II.

Spinal Fluid findings of Group I, Early Asymptomatic

Neurosyphilis.


Wasserniann


Colloiilal Cold Colloidal Mas<


Zx2


1 8


-t






1222110000


1000000000


Yxll


10


+ +






2211100000


2221000000


Jx20


8


±






j 1122222200


2100000000


Hx8


13 1


±






1100000000


2210000000


Bx2


9


+






1122211000


2210000000


Fx24


8


±






1111100000


2210000000


Fx6


21


4






0011100000


2210000000


E:x12


18


+ +






1222100000


2221100000


20


13


+






1221000000



Gx30


7


+ +






lllllOOOflO


lllOOOOOOO


Px21


^ 1


±






0111100000


2100000000


Nx29


20 1


+





"


1122211000


1000000000


Hx28


8 1


±






oooonooooo


2222100000


6


g 1


±






0011000000



T16


8 1


±






1221000000



Lxl6


15


+






nooooooooo


1111100000


M31


8


-f +


I





1110000000



KxlS


10 1


+


^





1100000000


1122110000


"Keidel, A., and Moore, J. E.: Studies in Asymptomatic Neurosyphilis: — I. A Tentative Classification of Early Asymptomatic Neurosyphilis. Arch. Neur. and Psych., VI, 286, (September) 1921.

' The standard of cell normality has been considered to be from to 5 cells. From 6 to 10 is considered borderline, and such a fluid has not been classed as pathologic unless there was a concomitant increase in the globulin content. More than 10 cells per cu. mm. is definitely abnormal. This standard is based on the work of W. Schonfeld, Ueber Befunde in der RUckenmarksfliissigkeit bei nervengesunden Menschen. Deutsche Ztschr. f. Nervenh., LXIV, 300, 1919.

'No stress is laid on alterations in pressure or on the isolated presence of a small amount of globulin, since both of these are frequently found in normal individuals. Both colloidal curves have been classed as negative if there was no change reading higher than 2.

'Justification for regarding these spinal fluid changes as evidence of neurologic damage is given by O. Fischer, (Die Anatomische Grundlage der Cerebrospinalen Pleozytose. Monatschr. f. Psych, u. Neur., XXVII, 512, 1910).


pleocytosis, usually slight,' a slight increase in glolmlin content, but negative Wassermann reaction and colloidal tests (Table II).* The discussion of treatment of this and other groups will be deferred till later in the jiaper, but it may be stated here that routine anti-.syjihilitic treatment suffices to clear up these alinornialities in practically all instances."

In (iroup II are included those patients whose spinal fluids show a more marked pleocytosis, with cells between 10 and 100, but usually less than 50; the globulin content also is greater than in Group I; the Wassermann reaction may be either positive or negative, but if positive, fixation ustially occurs only with large amounts of fluid ; of the two colloidal tests, either or botji may be

TABLE III.

Spinal Fluid findings in Group II, Early Asymptomatic

Neurosyphilis.


Case


Cells


Clol..


Wasserma


n


Colloidal Gold


MasliiC.lloidal


0.2


0.4


1.0


B4


56


+ -f +


4


4


4


1123311000



C13


98


-1

1


3


4


1234421100



M18


63


-f + +


4


4


4


1123332100



Fxl4


15


+ +






0011110000


3222U0O0O0


Abl4 Ru


10 12


+

+








222+32+110010112110000


1100000000 3211000000


Sy


28


+





4


1211100000


5543220000


Px22


29


±





4


1111000000


2210000000


Gxl


3


+ + +





4


1111110000


3221000000


Axl7


21


-f +






2445522100


2111000000


1x17


14


+ +-f


4


4


4


2222200000


4322200000


Ixl


2


+






1233332000


1000000000


Bx29


21


+





1


1112333000


.5432110000


C15


?


+





4


1234411000



Mx20


6







1234411000


2210000000


121


16


+ +





4




Kx9


14


+



4


4


1111100000


2210000000


Sxl2


?


±





4


1222100000


2210000000


Di


18


+ +






2223222100


5543100000


Dm


16


±






2343100000


2211000000


Fx8


2


+






1211000000


3322100000


B19


19


±


4


4


4


1222100000


5543210000


Zxl4


12


±






12*33100000


2100000000


FX12


2


-f +






1111200000


3222200000


Kx2


24


+





4


0001100000


2210000000


Nx27


5


+






0134211000


2000000000


Cx23


16


+






0123100000


4322100000


FxlO


8


+ +



1


4


3433211000


5543200000


BX15


?


-t

1


4


4


1123110000


3222100000


.1x16


2


+ +






3333210000


3221000000


Px3


7


+






2332110000


3220000000


Px5


3


+ +






1133110000


'.221000000


Dxl5


40


+ + -f





4


1123311000



Dx5 Nx20


4


-f + +

+ +








2233100000 0123322000


2220000000 2210000000


Nx30


2


-f-f +





4


1555555210


0033220000


BblG


4


±






443+3321000


4321000000


positive, the gold being of the syphilitic zone type, and the mastic curve usually to 3, or rarely paretic. Table III shows the detailed findings in 37 cases. It is ajiparent tiiat Group II is the most elastic of the three groups.


234


[Xo. 377


and that certain cases fall into this gronp, instead of into Gronps I or III, only becanse of the resnlts of the colloidal tests. It is for this reason that we do not consider a flnid examination conijplete, unless at least one and preferably both of the colloidal tests can be performed. In this group also a serologic and clinical "cure" '" may be obtained by slight modifications in the usual routine of anti-syphilitic treatment without the addition of intraspinal therapy.

(Jroup III includes those cases in which the spinal fluid ciianges are of a more advanced type. The cell count is high, ranging from 50 to 200. The globulin content is markedly increased ; the Wassermann reaction is positive with small amounts of fluid (0.2 cc. or less) ; and the colloidal gold and mastic curves are both paretic (Table IV). The abnormalities of this group are much more

TABI^E IV.

Spinal Fluid iindings in Group III, Early Asymptomatic

Neurosyphilis.



Cells


1

1 Glob.


Wassermann


Colloidal Gold







Colloidal Maslic




1


0.2


0.4


1.0




11


32


1

+ + +





5554310000



13


91


+ -f + +


i




5555540000



77


58


1 + + + +





5552110000



90


GS


1 + +





5555431000



01


12


+ + +


4




5555321000



X4


64


+ +


4




5555542000



S32


18


+ + +


i




5554210000



S47


28


-)- +


i




5555553100


Gxl8


42


+ + +





5555533200 | 5543210000


Hx5


65


+ + + +


4




2211000000 1 5543210000


Jxl


98


+ + +


4




5555543000 : 5532100000


Qx27


150


-)- + + +





5555442100


5555542100


Du


112


+ + -)


4



5441100000


5532100000


Mo


156


+ + + +


4



5555520000



Ze


131


-f + + -f





5555554100



Br


37


1 + + + +





5555521000



Ho


40


1 + + + +



4



5555421000



resistant to treatment than the preceding two; and practically no imi)rovenient restilts from the routine use of arsphenaniin and the mercurials. Intraspinal therapy as an adjunct to routine treatment offers almost the only chance of a serologic cure.

The relative incidence of these three groups is shown in Table V. Of (>7 patients with primary syphilis, 20.9 per cent had abnormal fluids (!).l jter cent fluid abnor "The word "cure" is here and elsewhere in this paper used to mean that the patient remains clinically well, and that the serology of the blood and spinal fluid becomes negative and remains so for the period of observation. It is not used in the sense of eradication of the last remaining organism. Hereafter, the quotation marks will be dispensed with.

"Particularly G. L. Dreyfus, (Miinch. Med. Woch., LXVII, 1369, 1920) who finds from 70 to 80 per cent of abnormal fluids in untreated secondary syphilis. See also U. J. Wile, and C. K. Hasley: Involvement of Nervous System during Primary Stage of Syphilis, Jour. Am. Med. Assn., 76, 8, (Jan. 1) 1921.


malities in seronegative, 26 per cent in seropositive, primary syphilis). In the 263 patients with .secondarysyphilis, 22.1 per cent of the fluids were abnormal. If argument for the early diagnosis and vigorous treatment of primary syphilis were needed, it would be fur TABLE V.

Incidence of early asymptomatic neurosyphilis in primary

and secondary syphilis.



Total


Normal


Abnormal


Fluids


falling into Croups



I


II


III


Primary


67


53


14 (20.9%)


3


9


2


Secondary


263


205


58 (22.1%)


15


28


15


Total


330


258


72 (21.8%)


18


37


17


nished by these figures ; although it is evident that in some instances neurologic invasion may occur no matter how early treatment is begun.

Under the conditions of this study (examination of the spinal fluid after a considerable amount of treatment) it appears that in (Jroup II we have the most frequent type of abnormal fluid. Of 72 cases of asymp tomatic neurosyphilis, 25 per cent fall into (Iroup 1 ; 51.3 per cent into Group II ; and 23.6 per cent into Group III. From the reports of other workers " on patients with untreated syphilis, it would seem that the minor abnormalities of Group I are much more frequent. Treatment, as we have employed it, may be considered to have accomplislied either one or both of two things: — a rapid disaiqiearance of the (iroup I changes, so that when examined the fluid appears normal; or the o]»posite eft'ect of intensifying the minor abnormalities, so that a patient who might belon